Beautiful Boy (18 page)

A mother of a child at Jasper and Daisy's school calls to recommend a local specialist in drug addiction, claiming that he helped a friend more than any of the other experts she saw. For some reason, we heed this recommendation and make an appointment to see him.

The therapist's office is up a flight of stairs above an art-supply store in San Anselmo. It is modest, shared with a marriage counselor, less formal than the psychologists' offices we have come to know. It seems as if we have seen every drug and alcohol counselor, psychologist, and psychiatrist in the San Francisco Bay Area, where one out of every three people seems to be a therapist of some sort. What does this say about us? Scott Peck said that the sickest and healthiest people are in therapy. Which are we?

The doctor has a calm smile on a lined face. Balding, he wears an open-collared shirt under a wool jacket. He seems solid, gentle, and empathetic; from his appearance and manner and soft voice and eyes, we understand that he knows our despair because he has experienced it.

We tell him all about Nic. We explain he's in rehab at Ohlhoff Recovery. We say that we are unsure if we have done the right thing. We say that we worry about Jasper and Daisy. We say that we have no idea what to do when the program ends.

To our surprise, he doesn't have much advice for us, at least not about helping Nic, though he is supportive of the decision to have him in rehab. Most of his counsel is for us.

"Take care of yourselves," he says. "Pay attention to your marriage. Marriages can be destroyed when a child is a drug addict." He says that we can't and shouldn't try to decide what to do when the program ends—much will happen in the interim. "Take it one day at a time." The cliché works, he says.

Late in the session, he leans forward and speaks with compelling poignancy: "Go out together on a date."

"We are," Karen replies dryly. "This is it."

She and I look at each other, sharing the irony. It is true that we have not been out alone in ages. Traumatized, we have wanted to stay close to home, and we have felt nervous about leaving the children. We finally left the kids with Nancy and Don this evening.

The therapist asks if we have tried Al-Anon.

I say no. "I thought Al-Anon was for..." My voice trails off.

He responds, "It might be worth a try."

The telephone may be forbidden, but on his third day at Ohlhoff, Nic manages to call, begging to come home. When I refuse, he slams down the receiver. Worried, I call the counselor assigned to him. She reports that Nic is surly, depressed, and confrontational, threatening to run away. "But they almost always start out this way," she says.

"What if he runs away?"

"We can't stop him. He's an adult."

Karen and I have a series of sessions with the drug and alcohol counselor. He is a good listener, which may be what we need most right now, but it's not only that. He helps us clarify what we can and cannot do for Nic. He says that one of the most difficult things about having a child addicted to drugs is that we cannot control it. We cannot save Nic. "You can support his recovery, but you can't do it for him," he says. "We try to save them. Parents try. It's what parents do."

He tells us Al-Anon's Three Cs: "You didn't cause it, you can't control it, you can't cure it."

Each time we leave his office, he reminds us, "Be allies. Remember, take care of yourselves. You'll be good for no one—for each other, for your children—if you don't."

***

Now that Nic is safe—for the moment—I am working more. One of my interview subjects is a recovering drug addict as well as a parent of one. I tell him that I have just gotten my son into rehab. He says, "God bless you. I have been there. It is hell. But he's in God's hands." It startles me. I mention that our family never believed in God. "I wish I did," I say. "I wish I could put it in someone else's hands. Someone powerful and benevolent. But I don't believe it."

"You will believe in God before this is over," he says.

I call Nic's counselor at Ohlhoff. I can tell that she is trying to put the best face on things, but she seems discouraged. She says: "Methamphetamine is particularly tricky. It's the devil's own drug. It's horrible what it does to them." She pauses, says, "It's early still, though."

This isn't the first time I've been told that meth is worse than most other drugs. To learn why, I continue my research, traveling to meet with more researchers who study meth. They explain that drug users often binge and increase their dosages in an attempt to recreate the initial high, but for meth addicts, with the depletion of as much as 90 percent of the brain's dopamine, it's no longer possible. As with many drugs, the dopamine deficiency causes depression and anxiety, but it's often far more severe with meth. This compels the user to take more of the drug, causing more nerve damage, which increases the compulsion to use—a cycle that leads to both addiction and relapse. Many researchers hold that this drug's unique neurotoxicity means that meth addicts, unlike users of most other drugs, may never completely recover. For me, this is obviously a chilling conclusion, injecting my research with even more urgency.

The Clinton administration earmarked millions of dollars for research into methamphetamine treatments when the epidemic was beginning to spread, and meth addicts had an unacceptably high rate of relapse and low rate of retention in programs. One of the goals of the research was to determine if addicts' brains were irreparably damaged. If so, as in Parkinson's, the best that could be done would be treating the symptoms or possibly slowing the degeneration. Full recovery would probably be impossible.

In 1987, the Partnership for a Drug-Free America launched the antidrug campaign "This is your brain on drugs." But the human
brain on meth does not look like fried eggs. It looks more like the night sky over Baghdad during the first weeks of the war. At least that's how it looks on the computer screen on the desk of Edythe London, a pharmacologist by training, who is a professor of psychiatry and biobehavioral sciences at the David Geffen School of Medicine at UCLA.

When she was an undergraduate, Dr. London took a test that told her that she had an aptitude for medical illustration. In a way, using functional brain-imaging technologies, she does exactly that. In 2000, London created pictures of the brains of sixteen meth-amphetamine abusers. As with most meth users when they stop taking the drug, her enlisted subjects slept in the hospital for two days after they were admitted. Several days after they awoke, London used positron emission tomography (PET) scans to map their brains. PET scans register brain activity by measuring blood flow and biochemical reactions through the movements and concentrations of radioactive tracers. The results are pictures of human brain function—and the measured activity can be related to emotion. Depending on the compound, or marker, used in a test, a scan can map general activity in the brain or the activity of a specific neurotransmitter. In scanning meth addicts, London's goal was to learn more about the state of users' brains when they were in the initial stages of withdrawal. That is, what shape were they in when they first entered rehab?

Dr. London is a soft-spoken woman with shoulder-length black hair and bangs. While I sit across from her in her small office at the medical center, she rotates her flat-panel monitor so I can see the image of the functioning (or, more accurately, malfunctioning) addict brain. She explains that the picture is the average of all sixteen addicts' brains, combining PET scans, which chronicle the activity, and MRIs, which provide a highly accurate background structure. These images are superimposed on the average of brains in the control group. London has assigned colors to the images. The result is before me: a map showing the stark difference between addicts' and normal brains. It is a lateral cross-section, with the gray matter—the MRI structure—in gray. Blue patches indicate where the activity in the brain of the meth user is significantly lower than
the control group's brains. Yellow to red areas are "hot," meaning that there is significantly more activity in the addicts' than the others' brains.

London stares intently at the screen. After a few moments, she sighs. "It's beautiful, but sad."

My mind goes to Nic. Assuming he is an average meth user, the largest sweep of the hottest colors, the size and shape of a small, tailless mouse, is located in the posterior cingulate. Pointing to the patch, yellow in the center radiating out to a circle of Halloween orange, London explains, "What is turned on here is exactly what turns on while people feel pain." The operative word is
while.
She goes on, "A person stops using methamphetamine, and this is awaiting them." Clinicians who work with meth addicts already know that addicts are often depressed, argumentative, anxious, and unwilling to engage in treatment—exactly like Nic—but London's scans reveal that these conditions have a biological basis. In addition, they indicate a level of severity unrecognized before. It led her to conclude that meth addicts may be unable, not unwilling, to participate in many common treatments, at least in the early stages of withdrawal. Rather than a moral failure or a lack of willpower, dropping out and relapsing may be a result of a damaged brain.

She explains that severe cognitive impairments may make patients incapable of participating in therapies that require concentration, logic, and memory. Also, patients with extremely high levels of depression and anxiety, and who are suffering a type of "chronic agony," as London describes it, are at a major disadvantage when taking part in cognitive and behavioral treatments. It's not surprising that Nic, in the first weeks in recovery, wants to flee. In fact, London's research worries me, because it, adding to others' research, shows how long it takes for the brain to return to normal—if it ever does.

After a month of abstinence, the depressive symptoms and pain following meth withdrawal are less severe in many of the abstinent meth users, but in a substantial number, they are far from abated. No wonder the odds are so bad—that is, no wonder the programs available in most rehab facilities in most communities fail most of the time. Some of the places I called are only several-day or week
long detox. Many of the programs, like Ohlhoff, last for twenty-eight days, but few cities have publicly funded long-term programs, and few private insurance plans include coverage for intensive ongoing treatment. Longer programs, especially inpatient programs, are prohibitively expensive for most people. But though a meth addict may become well enough in four weeks to understand the need for ongoing care, he or she may not become well enough to follow through on it. Dr. London's pictures illustrate why programs most likely to be effective would last for many months. It probably takes at least a couple months for a patient to recover enough to engage in treatments in meaningful ways.

What should be done for patients when they arrive in these programs? It would be ludicrous to try to treat heroin addicts in the few days after their last fix with cognitive and behavioral therapies, the mainstays of rehab programs. Heroin addicts have a well-documented physical withdrawal from the drug that includes shakes, convulsions, and the like. The physical effects of withdrawal from methamphetamine, however, manifest in symptoms that we usually associate with psychology and emotion, but—and on Dr. London's computer screen is blue-and-orange proof—they have physical bases.

There are many spots of "hot" brain activity that correlate to trait (ongoing) and state (situational) anxiety, far more than the control subjects. The picture is unique to this drug, London explains. "Scans of the brains of heroin, cocaine, or alcohol abusers do not show changes like these."

The images also suggest cognitive impairments. A blue patch in the medial orbitofrontal cortex is worrisome to London because activity in this area is related to decision-making ability. It is distinctly blue, with a whitish center. Meanwhile, the posterior cingulate, related to pain and emotion, isn't activated in the control subjects, but is brightly lit up in the meth users. It is logical that it would be harder to think when parts of the brain related to negative emotion are active. "In the meth users, at least in the first weeks, the cognitive strategies that the brain is using are abnormal," London says. This means that, in addition to the biologically rooted high anxiety and depression, people getting off meth have severely impaired cognitive functioning.

I check further and come across a study that was conducted three years before London's by Stephen Kish, a doctor at the University of Toronto's medical center, who autopsied the brains of meth users. (They were the brains of people who died of a meth-amphetamine overdose or who had a high level of the drug in their system when they were killed by a gunshot or died in an accident.) In slide shows in generations of high school health classes, the shrunken, dehydrated, eroded brains of alcoholics were compared to healthy brains, creamy white and spongy. Unlike alcoholics, there is no damage in the brains of meth addicts that is visible to the naked eye. At the microscopic level, however, the fried-egg "this-is-your-brain-on-drugs" metaphor applies. Researchers have seen that some neuron ends are essentially singed.

Biopsies of brain cells tell more. To analyze them, Kish used biochemical probes and scooped out twenty-milligram chunks of brain. He measured the amounts of specific neurotransmitters, and compared them to the amounts in normal brains.

His study showed modestly diminished levels of serotonin and other neurotransmitters but "grossly lower"—by 90 to 95 percent—levels of dopamine. Kish also studied the presence of dopamine transporters, from where the chemical is released. These, too, were depleted. Other scientists found similar depletions when they looked at the brains of meth-addicted monkeys, baboons, mice, and rats, leading to the conclusion that meth is neurotoxic, physically changing the brain far more than cocaine and most other drugs do. It raised an essential question—my essential question: even if Nic stops using, can his brain recover?

It was established that dopamine is dramatically reduced, but not whether there is a physical loss of the dopamine terminals. According to Dr. Kish, if the drug permanently destroys the terminals, there's not much chance of recovery. So in his brain samples, Kish looked at a marker called vesicular monoamine transporter, or
V-MAT2.
In Parkinson's patients, where there is a permanent loss of dopamine neurons,
V-MAT2
levels are extremely low. If the marker is depleted in meth addicts' brains, it's likely that there is a loss of nerve terminals, and the brain damage is irreversible. However, when Kish tested for
V-MAT2
, he found normal levels. It was a surprising, and hopeful, finding. This and subsequent research
indicate that the "fried" nerve endings probably do grow back, though it may take as long as two years. Two years.