Zooming In and Out on Faces of Addiction

Photo identification cards are meant to serve as simple bureaucratic instruments of state control. We present them to the relevant authorities as requested with the simple underlying logic: “Here is a card that swears, officially, ‘I am me’”. On a recent critical care rotation, I cared for a patient whose photo identification had become so discrepant from the person in front of me, it might as well have been captioned “I swear this who I used to be”. In its 2x2-inch frame uploaded to the electronic medical record, even with pixelation I looked clearly upon a full, cheerful and rosy face with an endearing half-smile. It was a face markedly free of what it would become – an amalgamation of the hallmarks of advanced cirrhosis: citrine skin and sclera, sunken wasted cheekbones, and bulging eyes imposed on a background of progressively wasting cachexia. As his care team, we were able to buy him enough extra time to delay the inevitable long enough for his family to come see him for final goodbyes. When his two young children came to his bedside, I wondered which image of their father would dominate their memories as they grew up and hoped earnestly for the healthy former over the sick latter. 

In caring for any patient with addiction, I find myself returning to the same basic question – how did we get here? I think on a micro level of the complicated personal journey of the patient in front of me – how did the snapshot I see of the person in front of me emerge? On the macro level, I constantly return to inquiries about the messy web of intersecting systems of healthcare policy, legal infrastructure, and societal norms that construct the material landscape of addiction as it presents today. In trying to stem addiction’s tide, it can sometimes feel as a single doctor at the intersection of these forces like riding a kayak through a series of tidal waves. In dealing with this feeling, I have found that looking outward for inspiration can serve as a life raft. I take solace and build motivation from others who espouse wielding human effort and creativity in the face of what can feel like systemic inevitability. 

One such inspiration for me comes from anthropologist David Graeber. A recently published posthumous essay collection of his entitled “The Ultimate Hidden Truth of the World…” centers a pointed quote that has come to summarize the central message of his work. It reads: “The ultimate, hidden truth of the world is that it is something that we make, and could just as easily make differently.” The quote is pulled from another book of his, “The Utopia of Rules”, which offers a critical analysis of the bureaucratic structures pervasive in modern life. In particular, the work unveils bureaucracy’s overlooked ideological underpinnings and inherent violence. Addiction medicine is filled with webs of bureaucratic structures that can harm patients. Graeber’s works give us the important reminder that the material reality of the world we inhabit did not passively emerge on a conveyor belt of history’s inevitable progression. Instead, it is created day-in and day-out by human decisions. Graeber prompts us to repeatedly ask: what would happen if we woke up and decided to do things differently? 

In deciding to change – that is, dismantling, reimagining, and re-arranging the intransigent human-created systems we encounter daily – among the first steps is embracing the imaginative, expansive capacities of the human-mind. We must think – what would it look like to re-make the world in our vision? If we are to put our imaginations to use and start from first principles, can we picture a system of addiction treatment that places the value of human-life at the forefront of its considerations? To what extent would such a system resemble the one we encounter today? 

I do not come to these questions with perfect answers in tow. As I look ahead to the nearing end of internal medicine residency and reflect through writing on my upcoming choice to pursue a fellowship in addiction medicine, I instead hope to cultivate a perspective of humility and renewed creative motivation. This too can feel daunting. The demanding work hours and steep learning curve of residency can drown away creative instincts and pursuits in their wake, replacing them with a mind that operates in rote, cut-and-dry algorithmic decision-making. In committing to continue to engage with others collectively striving to change the field of addiction medicine, I am reminded that remaining imaginative will be invaluable.

My hope is that together we can change the small glimpses of our patients' lives we see – whether captured in a still-frame image uploaded to their medical record or stored in the visual memories we keep of the fleeting interactions we have with them. May we look upon joyous photos to come. 

Written by Anonymous