The stories we tell ourselves matter: As Joan Didion memorably put it, “We tell ourselves stories in order to live.” But journalists have a special responsibility because the way we frame our narratives doesn’t only affect us—it can influence readers and public policy. And the story we are telling about drugs isn’t working.
A front-page article in last Sunday’s New York Times is a classic example. Headlined “Heroin Takes Over a House, and Mom, on New York’s Staten Island,” it tells the tale of a mother of three who lets her home become a heroin dispensary and shooting gallery as she begins selling the drug with her boyfriend.
From the start, we know what to expect. A white housewife, seduced by an evil drug. And soon, that’s the description we get of 45-year-old Laurie Sperring:
Ms. Sperring’s fall from life as a suburban mom and a wife played out with dizzying speed. By the end, her modest condominium was a locus for a borough’s ravenous heroin demand. Dealers set up there; Staten Island’s bands of addicts, linked by word of mouth and cellphone connections, descended en masse; the police followed.
But that summary leaves out information that in a more accurate framing would be central. For one, Sperring was not just a bored homemaker who recklessly experimented with an opiate and got hooked: She’d already been addicted to crack cocaine and possibly alcohol for years and had lost her husband, daughter and two stepchildren as a result of her refusal to deal with those addictions.
In fact, she met the dealer she lived with through a woman she was locked up with on Riker’s Island. Before even trying heroin, then, she’d served an eight-month sentence for identity theft, which she’d been committing to support her crack habit.
Indeed, in the 1980s, the Times would almost certainly have told her story as one that illustrated the terror of crack, the demon drug of that period. The paper focuses on her heroin addiction now because that is the current drug-of-obsession.
This is how the Times describes those events:
To witness what happened in 19 Wood Court, to grasp the mix of temptation, chance and dark opportunity that took place there, is to see how heroin addiction can metastasize and ruin the many lives it touches. The drug has been found in all walks of life on the island, but Ms. Sperring’s addiction offers a vivid, telling example of the blight, one that drove away her family and poisoned her neighborhood.
Except, as the Times reports only later in the piece, the “blight” that made her family leave was this:
She sold her jewelry for money to buy cocaine. When that was gone, she turned to her daughter’s. “She stole my tennis bracelet,” Ms. Potter said. It was engraved, a gift from her mother.
She ran up credit card charges. She went to a P.C. Richard & Sons electronics store with her cocaine dealer and let him pick out a new computer and a camcorder for himself in exchange for $500 or so worth of drugs.
Her husband found out. “That’s when the fighting started,” Mr. Sperring said.
Saying Sperring’s problem is heroin doesn’t tell the real story. Even if she’d never tried it, addiction had already “taken over” her life and addiction isn’t just about a particular drug. The predisposition to it may not have anything to do with drugs at all, in fact—and may simply incline particular people to compulsive behavior across many dimensions. Research shows, for example, that at least half of all addicted people have more than one type of substance problem—and the more severe the addiction, the more likely it is to involve multiple drugs.
And there’s another critical issue that gets elided in the Times’ rush to blame a trendy drug for a downfall. Sperring’s crack addiction didn’t come out of nowhere: She’d apparently been a longtime functional cocaine user before tragedy hit her family. Then, in 2010, her aunt’s son stabbed both of his parents to death.
These weren’t distant relatives. Sperring worked for her aunt and uncle and was so close to her aunt that she saw her as almost a second mother, visiting with her daily. The young man who killed his parents suffered from schizophrenia, a condition that has genetic roots and that may also offer insight into Sperring’s story.
Not only do most people with addictions misuse multiple drugs, around half have pre-existing mental health problems. For women, the rates are even higher. These conditions tend to run in families. In fact, the same genes that increase risk for schizophrenia can also increase risk for depression and bipolar disorder—and all of these conditions also increase risk for addiction.
Yet year after year, the media tells us stories of “drug epidemics” that sweep in, apparently from nowhere, and “take over” apparently random people and communities. What this narrative obscures is that the demand for some type of escape is reasonably constant and that the people who are affected share some key characteristics, which make all the difference.
Among people who have good coping skills, a sense of meaning and purpose, the opportunity for productive work and good mental health, addiction is rare. Only about 10-15% of people who try heroin become addicted to it; the same is true for crack. If you don’t use these drugs during adolescence or early adulthood, the odds of addiction in later life are in the single digits.
And who tends to use earliest? People who have experienced trauma and neglect, those who live in violent, chaotic neighborhoods, have addicted or mentally ill parents and/or who show early signs of mental illness and behavioral problems themselves.
Drug epidemics also have clear antecedents and they don’t just happen anywhere. Rising unemployment tends to precede them, and despite media fear-mongering, they never hit employed middle-class people and the neighborhoods they live in as hard as they slam those without means, alternatives, education and opportunity.
Many of the young men who sold crack in the 1980s, for example, had lost factory jobs, as the research of anthropologist Philippe Bourgois showed. De-industrialization and large job losses often directly precede an epidemic in a community.
When we tell drug stories as accounts of individual sin and redemption, we ignore this larger context. When we try to claim that heroin is an “equal opportunity” drug, we miss the story of who is most at risk and why.
Ms. Sperring told the Times, “People have this misconception that you have to look a certain way. There’s not a face of heroin.” While that’s true—the stereotype of the junkie is racist and the idea that white people are rarely affected is false—it is also incorrect to claim that all people are at equal risk of getting hooked. Employment, education, trauma and mental health are critical.
And so rather than focusing on one drug after another, we need to look at why the demand for them is always there, at how to help people who are traumatized or mentally ill and at how to increase meaningful employment. In Sperring’s case, for example, a sensible system would have evaluated her when she was arrested during her cocaine addiction, would have offered treatment for her addiction and for the trauma that preceded it, and would have tried to help her re-assemble her life.
In fact, New York Mayor Bill DeBlasio has just proposed a new initiative that will try to provide services to extricate mentally ill and addicted people from the criminal justice system or to try to keep them out of it in the first place.
But if we continue to focus on particular substances and the idea that they come out of nowhere and can “take down” anyone, we won’t support policies that actually work. If heroin were the problem, reducing supply would be the solution—however, we already know how well that works. The recent rise in heroin use itself followed a crackdown on supplies of opioid painkillers—rather than stopping addiction, this merely displaced it.
By continuing to chase drug after drug, we miss the chance to target the real causes of addiction and to ensure that supply-side strategies don’t increase harm by pushing people to more dangerous substances or activities.
To support better policies, we’ve got to tell better stories.
One reason that media coverage of drugs so frequently sucks is that few reporters follow the subject regularly enough to develop any real expertise. But the opposite is true for British journalist Mike Power.
He leads the world in his reporting on “legal highs”—a class that includes drugs like Spice, K2 and “bath salts,” which are sold online and in convenience stores as alternatives to illegal substances like marijuana and amphetamine. Because these chemicals are new to the market, they occupy a gray zone—not technically illegal because they haven’t specifically been banned, but not exactly legal, either, because they haven’t been tested or approved for human consumption.
Once relegated to the back pages of High Times or the dark corners of head shops, they are now so popular that by 2012, one in nine high school seniors reported having tried one, meaning that more teens have taken these untested substances than have tried prescription painkillers, heroin, ecstasy (MDMA) or cocaine. The combination of the Internet and Chinese labs that can make chemicals to order with few questions asked is upending the drug trade.
An updated version of Power’s excellent book, Drugs Unlimited: The Web Revolution That’s Changing How the World Gets High, was just published in the US. (It was previously released in the UK under the title Drugs 2.0.) I spoke with him about his work and why “legal highs” present a unique challenge to drug prohibition.
Maia Szalavitz: What got you interested in legal highs?
Mike Power: The thing that interested me was when, in about 2008, supplies of ecstasy, which is the most popular club drug in the UK, completely dried up. There wasn’t any MDMA to be had, which is unusual in a market with 500,000 participants every week.
That was the question I set out to ask in my book: “Why is there no MDMA? Suddenly, after almost uninterrupted supplies for decades.” The answer was, the United Nations [Office of Drugs and Crime] in 2008 burned 33 tons of safrole oil [a precursor used to make MDMA, which it had confiscated in Cambodia].
And how did that affect legal highs?
The [ecstasy] market was incredibly toxic and very desperate, and into that gap came mephredrone. In the space of 12 months, it became the fourth most popular drug in the UK.
The concept of “legal high” was kind of nonexistent. The legal highs before mephedrone, which is 4-methylmethcathinone [a synthetic stimulant], were normally caffeine or ephedrine and didn’t really have an effect. Whereas mephedrone has an extraordinarily powerful effect.
And [eventually] it started to become rebranded as a “legal high” rather than, as previously, a “research chemical” [which was used by a few drug geeks on the Internet].
The role that the internet plays in this is fascinating because the very early Internet was populated with Deadheads and psychonauts of various types.
In those early days it seemed to offer a space beyond hierarchy that was ungovernable. It was part of the whole antediluvian hippie dream, where we could all just communicate and do what we wanted.
What is mephedrone like, compared to ecstasy?
Personally, I couldn’t tell you.
But you have taken some drugs yourself…
I took ecstasy [aged 18] and it was a wonderfully revelatory experience. It taught me a lot about music, sound, dancing and about human interrelations. I smoked pot when I was 16 and 17, loved it and thought it was a wonderful waste of time, a wonderful way to relax and listen to music. For me drugs are always connected to music and socializing.
How has your own experience affected your reporting in this area?
I always wanted to understand ecstasy. I think it’s a fascinating chemical. My experiences of ecstasy were so positive and so discordantly different to the prevailing [media coverage of drugs].
I thought, I understand the drug story really well—I’ve got the background in having a kind of insight into the drug culture from my teens and early 20s—and I was looking at [the reporting on] this mephedrone story, and everyone was talking nonsense. Nobody had any scientific, academic or cultural rigor at all.
So how do they describe the mephedrone high?
The reports are that it is a very fast and harsh buzz. You have a very quick onset, like a quick empathetic beginning, and then it trails off to become more speedy, followed by a kind of jittery anxiousness. That just sounds very unpleasant, but compared to [the alternatives that were available] it was better.
It sounds like mephedrone interrupted the drug markets in the UK just as profoundly as crack did in the US, but it didn’t cause the same kind of violence. Why?
Because it was virtualized, it was online. And the market was big—it was the fourth most popular drug. And we don’t have [so many] guns in the United Kingdom.
And it’s less addictive?
It was a nightclub drug, a party drug rather than a drug of hardcore social deprivation and abuse, although since it’s been banned, it’s become that. People are compulsively injecting it.
[But] even when it was just being snorted, it had a compulsive use profile because it crossed the blood brain barrier very quickly. [It] lasts 45 minutes and then it falls off a cliff, so people would be high as a kite and then down, high as a kite and down.
It was like a cross between crack and ice [smokeable methamphetamine]. It seized the more economically deprived sections of the drug user community. Max Daly has written about compulsive mephedrone injectors who just lost every vein in their body.
You wrote a story for the online magazine Matter in which you had a Chinese lab make an analog of a type of speed taken by the Beatles. What gave you the idea to do that?
I’ve been asked to do this a dozen times. Every editor said to me, “Can you make us a drug?” and I said, “Yes, but what would the point be?” And they couldn’t give me an answer. [Then] I started talking with Bobby Johnson, an editor at Matter. I said, “What was the point at which, culturally, drugs actually became part of the weave of every day society?”
My contention would be that that was the birth of LSD and the Beatles and the ‘60s. So I thought, What was the first drug experience that the Beatles had? And it was Benzedrine, but I didn’t fancy making Benzedrine [an amphetamine] because it isn’t as unusual.
The legal high story represents a pivotal change in the way that drugs are manufactured, consumed, experienced and mediated in a society, and I wanted to find a drug that was taken by the man who introduced LSD to the United Kingdom.
There is a picture of the Beatles holding tubes of Preludin. I thought, that’s no different than young kids posing on Facebook with a pile of mephredrone—except for the way the whole world is so interconnected.
It just tied together a few strings for me: privacy, publicity, the consequences of drug use. [I wanted] to make a legal version of John Lennon’s favorite drug. It’s a great headline, isn’t it?
What was your scariest moment when you were having the drug made?
When I went to collect it, walking through the streets of London with a bag of five grams of white powder. If the police stopped me, I would have to tell them that it was actually a legal version of Preludin that I had had synthesized in a Shanghai laboratory.
I don’t fancy my chances that the police would have believed me. I think I would have been taken to the cells while they sent it off for testing. That was really scary.
Now, politicians in the UK are considering trying to ban any substance that could get you high and then making exceptions for alcohol, caffeine and tobacco. What’s wrong with that approach?
Where does that leave a drug like nitrous oxide [laughing gas, which can be bought for use in making whipped cream]? And on a moral basis, why those three drugs? Why should alcohol, which kills several hundred thousand people per year, be allowed to remain legal?
This whole issue shows that drug prohibition is a result of prejudice, not an attempt to protect people. Historically, we’ve banned drugs in bouts of racist hysteria, while generally allowing those that white Europeans have decided are acceptable.
Absolutely. The legal high question just shines the light onto the logical fallacy of all prohibition. It’s like, “OK, so this drug is bad because it’s banned, but this one is legal, even though it’s more harmful. In that case, why is it legal?” Because we haven’t quite banned it. It’s circular logic.
Also, if you say, “We’re banning everything except alcohol, tobacco and caffeine,” how does a pharmaceutical company know what’s legal? It seems unenforceable.
Medical research could be limited severely by such moves. One of the key [insights] that I had in my study of the new drug market is that the only reason that people take these drugs is that they can’t get the ones that they want.
Out of the 75 new drugs in the European Union last year, the vast majority were cannabinoids. They are trying to replicate a completely safe, nontoxic plant that doesn’t kill anybody.
I interviewed a woman whose son died from three tokes on one synthetic cannabinoid joint. The boy died because his blood pressure suddenly dropped, he had a stroke and then a catastrophic system failure and died— that’s from a synthetic cannabinoid that he bought legally down at the shops, when, if there was a more rational drug policy, if he were allowed to buy marijuana, he would be alive today.
So what do you think should be done?
Let’s legalize: “Anyone can buy and sell marijuana.” If we had courage to do that, straightaway we would cut out at least 60% of the legal high market.
What do you think is the future of drugs?
I think it’s digital: More and more people will buy their drugs on the Internet. On a policy level the future of drugs has to be to dismantle prohibition because it’s discredited. It does not work.
The following first appeared in Substance.com:
Pretty much everyone who has spent time smoking marijuana knows at least one diehard stoner. The guy whose eyes are always red, the girl who doesn’t use the term “wake and bake” ironically, the person who just can’t seem to ever get it together. These heavy smokers might work at a low-level job or they may be unemployed—but everyone who knows them well knows that they are capable of much more, if only they had any ambition.
Is this really addiction? I believe that it is (and I don’t think that’s an argument against legalization). In fact, the reasons why marijuana is addictive elucidate the true nature of addiction itself. Addiction is a relationship between a person and a substance or activity; addictiveness is not a simple matter of a drug “hijacking the brain.” In fact, with all potentially addictive experiences, only a minority of those who try them get hooked—and people can even become addicted to apparently “nonaddictive” things, like carrots. Addiction depends on learning, context and psychology, not just neurotransmitters.
With two states having already legalized recreational marijuana use and several more considering doing so, understanding the nature of addiction is more important than ever. Partisans on both sides of the debate have made extreme claims here; some legalizers saying there’s no such thing as marijuana addiction, while some prohibitionists claim “cannabis as addictive as heroin.”
Our concepts of addiction, however, come primarily from cultural experience with alcohol, heroin and, later, cocaine. No one has ever argued that opioids like heroin don’t have the potential to cause addiction because the withdrawal symptoms—vomiting, shaking, pallor, sweating and diarrhea—are objectively measurable. Opioids cause physical dependence that is evident when they become unavailable. The same is true for alcohol, where withdrawal is even more severe and can sometimes even be deadly.
So early researchers focused on these measurable symptoms related to alcoholism and opioid addictions in defining addiction: Using a drug could lead to becoming tolerant to it, tolerance could lead to dose escalation, which could in turn lead to physical dependence, and then the addiction could be driven by the need to avoid the painful symptoms of withdrawal. It was simple and physical.
In this view, however, cocaine and marijuana were not “really” addictive. While people can experience withdrawal symptoms like irritability, depression, craving and sleep problems when quitting these drugs, these are much more subjective and therefore can be dismissed as “psychological” rather than physical. You might really want coke or pot, but you didn’t need it like a real junkie, the thinking went.
And since most of us like to believe that we have much more control over our minds than we do over physical symptoms, “psychological” addiction is seen as far less serious than the “physical” type. It’s the remnants of this kind of thinking that mainly underlie the idea that marijuana addiction doesn’t exist. Unfortunately, that view of addiction is stuck in the 1970s.
In the 1980s—ironically, not long after Scientific American caused a big controversy by arguing that snorted cocaine is no more addictive than eating potato chips—entrepreneurs began marketing a ready-made smokeable form of the drug. The birth of crack shattered the idea that “physical” dependence is more serious than psychological dependence because people with cocaine addictions don’t vomit or have diarrhea when they quit; while they may appear desperate, it’s not in the physically obvious way of heroin or alcohol withdrawal. And so, if you are going to argue that marijuana is not addictive because you don’t get sick when you quit, you also have to argue the same for crack.
Good luck with that one, I say. Clearly, crack-addicted people are every bit as compulsive as those with heroin problems—and their criminal involvement if they can’t afford the drug is at least equally likely, though not as common as has been claimed. Crack dealt a deathblow to the “psychological” vs. “physical” distinction—and if it hadn’t, neuroscience was creeping up to show that the psychological and the physical aren’t exactly distinct anyway.
In the ‘70s and ‘80s, researchers also began recognizing that simply detoxing heroin addicts—getting them through the two-week period of intense physical withdrawal symptoms—is not effective treatment. If heroin addiction was driven primarily by the need to avoid withdrawal, addicted people should be out of the woods after they complete cold turkey. But as those of us who have been through it know, that is far from the hardest part.
While kicking heroin isn’t fun, staying off it in the long run is the problem—those “mere” psychological cravings are what drive addiction. Physical dependence isn’t the main problem; it isn’t even necessary. Indeed, we now know that you can actually have physical dependence without any addiction at all: There are some blood pressure medications, for example, that can have deadly withdrawal symptoms if not tapered properly, but people on these meds don’t crave them even though they are quite dependent. Similarly, antidepressants like Paxil have physical withdrawal symptoms, but because they don’t produce a high, you don’t see people robbing drug stores to get them.
So what is addiction, then, if tolerance, withdrawal and physical dependence aren’t essential to it? All of these facts point to one definition that can sum up the problem: Addiction is compulsive use of a substance or engagement in a behavior despite negative consequences. (Put more in neuroscience, addiction is a learned distortion in the brain’s motivational systems that make us persist in pursuing things linked to evolutionary fitness like food and sex.) Anything that causes pleasure via these systems—and that’s basically anything that is possible to enjoy—can be addictive to some person at some time. And that includes marijuana (and, for that matter potato chips).
This doesn’t mean that marijuana addiction is necessarily as severe as cocaine, heroin or alcohol addiction—in fact, it typically isn’t. If given the choice, most families would vociferously prefer having a member addicted to marijuana rather than to cocaine, heroin or alcohol. The negative consequences associated with marijuana addiction tend to be subtler: lost promotions, for example, rather than lost jobs; worse relationships, not no relationships. And of course, no risk of overdose death.
But this is also what can make it insidious. Marijuana addiction may quietly make your life worse without ever getting bad enough to seem worth addressing; it may not destroy your life but it may make you miss opportunities. With any pattern of regular drug use, it’s important to continually track whether the risks outweigh the benefits, keeping in mind that addiction itself may distort this calculation. This is especially true with marijuana.
However, as with all other drugs, only a minority of marijuana users ever struggle with addiction. Research suggests that about 10% get hooked—and on average, marijuana addiction lasts six years. Even more than other addictions, marijuana addiction seems to be driven by self-medication of mental health problems—90% of people with marijuana addiction also have another addiction or mental illness, typically alcoholism or antisocial personality disorder.
This suggests that exposing more of the population to marijuana won’t necessarily increase the addicted population. First, people with antisocial personality disorder, by definition, tend not to be law abiding, so most have probably already tried it. Second, the percent of people with other pre-existing mental illness will not change because marijuana becomes legal—in fact, in the UK, when they reversed their prior liberalization of marijuana law because of fears related to increased schizophrenia, psychosis rates actually went up. (The link probably wasn’t causal, but it does suggest that legal crackdowns on cannabis don’t prevent related psychosis).
If some people with alcohol, cocaine or heroin addiction switch to marijuana instead, overall harm would be reduced. As I and others have been reporting at least since 2001, using marijuana as an “exit” drug is a real phenomenon, both in cocaine and opioid addiction.
When we consider the risks of various substances, we tend to do so in isolation—but that’s not how choices are made in the real world. Most people would rather their partners have no addictions—but again, some are clearly worse than others. Marijuana craving is rarely as severe as crack craving, as is obvious.
Still, like anything that can be pleasurable, marijuana can be addictive. This doesn’t mean all addictions are the same or that it is as addictive as the currently legal drugs alcohol and tobacco—the data shows it is less so. Pretending it can’t do any harm at all, however—or that there aren’t people who are addicted to it—does no one any good. If we want better drug policy, as with other types of recovery, we need to avoid denial.
When I stopped shooting coke and heroin, I was 23. I had no life outside of my addiction. I was facing serious drug charges and I weighed 85 pounds, after months of injecting, often dozens of times a day.
But although I got treatment, I quit at around the age when, according to large epidemiological studies, most people who have diagnosable addiction problems do so—without treatment. The early to mid-20s is also the period when the prefrontal cortex, the part of the brain responsible for good judgment and self-restraint, finally reaches maturity.
According to the American Society of Addiction Medicine, addiction is “a primary, chronic disease of brain reward, motivation, memory and related circuitry.” However, that’s not what the epidemiology of the disorder suggests. By age 35, half of all people who qualified for active alcoholism or addiction diagnoses during their teens and 20s no longer do, according to a study of over 42,000 Americans in a sample designed to represent the adult population.
The average cocaine addiction lasts four years, the average marijuana addiction lasts six years, and the average alcohol addiction is resolved within 15 years. Heroin addictions tend to last as long as alcoholism, but prescription opioid problems, on average, last five years. In these large samples, which are drawn from the general population, only a quarter of people who recover have ever sought assistance in doing so (including via 12-step programs). This actually makes addictions the psychiatric disorder with the highest odds of recovery.
While some addictions clearly do take a chronic course, these data, which replicate earlier research, suggest that many do not. And this remains true even for people like me, who have used drugs in such high, frequent doses and in such a compulsive fashion that it is hard to argue that we “weren’t really addicted.” I don’t know many non-addicts who shoot up 40 times a day, get suspended from college for dealing and spend several months in a methadone program.
If addiction were truly a progressive disease, the data should show that the odds of quitting get worse over time. In fact, they remain the same on an annual basis, which means that as people get older, a higher and higher percentage wind up in recovery. If your addiction really is “doing push-ups” while you sit in AA meetings, it should get harder, not easier, to quit over time. (This is not an argument in favor of relapsing; it simply means that your odds of recovery actually get better with age!)
So why do so many people still see addiction as hopeless? One reason is a phenomenon known as the "clinician’s error,” which could also be known as the “journalist’s error” because it is so frequently replicated in reporting on drugs. That is, journalists and rehabs tend to see the extremes: Given the expensive and often harsh nature of treatment, if you can quit on your own you probably will. And it will be hard for journalists or treatment providers to find you.
Similarly, if your only knowledge of alcohol came from working in an ER on Saturday nights, you might start thinking that prohibition is a good idea. All you would see are overdoses, DTs, or car crash, rape or assault victims. You wouldn’t be aware of the patients whose alcohol use wasn’t causing problems. And so, although the overwhelming majority of alcohol users drink responsibly, your “clinical” picture of what the drug does would be distorted by the source of your sample of drinkers.
Treatment providers get a similarly skewed view of addicts: The people who keep coming back aren’t typical—they’re simply the ones who need the most help. Basing your concept of addiction only on people who chronically relapse creates an overly pessimistic picture.
This is one of many reasons why I prefer to see addiction as a learning or developmental disorder, rather than taking the classical disease view. If addiction really were a primary, chronic, progressive disease, natural recovery rates would not be so high and addiction wouldn’t have such a pronounced peak prevalence in young people.
But if addiction is seen as a disorder of development, its association with age makes a great deal more sense. The most common years for full onset of addiction are 19 and 20, which coincides with late adolescence, before cortical development is complete. In early adolescence, when the drug taking that leads to addiction by the 20s typically begins, the emotional systems involved in love and sex are coming online, before the cognitive systems that rein in risk-taking are fully active.
Taking drugs excessively at this time probably interferes with both biological and psychological development. The biological part is due to the impact of the drugs on the developing circuitry itself—but the psychological part is probably at least as important. If as a teen you don’t learn non-drug ways of soothing yourself through the inevitable ups and downs of relationships, you miss out on a critical period for doing so. Alternatively, if you do hone these skills in adolescence, even heavy use later may not be as hard to kick because you already know how to use other options for coping.
The data supports this idea: If you start drinking or taking drugs with peers before age 18, you have a 25% chance of becoming addicted, but if your use starts later, the odds drop to 4%. Very few people without a prior history of addiction get hooked later in life, even if they are exposed to drugs like opioid painkillers.
If we see addiction as a developmental disorder, all of this makes much more sense. Many kids “age out” of classical developmental disorders like attention deficit/hyperactivity disorder (ADHD) as their brains catch up to those of their peers or they develop workarounds for coping with their different wiring. One study, for example, which followed 367 children with ADHD into adulthood found that 70% no longer had significant symptoms.
That didn’t mean, however, that a significant minority didn’t still need help, of course, or that ADHD isn’t “real.” Like addiction (and actually strongly linked with risk for it), ADHD is a wiring difference and a key period for brain-circuit-building is adolescence. In both cases, maturity can help correct the problem, but doesn’t always do so automatically.
To better understand recovery and how to teach it, then, we need to look to the strengths and tactics of people who quit without treatment—and not merely focus on clinical samples. Common threads in stories of recovery without treatment include finding a new passion (whether in work, hobbies, religion or a person), moving from a less structured environment like college into a more constraining one like 9 to 5 employment, and realizing that heavy use stands in the way of achieving important life goals. People who recover without treatment also tend not to see themselves as addicts, according to the research in this area.
While treatment can often support the principles of natural recovery, too often it does the opposite. For example, many programs interfere with healthy family and romantic relationships by isolating patients. Some threaten employment and education, suggesting or even requiring that people quit jobs or school to “focus on recovery,” when doing so might do more harm than good. Others pay too much attention to getting people to take on an addict identity—rather than on harm related to drug use—when, in fact, looking at other facets of the self may be more helpful.
There are many paths to recovery—and if we want to help people get there, we need to explore all of them. That means recognizing that natural recovery exists—and not dismissing data we don’t like.
How do you measure the pleasure that you lose when you end an addiction? To most formerly addicted people, the question makes little sense because by the time they quit, it’s often been years since the benefits of the drugs in any way outweighed their negative consequences. However, pleasure is an essential part of life: It’s not for nothing that the pursuit of happiness is highlighted in America’s founding document. Including measures of pleasure is critical to regulating addictive drugs, in fact—but only if it’s done right.
This issue is now faced by the FDA, which, under federal law, must weigh benefits against costs when creating regulations and avoid making rules that are too expensive. The agency must calculate the value not only of health gains from reduced smoking rates, but also of enjoyment lost by smokers who quit. Not surprisingly, that sort of pleasure is difficult to quantify in dollar terms, as the FDA is learning to its dismay.
The government’s calculations recently caused consternation among antismoking groups, who claim that the agency has given too much weight to the hedonic “benefit” of smoking—and the loss of this that comes with quitting—in making its latest tobacco rules and rejecting the idea of graphic warning labels on cigarette packs.
Earlier this month, a group of heavyweight economists (including a Nobel laureate) released a critique of the new regulations as part of the public comment period required when new rules are considered. Here’s how the New York Times described it:
Buried deep in the federal government’s voluminous new tobacco regulations is a little-known cost-benefit calculation that public health experts see as potentially poisonous: the happiness quotient. It assumes that the benefits from reducing smoking—fewer early deaths and diseases of the lungs and heart—have to be discounted by 70% to offset the loss in pleasure that smokers suffer when they give up their habit.
Experts say that calculation wipes out most of the economic benefits from the regulations and could make them far more vulnerable to legal challenges from the tobacco industry. And it could have a perverse effect, experts said. The more successful regulators are at reducing smoking, the more it hurts them in the final economic accounting.
Described that way, the cost-benefit analysis includes measuring pleasure when regulating addictive drugs like cigarettes is pernicious. Reducing the financial “benefit” side of the calculation by 70% to “balance” the pluses of longer lives and better health against the “lost pleasure” of smoking clearly goes too far. Indeed, in their critique, the economists note that more than three-quarters of all smokers start their habit while underage, meaning that they are probably not making a completely rational consumer choice. It’s well-known that youth are not always good at linking their current actions with future consequences—and indeed, most young smokers believe that they will have quit long before they actually do so.
Antismoking groups say that the FDA has given too much weight to the hedonic “benefit” of smoking—and the loss of this that comes with quitting—in making its latest tobacco rules.
Moreover, the authors note that if smokers were making a rational choice about the benefits of smoking compared to its risks, the proposed graphic warning labels would have no effect—since the smokers would already have taken into account the risk of cancer and other gruesome outcomes. They suggest instead applying that 70% discount only to the 9% of smokers who say that knowing what they now know about tobacco, they would still choose to start smoking.
But while the way the FDA did its calculations here is troubling, we shouldn’t entirely reject the idea of including pleasure in calculating the viability of a particular drug policy.
Indeed, one reason that we have failed to think rationally about drug laws is that we don’t give any weight to the positive experiences of drug users. When people say that alcohol relaxes them or that marijuana inspires them, we tend to think they are, at best, thinking wishfully or, at worst, in denial. When people claim benefits like enjoyment or even enlightenment from LSD or MDMA, we write them off as dirty hippies.
Though my own heroin and cocaine addiction certainly wound up being more painful than pleasurable, there were plenty of times, especially early on, when those drugs gave me relief, euphoria, a sense of social connection and energy that I cannot deny. When it worked, heroin gave me what I now find to be a primary benefit of antidepressants—not euphoria or a “high,” but simply a feeling of wellness, instead of constant dread. The use of all these drugs persists outside of addiction because people do find the experience valuable.
Consequently, cost-benefit analysis should include pleasure in proportion to the percentage of people who are addicted to a drug—the higher the rate of addiction, the less pleasure should count. That’s because addiction actually robs people of pleasure: There is little fun about using when you know you are hurting yourself and/or those around you, but can’t manage to stop. While there may be some pleasure and relief in avoiding withdrawal and craving, it doesn’t outweigh the harm—otherwise, you wouldn’t be addicted, you’d be rationally choosing to take drugs.
Because different substances produce different rates of addiction, rational drug laws would adjust for pleasure in considering their regulation in a way that would take this into account.
An appropriate accounting, then, would mean that cigarettes’ pleasure should be given very little weight: 60% of smokers smoke daily, for example, meaning that they are both physically dependent on nicotine and qualify as being addicted to it. The comparable figure for marijuana smoking is just 17%—and even here, not all of these users qualify as addicted (some are medical users, for example, and others do not have the compulsive behavior despite negative consequences that would define them as addicted, just as many daily drinkers are not alcoholics).
Because different substances produce different rates of addiction, rational drug laws would adjust for pleasure in considering their regulation in a way that would take this into account. And because different substances produce differing amounts and types of benefits, these, too, need to be considered—all, of course, in light of their risks and harms.
Drug laws for too long have only weighed risks—seeing only addiction, health problems and crime while failing to account for why people who are not addicted risk addiction in order to take them and failing to quantify the harm done by prohibition itself.
If we analyzed sports this way, we would outlaw them, too: There’s far better data showing that football can produce irreversible brain damage, for example, than there is for marijuana. But few people call for outlawing football because we see team sports as a valuable pursuit that teaches things like teamwork, persistence and courage.
Drugs, in contrast, are not valued because the pleasure they bring is seen as unearned: The culture that has sprung up around illicit drugs is viewed as entirely detrimental; its positive facets—like accepting the weird kids who don’t fit into other social groups—are almost never mentioned. Indeed, saying anything positive about drugs is virtually a taboo in the US and Europe: In Britain, for example, when a drug reform group tried to run an anti-stigma campaign with the tagline “Nice people take drugs,” the ads were banned from appearing on public transit.
Factoring drug-related pleasure into a cost-benefit analysis of laws and regulations, then, could be a positive step. Its results, however, might produce outcomes that make us deeply uncomfortable—like having to face the profound irrationality of current drug laws.
Robin Williams has long been a hero to people in recovery. His drug humor always had the bittersweetness that comes from painful experience and his sheer brilliance and exuberance made many recovering folk proud to claim him as “one of us.” Watching him improvise, the presence of genius was visceral.
This makes his death—and some of the knee-jerk attempts to draw lessons from it—even more painful. We know that he had just left Hazelden when he died; we also know that he had publicly acknowledged struggling with addictions, even if we don’t know how this affected the beloved comedian.
What surprises and saddens me, however, is that while you could use some of Williams’ monologues as textbook illustrations of the “pressured speech” and “racing thoughts” that characterize hypomania and mania, he does not seem to have been diagnosed with or at least, come out about, having mental illness. In fact, he told Terry Gross of NPR in 2006 that his manic antics were merely a performance and he’d never had “clinical” depression.
After appearing on a magazine cover for a story about medication, Williams said, “I was branded manic depressive. Um, that’s clinical, I’m not that. Do I perform sometimes in a manic style? Yes. Am I manic all the time? No. Do I get sad? Oh yeah. Does it hit me hard? Oh yeah.”
Of course, he may have been trying to keep the highly stigmatized diagnosis private—or he may have refused to accept it. He may also have feared that accepting a diagnosis would mean taking medication that might affect not just his lows, but his art and his highs. As Dr. John Grohol, the psychologist who founded PsychCentral, put it in an editorial note in his piece on Williams, “We acknowledge Williams himself has never stated to our knowledge that he was formally diagnosed with bipolar disorder or depression. Yet given his behaviors and symptoms, it seems far more likely that he suffered bipolar disorder—of which depression is a significant component.”
Now, of course, we’ll probably never know what—if anything—Williams had. But if there are any lessons to be learned from this wretched tragedy, two seem clear to me.
First, stigmatizing mental illness is dangerous—and can be deadly. If someone as accomplished and acclaimed as Williams cannot publicly acknowledge “clinical” depression or bipolar disorder, we have a long way to go in making the world safe for people who suffer from these illnesses. When even today’s headlines about addiction and mental illness refer to struggles with “demons,” you know that stigma remains strong.
Whatever else is true, Williams’ gifts were clearly on the manic spectrum. Even if he never crossed the line into “clinical” problems, it’s worth acknowledging this. Understanding that conditions like bipolar, depression, schizophrenia and autism are not out of the realm of human experience—and can produce talent and creativity, not just disability—is critical to reducing stigma. If we know that these conditions—including addiction—are exaggerations of “normal,” not alien “craziness,” we will be a lot better at accepting those who are affected.
And when we see the gifts that can accompany these conditions, we tend to be less prejudiced and more understanding. Research clearly links mental illness, autism and addiction with creativity across the arts and sciences. Of course, disabled people shouldn’t have to prove they are also gifted to be accepted. But it remains true that public acceptance of disabled people often follows when those whose gifts we have loved or benefitted from—Paralympians, for example—are open about their struggles. It’s sad that the typically kind, empathetic and open Williams may have felt unable to either accept his own mental illnesses, or to disclose them.
Second, we need to end the division of services and even of language between addiction and other mental illnesses. Around half of all addicted people—and up to 80% for women and teens—suffer from an additional mental illness. While the prevalence of addiction in mentally ill people varies by condition, again, 40-50% overall are affected.
Unfortunately, most addiction treatment programs—despite claims to the contrary—are not well-equipped to handle “dual diagnosis” cases. Even at well known programs like Hazelden, some patients report difficulty getting specialized treatment for mental illness.
For example, Isabella, who is 55, attended Hazelden’s Springbrook facility in Oregon while Robin Williams was receiving treatment there following his relapse in 2006.
“I suffered from severe depression and excessive alcohol use, culminating in my swallowing a bottle of Xanax and ending up in the hospital,” she says. “I was then accepted by Hazelden into their 28-day program. They knew I was suffering from depression and about my history.”
Isabella describes how she was only permitted to see the facility’s psychiatrist for 15 minutes for an initial evaluation—and says that she asked repeatedly for further visits to discuss her depression. But throughout the rest of her stay, she only received an additional half hour with the doctor, who simply added a new antidepressant to her existing meds, she says.
“The focus was on forcing me to participate in 12-step-based activities—if I stayed in my room to read or work on assignments, I was dragged out to the group,” Isabella adds. “I was told I wasn’t allowed to isolate. I feel that they ignored obvious signs of my depression.”
Of course, other patients have reported better experiences, and it is always hard to know what the best course of action is in any particular case. And Hazelden now may be different than it was in 2006. But it’s clear that even now, many treatment providers remain either biased against the use of medication, or unskilled in treating mental illness, or both.
Some 12-step focused counselors and members still try to convince clients that medication or other help for mental illness is unnecessary and that all the answers are in the Steps. To make matters worse, many programs still rely for evaluations on people who do not have the training to understand and diagnose mental illness—or on overly brief encounters with actual physicians.
On the other side of the coin, mental health programs also frequently fail to deal adequately with addiction—sending away those who need help if they are still using drugs, or leaving addictions untreated in hopes that the treatment for the mental illness alone with suffice. This is also unacceptable: Treatment needs to be fully integrated.
I hope Robin Williams was not harmed by the outdated barriers that still exist between addiction and mental health care; I hope he was not advised to rely only on the Steps or to avoid medication. I hope whoever treated him took into account both his frequently manic behavior and his depression. If any of these factors played a role in his death, it’s truly shameful.
But I also think we have to acknowledge that even the best treatments for both mental illness and addiction still fail far too many patients. Even if Williams did receive optimal care, what we have now isn’t good enough: We need more research, more options and better pathways to get evidence into practice.
Addiction and mental illness are not demons. Let’s stop acting as if prayer is the main answer.
The following article first appeared on Substance.com:
The New York Times is demonstrating the positive power of journalism in its recent editorial series, “Repeal Prohibition, Again,” calling for full legalization of marijuana. In each of its historic articles, it has plainly debunked propaganda it previously legitimized and finally given the mainstream stamp of approval to the perspective that has seemed obvious for decades to anyone who seriously investigated the issue. This may well help turn the tide for national change.
In its coverage of other drugs, however, the Timesremains blinded by the blinkers of prohibition, stigma and criminalization. In an article headlined “Missouri Remains Alone in Resisting Prescription Drug Database,” reporter Alan Schwarz tells the story of a pharmacist who is also a deputy sheriff, investigating the private medical records of patients suspected of obtaining prescription painkillers illegally.
He describes the officer in what can fairly be viewed as heroic terms:
Mr. Logan, 61, holstered two guns, slipped on a bulletproof vest and jumped into his truck. Because in his small corner of America’s epidemic of prescription drug abuse, Mr. Logan is no ordinary pharmacist. He is also a sheriff’s deputy who, when alerted to someone acquiring fraudulent drug prescriptions, goes out to catch that person himself.
“I’m only one guy, and for every person we get to, there are probably 100 who we can’t,” Mr. Logan said. “How many people have to get addicted and die for us to do what everyone else is doing about it?”
The 49 other US states have databases that allow varying degrees of law enforcement access to medical records of people who have been prescribed controlled substances like Oxycontin, Valium, Percocet and Xanax. And the opposition to creating such a database in Missouri is based on a frankly odious perspective. While arguing that medical records should remain private, the leading opponent of creating a database—Rob Schaaf, a Republican state senator with a penchant for “liberty” talk—says he doesn’t care if privacy for some leads to overdose for others because “If they overdose and kill themselves, it just removes them from the gene pool.”
I imagine there would be far more resistance—and a far more balanced article on the relative value of privacy compared to the needs of law enforcement—if states were considering a database of Viagra recipients or women who take birth control.
But this is an article about the evils of misusing opioids, so the Times leaves the privacy argument to fester in the eugenic stew of its Republican advocate. (To be fair, it does also quote a pain patient regarding her desire not to be stigmatized.)
Schwarz goes on to describe how deputy/pharmacist Logan sometimes actually jumps over the counter and arrests people “on the spot” if they come to one of his stores with a forged or otherwise illegitimate prescription. That’s a real health-care pro in action!
And throughout, Schwarz tells the story of one of Logan’s arrests, describing a sobbing mother—the one he’d holstered his guns and put on his bulletproof vest to go out and arrest—now in jail. She was charged with “doctor shopping” after being tipped off by a physician’s assistant who suspected she was lying to get drugs. Logan found that “in the previous 10 weeks, [she] had been prescribed, from three doctors, 171 total days’ worth of hydrocodone, and 140 days’ worth of tramadol and Percocet, other painkillers.”
However, the mom—whom the Times names, and even photographs during her arrest, despite the fact that she has not been convicted or taken a plea and refused to speak to the reporter—tells it differently. Shwarz, who is at the precinct observing even the interview the woman gives to a detective, reports that she says that she had pain from scoliosis and surgery and didn’t know it was illegal to go to several doctors seeking relief—and she doesn’t see herself as addicted.
The article closes with this quote from the sheriff:
“I understand what they’re saying about privacy, I really do,” Sheriff Walter said. “But look at this—this is just one woman, one family. Those kids, they’re wondering where Mama is tonight. She’s hooked on painkillers, because the system allowed her to be.”
She’s not with her children because she was arrested and put in jail by a supposed healthcare provider—not because of anything intrinsic to her use of opioids—and is basically portrayed as guilty unless proven innocent.
Is there any other medical condition in the world for which this would be acceptable treatment? No evidence is provided that suggests she’s not a genuine pain patient beyond the number of pills she was prescribed—and it’s well known in pain management that some patients require extremely large doses. If she is simply seeking pain relief, this is a travesty. It’s not an argument for a prescription drug database for Missouri—it’s a cautionary tale for the rest of the states.
But it’s just as absurd if we genuinely see addiction as a disease. Jail is not going to help this mom with either her pain or her addiction, if it actually exists. In fact, it could cost her her job and her children—both factors that might aid her recovery, if her recovery was actually what was being sought here.
A sensible system, upon catching someone with a potentially dubious prescription, would not rip them from their family and cold-turkey them in a cage. Indeed, given that the best treatment for opioid addiction is maintenance with an opioid, why not immediately offer her a Suboxone or methadone prescription, following a proper psychiatric and medical examination, along with counseling and other support as needed?
The fact that no one has even tried creating such a process in the US speaks to the reality that we still see addiction as a crime.
While a prescription drug database might fight opioid addiction if it were used to help affected patients, this is not what’s going on here. And the Times seems completely blind to the problems with this approach to addiction. In singling out Missouri for not having a database and profiling uncritically someone who arrests addicted people, it sends the implicit message that adding a database so more such arrests can occur is a useful tactic.
The establishment now recognizes that marijuana possession arrests are senseless but, at least as far as this article goes, seems unable to see that the same is true for other drugs as well.
The following first appeared on Substance.com:
We Americans like to think of ourselves as exceptional, the land of the free and the home of the brave, the City on the Hill and all that. When it comes to the politics and culture of drugs, we are indeed special—or at least dramatically different from the rest of the Western world. Too often, however, we are special for the wrong reasons.
1. We Try More Drugs Than Anyone Else
Americans are more likely to try illegal drugs than anyone else in the world, according to global survey data from the World Health Organization.
42% of American adults have tried marijuana, for example, while only 20% of the Dutch have done so—despite the Netherlands’ long-running policy of tolerating sales and possession without criminal penalties. We’re also number one in terms of the percentage of our population that has tried cocaine (16%), with most European countries (including Holland) having averages around 1% to 2%. In Colombia—a major source country for the drug—only 4% of the population has taken cocaine.
In terms of lifetime tobacco use—coming in at 74%—we’re also a serious outlier: In most of Europe, only around half the population tries smoking or other tobacco products.
Not surprisingly, we’re also number one in terms of annual prescription painkiller misuse—with 5.1% of the population reporting taking such drugs for nonmedical reasons, compared to 1% in Canada and 3% in Australia.
But we’re lagging behind on illegal opiate use, which includes drugs like heroin and opium. According to this year’s World Drug Reportfrom the UN, in the Middle East and Southwest Asia, 1.25% of the population has taken these drugs at least once in the past year. In the US and Canada, that number is less than 0.5%. Clearly, we have some work to do!
2. We Incarcerate More People Than Anyone Else
Sadly, we’re not in any threat of losing our dominance in incarceration any time soon, at least in terms of the raw number of prisoners we hold. Some 2.2 million Americans are locked up at any given time—compared to a mere 676,000 in Russia and 385,000 in India.
17% of state prisoners and half of all federal prisoners are incarcerated for drug crimes—and this doesn’t count the percentage who committed other crimes linked to addiction problems, which is far higher.
Per capita, the tiny island nation of the Seychelles has matched our rate of 707 prisoners per 100,000 members of the population—but we are still far ahead of slackers like the UK, at 149, and the Netherlands, at 75.
Ya think that maybe incarceration isn’t a good way to stop drug use?
3. We Use More Opioids Medically (But Not for the Reasons You Might Think)
America is actually number two in terms of per capita consumption of opioid pain medication (measured by dose equivalence between the various opioids)—contrary to recent CDC claims citing old data; these days Canada wears the crown. Canadians take 812 mg of morphine equivalents per capita, compared to 748 for the US. Other high-consuming countries include Denmark and Australia.
But high per capita consumption for pain treatment doesn’t automatically translate into high rates of misuse and addiction. Canada has an annual prevalence of prescription opioid misuse of 1%; the rate for the US, as noted above, is just over five times that, despite our lower levels of medical use.
Another important fact to note about our elevated levels of medical opioid use is that it comes in the context of extremely low levels of use in the rest of the world. Around two-thirds of the world’s population live in countries where even if you are dying of cancer, strong opioids are basically unavailable. Only 7% of the global population is believed to have adequate access to appropriate pain relief, according to the World Health Organization. Compare that to the US, which has only 5% of the world’s population but consumes 80% of its opioids.We surely overprescribe in some cases—but everyone else’s cruel under-prescribing needs to be taken into account, too.
4. We’re in the Middle of the Road on Alcohol
America’s multicultural society means that we aren’t as extreme on alcohol as you might expect. Sociologists who have compared drinking patterns cross-culturally tend to find two broad patterns. The first is a “Northern” style of drinking where alcohol is seen as an intoxicant and heavy drinking is associated with masculinity and tends to take place in bars. Binging is the standard pattern of use here; daily drinking is seen as a sign of alcoholism. Countries with this pattern include the UK, Ireland, Russia and the Scandinavian ones.
In contrast, “Southern”–style drinking cultures see alcohol as a food, and drinking takes place daily with meals and is associated with family. Celebrations can include excess consumption, but drunkenness, not daily drinking, is seen as aberrant. This style has historically been associated with reduced harm in terms of violence, accidents and alcoholism (but not always cirrhosis). France and Italy are the exemplars here.
The US is primarily a Northern drinking culture, but it is not at the extreme end. Russia, for example, consumes 15 liters of alcohol per capita and has a 9% alcoholism rate (based on the DSM IV diagnosis). Americans, however, consume only 9.2 liters per capita and have a past-year alcoholism rate of 4.7%. Contrast this with Italy, where a mere 6.7 liters per capita are consumed and alcoholism affects only 0.5% of the population annually.
5. We Have the World’s Highest Legal Drinking Age
Although Kazakhstan, Japan, Iceland and several other countries also have a legal age of 21, most countries that set a legal drinking age choose 18.
Advocates of America’s high drinking age have argued that it has reduced accident deaths and high school binge drinking, which, contrary to media headlines, has actually declined substantially since the early 1980s. In 1983, 41% of 12th graders reported having had five or more drinks on one occasion in the past two weeks; the number for 2013 was 22%, a drop of nearly half. Drunk driving deaths have also plummeted, falling from some 21,000 in 1983 to around 10,000 in 2013.
But it’s not clear that the actual drinking age is the main factor here. Canada, with a drinking age of 19, has seen the same kind of declines and now has fewer lives lost to drunk driving in an age-adjusted measure, when compared to the US, 11.0 for them to 19 for us.
Reduction in drunk driving deaths may have had more to do with setting a uniform national drinking age so that people don’t drive to states with a lower drinking age to get drunk—rather than the age itself.
If a higher drinking age actually did prompt drinkers to begin boozing at later ages, it might reduce alcoholism risk, which increases with younger ages of initiation. It’s not clear that 21 age limits do so, however—and younger ages of initiation are also linked with things like growing up in an alcoholic family, which can independently affect risk, so postponing initiation might not help that much.
6. Our Treatment System Is Dominated by 12-Step Programs
95% of American addiction treatment programs refer patients to 12-step meetings as a matter of course and 90% base a good portion of their treatment on 12-step principles. Fundamental to treatment in this system is the idea that complete abstinence from all “mind and mood altering” substances is the basis of recovery, though some programs are changing to allow maintenance drugs like Suboxone to be seen as part of recovery. People who recover on their own are viewed with skepticism (possibly as “dry drunks”) and the idea that one can stay sober without meeting attendance is seen as “denial.”
This is not the case in many other countries, where treatment, particularly for alcohol, is more varied and can include attempts at moderation. In the UK, for example, the majority of treatment for alcohol problems consists of talk therapies like cognitive behavioral therapy.
7. Coercion Is a Common Route to Treatment
The majority of addiction treatment in the US is now outpatient—and 49% of all patients in these programs are referred to them (typically as an alternative to incarceration) by the criminal justice system. In long-term residential treatment, criminal justice referrals are also the main source of patients, accounting for 36% of all participants. 29% of residents in long-term treatment make the choice for themselves, while the rest are primarily referred by other treatment or healthcare providers.
It is not clear how this percentage compares to that seen in the rest of the world, although the US does arrest far more people for drug crimes than other countries do, so it is likely that this proportion is higher.
8. We Spend the Most Money on Addiction Research
The National Institute on Drug Abuse is the world’s largest funder of research on psychoactive drugs and addiction. In fiscal year 2012, its budget was $1.05 billion. But that’s not the only major federal funder of addiction research in the US: We have another two national institute that covers addiction, the National Institute on Alcoholism and Alcohol Abuse, whose 2012 budget was $459 million.
So we spend nearly $1.5 billion a year, mainly on basic neuroscience research that, while generating enormous value in terms of understanding fundamental brain systems, has not yet generated much that is of direct use in treatment.
9. We Determine What Is and What Isn’t Legal Worldwide (But for No Rational Reason)
Ever wonder why marijuana is illegal but alcohol and tobacco are legal? It has nothing to do with the relative risks of the drugs—both legal drugs kill and addict larger proportions of their users than the illegal one does.
So why was marijuana prohibition retained while alcohol prohibition was ended? And why, for that matter, are heroin, MDMA, cocaine and LSD illegal? Drugs are made illegal based on who is perceived to take them and on racial politics—science is rarely considered in these decisions.
If a drug’s perceived primary users are not white, the drug tends to be banned—and stay that way. The US and Europe have legalized their own preferred drugs and banned those of all other nations—and those perceived as “corrupters of youth”—for the past century.
However, that may be changing. Since Colorado and Washington state have legalized marijuana, the US can no longer impose international prohibition with the vehemence it previously exhibited. With the world conventions governing the legality of drugs up for review at the UN next year, changes that would allow countries to experiment with a wider range of drug policies are more likely than ever before.
10. We’re Not Very Good at Measuring Addiction
I was going to conclude by comparing rates of addiction to various drugs in the US and other countries and how they’ve changed over time. However, while we’re pretty decent at tracking the percentage of people who try and who use drugs, we don’t look very hard at the proportion who actually develop the most serious problems with their drug use. Nor do we look too closely at cross-addiction, such as what percentage of those we’ve labeled as having cocaine addiction are also addicted to heroin or alcohol (and vice versa).
This may be because the rates of problem use are actually quite low compared to the rate of overall use, which is an inconvenient truth for drug warriors.
To be fair, it’s also somewhat hard to measure: Addicted people can be hard to find and survey accurately because of stigma and also because definitions of addiction have changed over time and are culturally sensitive. For example, if one country arrests a large proportion of drug users while another doesn’t, the group in the harsher country may have greater “addiction” rates because there are more negative consequences associated with their drug use—but that doesn’t mean the drug is causing those problems.
Nonetheless, here are the statistics I could find. New Zealand has the world’s highest rate of marijuana addiction, with 9% of its population meeting “cannabis dependence” criteria under DSM IV, at least as measured in 2000. Canada and the UK come in second, with 3% annual dependence rates for cannabis, measured in 2000 and 2007 respectively. The US rate is 1%—or was in 2007.
Iran is the record holder for opioid addiction, with a whopping 8.8% of its population having an addiction in the past year as of 2003. The current US rate for opioids is between 0.2% and 0.7%, depending on if you include prescription drug dependence or just heroin and depending on where on the scale of severity, based on DSM IV, you define the diagnosis.
We beat Iran on cocaine addiction, however, with 0.5% annual prevalence compared to their .07%. But meaningfulness of these comparisons and the accuracy of these statistics is dubious, given that they were collected in different years and include somewhat different population age ranges.
If you want to count the percentage of Americans overall with some type of substance problem, including alcohol, the latest figures from the National Institute on Drug Abuse show a rate of 9% in the past year, including both abuse and dependence. But good luck finding genuinely comparable international statistics!
What we can say for sure is that there’s no relationship between the harshness of a country’s drug policy and its rate of addiction—or if there is one, it may be inverse. Iran, for example, with its enormously high opioid addiction rate, executes people for drug crimes—and the US holds the world’s record on both the rate of many types of drug use and on incarceration of users.
As we celebrate the Fourth of July and our much-ballyhooed love of freedom and family, we should pause for a moment to reconsider our role both as the world’s largest jailer—and as the country in which children are most likely to try illegal drugs.
The following article first appeared on Substance.com:
When a child dies, our natural impulse is often to look for someone to blame—and some way of making them pay for the incalculable pain they have caused. But while this desire for revenge is understandable, when it comes to drug-related deaths, it can do far more harm than good.
Take the case of Tara Fitzgerald, a 17-year-old Minnesota honor student who died in January of an overdose of the synthetic hallucinogen 25i-NBOMe. Known as N-Bomb, the super-potent drug is similar to LSD but far more dangerous (while an LSD overdose can cause unpleasant hallucinations that can last for weeks, at least it won’t kill you).
Five teens have just been arrested for murder in her case: a 19-year-old dealer who was caught with 305 doses of the drug; another 19-year-old, who bought the drug from him; and three younger adolescents, all 17, who sold it down the chain to Fitzgerald. She took it along with a girlfriend during a sleepover—but that friend apparently has not been charged. All of the others, including the 17-year-olds, are being charged as adults—with third-degree murder.
“When an illegal drug enters our community, all of those involved—those who create it, sell it or give it away—are responsible for what happens with that drug,” the local county attorney said by way of explaining the extremely harsh charges. “We think there’s a moral obligation to keep kids free of drugs. We’re sending a message that suppliers will be held fully to account.”
Although getting lengthy sentences for these teens may provide some satisfaction to prosecutors—and perhaps to Fitzgerald’s family—that “something has been done,” the ultimate results are unfortunately likely to be counterproductive. The immediate effect could be to compound the tragedy so that five additional families are further devastated as a result of adolescent misjudgment—and the long-term outcome will not be to reduce dealing, but instead to deter help-seeking when overdose is suspected.
Here’s why. Sorting out “users” from “dealers”—especially among teens—can be a tricky business. Almost every user has purchased drugs at least once for friends or shared drugs with others, both of which are legally considered dealing. Most teen “dealers” are also users themselves. In the main, they sell extremely small amounts or simply pool money to make purchases; their motivation is not profit, but to supply themselves and their friends and enhance social ties. In the UK, this is referred to as “social dealing” and sentencing guidelines suggest reduced penalties in such cases.
That’s because today’s “dealer” may well be tomorrow’s “user”—and vice versa. Consequently, it’s not at all clear that one is more criminally responsible than the other. A similar approach is often taken with addicted dealers, who are trying to support their own habits, not profit from those of others. In the case of both adolescence and addiction—and particularly with the two together—decision-making is not exactly optimal and well considered.
Given all this, when a fatal overdose occurs, the odds are that the victim had previously committed the same crimes as the people who are charged in the death have—and luck is a far greater factor in determining which person overdosed and which did not.
This is not to say either that dealers have no responsibility in these deaths or that there aren’t any overdose victims who have never sold or shared drugs. However, lengthy mandatory minimum sentences for dealers and murder prosecutions for ODs have failed to reduce the supply of drugs. And drug war “successes” like taking out two big LSD labs in 2000 have led not to a reduction in the demand for hallucinogens but to the availability of more dangerous drugs like nBOME, which was synthesized in 2003 and first sold online in 2010.
Perhaps even more important, harsh penalties for dealing and possession deter help-seeking at a time when seconds may count—the last thing an overdose victim’s parents should want is those people around the victim worrying about whether or not they’ll get in trouble if they call 911. (Indeed, Tara Fitzgerald’s parents made a point of telling the press that “if there’s a lesson in the tragedy, it’s that all teenagers should know to summon help—even if they’ve done something wrong—to save a life.”) That’s why 15 states and the District of Columbia so far have passed “Good Samaritan” laws, which exempt people who call for help from being prosecuted for possession of small amounts of drugs.
If we want to prevent deaths like Fitzgerald’s, prosecuting for murder the hapless teens who sold to her is not the way to go. While they certainly should face some consequences, these should be proportionate and rehabilitative. It makes no sense to ruin five lives to “send a message” to those who are either too young or too impaired (or both) to benefit from it.
Charging and sentencing in such cases should explicitly take into account youth and any addictions—not bizarrely assume that because an overdose occurred, a 17-year-old “dealer” suddenly has the maturity to face adult criminal responsibility.
Instead, we need to recognize that adolescents are always going to take stupid risks—whether using, dealing, driving fast or in other ways—and try to reduce the odds that the outcome will be fatal. Throwing more people in jail might satisfy a desire for vengeance, but it makes overdose deaths more likely, not less. Your kid could just as easily be the addicted person whose poor judgment leads to a charge of causing an overdose as the person who falls victim to one.