'We have it on good authority that you're injecting Ritalin."
Gabor Maté leans toward his patient, a young man dressed in black, chains swinging from the waist of his pants. Partially hidden by the hood of his sweatshirt, his face is thin and white; his eyes circled with black liner. A blue, graphic tattoo runs down the length of his nose. He looks like a grim reaper who could claim his own life.
In a small office in Vancouver's Downtown Eastside, Canada's notorious drug ghetto, this is the realm of hungry ghosts, which is the title of Dr. Maté's latest book, a moving, debate-provoking and multi-layered look at how addiction arises, the people afflicted with it and why he supports decriminalization of all drugs, including crystal meth.
He advocates for the controversial harm reduction facilities, such as the safe injection site down the street, where drug users sit in front of stainless steel countertops in cubicles, bent over the project of injecting themselves, as if studying for an exam in a library.
For 10 years, he has been working as a doctor in the Portland Hotel, a "pioneering social model," he writes, that provides safety and care for people who would otherwise be homeless.
This patient, who says his father is an osteopath, suffers from severe attention deficit hyperactivity disorder, which Dr. Maté diagnosed and for which he prescribed methylphenidate, commonly known as Ritalin, the drug that calms hyperactivity.
"No, I am not injecting it," the young man asserts.
Ritalin has potential for abuse, as it produces a cocaine-like stimulant effect. Addicts often crush the tablets, dissolve them in water and cook the mixture for injection.
Dr. Maté, a small, wiry man of 64, speaks quickly in a soft-spoken voice.
"The first impulse you have is that you're going to deny. You're going to say no," he explains calmly, looking at him with a steady gaze though his small, round glasses. "So, please think first about my question before answering."
The young man repeats his denial, then asks for his dose to be increased. "It's not working as good as it was before," he tells the doctor.
No longer looking at the patient, Dr. Maté hands him a small bottle and asks him to provide a urine sample to screen for drugs - in this case, he suspects cocaine.
A few minutes later, the young man returns, saying he cannot produce one.
"If you cannot give me a clean sample, I'm not going to increase the dose," Dr. Maté says, his face a mask of professional objectivity.
"But if you increase my dose, it will reduce my craving for cocaine," the young man explains.
Dr. Maté understands the limitations of his practice. In the short time I spent with him in his office, he tended to a native man who eyed the vial of methadone, a treatment for heroin addiction, as if it were his long lost mother; a weeping native woman with a badly bruised elbow, sustained in a fall while drunk; and a painfully skinny heroin addict whose pretty face was gaunt, her smile toothless. "Having worked in palliative medicine, care of the terminally ill, I have encountered death often," he writes in his book. "In a real sense, addiction medicine with this population is also palliative work. We do not expect to cure anyone."
For 20 years, Dr. Maté had a family practice in Vancouver, which he sold. He is not making any less money now, the father of three confesses, but income has never been the incentive. "Why does someone go into medicine, but to help the suffering of humanity? And you can't help the suffering in humanity unless you go to where the suffering is."
But if he is a saint to the hungry ghosts, he is an imperfect one who takes pains to point out his faults, including his own addictions and his attempts to overcome them. The book has been a way of processing his own inner demons.
Born in 1944 in Budapest, Hungary, two months before the Nazi occupation, he was sent to live with relatives, living outside the Jewish ghetto, when he was one year old. His grandparents were killed in Auschwitz when he was five months old. Sensitive from a young age to the terror of the Holocaust, he learned "something about the undeserved-ness of suffering," he explains. The family later reunited and immigrated to Vancouver when he was a boy. He has two younger brothers.
But just as he writes about the childhood trauma of the drug users he treats, in an effort to illuminate the root causes of addiction, so too he describes his early years as an explanation for his workahol-ism and his search for something to soothe himself.
His addiction is not to drugs or alcohol, but classical music CDs. He is careful not to equate his musical obsession to the life-threatening addictions of his patients. His wears "dainty white gloves" compared to theirs.
His compulsion to find versions of the same piece of music - more than he would ever possibly listen to - has had negative effects on his personal life, he explains. He often lied to Rae, his wife of 38 years, about his purchases. He spent nearly $8,000 in one week in his worst spending spree, but the nadir, though not the end, of his obsession came when he once left a patient in labour to run out to his favourite music store in midday traffic to search for CDs to buy. He missed the delivery.
In person and in his book, he often quotes from spiritual teachers, including Jesus, Buddha and Eckhart Tolle, to help articulate his understanding of what addiction is - a search for something on the outside that we should be able to find within. It is different from healthy passions, he says.
Both he and his wife, an artist and children's book illustrator, are unfazed by the revelations about their personal life in his book. "I feel like everybody has pain," says Ms. Maté, 59, a slim, self-possessed woman who talks to me later in their bohemian Vancouver home. "Everybody has issues. That's what's normal. By sharing it, that helps others be authentic, too."
Authenticity is important to Dr. Maté. It is why In the Realm of Hungry Ghosts: Close Encounters with Addiction, which took three years to write, reads not only as a lively textbook analysis of the physiological and psychological causes of drug addiction, but also as an investigation into his heart and mind.
There is an agitated, quixotic nature to Dr. Maté. He speaks so fast, he is often unintelligible. He walks slightly hunched over as if he's hurling himself, like a rocket, toward his destination. He moves from sombre insight to spiritual teachings to humour ("I saw the cockroaches and fell in love," he says of the Portland Hotel) to self recrimination ("I am arrogant. I like attention," he points out more than once) to scientific analysis at lightening speed.
If there's any addiction evident, however, it is one of intellectual curiosity and self-discovery. He admits to choosing the job at the Portland and to pursuing the other medical consulting work he does because he likes, even needs, to be continually challenged. He attributes some of that to having attention deficit disorder - he wrote a book, Scattered Minds, about the problem. "You get easily bored and you want to move on," he explains. But there's a sense that he over-diagnoses himself, always palpitating his psyche for problems he can label.
In many ways, he is also just a restless and gifted intellect who wants to understand the world and himself. The research for In the Realm of Hungry Ghosts involved reading close to 400 medical journals on recent studies into drug addiction and psychology.
He feels compelled to learn, and within himself, to evolve. "Life is a process of liberation," he says at the end of the almost four-hour interview, as he sits in a comfortable chair in the living room of his house, spooning yogurt out of a tub and eating a banana, while he talks. His legs often jiggle with tension. "You don't want to get stuck in old age, being cynical and rigid. Age takes away everything: good looks, strength of the body, everything. And that's why the universe gave us old age. It's our chance to be free."