One of the elements of dramatic tension in the wonderful Master and Commander series of books is the relationship between the brilliant and resourceful ship’s surgeon, Dr. Maturin, and the laudanum with which he self-medicates. Author Patrick O’Brian is widely praised for the authenticity of his rendering of the language, behaviors, and mores of Napoleonic times, but here he projects contemporary issues onto his characters and their circumstances. A real Dr. Maturin, like his contemporary Capt. Meriwether Lewis—with his famous “melancholia”—would have been perfectly free to medicate himself to his heart’s content without enduring either social opprobrium or shame and self-doubt. If Rush Limbaugh lived in any other era, we would not be having a national conversation about his behavior and the state would never be pursuing his medical records for evidence of crimes he may or may not have perpetrated upon himself.

Over the decade I have spent as a practitioner licensed by my state to treat, among other things, addiction and addiction-related disorders, I have become increasingly troubled by things other than my patients’ actual use. As I have transitioned from in-patient addiction treatment and private practice to working with head-injured and often severely disabled patients, I have become less doctrinaire about use itself and more aware of complexities of circumstance as they affect individuals. The cases causing me the greatest concern have one common element: they involve pain medication.

Until the great government power-grab of Franklin Roosevelt’s New Deal, Americans were assumed competent to treat themselves for chronic or acute pain, as well as for what we now imperfectly describe as chemical imbalances of the brain—such as bipolar disorder—by simply stopping at a corner apothecary and purchasing such tincture of opium as they judged appropriate for their needs. This actually went on for centuries without generating serious social or moral problems. Undoubtedly, many individuals became “addicted” and the opportunity for drug “abuse” abounded, but such excesses were the business of family and community. No tyrannical European king or dictator even dreamed of so intruding on the private lives of individuals as to interfere with access to pain relief and psychological equilibrium. At least not until FDR’s Harry Anslinger, of the Bureau of Narcotics and Dangerous Drugs, set about criminalizing vast tracts of human behavior in his push to build a crime-fighting empire on behalf of the state whose power he and his boss were so dedicated to expanding.

I should point out that the development of highly refined opiates such as morphine and, later, heroin in the early 20th century changed opiate use, and serious social consequences emerged that were not present in the earlier age of laudanum. Also the proliferation of powerful stimulant, sedative, and hallucinogenic drugs with no significant medical application, but with enormous potential for abuse, contributes to a horrible national and international drug problem. The idea that the family and community, in decline if not disintegration, could provide a bulwark against these problems is laughable. But it is equally fair to say that the magnitude of the drug problem in society coincides with the blanket criminalization of medical as well as non-medical drug use, and the preposterousness of Limbaugh’s pain treatment as a public obsession and a license for abuse of power by the state shows that the “drug problem” is not always just about use.

As I become a more experienced therapist, I am less sanguine about treating addiction as such and not entirely sure that I know what addiction is. The term has been so widely misapplied as to become, like “terrorism,” essentially empty of meaning except in terms of the biases and agenda of the person using it. Addiction is applied to tobacco use by the anti-smoking crowd, to fast food, exercise, sex; so many things, in fact, that if I am going to treat addiction, I may as well be treating Original Sin but, of course, only those elements of the Fall currently out of favor with the state or organized groups and constituencies. This is not healing art; this is the therapist in some Orwellian nightmare as manipulative enforcer of conformity and adversary of spontaneity and individuality. But in a society where choice has come to mean the taking of innocent life as a matter of personal convenience, I guess the idea of the individual actually choosing anything as mundane as how to treat his own physical or psychological pain has no value at all.

Over time, I have come to view my work in increasingly simple terms: consequences. I factor in, but do not really weigh, what a patient uses, how much he uses, how often he uses, what his spouse, mother, boss, or society thinks about his use. These are problems only insofar as they generate consequences for the patient as an individual. If a patient is experiencing serious consequences related to his use that he is incapable of dealing with rationally, then that patient has a problem and I can help. But if the patient is fully functional and the consequences are related entirely to supply, then I’m beginning to have a problem. And these are the people this piece is about.

It didn’t used to be that way. I bundled consequences related to supply right in with consequences related to use, as I was trained to do. Thus the fully functional guy with the landscaping business experiencing legal consequences as a result of altering a Loritab prescription was in the same boat as the professor whose life was falling apart and had legal consequences from his second DUI. One is a mess because of the effects the drug has on him, the other has no problems caused by the drug itself, but his life is a mess because he has the arrogance to think that he knows what he needs and the impulse to take serious risks to get it. But I would see them both the same, insist on total abstinence, and send them both back to the slammer when they screwed up. (Yes, we do have that kind of power, lots of it, and it is arbitrary and unreviewable.)

For me, the problem began to emerge in the out years. I live and work in a small city where I regularly run into former patients. When I see the professor, my sense of professional satisfaction is enormous. Now something of an AA elder, he’s the picture of social and emotional health, happily remarried, his life fully restored. He is a beacon of recovery to others likewise afflicted. He sees treatment as an instrument of his liberation from a horror that was killing him while destroying, one ugly episode at a time, everything that mattered in his life. This man was very sick, and now he’s better.

Once a year I hire a crew from the landscaper because it remains the best-run business of its kind in town. The boss always comes by to check. He too is clean and sober but the recovery that the professor radiates is not available to him. Not because he wouldn’t do anything to have it, but because abstinence is not the cure for his affliction. Treatment has helped him find ways to cope that have enabled him finally to get the correctional people out of his life. But I see in him deep sorrow and loss, and I despise a piece of what I do. This man remains unwell and doubly afflicted because though he knows exactly how to get well, the means are simply not available to him.

So, after a few years, a line began to emerge differentiating ostensibly successful treatment outcomes as I was able to observe the longer-term realities of the business I am in. The treatment failures are not a problem for me. They are fewer than the layman would imagine, but I have my full fair share of drunks who won’t stop destroying themselves and everyone around them; speed and coke freaks who wind up in prison because they won’t stop cooking, dealing, and acting out; potheads who squander their God-given potential in delusional hazes; barbiturate users wallowing in the pathos of their petty neuroses. Such things are about life and human weaknesses, so let God sort them out, I say. But with some of my opiate patients, something else is going on, and I began to connect this to the fact that opiates, unlike liquor, speed, coke, and pot, have remarkable, powerful, unique, and irreplaceable medical efficacies.

My melancholia patients represent a small portion of my patient population—about one in 30 overall, and 20 percent of my opiate load—so it would have been easy never to stumble on this line. But once stumbled upon, it had to be explored, and the line has become much brighter as I have contemplated the body count. Among the patients I have treated over the last ten years who have had successful treatment outcomes, five committed suicide. These five have one thing in common—opiate “melancholia.” In addition, all were high-functioning, bright, imaginative people with intact lives, families, and careers. Each reported reactions to opiates that mirror giving ADD kids stimulants to calm them down: the opiates energize rather than sedate; they organize rather than disorient thinking. These patients had explored the vast new pharmacopeias of anti-depressant drugs now available—and so efficacious for so many—but without result for them. All had been clean, sober, and ostensibly in recovery for at least two years. They faced recovery with diligence and commitment, but with stoicism rather than more common resistance or enthusiasm. Importantly, each was introduced to opiates by physicians in the course of legitimate medical applications. And the consequences related to their use were legal in nature and had solely to do with securing supply.

So the line differentiating some of my pain-pill people from all the other substance-dependent patients I treat has become brighter as time clarifies outcomes. Just now it is blinding me a little bit because I have one of these patients, whom I believe will not survive, and I am not enjoying much success in my search for a solution. He is known to have committed the now infamous crime of “doctor shopping,” so we have a problem. No doctor in this town will even talk to me about this man.

I can’t help noting the sad irony here: it is unthinkably politically incorrect for a doctor to hold a patient responsible for a basket of conditions—STDs, Hepatitis C, AIDS, alcoholism—in which the patient’s own behavioral choices play an important causal role. But when the survival instincts of these melancholia patients, awakened by legitimate medical procedures, start to take over and they begin seeking opiates, they are not only judged, they are cast out as moral lepers. This is not only socially acceptable but encouraged.

It’s hard not to sympathize with the box the doctors are in. Untold billions spent by pharmaceutical companies over the past century have failed to produce anything remotely as effective as opiates for acute pain relief. Doctors, who have a moral and ethical imperative to reduce the suffering of their patients, have no alternative but to prescribe opiate-based pain medication. Thus my melancholia patients are exposed, in the normal course of medical care, to a substance that not only relieves pain but also acts as a wonderfully effective antidote to problems derived from the peculiar chemistry of their brains. Feeling competent, functional, and emotionally stable for the first time in their adult lives, these patients can become quite devious in efforts to secure their supply—not to get high, as the doctors assume, but to feel functional. Fearing addiction, the doctors inevitably cut the patient off, and the patient either begins doctor shopping or seeks supply on the illegal market. Eventually, the patient’s schemes collapse, and he winds up in the care of people like me, cast into the mix with other substance-dependent people and provided undifferentiated abstinence-based treatment. Of course it doesn’t work and, worse, when treatment appears to work, the results can be lethal.

The appalling problem for doctors and patients alike is that this is a game with no rules—only dire consequences, arbitrarily applied. Unless this is to remain some kind of deadly game of gotcha, protocols and procedures must to be established that kick in when opiate-based pain medication is prescribed for more than two or three weeks. This would not be complicated. Patients would agree to provide a clean urine sample every two weeks, which would require them to abstain for 48 hours or so and prevent buildup of tolerance. In return, the patient could determine the length of time opiate treatment, whether for pain or melancholia, would continue and, within reasonable limits, the appropriate dosage. Something this simple would work for 90 percent of chronic pain patients as well as all of my dead patients, along with those for whom successful treatment was just another mile marker on hell’s highway. And it would relieve doctors of trying to figure out which patients are conning them, who has legitimate need, and who is going to get strung out and come back and bite them, which is what they evidently fear the most.

So the question becomes, why bother with defectives that have the gall to self-medicate? Well, take Limbaugh, for instance. Never mind his beliefs or character—we can all agree he demonstrates extraordinary vitality, talent, capability, and effectiveness. The crazy uncle in the attic that no one really wants to talk about here is that, while admittedly using very large amounts of opiates, he remained vital, talented, capable, and effective. I suspect that he fits my profile because if his brain functioned normally, and he was doing that much opium for any length of time, he would be slothful, disorganized, incompetent, dysfunctional, and probably dead. (All of my dead patients were people of unusual vitality, talent, capability, and effectiveness, too.)

One of these “addicts” was lost to us on a rainy Tennessee day in the spring of 1809. Meriwether Lewis was the greatest national hero of those times and the designated political heir to Thomas Jefferson. He was, presumptively, the sixth or seventh president of the United States. In historical terms, his suicide marked the passing of the torch from Jeffersonian to Jacksonian democracy and had a profound impact on the nature of our country. The continental vision he shared with Jefferson was replaced by “manifest destiny” and the Trail of Tears. Conquest by force of arms replaced diplomacy and guile as the hallmark of American expansionism. Slavery ceased to be an abomination that we had to be lead out of and became, instead, a bargaining chip to be cynically used, always to the accrual of federal power. The loss of this junkie was transformational and, in the aftermath of his suicide, when his personal effects were sent home to Virginia and inventoried, there wasn’t any laudanum to be found.

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Jim Pittaway is a licensed psychotherapist. He resides and practices in Missoula, Montana.