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America's Altered States (An essay in the May issue of Harper's magazine by
Joshua Wolf Shenk, a psychiatric patient who has tried countless medicines,
and still uses marijuana medically on occasion, deconstructs the primitive
beliefs about drugs that prevail in the United States. The drug wars and the
booming pharmaceutical industry are interrelated. The hostility and
veneration, the punishment and profits, these come from the same beliefs and
the same mistakes. Our faith in pharmaceuticals is based on a model of
consciousness that science is slowly displacing. "Throughout history,"
writes chemist and religious scholar Daniel Perrine in The Chemistry of
Mind-Altering Drugs, "the power that many psychoactive drugs have exerted
over the behavior of human beings has been variously ascribed to gods or
demons." In a sense, that continues. "We ascribe magical powers to
substances," says Perrine, "as if the joy is inside the bottle. Our culture
has no sacred realm, so we've assigned a sacred power to these drugs.")
Date: Wed, 5 May 1999 21:33:25 -0700
From: owner-mapnews@mapinc.org (MAPNews)
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Subject: MN: US: America's Altered States
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Pubdate: May 1999
Source: Harper's Magazine
Contact: letters@harpers.org
Web: http://www.harpers.org
Author: Joshua Wolf Shenk
AMERICA'S ALTERED STATES
When Does Legal Relief Of Pain Become Illegal Pursuit Of Pleasure?
"My soul was a burden, bruised and bleeding. It was tired of the man
who carried it, hut I found no place to set it down to rest. Neither
the charm of the countryside nor the sweet scents of a garden could
soothe it. It found no peace in song or laughter, none in the company
of friends at table or in the pleasures of love none even in hooks or
poetry. Where could my heart find refuge from itself? Where could I
go yet leave myself behind?" -St. Augustine
To suffer and long for relief is a central experience of humanity. But
the absence of pain or discomfort or what Pablo Neruda called "the
infinite ache" is never enough. Relief is bound up with satisfaction,
pleasure, happiness - the pursuit of which is declared a right in the
manifesto of our republic. I sit here with two agents of that pursuit:
on my right, a bottle from Duane Reade pharmacy; on my left, a bag of
plant matter, bought last night for about the same sum in an East
Village bar from a group of men who would have sold me different kinds
of contraband if they hadn't sniffed cop in my curiosity and
eagerness. This being Rudy Giuliani's New York, I had feared they were
undercover. But my worst-case scenario was a night or two in jail and
their's a fifteen-year minimum. As I exited the bar, I saw an empty
police van idling, waiting to be filled with people like me but,
mostly, people like them, who are there only because I am.
Fear and suspicion, secrecy and shame, the yearning for pleasure, and
the wish to avoid men in blue uniforms. This is (in rough, incomplete
terms) an emotional report from the front. The drug wars - which,
having spanned more than eight decades, require the plural - are
palpable in New York City. The mayor blends propaganda, brute force,
and guerrilla tactics, dispatching undercover cops to call "smoke,
smoke" and "bud, bud" - and to arrest those who answer. In Washington
Square Park, he erected ten video cameras that sweep the environs
twenty-four hours a day. Surveillance is a larger theme of these wars,
as is the notion that cherished freedoms are incidental. But it is
telling that such an extreme manifestation of these ideas appears in a
public park, one of the very few common spaces in this city not
controlled by, and an altar to, corporate commerce.
Several times a month, I walk through that park to the pharmacy, where
a doctor's slip is my passport to another world. Here, altering the
mind and body with powders and plants is not only legal but even
patriotic. Among the souls wandering these aisles, I feel I have kin.
But I am equally at home, and equally ill at ease, among the outlaws.
I cross back and forth with wide eyes.
What I see is this: From 1970 to 1998, the inflation-adjusted revenue
of major pharmaceutical companies more than quadrupled to $81 billion,
24 percent of that from drugs affecting the central nervous system and
sense organs. Sales of herbal medicines now exceed $4 billion a year.
Meanwhile, the war on Other drugs escalated dramatically. Since 1970
the federal anti-drug budget has risen 3,700 percent and now exceeds
$17 billion. More than one and a half million people are arrested on
drug charges each year, and 400,000 are now in prison. These numbers
are just a window onto an obvious truth: We take more drugs and reward
those who supply them.
We punish more people for taking drugs and especially punish those who
supply them. On the surface, there is no conflict. One kind of drugs
is medicine, righting wrongs, restoring the ill to a proper, natural
state. These drugs have the sheen of corporate logos and men in white
coats. They are kept in the room where we wash grime from our skin and
do the same with our souls. Our conception of illegal drugs is a
warped reflection of this picture. Offered up from the dirty
underworld, they are hedonistic, not curative. They induce artificial
pleasure, not health. They harm rather than help, enslave rather than
liberate.
There is some truth in each of these extreme pictures. But with my
dual citizenship, consciousness split and altered many times over, I
come to say this: The drug wars and the drug boom are interrelated, of
the same body. The hostility and veneration, the punishment and
profits, these come from the same beliefs and the same mistakes.
I.
Before marijuana, Cocaine or "Ecstasy," before nitrous oxide or magic
mushrooms, before I had tried any of these, I poked through the foil
enclosing a single capsule of fluoxetine hydrochloride. My drug story
begins at this point, at the end of a devastating first year of
college. For years, I had wrapped myself in an illusion that my
lifelong troubles - intense despair, loneliness, anxiety, a relentless
inner soundtrack of self-criticism - would dissolve if I could only
please the gatekeepers of the Ivy League. By the spring of freshman
year, I had been skinned of this illusion and plunged into a deep
darkness. From a phone booth in a library basement, I resumed contact
with a psychiatrist I'd begun seeing in high school.
I told him how awful I felt, and, after a few sessions, he suggested I
consider medication. By now our exchange is a familiar one. This was
1990, three years after Prozac introduced the country to a new class
of antidepressants, called selective serotonin reuptake inhibitors.
SSRIs were an impressive innovation chemically but a stunning
innovation for the market, because, while no more effective than
previous generations of antidepressants, SSRIs had fewer side effects
and thus could be given to a much broader range of people. (At last
count, 22 million Americans have used Prozac alone.) When my doctor
suggested I take Prozac, it was with a casual tone. Although the idea
of "altering my brain chemistry" unsettled me at first, I soon
absorbed his attitude. When I returned home that summer, I asked him
how such drugs worked. He drew a crude map of a synapse, or the
junction between nerve cells. There is a neurotransmitter called
serotonin, he told me, that is ordinarily released at one end of the
synapse and, at the other end, absorbed by a sort of molecular pump.
Prozac inhibits this pumping process and therefore increases
serotonin's presence in the brain. "What we don't understand," he
said, looking up from his pad, "is why increased levels of serotonin
alleviate depression. But that's what seems to happen."
I didn't understand the importance of this moment until years later,
after I had noticed many more sentences in which the distance between
the name of a drug - Prozac, heroin, Ritalin, crack cocaine - and its
effects had collapsed. For example, the phrase "Prozac eases
depression," properly unpacked, actually represents this more
complicated thought: "Prozac influences the serotonin patterns in the
brain, which for some unknown reason is found to alleviate, more often
than would a placebo, a collection of symptoms referred to as
depression." What gets lost in abbreviation - Prozac cures! Heroin
kills! - is that drugs work because the human body works, and they
fail or hurt us because the body and spirit are vulnerable. When drugs
spark miracles, prolonging the lives of those with HIV, say, or
dulling the edges of a potentially deadly manic depression - we should
be thankful.[1] But many of these processes are mysteries that might
never yield to science. The psychiatric establishment, for example,
still does not understand why serotonin affects mood. According to
Michael Montagne of the Massachusetts College of Pharmacy, 42 percent
of marketed drugs likewise have no proven mechanism of action. In
"Listening to Prozac," Peter Kramer quotes a pharmacologist explaining
the problem this way: "If the human brain were simple enough for us to
understand, we would be too simple to understand it." Yet
pharmaceutical companies exude certainty. "Smooth and powerful
depression relief," reads an ad for Effexor in a recent issue of The
American Journal of Psychiatry. "Antidepressant efficacy that brings
your patients back." In case this message is too subtle, the ad shows
an ecstatic mother and child playing together, with a note written in
crayon: "I got my mommy back."
The irony is that our faith in pharmaceuticals is based on a model of
consciousness that science is slowly displacing. "Throughout history,"
chemist and religious scholar Daniel Perrine writes in The Chemistry
of Mind-Altering Drugs, "the power that many psychoactive drugs have
exerted over the behavior of human beings has been variously ascribed
to gods or demons." In a sense, that continues. "We ascribe magical
powers to substances," says Perrine, "as if the joy is inside the
bottle. Our culture has no sacred realm, so we've assigned a sacred
power to these drugs. This is what Alfred North Whitehead would call
the 'fallacy of misplaced concreteness.' We say, 'The good is in that
Prozac powder,' or 'The evil is in that cocaine powder.' But evil and
good are not attributes of molecules."
This is a hard lesson to learn. In my gut, where it matters, I still
haven't learned it. Back in 1990, I took the Prozac and, eventually,
more than two dozen other medications: antidepressants,
antipsychotics, antianxiety agents, and so on. The sample pills would
be elegantly wrapped. Handing them to me, the doctors would explain
the desired effect: this drug might quiet the voices in my head; this
one might make me less de-pressed and less anxious; this combination
might help my concentration and ease my repetitive, obsessive
thoughts. Each time I swelled with hope. I've spent many years in
therapy and have looked for redemption in literature, work, love. But
nothing quite matches the expectancy of putting a capsule on my tongue
and waiting to be remade.
But I was not remade. None of the promised benefits of the drugs came,
and I suffered still. In 1993, I went to see Donald Klein, one of the
top psychopharmacologists in the country. Klein's prestige,
underscored by his precipitous fees, again set me off into fantasies
of health. He peppered me with questions, listened thoughtfully. After
an hour, he pushed his reading glasses onto his forehead and said,
"Well, this is what I think you have." He opened the standard
psychiatric reference text to a chapter on "disassociative disorders"
and pointed to a sublisting called depersonalization disorder,
"characterized by a persistent or recurrent feeling of being detached
from one's mental processes or body."
I'm still not certain that this illness best describes my experience.
I can't even describe myself as "clinically ill," because clinicians
don't know what the hell to do with me. But Klein gave me an entirely
new way of thinking about my problems, and a grim message.
"Depersonalization is very difficult to treat," he said. So I was back
where I started, with one exception. During our session, Klein had
asked if I used marijuana. Once, I told him, but it didn't do much.
After he had given me his diagnosis, he told me the reason he had
asked: A lot of people with depersonalization say they get relief
from marijuana." At that time, I happened, for the first time in my
life, to be surrounded by friends who liked to smoke pot. So in
addition to taking drugs alone and waiting for a miracle, I looked for
solace in my own small drug culture. And for a time, I got some. The
basic function of antidepressants is to help people with battered
inner lives participate in the world around them. This is what pot did
for me. It helped me spend time with others, something I have yearned
for but also feared; it sparked an eagerness to write and conjure
ideas - some of which I found the morning after to be dreamy or naive,
but some of which were the germ of something valuable. While high, I
could enjoy life's simple pleasures in a way that I hadn't ever been
able to and still find maddeningly difficult. Some might see this (and
people watching me surely did) as silly and immature. But it's also a
reason to keep living.
Sad to say, I quickly found pot's limitations. When my spirits are
lifted, pot can help punctuate that. If I smoke while on a downward
slope or while idling, I usually experience more depression or
anxiety. Salvation, for me at least, is not within that smoked plant,
or the granules of a pill, or any other substance. Like I said, it's a
hard lesson to learn.
To the more sober-minded among us, it is a source of much
consternation that drugs, alcohol, and cigarettes are so central to
our collective social lives. It is hard, in fact, to think of a single
social ritual that does not revolve around some consciousness-altering
substance. ("Should we get together for coffee or drinks?") But drugs
are much more than a social lubricant; they are also the centerpiece
of many individual lives. When it comes to alcohol, or cigarettes, or
any illicit substance, this is seen as a problem. With
pharmaceuticals, it is usually considered healthy. Yet the dynamic is
often the same.
It begins with a drug that satisfies a particular need or desire -
maybe known to us, maybe not. So we have drinks, or a smoke, or
swallow a few pills. And we get something from this, a whole lot or
maybe just a bit. But we often don't realize that the feeling is
inside, perhaps something that, with effort, could be experienced
without the drugs or perhaps, as in the psychiatric equivalent of
diabetes, something we will always need help with. Yet all too often
we project upon the drug a power that resides elsewhere. Many believe
this to be a failure of character. If so, it is a failure the whole
culture is implicated in. A recent example came with the phrase "pure
theatrical Viagra," widely used to describe a Broadway production
starring Nicole Kidman. Notice what's happening: Sildenafil citrate is
a substance that increases blood circulation and has the side effect
of producing erections in men. As a medicine, it is intended to be
used as an adjunct to sexual stimulation. As received by our culture,
though, the drug be-comes the desired effect, the "real thing" to
which a naked woman onstage is compared.
Such exaltation of drugs is reinforced by the torrent of
pharmaceutical ads that now stuff magazines and blanket the airwaves.
Since 1994, drug-makers have increased their direct-to-consumer
advertising budget sevenfold, to $1.2 billion last year. Take the ad
for Meridia, a weight-loss drug. Compared with other drug ads ("We're
going to change lives," says a doctor pitching ac-ne cream. "We're
going to make a lot of people happy"), it is the essence of restraint.
"You do your part," it says in an al-lusion to exercise and diet.
"We'll do ours." The specific intent here is to convince people who
are overweight (or believe themselves to be) that they should ask
their doctor for Meridia.[2] Like the pitch far Baby Gap that
announces "INSTANT KARMA" over a child wrapped in a $44 velvet jacket,
drug ads suggest - or explicitly say - that we can solve our problems
through magic-bullet consumption. As the old saying goes, "Better
living through chemistry."
It's the job of advertisers to try every trick to sell their products.
But that's the point: drugs are a commodity designed for profit and
not necessarily the best route to health and happiness. The "self
help" shelves at pharmacies, the "expert only" section behind the
counter, these are promised to contain remedies for all ills. But the
wizards behind the curtain are fallible human beings, just like us.
Professor Montagne says that despite obvious financial incentives,
"there really is an overwhelming belief among pharmacists that the
last thing you should do for many problems is take a drug. They'll
recommend something when you ask, but there's a good chance that when
you're walking out the door they'll be saying, 'Aw, that guy doesn't
need a laxative every day. He just needs to eat right. They don't need
Tagamet. They just need to cut back on the spicy food.'" It is hard to
get worked up about these examples, but they point to the broader
pattern of drug worship. With illegal drugs, we see the same pattern,
again through that warped mirror.
Not long after his second inauguration, President Clinton signed a
bill earmarking $195 million for an antidrug ad campaign - the first
installment of a $1 billion pledge. The ads, which began running last
summer, all end with the words "Partnership for a Drug Free America"
and "Office of National Drug Control Policy." It is fitting that the
two entities are officially joined. The Partnership emerged in 1986,
the year basketball star Len Bias died with cocaine in his system and
Presi-dent Reagan signed a bill creating, among many other new
penalties, mandatory federal prison terms for pos-session of an
illegal substance. This was the birth of the drug wars' latest phase,
in which any drug use at all - not abuse or addiction or "drug-related
crime" -became the enemy.[3] Soon the words "drug-free America" began
to show up regularly, in the name of a White House conference as well
as in legislation that declared it the "policy of the United States
Government to create a Drug-Free America by 1995."
Although the work of the Partnership is spread over hundreds of ad
firms, the driving farce behind the organization is a man named James
Burke - and he is a peculiar spokesman for a "drug free" philosophy.
Burke is the former CEO of Johnson & Johnson, the maker of Tylenol and
other pain-relief products; Nicotrol, a nicotine-delivery device;
Pepcid AC, an antacid; and various prescription medications. When he
came to the Partnership, he brought with him a crucial grant of $3
million from the Robert Wood Johnson Foundation, a philan-thropy tied
to Johnson & Johnson stock. Having granted $24 million over the last
ten years, RWJ is the Partnership's single largest funder, but the
philanthropic arms of Merck, Bristol-Myers Squibb, and Hoffman-La
Roche have also made sizable donations.
I resist the urge to use the word "hypocrisy," from the Greek
hypdkrisis, "acting of a part on the stage." I don't believe James
Burke is acting. Rather, he embodies a contradiction so common that
few people even notice it - the idea that altering the body and mind
is morally wrong when done with same substances and salutary when done
with others.
This contradiction, on close examination, resolves into coherence.
Before the Partner-ship, Burke was in the business of burnishing the
myth of the uberdrug, doing his best - as all marketers do - to make
some external object the center of existence, displacing the
complications of family, community, inner lives. Now, drawing on the
same admakers, he does the same in reverse. (These admakers are happy
to work pro bono, having been made rich by ads for pharmaceuticals,
cigarettes, and alcohol. Until a few years ago, the Partnership also
took money from these latter two industries.) The Partnership formula
is to present a problem - urban violence, date rape, juvenile
delinquency - and lay it at the feet of drugs. "Marijuana," says a
remorseful-looking kid, "cost me a lot of things. I used to be a
straight-A student, you know. I was liked by all the neighbors. Never
really caused any trouble. I was always a good kid growing up. Before
I knew it, I was getting thrown out of my house."
This kid looks to be around seventeen. The Partnership couldn't tell
me his real name or anything about him except that he was interviewed
through a New York drug-treatment facility. I wanted to talk to him,
because I wanted to ask: "Was it marijuana that cost you these things?
Or was it your behavior while using marijuana? Was that behavior
caused by, or did it merely coincide with, your marijuana use?"
These kinds of subtleties are crucial, but it isn't a mystery why they
are usually glossed over. In Texas, federal prosecutors are seeking
life sentences for dealers who supplied heroin to teenagers who
subsequently died of overdose. Parents praised the authorities. "We
just don't want other people to die," said one, who suggested drug
tests for fourth-graders on up. Another said, "I kind of wish all this
had happened a year ago so whoever was able to supply jay that night
was already in jail." The desire for justice, and to protect future
generations, is certainly understandable. But it is striking to note
how rarely, in a story of an overdose, the sur-vivors ask the most
important question. It is not: How do we rid illegal drugs from the
earth?[4] Despite eighty years of criminal sanctions, stiffened to the
point just short of summary executions, markets in this contraband
flourish because supply meets demand. Had Jay's dealer been in jail
that night, jay surely would have been able to find someone else-and
if not that night, then soon thereafter.
The real question - why do kids like Jay want to take heroin in the
first place ? - is consistently, aggressively avoided. Senator Orrin
Hatch recently declared that "people who are pushing drugs on our kids
... I think we ought to lock them up and throw away the keys."
Implicit in this re-mark is the idea that kids only alter their
con-sciousness because it is pushed upon them.
Blaming the alien invader - the dealer, the drug - provides some
structure to chaos. Let's say you are a teenager and, in the course of
establishing your own identity or quelling inner conflicts, you start
smoking a lot of pot. You start running around with a "bad crowd."
Your grades suffer. Friction with your parents crescendos, and they
throw you out of the house. Later, you regret what you've done - and
you're offered a magic button, a way to condense and displace all your
misdeeds. So, naturally, you blame everything on the drug. Something
maddeningly complicated now has a single name. Psychologist Bruce
Alexander points out that the same tendency exists among the seriously
addicted. "If your life is really fucked up, you can get into heroin,
and that's kind of a way of coping," he says. "You'll have friends to
share something with. You'll have an identity. You'll have an
explanation for all your troubles."
What works for individuals works for a society. ("Good People Go Bad
in Iowa," read a 1996 New York Times headline, "And a Drug Is Being
Blamed.") Why is the wealthiest society in history also one of the
most fearful and cynical? What root of unhappiness and discontent
spurs thousands of college students to join cults, millions of
Americans to seek therapists, gurus, and spiritual advisers? Why has
the rate of suicide for people fifteen to twenty-four tripled since
1960? Why would an eleven- and a thirteen-year-old take three rifles
and seven handguns to their school, trigger the fire alarm, and shower
gunfire on their schoolmates and teachers? Stop search-ing for an
answer. Drug Watch International, a drug "think tank" that regularly
consults with drug czar Barry McCaffrey and testifies before Congress,
answered the question in an April 1998 press release: "MARIJUANA USED
BY JONESBORO KILLERS." [5]
II.
In 1912, Merck Pharmaceuticals in Germany synthesized a type of
amphetamine, methylenedioxymethamphetamine, or MDMA. It remained
largely unused until 1976, when a biochemist at the University of
California namedAlexander Shulgin, curious about reports from his
students, produced and swallowed 120 milligrams of the compound. The
result, he wrote soon afterward, was "an easily controlled altered
state of consciousness with emotional and sensual overtones."
Shulgin's immediate thought was that the drug might be useful in
psychotherapy the way LSD had been. In the two decades after its
mind-altering properties were discovered in 1943 by a chemist for
Sandoz Laboratories, LSD was widely used as an experimental treatment
for alcoholism, depression, and various clinical neuroses. More than a
thousand clinical papers discussed the use of LSD among an estimated
40,000 people, and research studies of the drug led to some
extraordinary advances - including the discovery of the serotonin
system. When LSD experiments were restricted in 1962 and again in
1965, Senator Robert Kennedy held a congressional hearing. "If they
were worthwhile six months ago, why aren't they worthwhile now?" he
asked officials of the Food and Drug Administration and the National
Institute of Mental Health. "Perhaps to some extent we have lost sight
of the fact that [LSD] can be very, very helpful in our society if
used properly."
The answer to Kennedy's question was that LSD had leaked out of the
universities and clinics and into the hands of "recreational users."
It had crossed the line that separates good drugs from bad. LSD was
outlawed three years later. In 1970, when a new law devised five
categories, or "schedules," of controlled substances, LSD was placed
in Schedule I, along with heroin and marijuana. This is the
designation for drugs with no accepted medical use and a "high
potential for abuse." In 1986, MDMA would be added to that list of
demon drugs. The question is: How does a substance get assigned to
that category? What separates the good drugs from the bad?
In the nineteenth century, now-illegal substances were commonly used
in medicine, tonics, and consumer products. (The Illinois asylum that
housed Mary Todd Lincoln in the 1870s offered its patients morphine,
cannabis, whiskey, beer, and ale. Sigmund Freud treated himself with
cocaine - and, for a time at least, praised it effusively - as did
William McKinley and Thomas Edison.) A new era began with the federal
Pure Food and Drug Act of 1906, which required the listing of
ingredients in medical products. Then, the 1914 Harrison Narcotic Act,
ostensibly a tax measure, asserted legal control over distributors and
users of opium and cocaine.
On the surface, this might seem progressive, the story of a
still-young nation establishing commercial and medical standards. And
there was genuine uneasiness about drugs that were intoxicating or
that produced dependence; with the disclosure required by the 1906
act, sales of patent medicines containing opium dropped by a third.
But the movement for prohibition drew much of its power from a far
less savory motive. "Cocaine," warned Theodore Roosevelt's drug
adviser, "is often a direct incentive to the crime of rape by the
Negroes." [6] As David Musto reports in The American Disease, the
prohibitions of the early part of the century were all, in part, a
reaction to in-flamed fears of foreigners or minority groups. Opium
was associated with the Chinese. In 1937, the Marihuana Tax Act
targeted Mexican immigrants. "I wish I could show you what a small
marijuana cigarette can do to one of our degenerate Spanish-speaking
residents," a Colorado newspaper editor wrote to federal officials in
1936. Even the prohibition of alcohol was underlined by fears of
immigrants and exaggerations of the effects of drinking. On the eve of
its ban in 1919, a radio preacher told his audience, "The reign of
tears is over. The slums will soon be a memory. We will turn our
prisons into factories, our jails into storehouses and corncribs. Men
will walk upright now, women will smile and the children will laugh.
Hell will be forever for rent."
But the federal authorities, temperance advocates, and bigots had
reached too far. Whereas alcohol (like coffee and tobacco) has been a
demon drug in other cultures, in Western societies its use in
medicine, recreation, and religious ceremonies stretches back
thousands of years. Most Americans had personal experience with drink
and could measure the benefits of Prohibition against the violence (by
gangsters and by Prohibition agents, who, according to one estimate,
killed 1,000 Americans between 1920 and 1930) and the deaths by
"overdose."[7] After Franklin Roosevelt lifted Prohibition, subsequent
generations knew that the drug, though often abused and often
implicated in crimes, violence, and accidents, differs in its effects
depending on the person using it. With outlawed drugs, no such reality
check is available. People who use illegal drugs without great harm
generally stay quiet.
Alcohol also can be legally used in medicines, such as Nyquil, or used
medicinally in a casual way - say, to calm shattered nerves. Demon
drugs, on the other hand, are prohibited or seriously limited even in
cases of exceptional need. Forty percent of pain specialists admit
that they undermedicate patients to avoid the suspicion of the Drug
Enforcement Administration. Their fear is justified: every year about
100 doctors who prescribe narcotics lose their licenses, including, in
1996, Dr. William Hurwitz, a Virginia internist whose more than 200
patients were left with no one to treat them. One of these patients
committed suicide, saying in a videotaped message, "Dr. Hurwitz isn't
the only doctor that can help. He's the only doctor that will help."
Chronic pain, mind you, doesn't mean dull throbbing. "I can't shower,"
one patient explained to U.S. News & World Report, "because the water
feels like molten lava. Every time someone turns on a ceiling fan, it
feels like razor blades are cutting through my legs." To ease such
pain can require massive doses of narcotics. This is what Hurwitz
prescribed. This is why he lost his license.
But at least narcotics are acknowledged as a legitimate medical tool.
Marijuana is not despite overwhelming evidence that smoking the
cannabis plant is a powerful treat-ment for glaucoma and seizures,
mollifies the effects of AIDS or cancer chemotherapy, and eases
anxiety. The editors of The New England Journal of Medicine, the
American Bar Association, the Institute of Medicine of the National
Academy of Sciences, and the majority of voters in California and six
other states (plus the District of Co-lumbia) are among those who
believe that these uses of marijuana are legitimate. So does the
eminent geologist Stephen Jay Gould. He developed abdominal cancer in
the 1980s and suffered such intense nausea from intravenous
chemotherapy that he came to dread it with an "almost perverse
intensity." "The treatment," he remembers, "seem[edj worse than the
disease itself." Gould was reluctant to smoke marijuana, which, as
thousands of cancer patients have found, is a powerful antiemetic.
When he did, he faund it "the greatest boost I received in all my
years of treatment." "It is beyond my comprehension," Gould concluded,
"and I fancy myself able to comprehend a lot, including much nonsense
- that any humane person would withhold such a beneficial substance
from people in such great need simply because others use it for
different purposes."
This distinction between "people in great need" and those with
"different purposes" is crucial to the argument for the medical use of
marijuana.[8] Like Gould, many who use marijuana for medical reasons
dislike the "high." Many others don't even feel it. But it is a
mistake to think that the reason these people can't legally use
marijuana is simply that other people use it for purposes other than
traditional medical need. Because the very idea of "medical need" is
constantly shifting beneath our feet.
I do not have cancer or epilepsy, or a disabling mental disorder such
as schizophrenia. The "other purposes" Gould refers to are, in many
ways, mine. The qualities of my suffering are (to simplify) anxiety,
numbness, and anhedonia. If these were relieved by a legal drug - in
other words, if a pharmaceutical helped me relax, feel more alive,
have fun - I would be fully in the mainstream of American medicine.
This is my strong preference. But when I returned to see Donald Klein
this past summer, hoping that new medications might have emerged in
the last five years, he told me that "there are lots of things to try
but there's only marginal evidence that any of them would do any
good." He also made it clear that I shouldn't get my hopes up. "What
you have," he said, "is not a common condition, and it's almost
impossible [for pharmaceutical companies] to do a systematic study,
let alone make money, on a condition that's not common." And so, yes,
I turn sometimes to marijuana and other illicit substances far the
(limited) relief they offer. I don't merely feel justified in doing
so; I feel entitled, particularly since, every year, the
pharmaceutical industry rolls out new products for pleasure, vanity,
convenience.
When Viagra emerged, it was not frowned upon by the authorities that
lead the drug wars. Instead, President Clinton ordered Medicaid to
cover the drug, and the Pentagon budgeted $50 million for fiscal 1999
to supply it to soldiers, veterans, and civilian employees. Pfizer
hired Bob Dole to instruct the nation that "it may take a little
courage" to use Viagra. This is a medicine whose sole purpose is to
allow far sexual pleasure; it was embraced by the black market and is
easily available from doctors, including some who perform
"examinations" via a three-question form on the Internet. But Viagra's
legitimacy was never questioned, because it treats a disease -
erectile dys-function. Before Viagra, when the only treatment options
were less-effective pills and awkward injection-based therapies, this
condition was referred to as impotence. The change in language is
interesting. The "dys" sits on the front of dysfunction like a streak
of dirt on a pane of glass. At a level more primal thati cognitive, we
want it removed. This is what we do with dysfunctions: we fix them.
Impotence, on the other hand, meaning "weakness" or "helplessness," is
something we all experience at one time or another. Applied to men
"incapable of sexual intercourse, often because of an inability to
achieve or sustain an erection," the word carries a sense of something
unfottunate but part of living, and particularly of growing older.
Thus the advent of Viagra does not simply treat a disease. It changes
our conception of disease. This paradigm shift is a common occurrence
but is below our radar. Hair loss becomes a disease, not a fact of
life. Acid indigestion becomes a disease, not a matter of eating
poorly. If these examples seem to make light of the broadening of
disease, the ascent of psychopharmaceuticals makes the issue urgent.
Outside the realm of the tangibly physical, the power of drugs and
drugmakers is far greater. What we now know as "anxiety disorder," for
example, existed only in theory from Freud's time through World War
II. In the early 1950s, a drug company polled doctors and found that
most had no interest in a medication that treated anxiety. But by
1970, one woman in five and one man in thirteen were using a
tranquilizer or sedative, and anxiety was a mainstay of psychiatry.
The change could be directly attributed to two drugs, Miltown and
Valium, which were released in 1955 and 1963, respectively. The
successor to these drugs, Xanax, introduced in 1981, virtually created
a disease itself. Donald Klein had already proposed the existence of
something called "panic disorder," as opposed to generalized anxiety,
some twenty years before. But his theory was widely refuted, and in
practice panic anxiety was treated only in the context of a larger
problem. Xanax changed that. "With a convenient, effective drug
available," writes Peter Kramer, "doctors saw panic anxiety
everywhere." Xanax has also become the litmus test for generalized
anxiety disorder. "If Xanax doesn't work," instructs The Essential
Guide to Psychiatric Drugs, "usually the original diagnosis was wrong." [9]
This is not to say that all specific disorders are arbitrary, just
that there is a delicate line to be drawn. "The term 'disease' - and
the border between health and disease - is a social construct," says
Steven Hyman, director of the National In-stitute of Mental Health.
"There are some things we would never argue about, like cancer. But do
we call it a disease if you have a few foci of abnormal cells in your
body, something that you could live with without any problem? There is
a gray zone. With behavior and the brain, the gray zone is much
larger." To Hyman's observation, it must be added that, whereas vague
dissatisfactions make money for psychic hot lines and interior
decorators, diseases make money for pharmaceutical companies. What
Peter Kramer calls psychiatric diagnostic creep is not an accident of
history but a movement engineered far profit.
We have only begun to grapple with the consequences. The example of
Prozac has been chewed over, but it's worth chewing still more -
because it is so typical of a new generation of drugs, which are being
used to treat debilitating conditions and also by people with far less
serious problems. With Lauren Slater, author of the fine memoir Prozac
Diary, we have a case anyone would regard as serious. Suffering from
obsessive-compulsive disorder, severe depression, and anorexia, she
had been hospitalized five times, attempted suicide twice, and cut
herself with razors. Prescribed Prozac in 1988, she found the drug a
reprieve from a lifetime sentence of serious illness - "a blessing,
pure and simple," she writes. The patients described in Peter Kramer's
Listening to Prozac are quite unlike Lauren Slater. They share, he
writes, "something very much like 'neurosis,' psychoanalysis's
umbrella term for the mildly disturbed, the neat-normal, and those
with very little wrong at all." The use of Prozac for these patients
is not incidental; they make up a large portion, probably a wide
majority, of people on the drug. (One good indication is that only 31
percent of antidepressant prescriptions are written by
psychiatrists.)
Throughout his book, Kramer flirts with "unsettling" comparisons
between Prozac and illegal drugs. Since Prozac can "lend social ease,
command, even brilliance," for example, he wonders how its use for
this purpose can "be distinguished from, say, the street use of
amphetamine as a way of overcoming inhibitions and inspiring zest. The
better comparison, I suggested in a conversation with Kramer, is
between Prozac and MDMA. Both drugs work by increasing the presence of
serotonin in the brain. (Whereas Prozac inhibits serotonin's reuptake,
MDMA stimulates its release.) Both can be helpful to the seriously ill
as well as to people with more common problems. Most of the objections
to MDMA - that it distorts "real" personality, that it rids people of
anxiety that may be personally or socially useful, that it induces
more pleasure than is natural - have also been marshaled against
Prozac. Both these drugs challenge our definitions of normalcy and of
the legitimate uses of a mind-altering substance. Yet Kramer rejects
the comparison. "The distinction we make," he told me, "is between
drugs that give pleasure directly and the drugs that give people the
ability to function in society, which can indirectly lead to pleasure.
If the medication can make you work well or parent well, and then
through your work or parenting you get pleasure, that's fine. But if
the drug gives you pleasure by taking it directly, that is not a
legitimate use." (Viagra, because it allows men to experience sexual
pleasure, falls on the side of legitimacy. But, Kramer said, a drug
that directly induced an orgasm would not.)
The line between therapeutic and hedonistic pleasure, however, is
awfully hard to draw. I think of a friend of mine who uses MDMA a few
times a month. His is a text-book case of "recreational" use. He takes
MDMA on weekends, in clubs, for fun. He is not ill and is not in
psychotherapy. But he will live for the rest of his life in the shadow
of a traumatic experience, which is that for more than two decades he
hid his homosexuality. Some might say the drug is an unhealthy escape
from "the real world," that the relaxation and intimacy he experiences
are illusory. But these experiences give him a point of reference he
can use in a "sober" state. His pleasure from the drug is entirely
social-being and sharing and loving with other people. Is this
hedonistic? "I found it astonishing," Kramer writes of Prozac, "that a
pill could do in a matter of days what psychiatrists hope, and often
fail, to accomplish by other means over a course of years: to restore
to a person robbed of it in childhood the capacity to play."
Perhaps I would find restrictions on MDMA more reasonable if they at
least carved out an exception for therapeutic use. Keep in mind,that's
where this drug started. After Shulgin's experiment word spread, and
thousands of doses were taken in a clinical setting. As with LSD, MDMA
was seen not as a medicine but as a catalyst to be taken just a few
times - or perhaps only once - in the presence of a therapist or
"guide." The effects were impressive. Many users found their artifice
and defenses stripped away and long-buried emotions rising to the
surface. The drug also had the unusual effect of increasing empathy,
which helped users trust their therapist - a crucial characteristic of
effective healing - and also made it useful in couples therapy. In a
collection of first-person accounts of therapeutic MDMA use, Through
the Gateway of the Heart, published in 1985, a rape victim described
working through her fears. Another woman described revelations about
her son, her weight problems, and "why angry men are attracted to me."
I can hear the skeptics shuffling their feet, wanting data from
double-blind controlled trials. But MDMA research never reached that
stage. Mindful of what had happened with LSD, the therapists,
scientists, and other adults experimenting with MDMA tried to keep it
quiet. Inevitably, though, word spread, and a new mode of use sprang
up - at raves, in dance clubs, in dorm rooms. An astute distributor of
the drug renamed it Ecstasy to emphasize its pleasurable effects.
("'Empathy' would he more appropriate," he said later. "But how many
people know what that means?")[10]
As the DEA moved to restrict MDMA, advocates of its medical use
flooded the agency with testimony, pleading for a chance to subject
the drug to methodical study. The agency's administrative-law judge,
Francis Young, saw merit in this argument. In a ninety-page decision
handed down in 1986, he recommended that the drug he placed in
Schedule III, which would allow for it to be prescribed by doctors and
tested further. Young cited its history of "currently accepted medical
use in treatment in the United States" and argued that "the evidence
of record does not establish that . . . MDMA has a high potential' for
abuse."
DEA officials overruled Young and placed MDMA in Schedule I, with the
assurance that its decision would be self-fulfilling. A Schedule I
substance cannot he used clinically and can be studied only with great
difficulty. So medical use is essentially forever impossible. That
leaves illicit use, which, by one common definition, is the abuse far
which Schedule I drugs have a "high potential." Since then,
government-funded researchers have sought to document MDMA's dangers.
Here we come to the truth about the line and how it is maintained.
With rare exceptions, everything we know about legal drugs comes from
research sponsored by the pharmaceutical industry. Naturally, this
work emphasizes the benefits and downplays the accompanying risks. On
the other hand, the National Institute on Drug Abuse, which funds more
than 85 percent of the world's health research on illegal drugs,
emphasizes the dangers and all hut ignores potential benefits.
One recent NIDA-funded study on MDMA was widely reported last fall.
Dr. George Ricaurte found, in fourteen men and women who had used MDMA
70 to 400 times in the previous six years, "long-lasting nerve cell
damage in the brain." Specifically, Ricaurte found decreases in the
number of serotonin-reuptake sites. The study begs three major
questions. First, do its conclusions really reflect the experience of
heavy MDMA users? British physician Karl Jansen reports that he
referred MDMA users who had taken more than 1,000 doses and that "they
were told by Ricaurte that they had a clean bill of health" but were
excluded from his study. Second, should the brain changes Ricaurte
found be called "damage," given that a number of psychiatric
medications, Prozac and Zoloft among them, decrease the number of
serotonin receptors by blockading them? As psychopharmacologist Julie
Holland writes, "This could he interpreted as an adaptive response as
opposed to a toxic or 'damaged' response." Third, do Ricaurte's
findings have any bearing on the use of MDMA in therapy, which calls
for a handful of doses over many months?
In this climate, it's hard to know. Charles Grob, a psychiatrist at
Harbor-UCLA Medical Center in Los Angeles, has been trying to restart
MDMA research for eight years. He received FDA approval to conduct
Phase I trials on human volunteers, to see if MDMA is safe enough to
be used as a medicine. But even with his impeccable credentials, the
backing of a prestigious research hospital, and an extremely
conservative protocol - involving terminal patients, Grob has faced a
seemingly interminable wait far permission to begin Phase II, in which
he would study efficacy. Grob's struggle explains why he has little
company in the research community. "When you have a drug that's
popular among young people," Grob says, "that's the kiss of death when
it comes to exploring its potential utility in a medical context."
There is another "kiss of death": lack of interest from industry. I
asked Lester Grinspoon, a professor of psychiatry at Harvard Medical
School, who led the legal challenge to the DEA's scheduling decision,
whether he had approached drug companies about supporting the effort.
"We didn't even consider it," he said. "No drug company is going to he
interested in a drug that's therapeutically useful only once or twice
a year. That's a no-brainer for them." When you see the feel-good ads
from the Pharmaceutical Research and Manufacturer's Association with
the tag line "Leading the way in the search for cures," keep in mind
that cure - conditions in which medication is no longer required - are
not particularly high on the pharmaceutical companies' priority list.
Market potential isn't the only factor explaining the status of drugs,
but its power shouldn't he underestimated. The principal psychoactive
ingredient of marijuana, THC, is available in pill form and can be
legally prescribed as Marinol. A "new" creation, it was patented by
Unimed Pharmaceutical and is sold for about $15 per 10-mg pill.
Marinol is considered by patients to he a poor substitute for
marijuana, because doses cannot be titrated as precisely and because
THC is only one of 460 known compounds in cannabis smoke, among other
reasons. But Marinol's profit potential - necessary to justify the
up-front research and testing, which can cost upward of $500 million
per medication - brought it to market. Opponents of medical marijuana
claim that they simply want all medicines to he approved by the FDA,
hut they know that drug companies have little incentive to overcome
the regulatory and financial obstacles for a plant that can't be
patented. The FDA is the tail, not the dog.
The market must be taken seriously as an explanation of drugs' status.
The reason is that the explanations usually given fall so far short.
Take the idea "Bad drugs induce violence." First, violence is
demonstrably not a pharmacological effect of marijuana, heroin, and
the psychedelics. Of cocaine, in some cases. (Of alcohol, in many.)
But if it was violence we feared, then wouldn't we punish that act
with the greatest severity? Drug sellers, even people marginally
involved in a "conspiracy to distribute," consistently receive longer
sentences than rapists and murderers.
Nor can the explanation be the danger of illegal drugs. Marijuana,
though not harmless, has never been shown to have caused a single
death. Heroin, in long-term "maintenance" use, is safer than habitual
heavy drinking. Of course, illegal drugs can do the body great harm.
All drugs have some risk, including many legal ones. Because of
Viagra's novelty, the 130 deaths it has caused (as of last November)
have received a fair amount of attention. But each year,
anti-inflammatory agents such as Advil, Tylenol, and aspirin cause an
estimated 7,000 deaths and 70,000 hospitalizations. Legal medications
are the principal cause of between 45,000 and 200,000 American deaths
each year, between 1 and 5.5 million hospitalizations. It is telling
that we have only estimates. As Thomas J. Moore notes in Prescription
for Disaster, the government calculates the annual deaths due to
railway accidents and falls of less than one story, among hundreds of
categories. But no federal agency collects information on deaths
related to legal drugs. (The $30 million spent investigating the crash
of TWA Flight 800, in which 230 people died, is six times larger than
the FDA's budget for monitoring the safety of approved drugs.)
Psychoactive drugs can be particularly toxic. In 1992, according to
Moore, nearly 100,000 persons were diagnosed with "poisoning" by
psychologically active drugs, 90 percent of the cases due to
benzodiazepine tranquilizers and antidepressants. It is simply a myth
that legal drugs have been proven "safe." According to one government
estimate, 15 percent of children are on Ritalin. But the long-term
effects of Ritalin - or antidepressants, which are also commonly
prescribed - on young kids isn't known. "I feel in between a rock and
a hard place," says NIMH director Hyman. "I know that untreated
depression is bad and that we better not just let kids be depressed.
But by the same token we don't know what the effects of anti-depressants
are on the developing brain. ... We should have humility and be a bit
frightened."
These risks are striking, given that protecting children is the
cornerstone of the drug wars. We forbid the use of medical marijuana,
worrying that it will send a bad message. What message is sent by the
long row of pills laid out by the school nurse - or by "educational"
visits to high schools by drugmakers? But, you might object, these are
medicines - and illegal drug use is purely hedonistic. What, then,
about illegal drug use that clearly falls under the category of
self-medication? One physician I know who treats women heroin users
tells me that each of them suffered sexual abuse as children.
According to University of Texas pharmacologist Kathryn Cunningham, 40
to 70 percent of cocaine users have pre-existing depressive conditions.
This is not to suggest that depressed people should use cocaine. The
risks of dependence and compulsive use, and the roller-coaster
experience of cocaine highs and lows, make for a toxic combination
with intense suffering. Given these risks, not to mention the risk of
arrest, why wouldn't a depressed person opt for legal treatment? The
most obvious answers are economic (many cocaine users lack access to
health care) and chemical. Cocaine is a formidable mood elevator and
acts immediately, as opposed to the two to four weeks of most
prescription anti-depressants. Perhaps the most important factor,
though, is cultural. Using a "pleasure drug" like cocaine does not
signal weakness or vulnerability. Self-medication can he a way of
avoiding the stigma of admitting to oneself and others that there is a
problem to be treated.
Calling illegal drug use a disease is popular these days, and it is
done, I believe, with a compassionate purpose: pushing treatment over
incarceration. It also seems clear that drug abuse can he a distinct
pathology. But isn't the "disease" whatever the drug users are trying
to find relief from (or flee)? According to the Pharmaceutical
Research and Manufacturer's Association, nineteen medications are in
development for "substance use disorders." This includes six products
for "smoking cessation" that contain nicotine. Are these treatments
for a disease or competitors in the market for long-term nicotine
maintenance?
Perhaps the most damning charge against illegal drugs is that they're
addictive. Again, the real story is considerably more complicated.
Many illegal drugs, like marijuana and cocaine, do not produce
physical dependence. Some, like heroin, do. In any case, the most
important factor in destructive use is the craving people experience
craving that leads them to continue a behavior despite serious adverse
effects. Legal drugs preclude certain behaviors we associate with
addiction - like stealing for dope money - but that doesn't mean
people don't become addicted to them. By their own admissions, Betty
Ford was addicted to Valium and William Rehnquist to the sleeping pill
Placidyl, for nine years. Ritalin shares the addictive qualities of
all the amphetamines. "For many people," says NIMH director Hyman,
explaining why many psychiatrists will not prescribe one class of
drugs, "stopping short-acting high-potency benzodiazepines, such as
Xanax, is sheer hell. As they try to stop they develop rebound anxiety
symptoms (or insomnia) that seem worse than the original symptoms they
were treating." Even antidepressants, although they certainly don't
produce the intense craving of classic addiction, can be habit
forming. Lauren Slater was first made well by one pill per day, then
required more to feel the same effect, then found that even three
would not return her to the miraculous health that she had at first
experienced. This is called tolerance. She has also been unable to
stop taking the drug without "breaking up." This is called dependence.
"'There are plenty of addicts who lead perfectly respectable lives,"'
Slater's boyfriend tells her. To which she replies, "'An addict? You
think so?"'
III.
In the late 1980s, in black communities, the Partnership for a Drug
Free America placed billboards showing an outstretched hand filled
with vials of crack cocaine. It read: "YO, SLAVE! The dealer is
selling you something you don't want.... Addiction is slavery." The ad
was obviously designed to resonate in the black neighborhoods most
visibly affected by the wave of crack use. But its idea has a broader
significance in a country for which independence of mind and spirit is
a primary value.
In Brave New World, Aldous Huxley created the archetype of
drug-as-enemy-of-freedom: soma. "A really efficient totalitarian
state," he wrote in the book's foreword, is one in which the "slaves
... do not have to be coerced, because they love their servitude."
Soma - "euphoric, narcotic, pleasantly hallucinogenic," with "all the
advantages of Christianity and alcohol; none of their defects," and a
way to "take a holiday from reality whenever you like, and come back
with-out so much as a headache or a mythology" - is one of the key
agents of that voluntary slavery.
In the spring of 1953, two decades after he published this book, Huxley
offered himself as a guinea pig in the experiments of a British
psychiatrist studying mescaline. What followed was a second masterpiece on
drugs and man, The Doors of Perception. The title is from William Blake:
"If the doors of perception were cleansed every thing would appear to man
as it is, infinite. For man has closed himself up, till he sees all things
thro' narrow chinks of his cavern." Huxley found his mescaline experience
to be "without question the most extraordinary and significant experience
this side of the Beatific vision ... it opens up a host of philosophical
problems, throws intense light and raises all manner of questions in the
field of aesthetics, religion, theory of knowledge."
Taken together, these two works frame the dual, contradictory nature
of mind-altering substances: they can he agents of servitude or of
freedom. Though we are deathly afraid of the first possibility, we are
drawn like moths to the light of the second. "The urge to transcend
self-conscious selfhood is," Huxley writes, "a principal appetite of
the soul. When, for whatever reason, men and women fail to transcend
themselves by means of worship, good works and spiritual exercises,
they are apt to resort to religion's chemical surrogates."
One might think, as mind diseases are broadened and the substances
that alter consciousness take their place beside toothpaste and
breakfast cereal, that users of other "surrogates" might receive more
understanding and sympathy. You might think the executive taking Xanax
hefore a speech, or the college student on BuSpar, or any of the
recipients of 65 million annual antidepressant prescriptions, would
have second thoughts about punishing the depressed user of cocaine, or
even the person who is not seriously depressed, just, as the Prozac ad
says, "feeling blue." In trying to imagine why the opposite has
happened, I think of the people I know who use psychopharmaceuticals.
Because I've always been up-front about my experiences, friends often
approach me when they're thinking of doing so. Every year there are
more of them. And yet, in their hushed tones, I hear shame mixed with
fear. I think we don't know quite what to make of our own brave new
world. The more fixes that become available, the more we realize we're
vulnerable. We solve some problems, hut add new and perplexing ones.
In the Odyssey, when three of his crew are lured by the lotus-eaters
and "lost all desire to send a message hack, much less return,"
Odysseus responds decisively. "I brought them back ... dragged them
under the rowing benches, lashed them fast." "Already," writes David
Lenson in On Drugs, "the high is unspeakable, and already the official
response is arrest and restraint." The pattern is set: since people
lose their freedom from drugs, we take their freedom to keep them from
drugs. [11] Odysseus' frantic response, though, seems more than just a
practical measure. Perhaps he fears his own desire to retire amidst
the lotus-eaters. Perhaps he fears what underlies that desire. If we
even feel the lure of drugs, we acknowledge that we are not satisfied
by what is good and productive and healthy. And that is a frightening
thought. "The War on Drugs has been with us," writes Lenson, "for as
long as we have despised the part of ourselves that wants to get high."
As Lenson points out, "It is a peculiar feature of history, that
peoples with strong historical, physical, and cultural affinities tend
to detest each other with the most venom." In the American drug wars,
too, animosity runs in both directions. Many users of illegal
drugs - particularly kids - do so not just because they like the feeling
but hecause it sets them apart from "straight" society, allows them
(without any effort or thought) to join a culture of dissent. On the
other side, "straight society" sees a hated version of itself in the
drug users. This is not just the 11 percent of Americans using
psychotropic medications, or the 6 million who admit to "nonmedical"
use of legal drugs, but anyone who fears and desires pleasure, who
fears and desires loss of control, who fears and desires chemically
enhanced living.
Straight sociery has remarkable power: it can arrest the enemy, seize
assets without judicial review, withdraw public housing or assistance.
But the real power of prohibition is that it creates the forbidden
world of danger and hedonism that the straights want to distinguish
themselves from. A black market spawns violence, thievery, and
illnesses - all can be blamed on the demon drugs. For a reminder, we
need only go to the movies (in which drug dealers are the stock
villains). Or watch Cops, in which, one by one, the bedraggled
junkies, fearsome crack dealers, and hapless dope smokers are led away
in chains. For anyone who is secretly ashamed, or confused, about the
explosion in legal drug-taking, here is reassurance: the people in
handcuffs are the bad ones. Anything the rest of us do is saintly by
comparison.
We are like Robert Louis Stevenson's Dr. Jekyll, longing that we might
he divided in two, that "the unjust might go his way and the just
could walk steadfastly and securely on his upward path, doing the good
things in which he found his pleasure, and no longer exposed to
disgrace and penitence by the hands of this extraneous evil." In his
laboratory, Jekyll creates the "foul soul" of Edward Hyde, whose
presence heightens the reputation of the esteemed doctor. But Jekyll's
dream cannot last. Just before his suicide, he confesses to having
become "a creature eaten up and emptied by fever, languidly weak both
in body and mind, and solely occupied by one thought: the horror of my
other self." To react to an unpleasant truth by separating from it is
a fundamental human instinct. Usually, though, what is denied only
grows in injurious power. We believe that lashing at the illegal drug
user will purify us. We try to separate the "evil" from the "good" of
drugs, what we love and what we fear about them, to enforce a
drug-free America with handcuffs and jail cells while legal drugs grow
in popularity and variety. But we cannot separate the inseparable. We
know the truth about ourselves. It is time to begin living with that
horror, and that blessing.
[1] Although I am critical of the exaltation of drugs, it must he
noted that a crisis runs in the opposite direction. Only a small
minority of people with schizophrenia, bipolar disorder, and major
depression - for which medication can he very helpful - receive
treatment of any kind.
[2] Fifty-five percent of American adults, or 97 million people are
overweight or obese. It is no surprise, then, that at least
forty-five companies have weight-loss drugs in development. itlut
niany of these drugs are creatures more of marketing than of
pharmacology. Meridia is an SSRI like Proac. Similarly, Zyban, a Glaxo
Wellcome product for smoking cessation, is chemically identical to the
antidepressant Wellbutrin. Admakers exclude this information because
they want their products to seem like targeted cures - not vaguely
understated remedies like the "tonics" of yesteryear.
[3] Declared Nancy Reagan, "If you're a casual drug user, you're an
accomplice to murder." Los Angeles police chief Daryl Gates told the
senate that "casual drug users should he taken out and shot." And so
on.
[4] Many people believe that this is still possible, among them House
Speaker Dennis Hastert, who last year co-authored a plan to "help
create a drug-free America by the year 2002." In 1995, Hastert
sponsored a hill allowing herbal remedies to bypass FDA regulations,
thus helping to satisfy Americans' incessant desire for improvement
and counsciousness alteration.
[5] The release describes Andrew Golden and Mitchell-Johnson as
"reputed marijuana smokers." No reference to Golden and pot could he
found in the Nexis datahase. The Washington Post reports that Johnson
"said he smoked marijuana. None of his classmates believed him."
[6] Such propaganda was crucial in convincing the South to allow the
Harrison Act's unprecedented extension of federal power. It would he
comforting to view this as a sad moment in history, but a prohibition
with racist origins continues to have a racist effect: Blacks account
for 12 percent of the U.S. population and 15 percent of regular drug
users. But they make up 35 percent of arrests for drug possession and
60 percent of the people in state prisons on drug offenses.
[7] Overdoses always increase in a black market, because drugs are of
unknown purity and often include contaminants. Although drug use
declined between 1971 and 1994, overdose deaths increased by 400 percent.
[8] A popular argument against medical marijuana is that it is a ruse
for the "real" goal of unrestricted use, but this argument is itself a
ruse. We put aside disagreements over amnesty to allow amnesty for
victims of political torture. We - at least most of us - put aside
disagreements over abortion in cases of rape. Medical marijuana use
for the seriously ill has the same unambiguous claim to legitimacy.
Yet sick people face arrest and punishment. In 1997, there were
606,519 arrests for marijuana possession and 118,682 arrests for
sale/manufacture; in the latter category fell an Oklahoma man with
severe rheumatoid arthritis who received ninety-three years in prison
for growing marijuana in his basement. The prosecutor had told the
jury that, in sentencing, they shouId "pick a number and add two or
three zeroes to it."
[9] Defining diseases around medication pleases drug companies as well
as HMOs. From 19811 to 1997, as general health-care benefits declined
7 percent, mental-health benefits fell 54 percent. Substituting pills
for psychotherapy helps cut costs.
[10] With a street name like Ecstasy, it is hard to take MDMA
seriously as a medicine, especially compared with words like
painKILLERS, or ANTldepressants, which signify the elimination of a
problem as opposed to the creation of pleasure. Rut the faux-Latin
pharmaceutical names are also designed to suggest the drugs' wonders.
David Wood, who used to run the firm that came up with the name
Prozac, explains it this way: "It's short and aggressive, the 'Pro' is
positive, and the Z indicates efficacy." One of Wood's employees
elaborated on good drug names: "Sounds such as 'ah,' or 'ay,' which
require that the mouth he open, evoke a feeling of expansiveness and
openness." As in Meridia, Viagra, Propecia.
[11] In the 1992 campaign, Bill Clinton said, "1 don't think my
brother would be alive today if it wasn't for the criminal justice
system." Roger served sixteen months in Arkansas State Prison for
conspiracy to distribute cocaine. Had he been convicted three years
later, he would have faced a five-year mandatory minimum sentence,
without the possibility of parole. If he had hod a prior felony or had
sold the same amount of cocaine in crack form, he would have
automatically received ten years.
-------------------------------------------------------------------
High Anxiety (The May issue of Reason magazine features senior editor Jacob
Sullum reviewing "Drug Crazy," by Mike Gray, and "Marijuana Myths: Marijuana
Facts," by Lynn Zimmer, Ph.D. and Dr. John P. Morgan.)
Date: Sun, 18 Apr 1999 18:08:15 +0000
To: vignes@monaco.mc
From: Peter Webster (vignes@monaco.mc)
Subject: [] Reason Magazine Reviews Drug Crazy and Marijuana Myths
Pubdate: May 1999
Source: Reason Magazine (US)
Copyright: 1999 The Reason Foundation
Contact: letters@reason.com
Address: 3415 S. Sepulveda Blvd., Suite 400, Los Angeles, CA 90034-6064
Website: http://www.reason.com/
Author: Jacob Sullum, Senior Editor jsullum@reason.com
Note: Senior Editor Jacob Sullum is the author of For Your Own Good: The
Anti-Smoking Crusade and the Tyranny of Public Health (The Free Press).
Note: Subject line by MAP. Also, we lost the newshawk's identity in
processing. Sorry!
HIGH ANXIETY
Drug Crazy: How We Got Into This Mess and How We Can Get Out, by Mike Gray,
New York: Random House, 251 pages, $23.95
Marijuana Myths, Marijuana Facts, by Lynn Zimmer and John P. Morgan, New
York: Lindesmith Center, 241 pages, $13.95 paper
Toward the end of Drug Crazy, Mike Gray takes us to the port of Los
Angeles, where shipping containers from all over the world, carrying
car parts, compact disc players, rattan furniture, and who knows what
else, are transferred from enormous vessels to trucks. This is one of
more than 300 ports of entry into the United States. "Los Angeles
alone will land 130,000 containers this month," Gray writes. "Customs
inspectors will examine 400. The other 129,600 will pass through
without so much as a tip of the hat....The entire annual cocaine
supply for the United States would fit in just thirteen of those steel
boxes. A year's supply of heroin could be shipped in a single container."
The image is worth remembering the next time a politician talks about
"cutting off the flow of drugs," as if the only obstacle were a lack
of resolve. The chief virtue of Gray's book, which includes some
firsthand reporting but relies heavily on secondary material and does
not offer much in the way of fresh analysis, is his ability to
succinctly and vividly communicate the futility of prohibition. A
screenwriter and director by trade, Gray has an eye for dramatic
juxtapositions and telling details, along with a smooth narrative
style that is rarely found in books about drug policy. As a result,
Drug Crazy is more accessible, though less rigorous and thorough, than
the scholarly work on which Gray draws. For a general audience, it is
probably also much more persuasive.
Say you want to convince someone that "source control" - a euphemism
for destroying drug crops and encouraging farmers to grow something
else - will never have a substantial or lasting impact on the supply of
cocaine. You could cite reports from the RAND Corporation, the General
Accounting Office, and congressional subcommittees. Or you could
recommend Gray's sixth chapter, "The River of Money," where he
observes: "The coca plant...is almost indestructible. It will grow
anywhere, including the sheer face of a cliff, and it will flourish in
soil too poor to support anything else. It has built-in resistance to
local bugs, and unlike tomatoes, rice, or beans - which have to be
reseeded each season - a single coca plant can last forty years.
Instead of one or two crops a year, you can harvest coca leaves every
ninety days. As a farmer-friendly shrub, about the only thing that
could beat Erythroxylon coca would be a money tree."
Similarly, Gray drives home the enormous profits created by
prohibition: "From farm to lab, it takes about 250 pounds of leaves,
worth say $150, to make a pound of cocaine you can sell in the
provincial capital for $1,500. But it is in the next step - getting it
from the jungle to the streets of Cleveland - that the price takes a
spectacular leap from $1,500 a pound to $15,000. This staggering
profit reflects the risk involved in moving the product from factory
to market." The profit margin for heroin is even bigger: "A kilo of
coke worth $2,000 in Bogota might bring $30,000 in Los Angeles, but
the identical block of heroin - only $6,000 in Colombia - could go for
$100,000 up north." It is hard to see how law enforcement agencies can
stand between determined criminals and this kind of business
opportunity.
Gray notes the temptations they face when they try. A Chicago
detective asks him to ponder a scenario: "You walk in a room - you're
making forty-five thousand a year - and there's a million dollars in
cash, and the guy jumps out the window. Do you chase him? Or do you
figure this is far enough?"
Prohibition breeds other kinds of corruption as well. Gray rides with
a group of cops who stop six black teenagers for no particular reason,
verbally abuse them, search them for drugs, find nothing, and let them
go. After this episode, one of the cops turns to him and asks, "So
what do you think the long-term sociological implications of this shit
will be?"
Gray observes assembly-line justice on the night shift at the Cook
County Courthouse, where he finds that police often misrepresent the
circumstances in which they find drugs so the evidence will be
admitted. "They lie, so we lie," one cop tells him. A public defender
notes that most of these cases involve simple possession, "so you have
a cop committing a greater felony [perjury] to convict a lesser
felony. It's gotta have an impact on a cop to stand up and lie on a
regular basis and think nothing of it."
Gray perceptively connects these routine violations to the motivation
behind the Fourth Amendment, which grew largely out of anger at
heavy-handed British efforts to locate smuggled goods. "In the drug
war," he writes, "we have discovered what King George understood so
clearly in the 1770s: it's practically impossible to catch buyers and
sellers of contraband if you stick to the rules. The illegal transfer
of goods between two people who are in agreement is a tough act to
interrupt."
By exploring how drug law enforcement actually works, Gray
demonstrates that prohibition is self-defeating, that it cannot
achieve its official goal of "a drug-free America." He also shows that
many people get trampled on the road to that ever-receding utopia. But
this is not enough to persuade the public that we would be better off
without prohibition. To do that, you have to assuage people's fears
about what the world would be like if the government stopped trying to
dictate the contents of our bloodstreams.
In this task, Gray is only partly successful. He highlights the
bigoted hysteria underlying the Harrison Narcotics Act of 1914 and the
Marihuana Tax Act of 1937: the talk of "numberless dope fiends,"
"cocaine niggers," marijuana-crazed Mexicans, and sinister Chinese
luring white women into their opium dens. He shows how drug users were
dehumanized, depicted as vampires who "infected everything they
touched." Heroin was said to "transform the addict into a monster who
has no control over himself and is compelled to spread his disease
like Count Dracula."
Gray contrasts this image with a 1914 report from the city health
officer of Jacksonville, Florida, who found that "a very large
proportion of the users of opiate drugs" - more than 80 percent - "were
respectable hard-working individuals in all walks of life." Gray
observes: "While it may seem bizarre to read that narcotics addicts
can hold down jobs and be useful, productive citizens, it turns out
there is no scientific evidence to the contrary. In fact, the medical
literature is filled with thoroughly documented records of addicts who
functioned normally throughout their lives."
On the same page, however, Gray asserts that "a junkie, though
starving, will trade food for dope." Later he uncritically repeats
another prohibitionist article of faith: "Crack cocaine, of course, is
an unparalleled menace." Since he does not bother to explain why,
readers are left to imagine the worst.
More fundamentally, Gray seems to endorse the disease model of
addiction, which says drug abuse is a disorder that should be treated
by medical professionals. The idea that heavy drug users suffer from a
compulsive illness may encourage compassion rather than hostility, but
it is not likely to reassure people who worry about the consequences
of repealing prohibition. Although less sinister, the drug user as
patient shares with the drug user as vampire one important
characteristic: Neither can be expected to control his impulses. This
assumed lack of responsibility is especially troubling when linked to
Gray's suggestion that heroin "be given away to serious addicts."
Gray is more persuasive when he talks about marijuana, which he
identifies as the "linchpin" of prohibition. "Take reefer out of the
equation," he writes, "and the number of illegal drug users instantly
drops from thirteen million to three million, and the drug war shrinks
from a national crusade to a sideshow." People are often surprised to
hear that marijuana is the main target of the war on drugs, accounting
for more than two-fifths of drug arrests, but it could hardly be
otherwise. Cannabis is by far the most widely used illegal drug: more
than four times as popular as cocaine, more than 40 times as popular
as heroin. Survey data indicate that about 70 million Americans,
one-quarter of the population, have tried it.
The fact that so many of today's voters smoked pot when they were in
high school or college creates a serious credibility problem for the
government. "When they failed to experience the instant insanity that
the authorities had promised," writes Gray, "it was for many an
epiphany more powerful than the drug itself - the realization that the
government makes stuff up....To bring these skeptics on board the war
on drugs, it was necessary to convince them that the basic facts about
marijuana had changed dramatically." Hence the ongoing propaganda
campaign warning us that marijuana is 1) more dangerous than we used
to think, or 2) more dangerous than it used to be.
In Marijuana Myths, Marijuana Facts, Lynn Zimmer and John P. Morgan
carefully refute both of these claims. The book is divided into 20
chapters, each addressing a particular belief about marijuana
illustrated by quotations from public officials or other sources
sympathetic to prohibition. Zimmer, a sociologist at the City
University of New York, and Morgan, a physician and professor of
pharmacology at the CUNY Medical School, provide extensive references
on topics such as addiction, brain function, pulmonary effects,
highway safety, and marijuana use during pregnancy. Their meticulous,
dispassionate, and concise summaries of the scientific literature make
the book a useful primer and a valuable research guide.
Despite decades of research, Zimmer and Morgan show, there is still
little evidence of significant hazards associated with moderate
marijuana use. The most serious health risk of heavy marijuana smoking
is probably bronchitis. Lung cancer is possible in theory, but you'd
have to smoke a hell of a lot to approximate the risk faced by the
typical tobacco smoker.
Zimmer and Morgan also demolish claims about marijuana's psychological
effects, including "amotivational syndrome." Their critique of the
"gateway theory" - the idea that marijuana use leads to the use of more
dangerous drugs - is particularly incisive. Prohibitionists are fond of
saying that people who smoke pot are 85 times as likely to use cocaine
as people who never try marijuana, which sounds like strong evidence
for the gateway theory. But as Zimmer and Morgan note, "The `risk
factor' is large not because so many marijuana users experiment with
cocaine, but because very few people try cocaine without trying
marijuana first."
To show why it does not necessarily follow that smoking pot makes you
more likely to snort cocaine, they offer an analogy: "Most people who
ride a motorcycle (a fairly rare activity) have ridden a bicycle (a
fairly common activity). Indeed, the prevalence of motorcycle riding
among people who have never ridden a bicycle is probably extremely
low. However, bicycle riding does not cause motorcycle riding, and
increases in the former will not lead automatically to increases in
the latter."
The book likewise makes short work of the argument that pot is more
hazardous nowadays because it's much more potent than it was when Bill
Clinton and Al Gore were toking up. First, claims of dramatic
increases in THC content are based on faulty sampling and invalid
comparisons. Second, even if average potency has risen, that would
tend to reduce health risks, since people would smoke less to achieve
the same effect.
Perhaps it's encouraging that defenders of prohibition are resorting
to such easily refuted arguments, which are so clearly aimed at
explaining away the hypocrisy of politicians who want to arrest people
for doing something those lawmakers once did with impunity. The heated
reaction of drug czar Barry McCaffrey and other federal officials to
the medical marijuana movement - which threatens to undermine just one
of the 20 myths that Zimmer and Morgan dissect - also suggests a
certain desperation.
The Clinton administration's official justification for the marijuana
status quo, as summed up by Secretary of Health and Human Services
Donna Shalala, goes like this: "Marijuana is illegal, dangerous,
unhealthy, and wrong." There's no denying that first part, and Zimmer
and Morgan do an admirable job of discussing just how "dangerous" and
"unhealthy" marijuana really is. But what does it mean to say that a
plant is "wrong"? It seems to mean that no good can possibly come of
it. To admit that anyone - even a cancer patient undergoing
chemotherapy - could smoke pot and be better off as a result would be
to admit that the federal government has been lying to the American
people about marijuana for more than 60 years.
Like McCaffrey and Shalala, Gray sees medical marijuana as a grave
threat to the war on drugs. "Prohibition, as a policy, can only
ratchet in one direction," he writes. "Each failure must be met with
more repression. Any step backward calls into question the fundamental
assumption that repression is the solution....Marijuana is the pawl on
the ratchet, the little catch that keeps the drum from unwinding....If
somebody jiggles that pawl and the drum slips, support for the current
policy will plummet like a loose cage in a mineshaft, because it
cannot sustain a serious evaluation." I'm not sure he's right, but I
like the metaphor.
-------------------------------------------------------------------
The Heroin Prescribing Debate: Integrating Science And Politics (Science
reviews the experience of Britain and Switzerland with heroin-maintenance
programs and concludes they will not replace oral methadone as the treatment
of first choice for stabilization. Its "short-acting nature" and expense
preclude its widespread introduction. More clinical trials are needed, but
the prescribing of heroin is about medicalization, not legalization, and so
does not violate the 1961 United Nations Single Convention on Narcotic
Drugs.)
Date: Fri, 28 May 1999 17:09:03 -0700
From: owner-mapnews@mapinc.org (MAPNews)
To: mapnews@mapinc.org
Subject: MN: US: The Heroin Prescribing Debate - Integrating Science And
Sender: owner-mapnews@mapinc.org
Reply-To: owner-mapnews@mapinc.org
Organization: Media Awareness Project http://www.mapinc.org/lists/
Newshawk: Bo
Pubdate: 01 May 1999
Source: Science, vol284, no5418, pp1277-1278
Contact: letters@starbulletin.com
Copyright: science_letters@aaas.org
Website: http://www.scienceonline.org
Authors: Gabriele Bammer, Anja Dobler-Mikola, Philip M. Fleming,
John Strang, Ambros Uchtenhagen
THE HEROIN PRESCRIBING DEBATE: INTEGRATING SCIENCE AND POLITICS
Heroin is abused in almost all countries. It is estimated that about 8
million people (0.14% of the world's population) use heroin each year
(1). Of the illegal drugs, it is associated with the highest mortality
and most emergency room episodes, and so is arguably the most
problematic from a health perspective (1). Along with prevention and
law enforcement strategies, treatment is an essential tool for
reducing illicit heroin use and its resulting problems.
The ultimate goal of treatment is to help those affected overcome
dependence and be fully reintegrated into society. Although dependent
users can proceed directly to detoxification and then strategies to
prevent relapse, this fails for a large proportion. Nonetheless, many
of these individuals may achieve new stability by daily oral
administration of methadone, which acts at the same cell surface
receptor as heroin. Methadone maintenance greatly reduces illicit drug
use and other criminal activities and improves health and social
behavior (2). It is the most widely practiced treatment for heroin
dependence in the developed world (1). But some fail to benefit from
methadone and other treatments, so that alternatives are needed for
these resistant individuals. Consequently, heroin itself has been
reconsidered as a treatment option.
The best information about the prescription of heroin as a maintenance
drug comes from decades of experience in the United Kingdom and from
recent Swiss cohort studies. Clinical trials have also commenced in
the Netherlands (3), and there is growing debate about initiating
trials in other countries. This debate should be informed by scientific
evidence and should address political, social, clinical, and scientific
concerns.
What Does Existing Evidence Tell Us?
In the United Kingdom, heroin prescription has existed within an
overall policy of prohibition for decades. The 1926 Rolleston
Committee (4) established the right of medical practitioners to
prescribe regular supplies of an opioid drug, including heroin, if
this would allow patients to lead "a useful and normal life" that
could not otherwise be achieved.
Heroin dependence in youths only became significant in the 1960s, and
thus heroin began to be prescribed more widely and in higher doses,
especially in the London area. Overprescribing by a small number of
practitioners also created a substantial black market (5). This was
rectified in 1968 partly through restriction of the right to prescribe
heroin to specially licensed doctors and the establishment of clinics
(6). There are, however, widely varying interpretations of the
effectiveness of heroin prescription in the UK. Although a randomized
controlled trial in which oral methadone was compared with injectable
heroin showed that neither was clearly superior (7), consensus among
clinicians led to a shift away from the prescribing of injectable
heroin to injectable and oral methadone in the 1970s.
Since then, heroin has only been prescribed for those with long
histories of dependence for whom other treatments have not been
effective. Currently around 300 people (between 1 and 2% of those
receiving a prescription for the treatment of opioid dependence)
receive pharmaceutical heroin (8), usually provided as take-home
supplies. Of the 109 doctors with licenses to prescribe heroin, fewer
than 50 currently use them and about 20 of these account for the bulk
of prescriptions (9). In a survey of physicians who treat people
dependent on heroin, half of the 105 respondents thought heroin
prescription was justified sometimes or often (10). A recent study
that gave 58 long-term dependent users the choice of injecting heroin
or methadone showed improvements in health and social functioning and
reductions in criminal behavior (11).
In Switzerland, a cohort study undertaken from 1994 to 1996 showed
that a system of supervised heroin administration at clinics with
restricted operating hours was feasible as well as politically and
socially acceptable. This result was documented in 17 clinics where a
total of 1035 individuals with chronic and treatment-refractory heroin
dependence were accepted for maintenance with supervised injectable
pharmaceutical heroin (often in combination with take-home oral
methadone) in the framework of a comprehensive assessment and care
program. Concerns about doses escalating out of control proved to be
unfounded, and most participants achieved stable doses in 2 to 4
months. Randomized studies showed that injectable heroin was superior
to both injectable morphine and injectable methadone in attracting the
target group, preventing premature treatment dropout, and reducing
illegal drug use (12).
Participants in this study showed substantial improvements in health
and well-being and very pronounced reductions in crime (12). Crime
reduction was verified by examination of police records and the
central criminal register. Similar results were found in a randomized
controlled study in Geneva (13). The results for the cohort study
participants were compared with those for 121 newly admitted patients
on methadone maintenance who received comparable psychosocial support.
Those in the cohort study showed significant reductions in illegal
heroin, cocaine, and nonprescribed benzodiazepine use, whereas the
methadone patients showed smaller reductions in illegal heroin use.
Both groups showed similar improvements in social integration. Thus,
heroin prescription can be helpful for those on methadone maintenance
treatment who continue to use illegal heroin regularly, as well as for
those who have dropped out of existing treatments (14).
Requirements for New Trials
If the pharmaceutical in question were not heroin and the disease were
not heroin dependence, the next step--a double-blind, double-dummy
Phase III clinical trial in which the new treatment would be compared
to the current gold standard (in this case methadone)--would be
straightforward. But pharmaceutical heroin is not simply a replacement
for methadone. The British experience and Swiss studies have shown
that to achieve stabilization lasting 24 hours, injectable heroin
(which is short-acting) is most often combined with a low dose of oral
methadone (which is long-acting). In addition, doses of both drugs are
tailored to individual requirements. Thus, fixed-dose comparisons
between heroin and methadone make little sense. In addition, unlike a
standard clinical trial, participants would be experienced users of
both heroin and methadone, so that double-blind, double-dummy studies
would not work. For trials targeting those who have failed methadone
treatment, the possibility of random assignment to methadone treatment
may limit those prepared to participate. A variety of trial designs,
each addressing a different issue about heroin prescription, is
therefore warranted. No one trial will provide a definitive answer,
but interlocking trials will allow decisions about the long-term value
of heroin prescription to be reached.
Defining the target population also raises challenges. There are three
target populations: those who have not been helped by existing
treatments, those currently in treatment who continue to use
substantial amounts of illegal heroin, and those who refuse to try
currently available treatment options. However, these definitions are
problematic. It is common for people to have several treatment
attempts before they are successful; continued use of illegal heroin
during treatment may be a reflection of too short a time in treatment
or of the treatment's inadequacy. Also, most dependent heroin users
are reluctant to enter treatment until compelled to do so by social,
legal, or economic crises. It can be argued that something other than
heroin prescription might be effective. A resolution would be to
include a third "arm," testing an alternative therapy, in each
clinical trial.
Risks
An Australian feasibility study (15) identified strategies to deal
with individual and social risks associated with trials of
pharmaceutical heroin. Because there is so little empirical evidence
about heroin prescription and because the issue is highly politicized,
it is difficult to estimate the likely magnitude of the potential
risks. There are five risks of overriding concern:
1. Heroin prescription might be linked with more permissive attitudes
to illegal drug use, encouraging use especially among young people.
This was the reason given by the Australian government for blocking a
proposal for a clinical trial of heroin prescription in 1997. However,
heroin prescription and permissiveness are not inevitably linked, as
the British experience and Swiss studies show.
2. There might be an influx of dependent users to the trial city. This
"honey pot" effect can be minimized by enforcement of strict residency
criteria, by limiting the number of trial participants, and by close
cooperation with the local police (16).
3. Heroin prescription may reduce the proportion of participants who
become abstinent. There has been little research into the achievement
of abstinence because of the long-term nature and expense of the
necessary investigations, hence the available figures are limited and
dated (17). Critics of the Swiss cohort study argue that it has failed
because only around 8% of participants moved into drug-free treatments
within 18 months (12). Yet, over this short time frame, the Swiss
results are consistent with existing evidence for chronically
dependent people (17) and may instead show that heroin prescription
does not reduce the rate of achievement of abstinence.
4. The introduction of heroin prescription may undermine the
attractiveness and effectiveness of other treatments. There is little
evidence on which to assess this risk.
5. Heroin treatment may be unaffordable, especially as ever-increasing
health costs are a concern of many governments. Results from the Swiss
cohort study, however, indicate significant overall savings (SF45 net
per person per day) (12).
Conclusions
Assessment of the effectiveness of heroin prescription for the
treatment of heroin dependence requires that standard clinical trials
be set up. However, the nature of the condition, problems with
consent, difficulties in running a double-blind trial, and more than
one outcome measure are major problems, although they are not
insurmountable.
Is the testing of heroin prescription worth the effort? Research
trials will be deemed unnecessary and inappropriate by various
parties - by some dependent heroin users and their advocates who
believe the benefits are self-evident, and by some who find such an
approach offensive and incompatible with the principles of medical
practice. But the debates about heroin prescription and the potential
hope it offers the chronically dependent cannot be resolved without
high-quality empirical evidence.
Where will it all lead? Heroin will not replace oral methadone as the
treatment of first choice for stabilization. Its short-acting nature
and expense (including the necessary social safeguards) preclude its
widespread introduction. The clinical trials are important to
determine whether heroin has a role as an adjunct to methadone
maintenance - to improve treatment success for those who have failed
existing treatments. Finally, the prescribing of heroin is about
medicalization, not legalization. The 1961 United Nations Single
Convention on Narcotic Drugs places effective constraints on
pharmaceutical heroin availability. These "limit exclusively to
medical and scientific purposes the production, manufacture, export,
import, distribution of, trade in, use and possession of drugs" (18).
Heroin prescription does not challenge the fundamentals of
prohibition. Indeed, the debate about heroin prescription should
promote continuing assessment of the scientific evidence underpinning
current treatment, law enforcement, and prevention policies, as well
as stimulating well-designed empirical investigations to find more
effective strategies.
References
1. United Nations International Drug Control Programme, World Drug
Report (Oxford Univ. Press, Oxford, 1997).
2. J. Ward, R. P. Mattick, W. Hall, Eds., Methadone Maintenance
Treatment and Other Opioid Replacement Therapies (Harwood,
Amsterdam, 1998).
3. Investigating the Medical Prescription of Heroin. A Randomized
Trial to Evaluate the Effectiveness of Medically Co-Prescribed
Heroin and Oral Methadone, Compared to Oral Methadone Alone in
Chronic, Treatment-Refractory Heroin Addicts (Central Committee
on the Treatment of Heroin Addicts, Utrecht, 1997).
4. Rolleston Report of the Departmental Committee on Morphine and
Heroin Addiction (Ministry of Health, London, 1926).
5. H. B. Spear, in Heroin Addiction and Drug Policy: The British
System, J. Strang and M. Gossop, Eds. (Oxford Univ. Press,
Oxford, 1994), pp. 3-28.
6. Interdepartmental Committee on Drug Addiction (Brain Committee),
Drug Addiction, Second Report (Her Majesty's Stationery Office,
London, 1965).
7. R. L. Hartnoll et al., Arch. Gen. Psychiatry 37, 877 (1980).
8. J. Strang and J. Sheridan, Drug Alcohol Rev. 16, 7 (1997).
9. P. M. Fleming, in Feasibility Research into the Controlled
Availability of Opioids, G. Bammer, Ed. (Stage 2 Working Paper
No. 14, National Centre for Epidemiology and Population Health,
Australian National University and Australian Institute of
Criminology, Canberra, 1997), pp. 1-8.
10. L. Sell, M. Farrell, P. Robson, Drug Alcohol Rev. 16, 221 (1997).
11. N. Metrebian, W. Shanahan, B. Wells, G. Stimson,
Med. J. Aust. 168, 596 (1998).
12. A. Uchtenhagen, F. Gutzwiller, A. Dobler-Mikola, T. Steffen,
Eur. Addict. Res. 3, 160 (1997); ____, M. Rihs-Middel, Eds.,
Prescription of Narcotics to Heroin Addicts. Main Results of the
Swiss National Cohort Study (Karger, Basel, in press).
13. T. V. Perneger, F. Giner, M. del Rio, A. Mino, Br. Med. J. 317,
13 (1998).
14. A. Dobler-Mikola, S. Pfifer, V. Muler, A. Uchtenhagen, Heroin and
Methadone Maintenance: A Comparative Study (Karger, Basel, in
press).
15. G. Bammer, Report and Recommendations of Stage 2 Feasibility
Research into the Controlled Availability of Opioids (National
Centre for Epidemiology and Population Health, Australian
National University and Australian Institute of Criminology,
Canberra, 1995), report and working papers available at
http://nceph.anu.edu.au/pub/opioids/opioids.htm; ------ and
R. M. Douglas, Med. J. Aust. 16, 690 (1996); G. Bammer, CNS Drugs
11, 253 (1999).
16. G. Bammer, D. Tunnicliff, J. Chadwick-Masters, Feasibility
Research into the Controlled Availability of Opioids (Stage 2
Working Paper No. 9, National Centre for Epidemiology and
Population Health, Australian National University and Australian
Institute of Criminology, Canberra, 1994).
17. A. Thorley, in Drug Problems in Britain: A Review of Ten Years,
G. Edwards and C. Rush, Eds. (Academic Press, London, 1981),
pp. 117-169.
18. Single Convention on Narcotic Drugs, 1961, as Amended by the 1972
Protocol Amending the Single Convention on Narcotic Drugs, 1961
(United Nations, New York, 1977), p. 19.
***
G. Bammer is with the National Centre for Epidemiology and Population
Health, Australian National University, Canberra ACT 0200, Australia.
E-mail: Gabriele.Bammer@anu.edu.au. A. Dobler-Mikola is with the
Addiction Research Institute, Konradstrasse 32, CH-8005 Zurich,
Switzerland. E-mail: isfdomi@isf.unizh.ch. P. M. Fleming is at the
Portsmouth City Drugs and Alcohol Service, 130 Elm Grove, Southsea,
Portsmouth, Hampshire PO5 1LR, UK. E-mail: PhilipFleming@compuserve.com.
J. Strang is at the National Addiction Centre, Institute of
Psychiatry, London SE5 8AF, UK. E-mail: j.strang@iop.kcl.ac.uk. A.
Uchtenhagen is at the Addiction Research Institute, CH-8005 Zurich,
Switzerland. E-mail: uchtenha@isf.unizh.ch.
to the 1999 Daily News index for April 30-May 6