The most difficult question I am asked, by patients, is "Why?" Why did I become an addict? Why do I still have cravings? Why do I slip up and use, even thought I know it's wrong and I feel stupid and horrible doing it?
When I was in 7th grade, at the height of the baby boom in New York City where average class size was between 35 to who knows what, I asked my biology teacher why the fur never fell out of fur coats. I thought it was a reasonable scientific question. My father was a furrier, and he didn't know. It just didn't. That's why mink coats lasted for years, providing steady work remodeling them, as fashions changed.
My over stressed biology teacher told me, "If the fur fell out, then nobody would buy fur coats!" In other words, "because." (The standard Mommy answer when asked too many questions by the indefatigable toddler.)
Among the many white coats I wear, I practice Addiction Medicine. I have a Suboxone license and I know how to use it. I am well studied in the biology and psychology of narcotic and alcohol abuse. I even give an occasional lecture. I am able to convince my colleague that I know of what I speak.
I have much more trouble convincing my patients.
The most difficult question I am asked, by them, is "Why?" Why did I become an addict? Why do I still have cravings? Why do I slip up and use, even thought I know it's wrong and I feel stupid and horrible doing it?
Despite all my knowledge, education, and experience, my answer essentially is "because.” All the opioid receptor research and all the psychologists' clinical studies tell us the "who, what, where, when" but never the "why.” (In general, doctors have never been good at "why.” Why did I get pneumonia? Why did I get cancer? Why do I have to die?)
After many years of frustration trying to answer this quite reasonable question, I finally hit upon an explanation that allows my patients to lean back, relax their shoulders, and say, "Oh, I get it."
I pose a question to the young man who sits across from me in my office. I ask him, "If a pretty girl wearing a string bikini opened that door and walked past us, could you not look at her?" (For my female addicts, I substitute a well dressed women wearing expensive shoes.)
Following the 'aw shucks grin, and acknowledgement that it would be impossible, I then ask, "Why?" Instant confusion, then slow comprehension. I explain about 'hard wiring' responses, how baby ducks take to water and falcon chicks leap from cliff edges instinctively. "Hard wiring" occurs after repetitive drug exposure, I tell them, and mimics what you're also born with. That's why at AA meetings, people stand up and say, "I'm John Smith, an alcoholic, sober 25 years." They never say, "I'm an ex-alcoholic, I'm cured."
At the beach, I sit with my wife and I watch the pretty girls walk by in their bikinis. I share with her how clever I think I am, coming up with the bikini analogy, for my patients who struggle to understand the cravings that will live with them forever. She listens, and then asks me, "So why do you look at girls in bikinis?"
"Because," I answer.
alan berkenwald, md