Fighting Fire With Fire
Dr. Bryon Adinoff, distinguished professor of alcohol and drug abuse research at UT Southwestern Medical Center at Dallas, is doing experiments to identify the causes of relapse and pave the way for medical treatments that could prevent it. He's concerned Prometa promises too much too soon.
His nightly transformation began with a twinge. Then, gnawing and relentless, it consumed him.
At 45, "Steve" was a hard-charging sales manager who'd snagged two promotions in three years. After work one spring day in 2006, he picked up his infant and toddler from day care, had dinner with his family and retired to his office in their spacious Plano home.
His wife assumed he was wrapping up the day's projects. As he thought about her lying in bed downstairs, trying to calm the agonizing headaches that had plagued her since she'd delivered their second daughter the year before, he felt like a terrible husband and father.
But as always, on the heels of guilt and resistance came desire, as though Daytime Steve, with his down-home East Texas upbringing and frequent workouts, his upscale job, polo shirts and fancy house, just disappeared. In his skin, The Addict emerged, a neurological creation as real as a tumor and just as dangerous.
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It's fine, The Addict argued, trotting out the usual rationalizations: He was doing everything he was supposed to do—working hard and caring for the girls when his wife didn't feel well, which was most of the time. Doing all that without a little help was impossible. What was the big deal?
He opened the desk drawer and pulled out a pipe. Then he placed a small, crystallized rock of methamphetamine into the bowl, heated it and inhaled. He felt a rush of relief, the rare combination of focus, drive and sweet calm that kept him coming back. As he eased into his reverie—literally a new state of mind—the office door opened.
His wife stood in the doorway. She wore a bathrobe and the pained expression that signaled pounding between her temples. Her eyes rested on the pipe. She yelled, knocked a piece of art from the wall and swiped the stacks of papers off his desk. "How could you?" she screamed.
"I'm sorry," he said lamely. They'd been through this before. He'd gone to therapy and quit for five months. But then the stress had returned and, with it, the craving. It existed only in his head, deep within loops of nerve and tissue, but it was overpowering.
Papers sailed through the air, and Steve watched his wife's mouth moving furiously, forming words he didn't want to hear. Suddenly, from somewhere behind The Addict's foggy gaze, Daytime Steve came back. He awoke with a jolt to see the life he'd spent decades building in mid-implosion. The Addict had beaten and cajoled him into defeat.
Steve agreed to move out of the couple's five-bedroom house and into a condo. "I didn't deserve to be there," he would later say. In the following weeks, while he was wracked by loss and shame and withdrawal, his wife recommended he try a controversial new medical program tailored to treat addiction. It was called the Prometa Protocol, an experimental combination of medication and counseling that has stirred excited anticipation, criticism and open conflict in the treatment community.
Hythiam Inc., the biotech firm that markets and sells Prometa, is based in Los Angeles, but Dallas has emerged as a crucial base for the treatment's clinical research trials and home to the company's first managed-care reimbursement deal with locally based Cigna Healthcare.
After reviewing the Prometa Web site and seeing local clinics that provided the treatment, Steve figured he'd test its promise to do what his willpower could not: beat back The Addict by targeting the chemical compounds that his brain kept unleashing on him.
Unlike the heart, lungs or stomach, the brain doesn't beat, inflate or gurgle. If you were to shrink and climb into it like Slim Goodbody, who in the '80s donned a bodysuit and gave guided tours of the human body on PBS, the brain would offer little action. Weighing three pounds and home to billions of neurons, it's one of the least visually dynamic organs but certainly the most complex, an exasperating biological riddle that scientists have been striving to unravel for centuries.
Thanks to the advent of new scanning technologies such as fMRI—a device that measures blood flow and neural activity, lighting up colors in images on a computer screen to show where the brain is most active—the last two decades have brought an explosion in scientists' understanding of addiction and the brain. Researchers in labs across the country have discovered how substance abuse affects different parts of the organ and why addicts' neurology may be unique to begin with. They've identified the flood of neurotransmitters that lulls users into ever-deeper levels of dependency, found genetic variants that make some people more vulnerable to addiction than others and determined that the impulse to take a drink or snort a line originates in specific parts of the brain.
Researchers have learned that while the brain holds specific receptors for various types of drugs, there are also basic brain patterns that all addicts share, no matter their substance of choice. This newfound knowledge has set the stage for treatments—on the market already or in development—with the potential to halt the cascade of chemical reactions that leads an addict from his first sip of beer at 15 to passing out in front of his kids at 40.
Such innovations have fueled a revolution of sorts within the treatment community. The American Medical Association first defined alcoholism as an illness in 1956, but for decades, the predominant treatment models combated the problem as a psychological condition or moral weakness. Alcoholics Anonymous became the most reputable way to help addicts live stable, productive lives, and one-on-one psychotherapy was incorporated into residential and outpatient treatment programs. While the 12 steps and behavioral modification remain central to treatment, the emerging paradigm considers addiction a biological condition as chronic and medically treatable as diabetes or high blood pressure.
"You can't say this is a medical disorder and then say the treatments won't be medical," says Dr. Bryon Adinoff, distinguished professor of alcohol and drug abuse research at UT Southwestern Medical Center at Dallas and a psychiatrist on the substance abuse team at the Dallas Veterans Affairs Medical Center. "Even 12 Steps says this is a medical disorder. I think of it like a blood pressure disorder—getting people to eat right, take meds, et cetera. Every chronic condition takes a combination of medical and psychosocial treatments."
Prometa is perhaps the most contentious new treatment. Hythiam claims the protocol curbs cravings and helps addicts stay clean and sober through a combination of pills and injectable medicines combined with follow-up psychological and nutritional counseling. Most medications used to manage substance abuse must be taken continuously, but Prometa takes the "drugs for drug abuse" approach to a new level: Do one round of the 30-day protocol, Hythiam and supportive clinicians say, and your brain is definitively altered.
Yet researchers, physicians and public officials say Hythiam may be taking too large of an intuitive leap with Prometa. They've criticized the company for marketing the treatment, which can cost up to $15,000 per person, to governments and private clinics without first proving its efficacy through the gold standard in medical research: a series of double-blind, placebo-controlled trials that are peer-reviewed and published in a medical journal. Those studies test two groups, one given a placebo and the other the real drug, while the subjects and researchers are uncertain which is which until the end of the trial.
Each of the three medications used in the Prometa Protocol has been separately approved to treat anxiety and seizure disorders, but the Food and Drug Administration hasn't evaluated using the combination for addiction. Doctors commonly use medications or drug cocktails for purposes other than what they were developed to treat, as many oncologists do for cancer, but rarely does a company license a specific combination and put major marketing muscle behind it, as Hythiam has done.
The company—led by Chief Executive Terren Peizer, who began his career as a bonds salesman and made headlines in the '80s by testifying against financier Michael Milken in the savings and loan debacle—bought the protocol four years ago from a Spanish researcher. Dr. Juan Jose LeGarda found that injecting patients with flumazenil—used for overdoses of drugs like Xanax or anesthesia—helped alcoholics abstain from drinking. (Other scientists had experimented with flumazenil to treat alcoholism but produced few positive results.) The program's other two medications, taken orally, are gabapentin, an anti-seizure drug, and hydroxyzine, an antihistamine used for anxiety.
Drug abuse alters the brain's receptors for GABA, the neurotransmitter that acts as the brain's brakes to inhibit impulsive behavior. Hythiam claims flumazenil changes the receptors back to their normal state while the hydroxyzine counters its side effects and the gabapentin curbs cravings.
"If they've figured out something that no one else has, then my hat's off to them," says Dr. Frank Vocci, director of pharmacotherapies for the National Institute of Drug Abuse. "But they don't have the evidence yet."
Chris Hassan, Hythiam's senior executive vice president, says the company didn't want to spend 10 years on traditional research channels before delivering a product that worked.
"Alcoholism is one of the top three leading causes of death in the U.S.," he says. "We believed this was a moral imperative. The patient responses were there; the recoveries were robust. This was real."
Hythiam also is betting a stronger market exists for addiction treatments than major pharmaceutical companies suppose. Though researchers say this is changing, many large drug companies have shied away from developing addiction-related medicines because of the stigma linked to alcohol and drugs.
"Guys in the trenches treating patients were at a loss because there wasn't much research being done on alcohol," Hassan says. "Our hope was, if we could make this medicine a success and help a lot of patients, maybe big pharma would realize the stigma is gone and there's money to be made."
Since late 2003, some 3,000 people have been treated with Prometa. Of those, several hundred have undergone the program at a handful of clinics in Dallas. Hythiam jump-started its effort to make Prometa a staple of health plans across the country when in May it won its first managed-care reimbursement deal with Dallas-based Cigna Healthcare. The health plan began covering qualifying patients for Prometa in July. Hassan expects to secure more deals as additional research is released.
In late June, Dallas psychiatrist and addiction specialist Harold Urschel presented the first double-blind, placebo-controlled trial on Prometa's impact on methamphetamine addicts. Urschel, who also wrote the only published study on the protocol—it wasn't placebo-controlled or double-blind—monitored 135 people over 30 days and showed decreased cravings and use.
But NIDA's Vocci still isn't convinced. "It's only a one-month study," he says. "You'd probably have to have a three-month study, minimum."
Yet clinicians like Dr. Lenae White, an addiction psychiatrist who has been involved in NIDA-sponsored research and in 2006 founded the Murray Hill Recovery clinic in the Park Cities, say there is more than enough proof that Prometa is a powerful tool for recovery. More traditional medical treatments combined with therapy often have a dismal success rate, she points out, citing the general consensus that within the first year of recovery, fully 80 percent of users relapse. By incorporating the Prometa Protocol and encouraging follow-up care, White says that instead of relapsing and disconnecting from treatment, most of her patients either remain clean and sober a year into recovery or are at least continuing treatment.
"We're reversing the trend," says White, who is a member of the Prometa medical advisory board. "Anything that jump-starts people's recovery is a tool we need to access. If someone wants to give this a try, they should be able to." She informs patients that the protocol is experimental, and most of the patients who opt for Prometa have unsuccessfully tried other treatments and aren't deterred by the cost, which is lower than many 30-day inpatient rehab programs. And, since it's outpatient, they can continue to work during treatment.
A 20-person Prometa pilot program in Collin County last year had 16 meth offenders testing negative for the drug after 90 days, a success rate that Collin County District Judge Charles Sandoval described to The Dallas Morning News as "spectacular." Efforts to expand the program hit roadblocks, however. In January, controversy erupted in Austin over $2 million earmarked to use Prometa to treat meth offenders in the criminal justice system. Skeptics such as Dallas Criminal District Judge John Creuzot called the move premature, and only a few counties accepted funding for Prometa, including Collin, Nueces and Lubbock.
To UT Southwestern's Adinoff, selling Prometa before the double-blind test results are released, peer-reviewed and published isn't just premature, it's unethical.
"They've taken three drugs and put them on the market and come up with some bizarre theories for why it might be working," he says. "It punishes those companies that play by the rules. It takes advantage of people who are desperate."
Despite the concerns, a growing group of doctors and clinicians across the country hail Prometa as one of the greatest tools yet in the struggle for sobriety, and an increasing number of patients say the program is the solution they've desperately sought.
For Steve, it all started after a Dallas Stars game in 2002. He and his wife were drinking at a relative's house when his cousin took out a clear pipe. "Give this a try," Steve recalls his cousin saying. "You might like it." Steve and his wife had never done drugs aside from marijuana in college. Just for the hell of it, they agreed to smoke the meth.
Steve immediately felt a surge of energy, heightened awareness and clarity. He no longer felt drunk. A few days later, he called his cousin and bought a couple of grams for about $100. "We were going to Vegas the next weekend, and I thought it would be great to take," he says. "My wife was like, 'We're not doing it anymore, it's over.' But it wasn't over for me."
He pretended to quit and became what the treatment community calls a functional addict, working by day and using at night. "I was performing at a higher productivity rate with it," he says. "I was staying up late, turning in a lot of work. I was afraid I wouldn't be able to produce at the same level without it."
He quit once, before their first daughter was born, but the infant brought more tasks and responsibilities. Overwhelmed, he returned to his secret habit. One night, his wife caught him smoking. She threatened to leave.
"My daughter and my wife were my heart, and I wasn't about to lose them," he says. "I went to counseling." He stayed clean for five months, and his wife again became pregnant. When she gave birth, something went awry, and she began to suffer from chronic headaches.
"I now had a wife in bed, two children, she couldn't handle the infant, I got a promotion—I felt an overwhelming pressure to perform," he says. "Using became, in my mind, necessary." He would work all day, pick up the kids from daycare in the afternoon and then smoke meth at night and stay up until 4 a.m. As the months dragged on, it seemed he and his wife lived in different worlds. He felt badly for her because she was in pain, but as they went to one neurologist after another and none of them helped her headaches, his exasperation peaked.
"She had this problem I didn't understand, and I had this problem she didn't understand," Steve says.
After she discovered him smoking meth in his office yet again and he moved out, his wife researched treatments online and came across the Prometa Web site. Steve called Murray Hill. He began seeing the center's therapist, and Dr. White recommended Prometa because she had found it to be most useful for meth addiction. Steve was determined not to touch the drug again, so for 20 days until his treatment began, he struggled with withdrawal.
"I was depressed about everything. It all looked very bleak," he says. "I got tired early at night, couldn't get up in the morning, missed days at work. I had to fight tooth and nail to get through every day." His body, having been kept in a hyper-alert state for so long, was crashing. A host of receptors in his brain, suddenly unoccupied, were signaling him to alleviate the exhaustion by using.
Steve's wife, though angry about his continued drug abuse, was committed to holding their marriage and family together. On May 31, 2007, she took him to Murray Hill, near Northwest Highway and Preston Road, for his first injection of flumazenil. He received additional injections in the following days, plus oral doses of hydroxyzine, which White says helps relieve flumazenil's side effects such as agitation and anxiety.
Steve says he felt the difference immediately. "I no longer had a mental craving. It was gone," he says. "I was elated. My wife was elated."
Free of the persistent longing for meth, the obsessing and resisting that had held him hostage for so long, Steve wholeheartedly embraced his recovery. "On the second day, I believed it was an end all, be all, a cure," he says. "But you can't get caught up in that—then you end up back where you were. You have to do the work [therapy and changing behavior patterns]." Within a month he'd moved back home and given his wife permission to randomly test his urine for drugs. "I felt good about that," he says. "It was a positive reinforcement for me."
For the next nine months Steve attended one-on-one therapy sessions twice a week and a small men's group each Wednesday night. Through therapy, he discovered that his insatiable overachieving had fueled his drug use. He'd grown up in a high-powered oil family, and no matter how much he accomplished, he wanted more. "Before, I had high expectations and zero patience," he says. "For years I prayed for patience for my New Year's resolution, and each year I broke it. I was never happy with my accomplishments. It was always something more, and I could never get to where I wanted to be. Therapy teaches you what will drive that mechanism up—high stress, et cetera—and how to avoid falling into it."
Steve acknowledges that part of his success staying sober is likely related to more effective counseling this time around. The first time he underwent therapy, it was in a group of some 30 people, many of whom he couldn't relate to because they were homeless or just out of jail. He ignored his problem by convincing himself that he was fine compared with "those people." He insists, however, that the key to his Murray Hill recovery was suddenly being free from the relentless desire for meth that had plagued him for six years.
"Those other times I quit, I always knew I was eventually gonna use again," he says. "When I did Prometa, that went away. It's like having two little guys talking on your shoulder, one telling you to use. That guy shut up."
The fMRI scanner looks like something out of 2001: A Space Odyssey. White and round and about the size of a small SUV, the magnetic tube brings to mind a massive donut and takes up most of a small lab room at UT Southwestern Medical Center. On a July morning, a 40-year-old man from North Dallas lies on his back inside the machine as it creates images of his brain on a computer screen in the next room.
Three of Dr. Adinoff's assistants huddle around the monitor. They're helping with an experiment that seeks to identify what causes relapse among addicts. The scientists make weekly visits to local shelters and rehab clinics like Homeward Bound and Nexus Recovery Center, looking for addicts who are willing to have their brains monitored within four to six weeks of their last drug use.
The man in the scanner today isn't an addict; he's a control subject. As he lies inside the scanner punching buttons on a videogame control box, the machine makes a chugging noise and clicks away as it rapidly snaps images. In just one second, the machine captures the entire volume of the brain in 36 different "slices."
Adinoff designed the experiment to test his hypothesis that addicts' brains have a hard time reversing or stopping habits based on certain cues. While in the scanner, people play a videogame in which they choose a sequence of shapes likely to win them money. When the cues are switched—meaning the shape combinations that win money versus lose money are reversed—the subjects must switch their choice accordingly. The process is based on the misfiring reward-response process of addicts, who continue to abuse drugs even when the pleasant payoff of getting high is replaced by negative consequences.
Adinoff predicts that when all the data is analyzed, it will show that addicts have more trouble "reversing their response" because of a problem with their orbital frontal cortex—the part of the brain just behind the forehead that's responsible for reasoning and logical decisions. That part, whether because of substance abuse or the genetic factors that preceded it, tends to suffer from low blood flow in addicts, he says, and therefore lacks the energy it needs to inhibit impulsive behavior.
Laurry Michlin, a retired clothing salesman who snorted cocaine for more than three decades and figures he spent about $25,000 per year on the drug, describes the struggle between various parts of the brain this way: "I'd go have lunch and give myself eight reasons not to use—it could lead to a heart attack or stroke, isolate me from family and friends, make me paranoid, and it costs a lot of money. But my middle brain would drive me over to East Dallas to buy cocaine."
Parts of the brain such as the amygdala and the insula, which record emotional and experiential memory, stoke cravings. At the same time, the orbital frontal cortex synthesizes information coming from various parts of the brain and drives more logical decision-making, such as the reasons not to reach for the bottle or the pipe.
The scenario is a biological version of the devil and angel over the shoulder. Philosophers and physicians, scientists and spiritual leaders have debated the mind-body connection for thousands of years, and according to Adinoff, the growing field of brain research points to an increasingly faint divide between the physical and the psychological.
He's conducting experiments to determine the role emotional trauma plays in relapse—powerful life experiences, especially negative ones, impact brain circuitry—as well as another to examine the impact of stress. Alcoholics eventually lose the ability to produce normal levels of cortisol, the steroid that helps the body cope with stress, which may make them more likely to relapse during a tense moment.
"All of this is to identify the brain mechanisms that make relapse more likely and then develop treatments specific to those brain areas, receptors and behaviors," he says. "The more we can isolate these regions and understand what's happening, the more we can design specific medications or psychosocial treatments. None of us are able to take a picture of someone's brain and say, 'this person has schizophrenia,' 'this person has depression' or 'this person has cocaine addiction,' but that's one of the major goals."
Past experiments, many of them involving modern scanning technology, yielded discoveries that gave rise to a host of current treatments. Prometa is hardly the first medicine purported to treat addiction, and it follows an array of more mainstream innovations.
Vigabatrin, a medicine for cocaine users that's being tested in double-blind, placebo-controlled trials, stimulates production of GABA, the inhibitory neurotransmitter. Naltrexone blocks opiate receptors in the brain from binding with opiates like heroin, and it's also effective for alcoholics because it regulates the release of the neurotransmitter dopamine, which is involved in the progression of addictive disorders.
According to NIDA's Vocci, the fact that the brain mechanisms involved in addiction are interrelated and that naltrexone can alleviate dependence on more than one drug means we're headed toward a one-size-fits-all cocktail that could curb a range of bad habits. There are even numerous vaccines in the works. Tom and Therese Kosten, a husband and wife team at the Baylor College of Medicine in Houston, have developed one for cocaine that could be on the market as early as 2010. Still in clinical trials, the inoculation enables the immune system to attack drug molecules and bar them from the brain.
The trend toward medicating addiction worries some members of the treatment community who say that it merely trades illegal drugs for legitimized meds that could be addictive in their own right. "My perspective is that medication is medication, whether it's illicit or prescribed, and the goal is to be natural," says one member of a local 12-step program who requested to remain anonymous in accordance with the group's rules. "I don't think it solves the problem. It's like what addicts do a lot, say, 'I'm not gonna drink liquor. I'll drink beer." When he went to rehab for alcohol and cocaine addiction, he says, he was wearing a nicotine patch in addition to smoking cigarettes and chewing tobacco. "It wasn't replacement. It was augmentation," he says with a laugh. "My definition of clean and sober is that you're not doing anything. Even with replacement, you're doing something."
Adinoff says such critics miss the point. He and other biochemical treatment advocates don't discount counseling or behavior modification therapy. The notion of psychological and physical addiction as separate is misguided, he says, because the genesis of all human behavior lies within the brain, which is affected and altered by all of our actions, thoughts and habits in addition to the substances we ingest. That's why the leaders in addiction research and clinical treatment use a multi-pronged approach to combat substance dependence. In fact, a growing number of patients and doctors say that the new medications are proving indispensable because they give the other rehabilitation tools a chance to work.
"If you have both the desire to use and the habit to use, and these are now hardwired in your brain, it takes an enormous amount of effort to stop," Adinoff says. "If I can treat somebody through medication that they take once a day and they have a stable family life, stay out of jail, are medically healthy and everything in their life is going well, who am I to refuse that to somebody? Especially when I know that if they don't take that medication there's an enormous likelihood that they'll go back to the previous lifestyle. You can't take a drug—you can't do anything repeatedly—without changing your brain...to say that you can just stop using a drug through willpower or whatever is just hope against hope."
While Adinoff works to pave the way for a relapse solution, addicts who have so far succeeded with Prometa say they've already found theirs—a formula that like the potion Dr. Jekyll used to keep the evil Mr. Hyde at bay, has the power to silence The Addict within them.
While Steve had quit and relapsed only twice, other Murray Hill Prometa patients say they'd relapsed numerous times over decades of use before they found the experimental protocol. Michlin, who had tried a residential treatment center and Narcotics Anonymous, found out about Prometa from a friend who saw it on the TV news program 20/20. On February 6, Michlin received his first injection of flumazenil at Murray Hill. He's been clean since and says he's never felt better. He still attends Narcotics Anonymous meetings, and he tells other addicts about Prometa whenever he gets the chance.
"The medicine got into my brain somehow, and I didn't want cocaine anymore," he says. "Compared to going to some clinic in Beverly Hills with a low success rate, it's dirt cheap! And with what I was spending on cocaine, the money I save, it pays for itself." To those who think Prometa sounds too good to be true? "It doesn't cure all of life's ills," he says. "I've got plenty of problems, but I don't want that crap anymore. I could jump out a window or something if life gets bad, but I don't want cocaine."
By the time David Cook turned to Prometa, he was willing to try anything. He and his wife were unemployed, on the verge of divorce and about to have their children taken away by relatives. They were spending around $700 per week on meth, and their lives had fallen into a routine of getting high, coming down and having tantrums until they could get more drugs, then doing it all again.
"We'd demolished the entire inside of the house," says Cook, who lives in Missouri and underwent the Prometa Protocol in Dallas. "There were holes through the walls, messes, projects that got started but never completed, Christmas lights strung all over the house...One time I'd thrown a table through a wall, and there was a 4-foot-wide hole. I have no idea what happened, but I guarantee it was something to do with not having drugs."
He got his first treatment at Murray Hill in February 2007.
"I woke up the next morning, and I knew what they'd done had fixed it because I had no urge, no craving," he says. His wife doubted his endorsement, but when he returned home and was able to spend time with her and her friends while they smoked meth without any desire to do it himself, she decided to do the protocol too.
Now, 18 months later, they attend regular Narcotics Anonymous meetings. "I'd do NA and couldn't get through a week, then I did Prometa and was there every day for a year," he says. The couple has since started a recovery group at their church. Cook is back to work at his vehicle repair business, his wife works at a nursing home, and they abandoned their divorce, remodeled their house and brought their children back home to live with them.
Steve and Cook have been clean for more than a year and Michlin almost six months, but to Adinoff, the jury is still out. Even at a year of sobriety, he says, addicts remain at risk. He fears that if Prometa turns out to be a sham, the disappointment could compromise the hard-won progress scientists have made in convincing people that addiction is not a personal failing but a biological condition that requires medical treatment.
"We'll come out with something really great," he says. "And people will say, 'Oh yeah, right, we've heard that before.'"
Yet Steve believes that without the medical component of the Prometa program, he would have been ripe for another relapse, unable to focus on therapy and learning to deal with day-to-day life without the old crutch. "For me," he says, "getting free of those thoughts firing all day, that was the key."
To scientists like Adinoff, Steve's 180 could have been the result of a placebo effect or sheer determination, considering that he was about to lose his family. But for Steve, whatever the explanation, life after Prometa has been radically different.
The last vacation he took before getting clean was a golf trip to Arizona. Unconcerned about drug-sniffing dogs or jail, he walked through airport security with a baggie of crystal meth tucked into his pocket.
Steve's recent family vacation was an experience he couldn't have imagined back then. As he and his wife got ready to leave the house in late July, she handed him a box. "Would you mind taking this test for me?" she said.
"Sure," he replied. Unlike two years ago, he doesn't resent her vigilance. Her random drug testing is just another safeguard against The Addict's clutches. There's nothing to hide, no drug escapes to plan, no shame.
Lounging on the beach and gazing out at the Atlantic, he's able to focus on his wife and children without being consumed by something else.
"Before, I'd be in the room with my kids while they were coloring, but now I'm talking with them, praising what they're doing, participating with them," he says. The days of covert drug deals seem almost like a bad dream. "Looking back, it seems so stupid—it's so great not to have to worry about all that, to be able to just hang out with everybody."
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