The Left Atrium · De l'Oreille Gauche

CMAJ 2000;162:1717-20

• A is for addiction
• Knowing the score
• Night thoughts
• Quitting smoking
• The pissin smell
• One thousand words

how to stop time: heroin from A to Z
Ann Marlowe
Basic Books, New York; 1999
$36.50 (cloth) 297 pp. ISBN 0-465-03150-1

Addiction, so conventional wisdom has it, is about loss. Loss of control. Loss of resources. Loss of good health. Loss of support. Ann Marlowe lost nothing. Her memoir has a hard, implacable edge, almost as though she were reporting on a study in which she is the single experimental animal. She sought, and apparently found, that fine line between the pleasures of addiction and its risks, quantified and deliberately avoided. (See under "junkie.")

Is Marlowe an addict or not? What is addiction? According to the DSM-IV, addiction involves substance tolerance, symptoms secondary to substance withdrawal, escalating substance use, reduction in social and recreational activities because of substance use, and an increased expenditure of time to obtain and use the substance. Given these criteria, it is difficult to label this author as an addict. As for her own definition of addiction, Marlowe writes: "I'd call it a form of mourning for the unrecoverable glories of the first time."

Marlowe dwells at length on the magic of the "first time" high and the endless pursuit of that magic. Magic and myth go hand in hand, but Marlowe is contemptuous of heroin mythology, especially the myth of heroin's glamour: "heroin isn't that wonderful: it's a substance some of us agree to pursue ... because it's easier to do that than figure out what is worth pursuing."

Still less does she buy into the popular view of addiction as uncontrollable need. "All but the severest dopesickness is no more rigorous than a nasty flu," she points out acerbically, and thus is no excuse for criminal activity or bad behaviour. Interesting stuff. But where does it leave us in considering Marlowe as an addict?

I'm not sure. I've never had a patient like this. In fact, I doubt if any of my patients would recognize her as a fellow addict. How relevant to everyday addiction medicine, then, is Marlowe's story? Not very, perhaps. But as a memoir of one drug user's personal philosophy, it is completely fascinating.

Marlowe's prose is spare and elegant. Her reflections are structured around alphabetical headings, just as she describes her life as structured around the rituals of heroin use. She makes incisive observations about the twin cultures of heroin use and rock music, both tactics to forestall confrontation with the future by a society that venerates instant gratification and entitlement. A need to keep returning to the past, she tells us, "isn't an innocent one. It's about stopping your passage to the future. It's a symptom of the fear of death and the love of predictable experience." This is a distillation of Western society's fascination with substances that numb the pain of loss engendered by continual fast-paced change. It is an acknowledgement of heroin's role in the search for predictability, ritual and the certainty of a particular social acceptance in an uncertain world.

Marlowe weaves a compulsive fabric connecting her experience with heroin use with a family history whose dark corners are revealed only fleetingly. Friends and lovers appear and reappear over the years, part of the drug culture's shifting world. But Marlowe remains a self-confessed loner: detached, emotionally uninvolved, an observer. Perhaps some of this book's fascination lies in a sense of deception. This coolly rational dissection of one woman's heroin use has several implicit flaws, not least of which is its variance from the experience of most other users. The author's revelations are layered and guarded. One suspects they only skim the surface.

Would I recommend this book to physicians practising addiction medicine? Absolutely. I would recommend it to anyone who has observed drug addiction either professionally or personally. Even if Marlowe is an outlier, her insights are acute. She makes no comment on the role of physicians in her world. I suspect they are of no importance, for they have nothing to offer her. No victim, this. In a world inhabited by victims, this book is refreshment indeed. Read and enjoy it. And be thankful if you don't have the challenge of a patient as formidable as Ann Marlowe in your practice.

Patricia H. Mark
Sow's Ear Medical Centre
Lantzville, BC

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Knowing the score The score: it's in your genes The Electric Company Theater Society Directed by Kim Collier Produced by David Hudgins Waterfront Theatre, Granville Island, Vancouver April 7­16, 2000

While he was organizing the Human Genome 2000 conference this spring, Dr. Michael Hayden of Vancouver's Centre for Molecular Medicine and Therapeutics was looking for innovative entertainment that would help the public keep up with the galloping pace of genetic research. His solution was to commission Vancouver's Electric Company Theater Society to create a play: the result, The Score, was a dynamic fusion of drama, song and dance played against striking black-and-white sets and original music.

Using multiple creative elements with a humorous flair, the play touches on a wide range of social and ethical concerns as it tells the story of Lynn Magnusson, a tyrannical geneticist running a small laboratory on the fast track to a groundbreaking discovery. A rival French laboratory is hot on her heels, and the competition is intensified by the prospect of a $3 million drug company investment with the potential to cut the time to discovery by five years. But time is also running out for Magnusson in the personal sphere. Her mother died of Huntington's disease, and Magnusson is unexpectedly forced to confront the possibility of carrying the gene herself when she discovers she is pregnant.

The public perspective on genetic research is conveyed through a mockup of Rex Murphy's CBC radio program, Cross Country Checkup. Concerned callers ask Magnusson about the implications of genomic knowledge on obtaining insurance and express fears about cloning and gene patenting. There are protests that "a sacred world has been breached" and that "the sanctity of human life has been devalued" by Magnusson's cutting-edge work. She responds that humans have always "tinkered" with their species through medical research and that genomic research will ultimately offer more benefits than drawbacks.

Back in the laboratory, tensions run high. Magnusson's team tries to outpace the French group; there is infighting over credit on scientific publications; and researchers fear the loss of their careers in the corporate culture of patenting. Ultimately, Magnusson's lab collaborates with the French group, which later pulls out and publishes their findings alone.

Magnusson, meanwhile, has tested herself for the Huntington's gene and discovers the results are positive. Her angst plays out in front of stage-sized slides of cells and gene micrographs, enhanced by musical and dance interpretations of her torment. In the end, her pregnancy and the discovery of her genetic destiny bring perspective to Magnusson's obsessive pursuit of mutations in her lab — which she leaves to her colleagues, still fiercely competing among themselves.

Heather Kent
Vancouver, BC

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The Winnipeg Art Gallery takes on an evocative theme with Nocturne: From Twilight Until Dawn, an exhibition of 47 paintings, drawings and prints by Canadian and international artists on view until Sept. 30. The gallery's permanent collections of historical, contemporary and Inuit art are tapped to explore, as curator Mary Jo Hughes writes, the many metaphors of night: "night as death, night as fear, night as loneliness, night as peace, and night as the seat of our unconscious."

Tom Lovatt, The Errors of the Moon, 1992. Oil on canvas, 5' × 10'. Collection of the Winnipeg Art Gallery. Acquired with funds from the Volunteer Committee to the Winnipeg Art Gallery.

The canvas reproduced here, The Errors of the Moon, is by Manitoba artist Tom Lovatt, who describes the work as part of a series of paintings "related to the same body of images." The moonlit garden, the floating man, the enigmatic woman, the urn and other elements suggest loss and regret. But for Lovatt they also describe the transition from one life stage to another and, ultimately, regeneration and regrowth. This is the contemplative aspect of night, through which one ascends from despair. From the dark night of the soul arises an eerie beauty.

Whatever the night holds for artists and mystics, the small hours have traditionally been onerous for physicians. Texas researchers¹ found that the rate of exposure to bloodborne pathogens among medical students and residents was 50% higher at night — hardly surprising in a group whose most well-known occupational hazard is sleep deprivation. As Vincent Hanlon writes of the ER night shift: "In this nocturnal labyrinth, we stumble repeatedly, bumping into the ill and injured. Other nights we walk the uneven terrain of Death Valley."²

Fear of the night has a long and articulate history. The evening rites of the Book of Common Prayer implore the Creator to "defend us from all perils and dangers of this night." But it seems that some things that go bump are really rattling around in our heads. A study on the acoustic startle reflex in humans suggested that although we are jumpy in the dark this may have more to do with our childhood fears of darkness than with heightened auditory attention.³ Besides, there is some evidence that it is not night but early morning that is perilous. A study in New York City showed a 60% rise in disease-related deaths beginning at 2 am and peaking at 8 am.⁴ This gives new depth to Thomas Browne's observation in 1643 that "We term sleep a death; and yet it is waking that kills us."

Anne Marie Todkill
CMAJ

1. Parks DK, Yetman RJ, McNeese MC, Burau K, Smolensky MH. Day­night pattern in accidental exposures to blood-borne pathogens among medical students and residents. Chronobiol Int 2000;17(1):61-70. [MEDLINE]
2. Hanlon V. The ABC of the ER [book and CD]. Winnipeg: Night Shift Productions; 2000.
3. Grillon C, Pellowski M, Merikangas KR, Davis M. Darkness faciliates the acoustic startle reflex in humans. Biol Psychiatry 1997;42(6):453-60. [MEDLINE]
4. Mitler MM, Hajdukovic RM, Shafor R, Hahn PM, Kripke DF. When people die. Cause of death versus time of death. Am J Med 1987;82(2):266-74. [MEDLINE]

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Contributor's note: This account, reproduced here with the patient's consent, is my recollection of her own words.

The pissin smell keeps coming over me. I can't get rid of it. It comes into my nose and fills my mouth and then I'm suffocating. Maybe four times a day it happens. I feel like I'm losing my mind. I feel like I'll suffocate with the pissin smell. I need air. Then I remember coming down on him, over and over, and the awful pissin smell. I can't stand remembering this. I feel shamed and dirty, and the smell — why can't I get rid of it? I tried to protect my young stepbrother. I tried to hide him all the time from Mr. C, always hiding him, so it wouldn't happen to him too. There were many others later who abused me, but I don't remember them as much. It's always Mr. C and the pissin smell that I remember. Then I feel angry, angry with Mr. C, angry that I was forced to live with him and his family. And then I become angry at all white people for what happened to me. Drugs for 25 years. Always drugs. Always thinking I was dirty and shameful. Now that I'm not on drugs, in here, I don't want to live. I want to die, to kill myself, so I don't have to remember this over and over.

That's why I want to go on the methadone. I've been talking with the alcohol and drug counsellor here. Maybe methadone will help me to stay away from the drugs. I went to see a methadone doctor when I got out of here last time. He gave me a script for the juice, with a piece of paper about where to go to get the methadone. I didn't want to tell the doctor that I can't read. I thought I'd ask people in the street how to get there, I'd show them the paper and they'd help me. Nobody would stop to help me. They all looked at me and saw a Native person, brown and ugly and poor, and nobody would read my paper and show me the way. I got very angry and frustrated. Then I saw a bus and saw HASTINGS and I knew that the bus would be easier than finding the methadone. That bus took me back to the life I've lived for 25 years, back to what I know. And now I'm in here again.

I'd like to start on methadone now. Then maybe when I get out of here I won't go back to the dope.

I want to learn to read. When I was a child our teacher read to us every day from a big, fat book about animals and insects that lived in a peach. I loved that story. I couldn't wait for the next day, to hear her read more about the peach. I loved going to school then. That was the only time I loved going to school. I think I could learn to read if I listened to stories like that again.

I'm working at my schoolwork in here, but I can't concentrate because that pissin smell keeps coming over me. Then I think I'm losing my mind and I can't figure out the words that I'm learning. The teacher says I should sort out my life first, then it will be easier to learn how to read. I pray a lot and go to the smudges and the sweats. I listen to Native music in my room in the evenings. It helps drown out the memories and the pissin smell.

Shortly after this interview I initiated methadone maintenance treatment for this patient in prison. During her incarceration, through the help of fellow inmates who read to her, and by listening to storybooks on tape, she learned to read and write.

Ruth Elwood Martin
Department of Family Practice
University of British Columbia
Vancouver, BC

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Operating room, Hôtel Dieu, Quebec City. No date.
[Photo courtesy of Jules-Ernest Livernois collection / National Archives of Canada / PA-24113]

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