The War for Drugs
After reading The Cult of Pharmacology by Richard DeGrandpre, I'm reminded of an issue with gun manufacturers brought up in Michael Moore's movie Bowling for Columbine. The fact is that most crime guns can be traced to a small number of retailers. What if the FBI were to provide this information to gun manufacturers, and they could refuse to sell their product to these retailers? If it were to reduce gun crime and improve public perception of guns, it would ultimately be in the manufacturer's interest to do so. But gun manufacturers don't want to touch this, partly because they want to keep their industry totally separate from what people choose to do with their product.
Psychoactive drugs are not so different. The synthesized drugs of the modern world, starting with cocaine, are not created and introduced to the public by the criminal gangs that now manage some of the biggest cash cows (like cocaine). Rather, while pharmaceutical companies are trying to beat the patent cycle to get their investment out of new compounds before they go to generic, another kind of "natural" sociological patent cycle is happening with the criminal world. Psychoactive drugs are introduced and popularized in the scientific, medicalized world, and then if they are profitable enough they go "generic" to the criminal world.
The end result of this is a real war, with real bullets, and real shattered communities, families and individuals. We gasp at the absurdities of the sugar wars of centuries past, and are incensed by whatever economic motives, real or surmised, motivates more recent battles. But in the economic war for drugs, "bad" people die to preserve the prosperity of pharmaceutical companies as they develop products for the "good" people. It is a battle between good and evil for angel and demon compounds (p. 139) where the AMA is the Vatican, the FDA is the Office of the Inquisition, and the DIA, CIA, etc. are the executioners.
Illegal or legal, America is the most lucrative market for drugs in the world. A rising tide lifts all boats, and Americans truly believe that drugs work- that certain chemicals will not only bring us back into balance or resist illness, but actually cause health, cause us to be "better than well." We believe it so strongly that the illegal use of drugs is much higher now than it was prior to the era of concern over drugs (p. 128). Additionally, the illegal drug trade directly feeds an industry built around treating addiction. Concepts of dependence and addiction, mythologies of the magical essence of drugs that can take over the soul, feed both the drug addiction and the "need" for drugs and a medicalized process to escape the addiction. The same concept of addiction that sells more cigarettes also sells more stop-smoking products. The war against drugs is a mislabeling; the war is for drugs and for which kinds of drugs will be used. Your therapist is no more likely that your crack dealer to support you in leaving the church of pharmacology.
How The War Was Won
While The Cult of Pharmacology elegantly lays out the meaning of drugs and how the battle lines were created, Generation Rx by Greg Crister recounts the history of one particular battle- selling a patriotism to pharmacology, that is, getting the public to stand behind the "right" side of the line with vigor. On it's own it presents a fascinating history that carefully weaves in the subtle intellectual shifts that arrived at the present day. However it also engages in lame sniveling attacks at pharma that pander to a public that wants to blame someone else for the distressing reality that drugs aren't angels or demons- they are merely chemicals, which many different effects on the mind and the body.
According to Crister, the turning point in modern Direct to Consumer (rather than filtered through doctors) marketing came in response to a book by Ivan Illich called Medical Nemesis. Illich was a philosopher who had written several other books about systems of modernity and he wrote sharply about the reductionism of modern medicine:
Before sickness came to be perceived primarily as an organic or behavioral abnormality, he who got sick could still find in the eyes of the doctor a reflection of his own anguish and some recognition of the uniqueness of his suffering. Now, what he meets is the gaze of a biological accountant engaged in input/output calculations. His sickness is taken from him and turned into the raw material for an institutional enterprise. His condition is interpreted according to a set of abstract rules in a language he cannot understand... Language is taken over by the doctors: the sick person is deprived of meaningful words for his anguish, which is thus further increased by linguistic mystification. (quote secondary from p. 41 of Generation Rx)
Illich was criticizing the message of the mass of the Cult of Pharmacology. Joe David, a high-flying advertising executive specializing in drug ads read it and saw a criticism of the mass being in Latin. According to Crister, this was the turning point which, after creative advertising and a few law suits, lead to the current Direct to Consumer age.
It is hard to argue against the idea that disease and drug information should be provided to consumers in plain English. The author tries to present sound arguments about why consumers should be protected from focused advertising, but most arguments are easily countered by the protection the consumer has in their ever increasing education. At one point he even criticizes the idea of creating one-a-day or combo drugs simply because they are more convenient. (pp. 124 - 125) But I've used one of medications he attacks and it is easier to use one product once a day than two different products twice a day (four uses per day). Eventually he ends up sounding nearly incensed (pp. 159 - 162) that consumers might be making their own drug choices.
Central to his argument is his buy-in that drugs are either angels or demons (although in his world they are all demons, "poisons"). Any safety issue could label the product a "harmful drug". (p. 191). But drugs are simply chemicals that have many effects on the body. (In his book, DeGrandpre comments on the strange fact that, when it comes to drugs, you find yourself repeating the obvious.) Users, and their advisors (doctors), select whether or what drug to use based on what risk they are willing to tolerate for relief from what symptom. That's medicine. The FDA regulates how much certainty we want to have in our knowledge of drug effects, and at what cost. Making that determination is politics. Absolutely nothing in the universe will make a drug equal health, no amount of kind spiritedness on the part of pharmaceutical stock-holders, no amount of regulation, nothing. A drug is just a chemical.
Dependence and Addiction in Context
Where The Cult of Pharmacology really shines is in discussion of exactly what drug dependence and addiction means. The author discusses a seven-level scale of drug use (abstinence, experimental, circumstantial, casual, regular, dependence, addiction) (pp. 94-95) and the complexities of drug effects on the body. He discusses the "placebo text", that is, the myth that tells an individual what will happen to their body when they consume a particular drug. (p. 120) The voluminous information about placebos is clear enough evidence the use of a drug is about much more than interactions of chemical. DeGrandpre presents a host of animal, human, and sociological studies that show drug effects to be infinitely more complicated than just the issue of chemical placebo hints at. The following is perhaps the heart of the book:
In fact, at the center of the new scientific wisdom remains a firm belief in the magicalism of millennia past. As a drug ideology derived from the eternal notion that psychoactive compounds contain a unique spirit or essence, the cult of pharmacology legitimized the belief that these spirits bypass all social conditioning of the mind and by themselves transform human thought and action. Unlike other worldly modes of influence on mind and human experience, and despite many real advances in the pharmacological sciences in the twentieth century, psychoactive substances continued to be treated in the main as spirits that could enter into the body and take possession of it. Yes, soul was translated into mind, and spirit was translated into biochemistry, giving the appearance that science and medicine had done away with the myths surrounding what had come to be understood as "drugs." Drugs were not demythologized, however, by rather remythologized. Psychobabble and biobabble replaced magical explanations of drug action, creating what had become by the end of the century a new, molecular pharmacologicalism. These modes of explanation were then used to forge a modern pseudoscience of good and bad drugs, enforced via a differential prohibition of angels (Like Ritalin) and demons (like cocaine). The "rational" science of drugs, in other words, carried myth along with it; it was itself framed and motivated by myth--a myth of angels and demons.(pp. 104 - 105)
Our belief in drugs is truly magical. Consider this: patients who are given a placebo and told that it is a placebo nonetheless frequently get better. (p. 60) We kill people at home and abroad over cocaine ("No doubt the war on drugs will one day rank amongst the most shameful periods in American history." -p. 174), but we give our children the virtually identical compound Ritalin. (p. 28) The placebo text tells us that one in a dangerous drug used by degenerates, and the other helps our children cope with the modern knowledge economy. The author notes:
Drugs contain potentialities that lie within the drug's chemical structure, pharmacologism posits, and when taken into the body, these potentialities take hold of and transform both brain and behavior. This way of understanding drug outcomes has great efficiency, for it affords society with the opportunity to classify drugs once and for all as angels and demons, independent of time, person, or place. Accordingly, the evil that some drugs pose is determined not by societal conditions or attitudes about these drugs--by experience--but by the drug's essence. A century of angels falling from grace did not diminish the popularity of this theory, moreover, since the notion of pharmacological determinism was never judged to be in error; instead, each fallen angel was declared, one after another, to have been inadequately assessed pharmacologically. (pp. 209-210)
I do think that the author goes a bit off in his argument against the negative effects of drug addiction. For example, he suggests that smoking mostly only reaches the level of dependence, not addiction, where addiction is defined as "an activity so all-consuming that it disrupts the normal functioning of a person's life." (p. 95) Risking a painful and early death cannot possibly be mere "dependence". Risking severe life disruption because of possible criminal persecution, even if an artificially created outcome, cannot possibly be mere "dependence." I see fellow food addicts trying to split this hair quite frequently. They want to say that they aren't addicted to food because they haven't done anything irrational to get food, or pursued food in an irrational way. True, but they are willing to endure the prison of obesity, and possible suffering and death as well, for the food. That rational error is addiction.
On the other hand, the war on drugs model mirrors a puritanical world-view where life is a series of tests by God. If you are not capable of passing the test, you are not welcome to participate in our society. It is very plausibly argued that the drugs test is not administered on a level playing field. And of course the law has in a certain sense caught up with this as the differential sentencing between powder and crack cocaine is being struck down. But beyond that it is a matter of presenting people of different social experiences and enrichments with an alienated drug alternative, blessing those who take the alternative one way (sanctioned drugs) and striking with lightening those who take it another way (street drugs). While it is not completely irrational for social ideals about drug use to be encoded into law, and especially not irrational for protections from irresponsible users (e.g. drunk drivers) to be legally encoded, there is a problem with the legal and scientific encoding of the irrational.
Personal Response to the Story of Addiction and the Demythologizing of the Angels
In discussion addiction as being about more than a simple chemical reaction, the author produces a description of opiate withdrawal that I can more than identify with as a food addict:
If and when the opiate user identifies opiate withdrawal as such, still another step must be taken for drug dependence to emerge. Specifically, he or she must complete a ritual activity that is partly physiological, partly cognitive, and partly behavioral. That is to say, the opiate user must experience withdrawal (a physical phenomenon), he or she must develop a concern over the withdrawal experience as such (a physical phenomenon), and then he or she must engage in drug use, take opiates repeatedly to eliminate or avoid opiate withdrawal (a behavioral phenomenon). A breakdown in any part of this biopsychosocial circuit can prevent a pattern of dependent opiate use from emerging. For example, an individual may experience little physical withdrawal following repeated opiate use, or, as found in Scharse's study of Mexican Americans, a person might interpret withdrawal as a sign of impending drug dependence and subsequently reduce or quit his or her drug habit. If, on the other hand, a withdrawal experience causes an individual to become obsessed with the prospect and experience of withdrawal--and to continually use in order to avoid it--the circuit will be completed, with the learning process now occurring repeatedly, thus reinforcing the drug habit at all three levels: physiological, cognitive, and behavioral. (pp. 119-120)
The consequences of food withdrawal are the simple experience of hunger and the re-emergence of the stress of everyday life. Hunger is not that dramatic, and the stress of life is not as overwhelming as it once was. However, I am capable of ending up in a pattern of obsession over the boogie-man of hunger. It takes a period of time where I can remove myself from everyday life and re-learn to experience and tolerate hunger before I can return to a normal pattern of eating, at which point it seems absurd that my fear of hunger could have ever been that extreme.
One study particularly caught my eye, which was the number of studies involving cocaine at different titrations vs. sucrose at different titrations (p. 200). All of this is meant to demonstrate that cocaine is not chemically addictive, and no attention seems to be paid to another possible interpretation, which is that sucrose is as addictive as cocaine.
An additional point is that ritual itself is not the problem. Every activity engaged in, every response to stimulus, has a psychosocial component. The goal is to create psychosocial experiences which are present and whole. Mal-adaptive drug (and food) rituals are the problem, where the experience is fragmented and alienated. It doesn't even take a substance to encourage the maladaptive ritual. Gambling addiction is commonly understood, and at different times and places street drugs become near placebos, such as the use of heroin nationwide in 1973 when a national storage drove the purity of street product as low as 0.5% (p. 203) meaning that this was no longer a maladaptive drug culture but a maladaptive injection ritual culture.
The author tries to make the point that making pharmacologism (as addiction) part of the study of pharmacology is like making sun worship part of astronomy (and cites the book Ceremonial Chemistry by Thomas Szasz in making this argument). (p. 221) But pharmacologism, the psychosocial relationship with the meaning of the drug, in inherent in the use of the drug. The author further tries to argue that drugs are only a kind of a stimulus, "...the core myth underlying the cult of pharmacology is that drugs are unique from other, traditional modes of experience..." (p. 240) Of course this is absurd; drug use will always be part of a wider story. Really, every stimulus is. Meaning can be imparted in a whole way: I once knew a breast cancer survivor on tamoxophin who kept notes about the success of tamoxophin all around her environment. Similarly, I've realized that my food withdrawal obsession focuses on certain symptoms. Would it not be reasonable to use the most simple and safest compounds, such as bicarbonate to prevent stomach pain, to reduce my concern about those symptoms? (I have to admit I find myself drawn to the scientific magic of ranitidine instead, and in fact in giving my food addiction a good smack down this weekend resorted to taking it rather than the bicarbonate that I had planned on. It was an illogical "pharmacologism" decision.)
The other side of withdrawal obsession is craving obsession. Interestingly, it seems that craving symptoms and actual drug use do not correlate. (p. 232) That is definitely true in my experience with food- cravings are just information. Sometimes they are information that the devil is knocking on the door and there is no way he should be invited in, literally, to supper. Other times it means I should feed him right away so that he'll go away and let me get back to the rest of my life.
As a last note, it is an interesting slap in the face to the addiction industry that it doesn't own the pathway to ending addiction- there are many pathways, and an individual is as likely to use the tools of the industry (medications, therapy, etc.) as not. (pp. 117-118, citation: Waldorf and Biernacki, The natural remission from opiate addiction: Some preliminary findings, Journal of Drug Issues II (1981): 61-74) "Recovery," whatever that means, is an individual process with an individual definition of attainment.
Meta-pharmacologism: The Hope Before Drugs
Ultimately reading these books has reinforced for me the idea that we need existentialism now more than ever. Critler, by no means writing a philosophical work, comes to the same conclusion which he couches in the term "notion of independence." (p. 250) He is talking from a behavioral and policy standpoint- as individuals, as patients, as doctors, as regulators, as a society, we each need to be approaching our decisions about drugs from a place of independence. We are not the unwashed worshiping at the alter of pharmacologism; we each can determine the meaning and experience of a drug for ourselves, appropriate for the particular role we fill.
Pharmacologism as a psychosocial story or myth, and pharmacology as a science, have both created reductionist beliefs about what a human "is". I view this reductionism as heretical. Reductionist concepts of addiction are the opposite of certainty about another person's choices in that it is certainty about their lack of choice. In this addiction concept, only other people can experience pure addiction. You yourself cannot, because your experience of your own complexity does not allow it. Where you have been convinced to ignore your own experience of your complexity and believe a reductionist theory of addiction, something evil has been done to you and it wasn't done by a chemical.
I am perhaps fortunate in that food does not lend itself to reductionist theories of addiction, though there are plenty hot on the efforts to shoehorn it into one. I did at one time think that there was nothing I could change about my relationship with food, that it's "just how I am." There are people who take set-point theories about body weight and try to sell them to the obese- how absurd is it to claim that my body wanted to be 300 lbs.? But that is the sale that is underway. In losing weight, I've proven more than that I can manage addiction, or that I have it in me to do things that I'm proud of doing. I've proven that as a human being, I can set the meaning of my own life. Meaning comes before direction and action, before chemicals and other things of the physical world, and is perhaps the most important thing that a human being creates.
P.S.
Another interesting looking book about the shaping of drug and medical information and meaning: Selling Sickness
Also by Greg Critser: Fat Land: How Americans Became the Fattest People in the World
Also by Richard DeGrandpre: Ritalin Nation: Rapid-Fire Culture and the Transformation of Human Consciousness
