largest sweep of the hottest colors, the size and shape of a small, tailless mouse, is located in the posterior cingulate Pointing to the patch, yellow in the center radiating out to a circle of Halloween orange, London explains, "What is turned on here is exactly what turns on while people feel pain." The operative word is while She goes on, "A person stops using methamphetamine, and this is awaiting them." Clinicians who work with meth addicts already know that addicts are often depressed, argumentative, anxious, and unwilling to engage in treatment—exactly like Nic—but London's scans reveal that these conditions have a biological basis In addition, they indicate a level of severity unrecognized before It led her to conclude that meth addicts may be unable, not unwilling, to participate in many common treatments, at least in the early stages of withdrawal Rather than a moral failure or a lack of willpower, dropping out and relapsing may be a result of a damaged brain She explains that severe cognitive impairments may make patients incapable of participating in therapies that require concentration, logic, and memory Also, patients with extremely high levels of depression and anxiety, and who are suffering a type of "chronic agony," as London describes it, are at a major disadvantage when taking part in cognitive and behavioral treatments It's not surprising that Nic, in the first weeks in recovery, wants to flee In fact, London's research worries me, because it, adding to others' research, shows how long it takes for the brain to return to normal—if it ever does After a month of abstinence, the depressive symptoms and pain following meth withdrawal are less severe in many of the abstinent meth users, but in a substantial number, they are far from abated No wonder the odds are so bad—that is, no wonder the programs available in most rehab facilities in most communities fail most of the time Some of the places I called are only several-day or week long detox Many of the programs, like Ohlhoff, last for twenty-eight days, but few cities have publicly funded long-term programs, and few private insurance plans include coverage for intensive ongoing treatment Longer programs, especially inpatient programs, are prohibitively expensive for most people But though a meth addict may become well enough in four weeks to understand the need for ongoing care, he or she may not become well enough to follow through on it Dr London's pictures illustrate why programs most likely to be effective would last for many months It probably takes at least a couple months for a patient to recover enough to engage in treatments in meaningful ways What should be done for patients when they arrive in these programs? It would be ludicrous to try to treat heroin addicts in the few days after their last fix with cognitive and behavioral therapies, the mainstays of rehab programs Heroin addicts have a welldocumented physical withdrawal from the drug that includes shakes, convulsions, and the like The physical effects of withdrawal from methamphetamine, however, manifest in symptoms that we usually associate with psychology and emotion, but—and on Dr London's computer screen is blue-and-orange proof—they have physical bases There are many spots of "hot" brain activity that correlate to trait (ongoing) and state (situational) anxiety, far more than the control subjects The picture is unique to this drug, London explains "Scans of the brains of heroin, cocaine, or alcohol abusers do not show changes like these." The images also suggest cognitive impairments A blue patch in the medial orbitofrontal cortex is worrisome to London because activity in this area is related to decision-making ability It is distinctly blue, with a whitish center Meanwhile, the posterior cingulate, related to pain and emotion, isn't activated in the control subjects, but is brightly lit up in the meth users It is logical that it would be harder to think when parts of the brain related to negative emotion are active "In the meth users, at least in the first weeks, the cognitive strategies that the brain is using are abnormal," London says This means that, in addition to the biologically rooted high anxiety and depression, people getting off meth have severely impaired cognitive functioning I check further and come across a study that was conducted three years before London's by Stephen Kish, a doctor at the University of Toronto's medical center, who autopsied the brains of meth users (They were the brains of people who died of a meth-amphetamine overdose or who had a high level of the drug in their system when they were killed by a gunshot or died in an accident.) In slide shows in generations of high school health classes, the shrunken, dehydrated, eroded brains of alcoholics were compared to healthy brains, creamy white and spongy Unlike alcoholics, there is no damage in the brains of meth addicts that is visible to the naked eye At the microscopic level, however, the fried-egg "this-is-your-brain-on-drugs" metaphor applies Researchers have seen that some neuron ends are essentially singed Biopsies of brain cells tell more To analyze them, Kish used biochemical probes and scooped out twenty-milligram chunks of brain He measured the amounts of specific neurotransmitters, and compared them to the amounts in normal brains His study showed modestly diminished levels of serotonin and other neurotransmitters but "grossly lower"—by 90 to 95 percent— levels of dopamine Kish also studied the presence of dopamine transporters, from where the chemical is released These, too, were depleted Other scientists found similar depletions when they looked at the brains of meth-addicted monkeys, baboons, mice, and rats, leading to the conclusion that meth is neurotoxic, physically changing the brain far more than cocaine and most other drugs do It raised an essential question—my essential question: even if Nic stops using, can his brain recover? It was established that dopamine is dramatically reduced, but not whether there is a physical loss of the dopamine terminals According to Dr Kish, if the drug permanently destroys the terminals, there's not much chance of recovery So in his brain samples, Kish looked at a marker called vesicular monoamine transporter, or V-MAT2 In Parkinson's patients, where there is a permanent loss of dopamine neurons, V-MAT2 levels are extremely low If the marker is depleted in meth addicts' brains, it's likely that there is a loss of nerve terminals, and the brain damage is irreversible However, when Kish tested for V-MAT2 , he found normal levels It was a surprising, and hopeful, finding This and subsequent research indicate that the "fried" nerve endings probably do grow back, though it may take as long as two years Two years This means that meth addicts can probably recover It's good news for a parent of an addict Of course I want Nic to survive, but I cannot help wanting something more for him I want him to be all right again Though inconclusive and still debated, the researchers' findings suggest that he can be, if he stays off the drug If he stays off the drug Karen and I eat dinner on Haight Street and then drag ourselves up the hill to what we have come to call the Count Ohlhoff house—Count Olaf is the villain in A Series of Unfortunate Events, the Lemony Snicket books we read to Jasper and Daisy Passing the smokers out front, we go through the wrought-iron gate After absorbing decades of cigarette smoke and addiction, the courtyard garden we walk through appears unable to sustain life We are here to meet with Nic for a family group session The meetings are held in a dank room Karen and I, along with other visiting parents or spouses or partners and our addicts, sit on worn couches and folding chairs A grandmotherly, whiskey-voiced (though sober for twenty years) counselor leads us in conversation "Tell your parents what it means that they're here with you, Nic," she says at our first session "Whatever It's fine." These are stark, haunting, heart-wrenching gatherings We get to know the other addicts and their families One of the meth addicts is a nineteen-year-old girl with the face of an ingénue, her tousled hair in a pair of coffee-colored pigtails, and dejected eyes She has lost custody of her baby—the child was born addicted to meth She looks like a child herself, except for the track marks Other patients include heroin addicts, potheads, and an ancient, blotchy Days of Wine and Roses alcoholic We hear their stories The alcoholic repeatedly left his children and their mother without a goodbye He would come home and apologize "After the first four or five times, the apologies meant almost nothing to them," he says He entered rehab when they left him One boy, slightly older than Nic, with colorless hair and eyes, is from New York City He came to San Francisco to study architecture, but, he says, "methamphetamine changed my plans." ... programs? It would be ludicrous to try to treat heroin addicts in the few days after their last fix with cognitive and behavioral therapies, the mainstays of rehab programs Heroin addicts have a welldocumented physical withdrawal from the drug that includes shakes,... associate with psychology and emotion, but—and on Dr London's computer screen is blue-and-orange proof—they have physical bases There are many spots of "hot" brain activity that correlate to trait (ongoing) and state (situational) anxiety, far more than the control... finding This and subsequent research indicate that the "fried" nerve endings probably do grow back, though it may take as long as two years Two years This means that meth addicts can probably recover