Kirsten Smith was 16 when a boy from school injected her with morphine, 18 when she and a date Googled how to crush up and inject themselves with oxycodone, and 19 when she first shot up heroin. Living in Knoxville, Tennessee and modelling herself on Pulp Fiction’s freewheeling Mia Wallace, Smith spent her days experimenting with alcohol, cannabis, ecstasy, mushrooms, LSD and benzodiazepines. She read Kurt Vonnegut and the Beats, and wrote poems on an actual typewriter while listening to the Velvet Underground. For Smith, as for thousands of Americans who came of age in the early 2000s, drug use was a seemingly harmless lifestyle choice.
That is, until she ran out of money. After Smith dropped out of high school and started regularly using heroin, she was caught stealing credit cards and chequebooks from a boyfriend’s wealthy parents, from a family friend at church and from her grandmother. On probation for two years, and forced by her parents into a month-long stay at an addiction treatment facility, Smith felt, for the first time, ashamed.
Returning to school was supposed to be Smith’s lifeline. She went to community college and got a job as a waiter at Charlie’s, a local restaurant chain. Then, in the summer of 2004, she met Brad Renfro, who had starred as a child actor in Hollywood films such as The Client and Sleepers. He introduced her to smoking crack cocaine and the best heroin she had ever known. After three months together, Smith began to wonder whether she would be a junkie for the rest of her life.
One day, standing in the living room of Renfro’s downtown boarding house, Smith watched him struggle to find a vein. Blood ran down his arm as he plugged in the dregs of his cocaine supply, a residue shot that Smith called a “low sad point in an addict’s life”. For her, Renfro had crossed a line into the shadowlands of compulsion. It was over between them. (Smith didn’t hear of Renfro again until he died of an overdose in 2008.)
While waiting on tables at Charlie’s, Smith met a young man named Michael, who had grown up in the same suburb as her. Michael was quiet and kept mostly to himself. His buzz cut and angular features contrasted with his sweet smile and blue eyes. The two clicked when Smith revealed that she had sent a fan letter to the author of Fight Club, Chuck Palahniuk, and had received a written response. Michael didn’t believe her until Smith brought the letter to work, dusty and charred by a house fire Smith had started when she was 15.
In 2005, Smith and Michael rented a one-bedroom apartment in an old building downtown. They also did drugs together, shoplifting to subsidise their lifestyle, which Smith described as a “romanticised junkiedom”. Through their network of white suburban addicts, Michael and Smith became hooked on expensive black tar heroin shipped in by a drug cartel that they referred to as “the Mexicans”. Despite their addictions, Smith and Michael maintained a stable, domestic existence. They wrote stories, paid their bills and owned two cats.
Later that year, Smith and Michael were both admitted to the University of Tennessee. This was Smith’s cue to get sober, but treatments for substance-use disorders and the torturous symptoms of withdrawal were limited. Relatively few medications were approved, and although behavioural and community-based treatments existed, when Smith, 23, tried to return to rehab, her stepfather’s insurance company rebuffed her.
The couple attended meetings at Narcotics Anonymous (NA), a 12-step programme, where they were told that recovery was only possible with total abstinence and strict adherence to a set of rules. To them, it seemed as if they were being made to feel helpless in the grip of their addictions, which were thought of as a lifelong disease. The concept, pervasive in treatment, that addiction is a disease, emphasises the power of compulsions to overwhelm the individual. The problem, Smith told me, was that no one asked or cared about what her desires were. “When I was young and wanted to be a heroin addict, my behaviours were in line with my desires. Was that addiction?”
After she was accepted to university, Smith continued to use heroin. This was less of a personal failure, in her view, and more of a series of decisions she made to try to pursue both drugs and education at the same time. As long as Smith had access to drugs and wanted to use, she was not going to choose abstinence. On one occasion, Smith and Michael flung their unused needles and syringes down a garbage chute, desperate to begin their fresh start. Within hours, they dived into a skip to get them back.
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After she was caught nodding out in front of customers, Smith was fired from her job, and later, so was Michael. Broke and withdrawing, they lay in bed until sunrise, racking their brains for fast money schemes to pay for heroin. Smith remembered hearing about an unsolved bank robbery near her parents’ home. The bank was a small redbrick building in an ideal location, abutting the entrance of the expressway, and it would be open at 8am.
While Michael slept, Smith collected her supplies: an Airsoft gun her stepfather had bought her for Christmas, the bright orange tip painted black; supermarket bags, a scarf to wrap around her head, and a pair of Jackie O sunglasses.
When she walked up to the front desk of the SunTrust bank and pointed her toy gun at the teller, Smith said: “You have 60 seconds to put money in these bags.” When the teller returned the plastic bags, Smith apologised and said: “Thank you.”
As her Volkswagen sped down Northshore Drive, a pack of dye in one of the bags detonated, staining the bills red and filling the car with scarlet smoke. On the expressway, Smith got out, tore the duct tape off her licence plate, and barrelled home. Stumbling into her apartment, Smith woke Michael up. After soaking the bills in their bathtub with water and bleach, they salvaged about $11,000, enough for two months of rent, food, and heroin.
The second robbery was more carefully planned. This time, Smith waited in the car while Michael went inside. But someone saw him leave the bank, and before they could get away, Smith and Michael were arrested.
Awaiting trial under house arrest at the home of her mum and stepfather, Smith handwrote letters to Michael, who was also under house arrest just a couple of blocks away. She told him about the cocktail of medications she was given, which included Xanax and Focalin, a stimulant used to treat ADHD that enabled her to write poetry, a “countdown to prison” journal and a 450-page novel, all in a week.
Smith also drank heavily during this time. One night, with an ankle monitor on, she drove off drunk in her stepfather’s new car. Within two miles, she crashed into a tree and ended up in an emergency room downtown. With blood all over her face and wires holding her teeth together, Smith looked down and saw that she still had her bag, containing her syringe. She remembers that the first thing she thought was: “I still have time to buy heroin.”
In December 2007, at Smith’s sentencing hearing, her stepfather testified that he hoped she would get the treatment she needed to overcome her problems. “She is a smart person who has made some mistakes,” he said. “Made them willingly.”
Was Smith a patient simply in need of the right medications or a criminal who deserved punishment for actively choosing to harm others – or both? Before the hearing, in a character letter sent to the judge, Thomas Varlan, Smith chose to take responsibility for her crimes. “I wasn’t abused or molested as a child,” she wrote. “I didn’t grow up on the ‘wrong’ side of town. I wasn’t raised by wolves but by a mother and stepfather who love me and gave me countless opportunities to succeed.”
Smith was steadfast in her belief that her actions were volitional from the start. Her drug use and crimes were not the products of an immoral character or a faulty brain incapable of change, but rather of an environment where heroin was accessible and desirable. This outlook determined her experiences in prison and beyond, ultimately leading her to dedicate her life to challenging predominant medical models of addiction with her research. Today, she is an assistant professor of psychiatry and behavioural sciences at Johns Hopkins University in Baltimore, Maryland.
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In light of the non-violent nature of their crimes and their youth, Judge Varlan sentenced Smith to 47 months in custody and Michael to 46 months, the minimum duration for their charges. Smith’s first destination, Blount county jail, was a concrete bunker or, as she put it, a “hell”. She went into drug withdrawal without a doctor to manage her symptoms. Without medical care, she had to remove the wires in her mouth with a fork.
Locked down 23 hours a day for two weeks with a wide-eyed stranger who rocked back and forth while withdrawing from cocaine, Smith, for the first time in her adult life, had no access to drugs or the outside world. The only reading material she had in the tiny room was a pocket-sized copy of the Gospels of the New Testament that community volunteers placed through a slot in the jail cell door. Smith read the words repeatedly to fall asleep; when she woke up, she started reading them again. After nine months, she was shipped to federal prison in Florida.
In Smith’s account of her story, no amount of psychiatric diagnoses or personal reflection helped her quit heroin. The only things that did were incarceration and forced abstinence, followed by her return to education. In prison, it occurred to Smith that there were only two things people could not take away from her: “my tattoos and my education”. After she was released, at the age of 27, she got a job serving sandwiches at a deli that hired former convicts – including Michael, although their romantic relationship was over. Smith stayed sober and was eventually accepted by the University of Kentucky, which – unlike some other institutions – did not require students to disclose past criminal charges. She excelled, and after four years of college went on to graduate school with the hope of becoming an addiction therapist.
Doing shifts at a rehab facility in 2015 while completing her master’s, Smith had a formative encounter with a man in his 20s who was detoxing from opioids. The patient mentioned to her that he had been drinking “a tea from Vietnam” called kratom. He said it soothed his anxiety and helped with his cravings for opioids. Although kratom is described by organisations such as the CDC as a stimulant, the patient said it did not make him feel high. However, the rehab facility enforced an abstinence-only approach to treating addiction, and Smith was required to report the young man. After he was kicked out of rehab, he stayed in contact with her, and told her about his commitment to achieving abstinence through the 12 steps. Two weeks later, he tried heroin and died from an overdose.
In an essay titled Disease and Decision, published in 2022 in the Journal of Substance Abuse Treatment, Smith wrote about how, disillusioned by medical systems with no individualised or evidence-based care, she decided to change careers and turn her ambitions towards research. Often, Smith argued, people with substance-use disorders are actively discouraged from vocalising what they want from the recovery process. “If they try, they are told that they are selfish; that their character defects and thinking were what got them into trouble; and that thinking for themselves is dangerous.”
For Smith, free will is a spectrum, and yet many volitional behaviours get jumbled together under the label “addiction”, as if people with substance-use disorders have permanently lost control over their actions. She believes that although her desires, intentions and choices were constrained by factors that developed from continued drug taking – such as a lack of access to medical care, running out of money, being locked out of the university system – she maintains her behaviour was always the result of conscious decisions. For the same reason, she emphasises that lifelong cravings and relapses are not inevitable. Like everyone else, people who use drugs are “complex systems that can change”, and she believes that they should be held responsible for enacting that change.
Smith is thin and pale, with green eyes and dark curly hair. Her arms are covered in tattoos. On her right forearm, sealing the spot where she used to inject most frequently, are the words “Room 101”, the location in George Orwell’s Nineteen Eighty-Four where Winston Smith betrays his lover to escape his greatest fear. When she was incarcerated, relapsing became Smith’s greatest fear. “That’s the betrayal,” she told me. “I would have broken my mother’s heart, and broken the people who invested love and hope in me.”
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The idea that addiction is a bodily disease was articulated in 1884 by the Scottish physician Norman Kerr. In his inaugural address to the Society for the Study and Cure of Inebriety, he said that addiction to alcohol is “for the most part the issue of certain physical conditions”. He continued: “Whatever else it may be, in a host of cases it is a true disease, as unmistakably a disease as is gout, or epilepsy, or insanity.”
Yet throughout most of the 20th century, a different model of addiction predominated in popular culture. The “moral model” sees addiction not as a disease of the body but of the will. Partly as a result, numerous countries adopted a penal approach to drug use that, particularly in the US, led to vast numbers of people being imprisoned for substance abuse.
A turning point came in 1997, when the then-director of the National Institute on Drug Abuse (Nida), psychologist Alan Leshner, published an article in the respected journal Science, in which he argued that addiction should be treated not as a moral failing but primarily as a chronic, relapsing disease of the brain. Addiction, according to Leshner, starts with voluntary consumption of drugs but over time the addictive qualities of the drug hijack the individual’s decision-making with uncontrollable cravings and compulsions.
When I spoke to Leshner earlier this year, he explained how he sought to change addiction from a criminal issue into a public health problem that could be treated with medication instead of incarceration. He had been inspired by how advances in neuroscience had shifted cultural assumptions about people with schizophrenia, who had come to be viewed in a far more humane manner: as people with neurological diseases who deserved medical care. “It became clear to me,” Leshner said, “that a core difference between addicted and non-addicted people was the same as the core difference between individuals with and without schizophrenia – which is that they have changes in their brains.”
Leshner stands by his 1997 article, in which he recognised the importance of environmental and socioeconomic factors on persistent drug use but argued that over-emphasising social and spiritual solutions to addiction only worsened “the tremendous stigma attached to being a drug user or, worse, an addict”. (By overturning the moralistic attitude towards drug use, Leshner also sought to justify putting medications such as buprenorphine – a weak opioid restricted because of its potential for abuse – into doctors’ offices and prisons.)
Leshner’s approach, known as the brain disease model of addiction or BDMA, became the model for teaching addiction in medical schools in the US and beyond, as well as shaping drug education campaigns in schools. However, this approach has itself come under attack. Critics of BDMA, such as Smith, believe that downplaying the role of free will in addiction can dampen the belief that full recovery is possible. Smith does not deny that brains change from drug use – the impact of addictive substances on the brain’s reward pathways is well established – but claims that a perception of people with substance-use disorders as “recovering” but never “recovered” does little to improve the general understanding of addiction and can destroy any shred of hope that they may hold. Smith argues that terms such as “chronic” and even “disease” can push people with substance-use disorders and the people around them to see relapse as “an inevitable outcome”.
Similarly, Eric Strain, an addiction psychiatrist who has helped mentor Smith at Johns Hopkins University, argues that the BDMA oversimplifies our understanding of addiction. The BDMA, according to Strain, says doctors know what people with substance-use disorders need. “It implies: ‘Just take Suboxone, everything will get better’,” Strain explained to me, referring to a commonly prescribed medication. But things are not always so simple. “Look at the treatment dropout rates,” he said. “They’re abysmally high.”
The label of “disease” has trailed Smith for most of her adult life. After she obtained her PhD, which studied the treatment of substance-use disorders in incarcerated women, Smith went on to complete a four-year research fellowship at Nida, the centre of American addiction research. But her postdoctoral position came with conditions: she was forbidden from handling any of the money used to pay research participants or the drugs being tested in the labs. The issue of trust, and the assumptions people made about her capacity to function and resist relapsing, would not go away.
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Smith belongs to a new generation of addiction scientists who are using their personal experiences to inform their research. Their focus is on helping people with substance-use disorders to identify the environmental factors that lead them to use drugs, and encouraging them to take action to change those factors.
In Smith’s own research at Johns Hopkins, which includes clinical trials and lab-based pharmacological studies, she interviews people with substance-use disorders about their experience of self-medication with unregulated substances like kratom. Instead of asking how the medical system can best force people into sobriety, Smith’s research asks how people with substance-use disorders have learned to manage their addictions themselves.
Justin Strickland, a behavioural pharmacologist who worked with Smith on models of addiction that emphasise environmental triggers, told me that there is actually more agreement than disagreement between supporters and detractors of the BDMA. “We all know that addiction is affected by neurobiology, genetics and childhood trauma,” he said. “The differences are in what is emphasised.” As the psychiatrist Carl Erik Fisher, who had an alcohol-use disorder during his medical training, wrote in his recent book about addiction, The Urge: “It is not that addiction is or is not a brain disease, or a social malady, or a universal response to suffering – it’s all of these things and none of them at the same time, because each level has something to add but cannot possibly tell the whole story.”
In the past five years, organisations such as Nida and the National Institutes of Health (NIH) have increasingly supported research into psychosocial approaches to addiction, harm reduction and methadone clinics, as well as community-based services that emphasise continuity of care. Meanwhile, some addiction scientists with histories of substance-use disorders think that the BDMA debate is still worth having. Noel Vest, a friend of Smith’s who is now an academic, began to use methamphetamines at the age of 21 and became addicted to alcohol. By 25, he had lost his business, his car and his house. After seven years in prison for multiple offences including identity theft, Vest became a drug and alcohol counsellor, which he abandoned when he realised his work was merely an extension of the criminal justice system he had just left. Treatment failure and missed appointments were an inherent part of recovery, and he refused to punish people for what he saw as the natural course of addiction. While on parole, Vest attended a local university and went on to complete a PhD in experimental psychology.
For Vest, the problem is not the BDMA itself but how early the concept of disease and the necessity of treatment is forced on to people with substance-use disorders. “If you tell someone early on in addiction – someone who can’t even tie their shoes because they can’t put a thought together – that they have this lifelong condition that will never get better, that’s a huge leap most are not ready for.”
In many of my conversations with scientists both for and against the BDMA, one idea kept coming up: indeterminism. In an indeterministic model of addiction, any outcome, whether that be relapse or recovery, is neither predestined, nor fully within our control. The structure of the brain and one’s environment, as well as the influence of one’s past, are dynamic processes that we can study and attempt to shape, either through policy, treatments or personal choices. Hope and courage can coexist with chaos and chance.
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In our conversations, Smith always maintained that her drug taking was a choice, and that she was saved from hitting rock bottom by her upbringing, which she frequently described as perfect. “I wasn’t abused,” she told me. “I practised violin. I had a lot of protective factors. A lot of people in prison do not have those things.”
Still, Smith’s childhood was not always straightforward. She describes her mother as a “good stay-at-home mother”, but she was also eccentric and volatile. When she divorced Smith’s father after 12 years of marriage, she plunged into a depression that she never fully rose out of. (“I had two people, whom I trusted and loved, telling me that the other person was evil,” said Smith, who was six when their drawn-out custody battle began.) While Smith was under house arrest, her mother attempted suicide for the first time. Returning home from prison years later, Smith found that her mother’s place was now packed with clutter. Her mother slept in the middle of the day, heavily medicated and not able to leave the house. In 2024, her mother died from complications with her medication regimen after a long struggle with mental illness. Months later, Smith’s stepfather also died.
It was in the period after her mother and stepfather’s deaths that Smith was hired as an assistant professor at Johns Hopkins. Last year, the district court in Knoxville invited Smith to speak at a graduation ceremony for a programme called Full Circle that allowed people in prison with substance-use disorders to leave federal probation early after a year of working with a mentor.
At the ceremony, Smith met the judge who had sentenced her all those years ago. The memory of that day, probably the bleakest of her existence, was a blur. “I remember looking up at this thing that was clearly a judge,” she recalled. “But I was crying so hard when I addressed him that I only remember sobbing.”
It was difficult to look him in the eyes. Judge Varlan was a head taller than Smith, with a wiry frame and a clean-shaven face. She was surprised how quiet he was. His cadence was slow, his demeanour laconic, but his smile was warm and fatherly. To the judge’s wife, Smith expressed how nervous she was to meet them. Mrs Varlan smiled with tears in her eyes, and reassured Smith that the judge had been looking forward to her visit.
In her speech, Smith told the graduates: “Most of us in this room are likely hard-headed and stubborn. Turning that stubbornness in the right direction can be a powerful thing.”
Shoulder to shoulder with Judge Varlan, Smith watched a dozen or so ex-inmates walk across the stage, many starting over at an older age than she had. It sank in how rare “full circle” moments were for people like her. She had willed it into existence by remaining, as the judge and his wife, and Smith’s mother and stepfather had been, stubborn about her ability to change.
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