Back then there was no SBIRT, screening for problem drinking and drug use, especially in adolescents, so that early intervention might be possible. Back then there was no MAT, medication-assisted treatment; he would have been a candidate for long-acting naltrexone (Vivitrol) had it existed. He had the support of his family, but that had its paradoxical side because he could not pursue a life away, a life of his own. There were no relapse prevention groups or CBT to help him regulate his impulses and self-destructive behaviors. My memory of Tom, his people, a world of unattainable opportunities, leaves me pained and empty. It also reminds me about how much we have learned about more successfully working with people with addictions. And it gives me the drive to keep trying to make a difference in the lives of people with substance use disorders, their families, and their communities. Even other people's encouragement didn't help. I once had a girlfriend who had a favorite expression. In a true Brooklyn accent, she would say, "Hey, don't sweat the small stuff!" I can only guess that she kept saying this to me because I was in the midst of a depression and this was her way of trying to help. One day I was talking with her about all of the things I needed to do when again she remarked, "Hey, don't sweat the small stuff!" I then thought about all of the things I'd been putting off that made me feel overwhelmed. I needed to buy stamps, I needed to buy milk, I needed to mop my apartment's floors, I needed to deposit my paycheck, and I needed to watch two television programs that I had recorded. I needed ..., I needed ..., I needed all of it to go away. I turned to her and said, "It's all small stuff! Everything I need to do is small stuff--and I can't do it!" Somewhere along the line, I had forgotten how to take care of my needs. I had lost my motivation and habitual procrastination had become a way of life. Simple tasks were tremendous burdens, complicated tasks seemed impossible to deal with, and I only dealt with tasks when I faced the threat of severe penalties, or because other people or institutions required me to act. There seemed to be little true pleasure in my life: only obligations and the avoidance of them. So, which came first--procrastination, or depression? Did my procrastination cause me to become depressed, or did depression cause me to procrastinate?

I believe that both fed each other--so no matter which came first, it was quite easy to tell what would come next. Chronic pain remains one of the most vexing medical problems facing us today--usually defined as persistent pain that lasts six months or longer, chronic pain can strike people of all ages. While estimates vary widely around the world, most surveys suggest that anywhere from 10 to 55 percent of all adults are going to report chronic pain problems at some point in their lives. In the United States alone, nearly half of all Americans suffer from one or more chronic conditions that can produce the kind of aches and pains that seriously undermine quality of life. And the costs of dealing with chronic pain are often astronomical. In the United States alone, the annual cost for society runs to about $125 billion annually in terms of health care services, disability payments, time lost from work, and lost taxes. But this doesn't even take into consideration how chronic pain can affect people, both mentally and physically. Along with familiar culprits such as arthritis, bursitis, fibromyalgia, gout, and stomach ulcers, people can also experience persistent pain from gallbladder disease, cancer, and multiple sclerosis to name just a few potential causes. But pain can also result from lifestyle issues such as poor posture, obesity, injuries from accidents, poor working conditions, and even simple repetitive movements that can lead to carpal tunnel syndrome, rotator cuff problems, joint aches, and so on. For that matter, many people going to their doctors complaining of persistent pain may not have any apparent physical cause. Doctors can often be as mystified as their patients over what can be causing the pain. Even with improvements in diagnosis and treatment, chronic pain can have multiple causes that are often difficult to untangle. This can mean years of treatment as doctors experiment with different medications, therapies, and surgeries to try to alleviate the suffering. There is also a lot of variation within countries. In the UK, people working in London endure the longest average commute (seventy-four minutes), and it has also been reported that almost 2 million Britons are travelling three hours or more for work daily. In a time when more and more of us are finding it difficult to juggle work and life and fit it all into the twenty-four hours of a day, it may not come as a surprise that, according to the Office of National Statistics, happiness seems to decrease with every mile a commuter travels. Using people who travel between one and fifteen minutes to get to work as the benchmark or reference group, it becomes clear that everyone else - those who need longer than that to get to work - feels less happy, while people who work from home (or live very close to their workplace) are happier. We see the same pattern if we examine the question of anxiety. People working from home are less anxious than others. However, it is interesting to notice that people travelling more than three hours for work are no more anxious than people who have a one- to fifteen-minute commute.

We do not fully understand why the negative effects of the commute seem to vanish once you hit three hours. Perhaps this group can make better use of their commute by reading or working - and perhaps they have made a conscious choice to work in London but live in the countryside and the benefits of their living environment counteract the negative effect of the commute. No matter what uncomfortable situation you deal with, talking and complaining about it doesn't do anything to make it better. In fact, it only reinforces the imagined pain in your mind. The more you complain about what you don't like and what makes you uncomfortable, the more you're rewiring and programming your brain to be negative, anxious, and weak instead of positive, motivated, and strong. Not listening to criticism or, at least, being open to it is the worst social move you can make. It causes you to lose respect, admiration, friends, jobs, and opportunities. While you're thinking you're smarter than everyone else, they're thinking you're too dumb and insecure to handle a little advice, correction, and direction. It means your ego is too delicate and you're an extremely weak-minded person. No one likes the person who isn't open to feedback, can't be told anything, thinks they're perfect, and knows everything because that person is dangerous and will wind up making catastrophic mistakes. The aircraft mechanics who never accepted feedback and never admitted they needed some help ALWAYS lost their jobs, made costly mistakes, and put people's lives in danger. Just because they failed to stop and say, "I need some help in this area" or "I can make some improvements", they caused MILLIONS of dollars in damage and even, in a few cases, ruined entire airplanes that now sit in aircraft boneyards in deserts. One time, I was 2 inches from getting crushed to death by a horizontal stabilizer because a mechanic failed to stop and ask what a certain tag meant - a tag that meant another person was in the tail and the lever with the tag should not be touched or moved. You will NEVER know everything. EVER. Even if you consume more knowledge per day than anyone else in the world, you will still be extremely ignorant in most areas and others will always have more experience and wisdom when it comes to new things. You should be completely open to consuming whatever feedback and knowledge they provide. If you don't like feedback, at least think long and hard about what they're saying to see if they have a valid point and they're hitting a blind spot in your thinking, behavior, and habits. Medical historians of addiction like to consider three, maybe four, eras of drug use in America. But a closer look reveals five eras, extending from this country's earliest days through the opioid epidemic presently seizing the United States.

The historiography of addiction points to an age-old debate: Does addiction derive from weak character, calling for criminalization, regulation, and stigma, as well as recovery approaches built on the twentieth-century 12-step model, a spiritual path meant to reclaim the addict's soul? Or is it a medical problem, undeserving of stigma and discrimination, which calls for humane prevention and treatment? These are the two competing visions, bad versus ill, that have done battle in this country for over two hundred years--and persist today, despite an abundance of evidence for the latter. A first era, often little noted, was depicted in the scandalous and popular Confessions of an English Opium-Eater by Thomas De Quincey, published in 1821. This paean to laudanum (opium dissolved in alcohol and imbibed) tells the story of De Quincey's first use of opium, considered of little risk, to relieve his joint pains. This pattern is eerily similar to that of the last twenty years of opioid use in America, when prescription pain pills provided by doctors spurred on by pharmaceutical advertisements and assurances of a low risk of addiction were instrumental in fostering the epidemic we now have. De Quincey wrote, "Happiness might now be bought for a penny . portable ecstasies might be had corked up in a pint bottle." Looking back, it is any wonder that I spent much of my free time watching television or sleeping a day away? These scenarios occurred more times than I can count--here's how they usually played themselves out: After watching television on my couch, I would start dozing off. Eventually, I would position myself to where I was lying across the couch, however, with my head uncomfortably propped against the couch's armrest. After twenty or thirty minutes asleep, I'd begin to feel an annoying pain in my neck; but having lost the plot of whatever I'd been watching, I would tell myself: "If you're going to sleep--then sleep!" and I'd stumble off to the bedroom, awakening some ninety minutes later. By then, the afternoon sky had turned dark and I would think, "What's wrong with me? I had time to get stuff done, and I've wasted it! How could I be so dumb?" Still, did I ever react to one of these all too frequent emotional downturns by springing into action to make up for lost time? No. Instead, I wallowed in my depression. Quite sick of myself, yet not knowing a different way of responding, I did the only thing I was really good at--I continued avoiding my tasks while now attempting to avoid the bad feelings that had come about from having fallen asleep on my couch. How I continued that avoidance depended on what I was up for. So, is it any surprise that people with chronic pain are especially prone to depression? As we have already seen, depression often arises from a sense of helplessness that certain problems have no solution.

People coping with long-term chronic pain often have to deal with additional problems such as loss of sleep, fatigue, worry about their financial future, and their long-term prospect for recovery. All of these factors are going to reduce their ability to cope with what they are experiencing. Add to that the sense that there is no apparent relief in sight, and feelings of depression are almost impossible to avoid. Research looking at chronic pain patients suggests that guilt and uncertainty are two of the main factors that can contribute to depression. The guilt is often due to patients being unable to function as they once did due to the pain. This means being less able to care for themselves and having to depend on other people. Since chronic pain patients also have no idea how long their pain will continue, this sense of uncertainty can also lead them to feel helpless and despondent about the future. But along with chronic pain causing depression, it is also possible for depressive symptoms to make the pain much worse. Depressed people are often going to ruminate about the problems in their life, and this frequent rumination will also make them less able to take their minds off the pain they are feeling. They are also prone to catastrophizing their pain (exaggerating symptoms to make them seem much worse than they actually are). As a result, their ability to cope with the pain is reduced as well. Looking across several indicators of well-being, the worst effects of commuting are associated with journeys lasting between an hour and an hour and a half. Jessica had one of those commutes. After getting a job in advertising in San Francisco, she found herself driving 90 kilometres each way. If she hit rush hour, the commute could eat up to four hours each day. But the money was good and the extra cash could help fund expensive fertility treatments. However, the long commute, after a long work day, took its toll on the thirty-five-year-old. She developed stress-related stomach problems, became depressed and developed pinched nerves in her lower back from so much time sitting behind the wheel. Nine months later, she had left her job and become self-employed, working as a freelance designer and photographer. The pay was less - but she could work from home.