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The AddictReview - The Addict
One Patient, One Doctor, One Year
by Michael Stein
Harper Perennial, 2009
Review by Chris Vaughan
Mar 9th 2010 (Volume 14, Issue 10)

Michael Stein is a professor of medicine and community health at Brown University, but for two days a week he works as an internist in a busy city hospital. The rest of the week he spends applying for grants, doing clinical research on drug addiction and publishing articles in scientific journals.

Somewhere in his busy schedule he finds time to write novels.  The Addict is a novelistic but true account of how he treated a patient, Lucy Fields, a 29 year old Vicodin addict, over a period of one year.  It is not, therefore, a case study, nor is it a policy document but a story, a fable even, since there are lessons to be learnt.

By presenting the particulars of Lucy case in this way, the author has a licence to use observations distilled from twenty years of dealing with and treating addicts and also to include himself in the narrative and to record his own personal thoughts and feelings.

The author has five novels to his credit and knows how to tell a good story and all the page-turning devices are here in evidence. The central character, Lucy Fields, is well-chosen. She is young, a graduate, from a professional background; she reads books -- Dickens, Nadine Gordimer, Toni Morrison,  Alice Munro -- and a physical examination reveals she has perfect teeth -- what is there not to like?

There are plot points, which lead us to ask:  Will Lucy be able to conquer her inner demons in her battle to break the grip of her Vicodin addiction? Is she determined enough to keep up her course of the opiate blocker, Buprenorphine which the author prescribes for her? And while the drug acts on suppressing her craving, will the good doctor be able to win her trust and discover the deep secret  hurt  she is using Vicodin to sooth?

The reader, then, can identify with Lucy and care about what happens to her. The author, too, is refreshingly honest about his interest in addiction and in treating addicts. Like all of us he gets satisfaction when he can help others. But he acknowledges there are more selfish reasons, too. Although their loneliness seems to resonate with his own childhood experience and create some kind of bond, he is fairly circumscribed as to who he will treat, where and when. He confines himself to opiate addicts who must take the prescribed course of Buprenorphine and will only treat in his clinic during office hours and  only the quota of addicts by federal legislation. He acknowledges, too, that youthfulness of addicts appeals, because there is hope for the future. He makes no claim to be a hero or messiah. He is a pragmatist with the self-respect and self-knowledge necessary for this kind of work.

As the year unfolds the author recounts his interviews with Lucy in chronological order, crosscut for illustrative purposes, with other patient histories. We are allowed only the information that he gathers from each particular interview with Lucy and the interpretation he put s on it at the time and the role he sees himself playing in her progress.

On the whole this is a well-written book aimed at a general, literate readership with parts showing great eloquence - lyricism even. But it is book that would also have some value as a teaching aid for undergraduates. Because of the need to maintain narrative flow, many of its theoretical assumptions are suppressed or merely hinted at, so the text cries out for interrogation and discussion.

The primary aim of this book is to  throw light on what is becoming an important social issue in America and the West in general -- an over reliance by a significant section of the community on prescription-only pain killers and it is an insight into one doctor's approach to dealing with the personal effects of that problem.  The recent deaths of celebrities involved in this kind of substance abuse have tragically highlighted the way lives can be wrecked. But because the author is intent on telling a good story and keeping it flowing, his treatment methods are not readily apparent in any formal sense. What are his aims, what is the rationale for the treatment path he follows? The author's thoughts and feelings are faithfully recorded but we have to infer what particular method or strategy he is following with the patient. Throughout the text he scatters hints and clues and leaves it to the reader, if they are interested, to piece them together. But on some issues it is still not entirely clear what path he is following.

Fairly early in the text, he states, fairly grandly, "As Lucy's internist, I wanted to manage her overall health, and I knew at some point, if she didn't flee, this would involve helping her identify, manage, and master the tyranny of her dangerous destabilizing needs."(p16)  But he doesn't state how he is going to go about doing that. He partly adheres to the bio medical model, because he thinks without medication it is almost impossible for an opiate addict to get their bearings. But he is convinced that medication isn't enough.  He is sceptical about the shortness of the cognitive behavioural time frame, although he is familiar with its methods and uses a cognitive approach with some of his patients.  He seems on the whole to favour a listening Rogerian approach, allowing the patients to think aloud and overhear themselves. CBT is too quick, he seems to say, the patient must be given time.  " But some days a patient begins speaking , and she isn't really speaking to me but to herself, and it isn't what she intended to say, but there it is, audible, and a surprise to both of us, and I never would have heard the story if I hadn't handed over an extra twenty or thirty minutes." (p126)

But elsewhere in the text he seems to contradict this with a rather aimless soliloquy.  "I have an unquenchable urge to delve, to draw things out of patients, to hear secrets, to hear everything. I like knowing secrets; not to know them is to miss a patient's life…If I didn't listen, it would be a violation of responsibility and trust…But I also listen because I have a need I don't understand." (p19).

Professor Stein maintains a proper neutral stance and keeps his focus on the patient and adopts the standard non-judgemental approach. He wears a white coat, has his certificates on the wall and unlike his colleagues doesn't deck out his office with his personal effects. However, to inject drama into the narrative he makes his feelings plain: his liking of Lucy, his anxiety over the direction the treatment is taking and whether he is taking the right approach and if she is complying. " I wanted to scream to wake her up…It was torture to remain in the room with someone who knew about the way she lived."  He doesn't make his feelings known, of course, either by screaming or leaving the room.

By maintaining his neutral, disinterested stance and by giving the patient time and space to talk, he hopes to win their confidence and be the recipient of the secrets, they cannot divulge to friends and family. "The sickest parts...are the parts addicts can't tell anyone, the parts they aren't ready to tell me until I've known them for a year or more." (p30)

It is not clear, however, after this revelation has appeared, how he intends to proceed thereafter. It is interesting that three years after she started her therapy and has learnt to trust him implicitly, Lucy is still one of his patients. Has she swapped one dependency for another, albeit a non-toxic one?

Given the information he has gleaned from Lucy, a whole discussion could be had from whether she  might  benefit more from family therapy rather than one to one counselling since issues with her parents and her sister start to emerge during the interviews and so much of her problem seems to stem from what remains unspoken between family members after a  tragedy that occurred during Lucy's childhood.  The professor seems to see a patient's family more as a support network for his remedies rather than contributing to the problem in the first place.   "When patients bring in family and friends…I can identify an ally who might assist me. I will have a witness, someone who can confirm my instructions, corroborate what I say." (p81)

This digression should not take away the achievement of Michael Stein in drawing the reader into the everyday reality of his clinical work as he reaches out to a problematic group trying unsuccessfully to self-medicate their troubles away.  One last question the informed reader might care to ask is: how does he do his reflective practice? An answer might be, by writing books as interesting and informative as this one.


© 2010 Chris Vaughan


Chris Vaughan writes about himself: I live in Birmingham, England. I am now retired after a career in the pharma industry and am very much involved in community activities. I am a board member of the Birmingham Environmental Partnership and chair a local patient network. I have written a book on the British Health Service and I currently write for a health website. I am very interested in the mind-body conundrum.


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