How Do I Get Really High and Not Die?

Twenty-one days was the longest I had ever been away from home. When I got back I was thrilled. It turned out to be easy to get off heroin. Not pleasant. But easy. It was blatantly obvious, the moment I was back, that continuing would have been the dumbest possible thing.

A week before, a day before, even a week into being in rehab, I didn't have that information available in the front of my mind. That's because the front of my mind was completely controlled by a Schedule I addictive drug I was mainlining daily.

I felt like I'd gotten over on something. I had made it in highly addicted, without injury, without a criminal record.

Looking around in the rehab, it was less funny. Most of the people had been there several times. Virtually everybody was under some kind of legal pressure. And virtually everybody was on opioid maintenance medication. Suboxone. Buprenorphine.

I was familiar with Suboxone. I called it going on a sub diet. Significantly cheaper than hundreds of dollars of oxycodone or heroin a day. Not as much fun, but it kept the withdrawal off. Everyone there seemed glad to get it.

I was in an extreme rush to reject it.

The doctors, one of whom resembled a dinosaur, were examining my arms. They had trouble locating the track marks. That was only because I used the entire length of my veins so I didn't damage them, like any sensible person would. There was some minor bruising. Nothing obvious. I'm sure it looked different than what they were used to seeing.

They told me three out of four people never get off heroin. I thought that was a fake fact. It didn't sound real. I never checked it while I was there.

They said I should stay on Suboxone. The first day I needed it, so I took it. The next morning I took it again. Then I realized: this is insane. I went back and told them I didn't want any more. I regretted taking the second one.

I wanted to be in withdrawal. The faster I got through it, the sooner I could start recovering. I deserved it. I had been using heroin daily. It didn't seem right that I didn't have to pay for that at least a little bit.

Back home as an outpatient, I made the mistake of telling my parents how good I was compared to the other people in the program at taking these drugs.

They did not congratulate me.

They expressed extreme disgust. I realized I still, after three weeks, had a pretty deranged perspective on the subject.

The prefrontal cortex.

I attribute all of it to the prefrontal cortex. Either malfunctioning under the influence, or functioning in ways that allowed me to stay alive. To make decisions that were, in some sense, responsible despite having chosen a very irresponsible pastime. To recognize the moment when stopping was possible. And even after clearly bypassing it, as when I told my parents how competent I was at something they found horrifying, it could still function.

That's the brake. The circuit that keeps people alive around opioids is the one that says: not this much. Not with this combination. Not tonight.

Not suddenly. Not dramatically. It thins gray matter in the prefrontal cortex and basal ganglia across years of low-level childhood exposure. From painted dishes. From leaded gasoline in the air during the 70s and 80s. From pipes. Children who grew up with more lead enter adulthood with structurally less of that brake available.

Three out of four.

The doctors' number turned out to be right. I looked it up later.

Lead-exposed communities have higher overdose rates. Not because of coincidence. Lead destroyed the exact structure responsible for the decision that ends most overdose deaths: combining substances, taking too much, going back after a tolerance reset.

Several people I knew who used opioids died. Not from the drug alone. From the combination. From the moment when the brake didn't engage. The prefrontal cortex is what should have said no to the second substance, or to the amount, or to the timing. In some people that circuit was smaller than it should have been before the first drug ever arrived.

Lead is one of the reasons it was smaller.

My prefrontal cortex was functional enough to recognize a reason to stop. Most people have that. Some have less of it than they were born with.

The human brain is not wired to do heroin. It is also not wired to do lead. The difference is that one of those, at least, was a choice.

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