Gabor Maté’s latest book is a sprawling but fascinating look at addiction that is part science, part diatribe, part character study, and part confessional. Maté, a physician at the Portland Clinic in Vancouver’s Downtown Eastside, treats the hardest of hardcore substance abusers. The facility houses North America’s first supervised injection site, focusing on harm reduction rather than the nebulous aim of  “fighting” addiction.

In fact, the formidable 400-plus pages here do not offer even one recovery story. At the Portland, says Maté, “there is no chimera of redemption nor any expectation of socially acceptable outcomes, only an unsentimental recognition of the real needs of real human beings in the dingy present, based on a uniformly tragic past.”

For a generation reared on the feelgood platitudes of daytime TV talk shows, it’s a decidedly unglamorous reality. Maté’s portraits of his clients are wrenching, despite the frequent glimpses of humanity that lurk beneath the lies, manipulations, and criminal behaviour. His analysis of the biology of addiction shatters the widespread notion that drugs themselves cause dependency, and he is virulent in his attack on the impotent “war on drugs” waged here and south of the border. Most compellingly, he demonstrates how addiction fills the void created by emotional trauma by mimicking the positive brain chemicals that most of us experience over the course of a normal, loving childhood.

Maté frequently turns the lens on himself, admitting to being a workaholic, being ruled by his ego, and sometimes feeling contempt for the people he treats. He also has an addiction – not to drugs, but to out-of-control spending on classical music. (He once left a patient in the final throes of childbirth to satisfy the compulsion.) Maté’s “confession” sets up an interesting meta-narrative that will make readers wonder if they, too, are being manipulated. After all, it’s a weakness that shores up a rather ego-affirming image: that of compulsive aestheticism.

In the Realm of Hungry Ghosts is longer than it needs to be, but the writing is powerful, despite many eccentricities. Above all, the book leaves the reader with a profound sense of empathy and understanding for some of society’s most marginalized victims.