In the Realm of Hungry Ghosts is a poignant and illuminating treatise on the nature of addiction. Maté, a physician in Vancouver’s Downtown Eastside, has been treating poor and homeless people addicted to various drugs, particularly cocaine, heroin, and methamphetamine, for many years and in this account his insights into the physiological, sociological, psychological, and political-economic nature of addiction are stunningly elucidated.

Addiction is an extremely complex phenomenon and Maté wants the reader to understand this. There is no shortcut or sound-bite that could possibly encapsulate the explanations Maté provides, and the book is a lengthy one, though exceptionally clearly-written and readable, at over 400 pages.

Firstly, Maté informs us, addiction is not necessarily addiction to a substance: “all addictions—whether to drugs or to non-drug behaviors—share the same brain circuits and brain chemicals.” While substance abuse addictions are the main topic of the book, Maté continually refers back to his own, far more minor addictions: workaholism and an addiction to buying classical music CDs. This sounds trivial compared to the suffering of the street addicts Maté treats and describes, but the problems caused by his personal addictions are real and his bravery in sometimes lightheartedly weaving this personal narrative throughout the book is admirable. The self-admission is important because as Maté later explains, judgmental attitudes about addiction are far more of a problem than we realize.

Maté’s description of addiction, its causes, and the best way of treating it are set forth. Addiction involves compulsive behavior one has little control over that is harmful to oneself, and cravings or dissatisfaction when the substance or behavior is unavailable. It is (generally) caused by environmental factors that negatively impact a baby’s brain in the uterus and during childhood, paired with later stresses. Poor quality of nutrition, lack of physical security and particularly insufficient emotional nurturance leads to chronic brain changes such as a diminished development in neurotransmitter receptors (frequent drug use later even further reduces the number of these receptors). This leads to a reduced ability to mature emotionally; to feel good, safe or confident naturally; and to take charge over one’s emotional state. Thus, any factors which affect parents’s (especially the mother’s) ability to provide an emotionally nurturing atmosphere for their children lead to an increased risk of addiction. Evidence clearly shows that a disproportionate number of adults addicted to opiates or stimulants suffered sexual abuse and/or physical abuse as children as well. All of this leads to further deleterious changes to the brain, and likewise to problems in personality development. Thus, a predisposition towards addiction is largely created during childhood by environmental factors and particularly by emotional stressors experienced by children. Addictions can then be towards any substance or activity which strongly boosts dopamine and/or endorphin levels to make up for these pre-existing deficiencies: use of cocaine, methamphetamine or other stimulants which primarily boosts dopamine; or opiate use which boosts endorphins. Overeating, sexual addiction, workaholism, compulsive shopping, gambling, addiction to wealth and power, and other non-substance related addictions may achieve similar results. Addictions to legal substances such as alcohol and nicotine are also related to dopamine and endorphin deficiencies, and frequently accompany addiction to illegal drugs. Genetics plays a far lesser role in the formation of any of these addictions than is conventionally believed, while social and psychological conditions as common as a mother suffering from depression, parental absence because of work schedules, or intense conflict between parents will help foster brain conditions that significantly raise the chances of a child suffering future addictions.

This is startling stuff in its implications for social and health policy. Despite seeming counter to much conventional wisdom on the topic, the evidence presented is assiduously footnoted with references to the primary research in addiction studies. It appears that there has been a revolution in science’s understanding of addiction over the last decade but little of this information seems to have trickled down to the general public, policymakers, or even medical professionals. Instead, a strongly moralistic and religion-based fundamentalism governs thinking in this field, with the assumption that “drug addiction is the addict’s choice” being the shorthand for this dominant paradigm and the cruel, ineffective, and personally destructive policies that follow. While individual choice is of course one component of any addiction and key to its successful treatment, Maté demonstrates convincingly that this is much less the case than our culture may wish to believe. This is because, Maté asserts, our society is itself privy to various addictive pursuits and distractions and is loath to confront the suffering of the self so many people feel.

Beyond the physiological and developmental aspects, In the Realm of Hungry Ghosts analyzes the sociocultural and political-economic roots of addiction. Mothers who are stressed from overwork; families in which economic distress has caused disintegration; minority populations whose cultures and support networks have been essentially erased [see The Globalisation of Addiction: A Study in Poverty of the Spirit for more on this topic]—all of these factors contribute to children with the brain dysfunctions which predispose individuals towards addiction. Drug prohibition and the marginalization of addicts increases this as does the increasing incarceration of mothers (and fathers) for drug-related crimes. Essentially, from this analysis, the war on drugs is an entirely misguided enterprise which is itself one of the primary factors leading to addiction. The other primary factors do involve some individual choice (both in how one cares for one’s children and in how one self-soothes or deals with emotional difficulties) but a great deal of social policy as well. If we want to end addiction, Maté argues, rather than dousing Colombia with pesticides and trying to prevent Afghan opium production, we might want to turn our attention towards a broad-based understanding of treatment and harm reduction. While not explicitly advocating it, programs to help the working poor and minorities, and particularly families with small children would obviously go further in addressing addiction than current policies which stress interdiction. Maté advocates decriminalization of all drugs, and though he worries about this with drugs such as crystal meth, he sees no alternative beyond a medical distribution model based on strategies utilized successfully in Switzerland, England, and Canada, despite US drug warrior efforts to stymie them.

Maté writes passionately about all of these topics, and tells the tragic stories of some street addicts he has known and treated. Including his own personal story of addiction, however minor, helps ground his recommendations for how to attempt to deal with addictions of all kinds. Essentially Maté recommends a model based somewhat on mindfulness—an ability to detach oneself from one’s emotions and craving without either succumbing (though this will generally happen—relapse being almost unavoidable) or blaming or denying oneself. For some, total abstinence is not a possibility and a maintenance regime of opioid substitution (such as methadone) or stimulant substitution (such as Ritalin) is the least bad option. His suggestions for treatment, stressing both internal and external factors, mindfulness, spirituality, use of a 12-step program at times, and other approaches are more complex than can be explained quickly, but are utterly pragmatic and consistent with the principle which underlies the entire book: a deeply felt, scientifically rational but spiritually informed humanism.

Reading In the Realm of Hungry Ghosts made me honestly examine a number of my own (minor) addictions and behavioral nuances and elicited a deep sense of compassion in me towards those who face more serious problems of this nature. Indeed, if addiction is so strongly controlled by physiological brain problems stemming from childhood, compassion and an evidence-based socio-scientific approach are the only ways with which one can rationally address the topic.

Too many books are described as essential reading, but for anyone who has ever been touched in any way by substance abuse or other addictions, or for anyone who knows someone who has, and especially for anyone dealing professionally with medical and policy issues related to addictive drugs, this book simply must be read. Its importance cannot be overstated.