- Title: On the Ravine
- Author: Vincent Lam
- Genre: Literary fiction
- Publisher: Knopf Canada
- Pages: 368
Last year in Canada, 20 people died every day from an opioid overdose. More than 32,000 people have succumbed over the past six years. Three-quarters ingested fentanyl, which is exponentially more potent and lethal and therefore more profitable to dealers than mere heroin. The federal government has spent nearly a billion dollars in the past five years to address the opioid crisis, and has loosened criminal drug possession laws to make way for a host of radical, user-friendly treatment programs.
The numbers raise questions as old as addiction, an ancient human problem. Why are people drawn to opiates, to the repetitive agony of failing to find painless oblivion? What causes that longing? Is it genetic, or learned and chosen? How much can you blame an addicted person for the chaos they cause? Are some people simply less equipped to endure the unavoidable pain of being human?
Vincent Lam battles these unanswerable questions in his new novel, On the Ravine. He knows the territory. When he isn’t writing, Lam is a Toronto doctor (he graduated from medical school in 1999, and has worked in both emergency and addiction medicine): his first book of short stories, Bloodletting & Miraculous Cures, which won the Giller Prize in 2006, followed the lives of four medical students as they became physicians. On the Ravine, his third work of fiction, picks up the story of two of them, Chen and Fitzgerald, both of whom have devoted their subsequent careers to opioid addiction, albeit in very different ways.
Chen runs a clinic that prescribes opioid agonist therapies. Methadone and buprenorphine, which are slow-acting opioids, replace heroin and oxycodone and their pals and theoretically make withdrawal less devastating, granting patients time and space to re-establish their lives. That’s the theory, anyway. Some patients refer to “bupe” and methadone as “liquid handcuffs” because, while they soften the craving, they maintain addiction. As Chen advises his favourite patient in the book, a “cure” takes at least two years.
Chen is a principled, evidence-addicted scientist with a penchant for caring too much about the people he treats. Caring, he points out, doesn’t save lives: diagnosis and treatment do. When he isn’t writing prescriptions for methadone and being a soft touch, fronting patients money, Chen roams the city on his bike, handing out naloxone overdose kits to pharmacies and the homeless. His bike routes are extensive and detailed (anyone who rides in Toronto will recognize them) – Lam’s way of telling us addiction is everywhere, afflicting the homeless and the wealthy alike. “The camps were all around him,” Chen observes, pedalling through the city’s wild subsurface ravines: “they were easy to miss but plain to see if you looked.” Most of us don’t want to look. We tell ourselves addiction is failure because we don’t want to admit how porous the membrane between addiction and health can be, how frequently and inexplicably smart and talented people fall through to the inferno of bottomless need below.
Lam manages a small miracle in On the Ravine: he turns the dreary sameness of addiction, as well as its impenetrable bureaucracies, into a compelling narrative: “Pills prescribed, pills bought, pills snorted, heroin snorted, heroin in needles …” Chen’s parlous obsession with his favourite patient, Claire – a talented violinist addicted first to oxycontin, then to heroin, then to everything – is a one-step-forward-two-steps-back map of the stuttering progress and (almost) inevitable backsliding of addiction. Claire has the gumption to sign up at Chen’s clinic, but then needs bigger and faster highs to feel confident enough (of her own talent) to play the violin at her freest and most artful. Her inevitable regressions, her cheesy rationalizations for reusing, her betrayals of everyone for money and dope, her harrowing flirtations with overdose and death, just to feel high again – Lam recreates the entire roller coaster in intimate detail, and leaves his reader shivering next to Claire, as hungry for his prose as the violinist is for her beloved but evermore adulterated “down,” the street name for heroin.
Of course, there is another approach to dealing with addiction (beyond prohibition, which never works): instead of treating it, you indulge it, and give the addicted person what they want, in a safe environment. This is the world of Chen’s friend and colleague, the fallen and cynical Fitzgerald – Chen’s former business partner (they sold their drug trial design consultancy to a private equity company), who was already a substance abuser by the end of Bloodletting.
Fitz has been defrocked as a doctor by the time On the Ravine opens. But he continues to care for the addicted by running what amounts to a safe injection site out of his vast and rambling mansion in Toronto’s prissy Rosedale neighbourhood, about which he swans in a satanic silk robe with an ever-filled tumbler of scotch. Both docs are addressing the opiate crisis, but from different (and equally humane) directions.
The house also provides Chen and Fitz with a steady supply of subjects for drug trials, for which Chen is hired as a consultant by venture capitalists eager to discover the next big thing in addiction research. Chen splits his fee, secretly, with Fitzgerald. Addiction is a tragedy, but it’s also a business addicted to making money, from Big Pharma down to the most impoverished and desperate user. (At one point in the course of the Purdue-created OxyContin crisis, people crushed 80-milligram Oxys, $8 a pill, and resold it in shootable form for $1 a milligram, which in turn created an entire underground economy of addiction.) It is only when Chen finally gives up on a patient who can’t stop transgressing his prim protocols that he sends them to Fitz – but he can’t stop himself from hoping they’ll recover, or from fearing that they’ll die. Every character in On The Ravine is addicted to something.
By the climax of the tale, everything is up for grabs or sale, including the future of Memorex, an experimental and potentially lethal ayahuasca-like compound that Chen’s venture cap pals pressure him to endorse as a way for addicted people to “forget” their traumatic needs. (“The resolution and integration of trauma!” Lam writes, mockingly. “Healing through forgetting!”) Chen is dedicated to his patients, but only by keeping his distance from others. When Chen and his Big Pharma executive girlfriend split – which they do with regularity – he is “surprised at how little he felt – just a minor unsettled feeling, like closing the door to a hotel room, wondering vaguely if there was an item left behind in the room.” Lam writes with sharp precision.
The doctor who can’t stop caring too much for the most desperate people in the ravine also can’t afford to care too deeply for anyone else: that way lies too much potential uncertainty and pain. In the purgatory of addiction, there is no free bliss, no silver bullet, no easy answer, not even an entirely satisfying outcome. But that’s true of life as well. The best we can hope for is to enlarge our sympathies and at best understand the need of the wanton Other. It’s hard work. We like to pretend addiction is a choice, a lazy lack of discipline, but we are all addicted to one self-perpetuating hunger or another: to “success,” to status, to talent, to beauty, to judging others, to our fixed belief that we have the answer, that we can control what happens. Eventually our illusions are bared, like a punctured forearm. The hardest lesson for brilliant doctors, and for everyone else, as Chen finally knows, “is that we are not so different from our patients.”