I was so excited to read On the Ravine by Dr. Vincent Lam after loving Bloodletting and Miraculous Cures many years ago.

I just finished it last night and am still in the process of formulating my thoughts so they may change a bit. My early thoughts are that this was a very good book about a very difficult topic.

In this story, which features two characters from his previous book (but it is not necessary to have read the other one to enjoy this one), we are given a very deep look at drug addiction. Dr. Chen runs a clinic called The Swan where he sees patients each day who are dealing with drug addiction. In addition to putting patients on methadone or Buprenorphine to settle their withdrawal symptoms, he is also a consulting doctor for drug trials. In comes Claire, an aspiring professional violinist. Claire has been using Oxycodone and heroin as an IV drug user and needs assistance in coming off the drugs. This is the beginning of a precarious doctor/patient relationship.

Addiction is a beast that many cannot reckon with. The chemical dependency and increasing tolerance usually results in the person using more drugs, more dangerously and experiencing withdrawal more and more quickly. Harm reduction is the current method used to stabilize patients but doesn’t offer freedom. The role of the doctor in determining just how much of an opioid will have the patient become a functioning person is a difficult balance and it is tested by addicts who will manipulate and lie to obtain their high. Please don’t take this as me judging addicts, this is not so simply the result of a chemical that has taken over the addict’s life.

In the story, Claire fights this battle and tells Dr. Chen that what she wants most is to be able to play her violin and become the music. She wants to reach beyond the formulaic playing of her violin and become immersed in the music. In addition to desperately wanting relief from her addiction, she has a sister who comes to stay with her who is also an addict. As someone who has worked as a youth worker with street addicted youth, we often say “people, places, and things” need to change in order for success.

When Dr. Chen contacts Claire after she has had two overdoses and tells her that he believes she may be suitable for a new drug trial, Claire jumps in with both feet.

Lam has written a story that one must finish to appreciate. The beginning third of the book takes its time in setting up what a drug trial looks like, the decline in an addict-especially with fentanyl out there, and the push and pull of a doctor who works in the field. I am concerned some will find this part of the book a little dry and not continue but I urge you to trust the process.

Dr. Chen is an interesting character on his own with his big heart and wanting to do the best for his patients. He is a hero character with faults and hindsight.

Big pharma and the interests of the players in the field was a little less dramatic and at times a bit lengthy but played a role in the crux of the story.

Thinking about the audience for this book has been with me during the night. This book could be highly triggering for anyone in recovery, or an active user. The processes and terms are very detailed and even the descriptions of dealers, users, drugs, places, and equipment has the potential to activate an addict’s brain to want to use. For those that are interested in the field of addiction or who can manage difficult stories, then I would feel comfortable in recommending this book.

With more and more deadly drugs on the street, this could also be a call to action. I live in Vancouver, Canada and we are currently experiencing overdoses at alarming rates. One of the pushes is to legalize drugs and offer a safe supply. Recent legislation passed has allowed small amounts of drugs to be carried without penalty but that doesn’t stop those drugs from being laced with fentanyl or carfentanil. Safe injection sites are available and drug testing kits and more people are being trained on how to use Nalaxone kits. I would be interested in revisiting this book in ten years and seeing how it fits into reality then.

Thank you to @netgalley and @penguinrandomca for an ARC of On the Ravine. It publishes February 28, 2023.

A compassionate accounting of a complex and seemingly unsolvable problem, this book takes a fictionalized look at a real-life physician’s perspective of drug addiction, focusing on fentanyl, heroin and opiates, and the depths of despair such an addiction cannot help but reveal.

As Dr Chen, who runs a Toronto-based addiction clinic and research center, our fictional third person POV narrator, tries to do his very best for his patients, he inevitably faces moral dilemmas and must rely on the judiciousness of his experience, as he encounters desperate and manipulative patients, suffering and out-of-control, in situations as bleak as they are heartrending.

Addictions for which, although somewhat alleviated by the tools modern medicine can provide, may be seen as merely transferred through treatment from one drug to another perhaps more manageable alternative.

As Dr Chen becomes ever more intertwined in the particularly heartbreaking world of Claire, a heroin-addicted violinist with talent and a seemingly broad world of opportunity, and Bella, a romantically-charged pharmaceutical rep with a vested interest in involving him in a new addiction-treatment modality, Dr Chen may or may not be in danger of losing some of his professional objectivity.

Hard to read in its unflinching and doubtlessly realistic portrayal of suffering, this is a book that will open your eyes to the depths experienced by those in the grips of this terrible problem, and the incredible strength and sensitivity of those who care for them.

A great big thank you to Netgalley, the author, and the publisher for an ARC of this book. All thoughts presented are my own.

I am a fan of Bloodletting and Miraculous Cures, and I enjoyed this window on Chen's life later in his career. That said, this is a standalone novel, and readers don't need to be familiar with the previous book.

I was hesitant to start this book because of the subject matter: I knew it would not be a light read. But I'm very glad I did read it. It gave me a much better appreciation for the human side of the opioid crisis I've read about in the news, and it was also just a great (Canadian!) story. I'll be recommending it widely.

Thanks to the publisher and to NetGalley for the opportunity to read an electronic version of the ARC.