Spend enough time in a psych ward, and you eventually wonder: How are these people here while others, considerably less functional, freely roam the Earth? A person who believes voices are commanding him is offered numerous treatment options. A person who believes the Earth is flat or vaccines cause autism — someone suffering from a different flavor of cognitive dysfunction — wanders around making podcasts and we’re all cool with it.

“The crack nowadays ain’t as good as it used to be.”

-Patient

For my second rotation, I spent time at an inpatient psych unit. During my four weeks, all patients had voluntarily admitted themselves due to substance abuse or difficulty coping with mental illness. Addiction dominated my tenure.

Most patients were older men. Their substance issues started early in life, some as early as 14. A depressed boy of the 1950s found ways to alleviate his funk, turning to stimulants. An anxious teenager of the 1960s self-medicated to slow his mind down, using alcohol, which flowed freely in those days. Maybe they stepped up to heroin. Now fifty years later, their lives are complicated and their health is quickly deteriorating.

Most of my patients had trouble with alcohol. Frankly, much of America does. It is the number one drug humans use to self-medicate. It works pretty well until it doesn’t. The effect is quick-acting, readily available, cheap, with no prescription needed. Side effects are manageable for many years before becoming problematic. While it does impair us, many drugs (like antihistamines) do too, so frequent users learn to cope. Unlike IV drug use, alcohol consumption is socially acceptable in public, even expected.

There are some downsides. It’s toxic. It makes some people angry, depressed, or violent. It destroys your liver, though weirdly it leaves other organs untouched. Kidding! It damages them all! It promotes cancer growth in a variety of places, like your, esophagus, prostate, pancreas, stomach, and liver. Screws up your metabolism. Wrinkles your skin. Disrupts your electrolytes. It profoundly affects your ability to compute long-term consequences in the moment, like whether or not to drive drunk or consort with a co-worker who is most definitely not your spouse.

Besides alcohol, many patients were dependent on stronger drugs and had been for most of their lives. A patient with severe sleep apnea — he would fall asleep walking — used cocaine to simply stay awake and function. Another patient, tired of hearing voices commanding him to commit suicide, used heroin to shut them up. A different patient, one with a wife and two kids, used cocaine to feel normal emotions he only felt when high. Many others took drugs to escape their very difficult housing or financial circumstances.

Side note: One refrain I heard often, “The crack nowadays ain’t as good as it used to be.” Perhaps you’re not familiar with the comparative qualities of street drugs circa 1985 versus today. Understandable. Just know many people have strong opinions on the matter. Globalization — it would seem — has come for us all.

I digress.

Addicts, regardless of their drug of choice, are stuck in a repeating loop of use and detox, of relief and shame, of forward progress and a relapse. They are stuck in time. Friends and family around them are not, and they eventually leave the addicts behind after tiring of the churn and drama drug and alcohol abuse inevitably cause. I heard many sad stories, and their rough outlines were essentially the same. “My wife, my kid, my family no longer speak to me because I can’t stop. I know I should stop. This time I will.” Research shows it takes many attempts. Sometimes during patient interviews, my eyes felt heavy with fluid. I would discreetly wipe them, hoping the patient did not notice. Addicts are many things, but they are not simply weak-willed, lazy people who just need to get it together. Ultimately, that was the entire point of this rotation.

I believe one day we will have more effective pharmacological treatments for addiction. GLP-1s, like Ozempic, have provided intriguing clues. People taking the drug for weight loss found themselves eating less, gambling less, and consuming less alcohol. Those reward pathways are, somehow, interconnected, and researchers are working hard to figure it out. Mainly to monetize it.

The fact that any of us get up in the morning and do not kill ourselves or each other is a miracle worth celebrating. COVID exposed how fragile our species’ mental health is. A few tweaks of my genome or circumstances and it could be me screaming into the wind, wandering subway stations, offering “proof” 9-11 was an inside job, addicted, stuck in time.

I am reminded of a quote attributed to John Bradford, a 16th-century preacher: There, but for the grace of God, go I.

News of the Rotation

Date	Major event
Throughout the rotation; ended Nov. 12	The longest U.S. government shutdown in history. The 43-day shutdown disrupted federal pay, air travel and food assistance before Trump signed a funding bill.
Oct. 18	“No Kings” protests across the U.S. Large crowds demonstrated against Trump’s administration at rallies nationwide.
Oct. 19	The Louvre jewel heist. Thieves broke into the Paris museum and escaped with historic French royal jewels in a brazen daylight robbery.
Oct. 28	Hurricane Melissa devastated Jamaica. The storm made landfall as a Category 5 hurricane, causing catastrophic damage, with impacts elsewhere in the Caribbean.
Nov. 1–2	The Dodgers won the World Series again. Los Angeles defeated Toronto 5–4 in an 11-inning Game 7 to secure consecutive championships.
Nov. 4	Democrats won several closely watched elections. Zohran Mamdani won New York City’s mayoral race, Abigail Spanberger won Virginia’s governorship and Mikie Sherrill won New Jersey’s.