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 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.
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.
Tina*, 19, woke up in a pool of blood with a suicide note next to her—and no memory at all of having written it during an alcoholic blackout.
Liam, 18, who started drinking at 11, spurred both of his addicted parents to start their own recoveries when he descended into heroin addiction at 17.
And Stacy*, 24, was already hospitalized for depression when she overdosed on pills while out on a day pass during her junior year of high school.
All three are now either graduates of, or currently attending, recovery high schools—in their cases, public schools, with a varying mix of city, state and private donations paying the bills. The schools aim to provide a supportive environment for adolescents with alcohol and other drug problems. They don’t admit students who don’t have a desire to stop drinking or using and the majority of students have completed at least one, often several, treatment programs.
Stacy, Tina and Liam are all drug-free now. Tina is headed to Northeastern University in the fall, Stacy has been accepted into the Peace Corps, and Liam is starting a carpentry apprenticeship.
At least two dozen recovery high schools now operate across the US, with more planned, although budget cuts have forced some to close and threaten others. The first opened in the late ’70s and early ’80s, with current schools located in Massachusetts, Texas, Minnesota, California, Wyoming and other states. Actress Kristen Johnston, best known for starring in 3rd Rock from the Sun, has been working for about five years to create New York City’s first sober high—she founded the nonprofit organization SLAM (Sobriety, Learning and Motivation) in order to do this. However, it is not easy to start schools in the city’s complex and financially strapped educational bureaucracy.
But do recovery high schools really help? Or are they simply an extension of an often-dysfunctional treatment system, which can sometimes do harm by concentrating troubled youth together and forcing them to accept a stigmatized identity as an addict before they even know who they really are? (This article focuses only on public non-boarding recovery schools: Some private boarding schools that sell themselves as recovery schools have been cited by former students for using tactics that are known to be abusive and harmful.)
While there is no controlled data so far on the outcome of public recovery schools, the early results look promising. Andrew Finch, assistant professor of counseling at Vanderbilt University, says that outcome studies find the reverse of what research on typical teen treatment like 30-day rehabs and intensive-outpatient programs shows: After treatment, about 70% of kids who return to their communities relapse within six months to a year; but after attending recovery schools, only about 30% relapse. Although this may reflect the fact that the schools admit only students who say they want to kick drugs and therefore might be more motivated than those who don’t attend, it doesn’t suggest that the programs do harm.
“I think the balance of risk vs. reward is weighted toward the reward side,” says Ken Winters, director of the Center for Adolescent Substance Abuse Research at the University of Minnesota, who is also working to evaluate recovery schools. “[Harmful] effects can happen. Every treatment and recovery group has to worry about that and keep on top of it.”
Consequently, many recovery schools seem committed to avoiding the mistakes often made in adolescent treatment—like “one size fits all” 12-step treatment, punitive and humiliating disciplinary practices, insistence on the acceptance of the “alcoholic” or “addict” label and rapid expulsion for relapse. Some even take a harm reduction approach, refusing to give up on teens who are not ready or able to become abstinent immediately.
“We work with a lot of vulnerable children,” says Michelle Lipinski, principal of the Northshore Recovery High School in Beverly, Massachusetts. “We have a lot of homelessness. We try to find the thing that they will grab onto to keep them from using. For us to mandate that you need to adhere to the 12 Steps, expect this many meetings a week, get a sponsor—it just doesn’t work for about half our population. You have to meet the kid where they are.”
Tina’s story reflects how this philosophy can bear fruit. She had suffered from anxiety disorders and depression since childhood. She began treatment for panic attacks in fourth grade. Her father died when she was 13, but she only learned recently that his heart attack was probably caused by cocaine.
Like Tina, around 75% of youth who attend recovery high schools also have diagnosable mental illnesses—and a large proportion also have family members with drug problems. Both issues are addressed regularly in counseling and group sessions in the schools. Unlike Tina, however, most students in these schools have previously been through addiction treatment, often multiple times.
Tina was already enrolled at Northshore when she had the relapse that ultimately spurred her recovery. She’d started attending after nearly dropping out of her prior high school because of her drinking and misuse of anti-anxiety medications like Xanax—but she wasn’t immediately able to commit to abstinence. “For the first year of me being here, I tried every two weeks to get sober and just couldn’t do it,” she says.
However, even when she was using, she usually made herself show up. At her former high school, she hadn’t done that because she says “no one cared,” but at Northshore “they gave a shit so I tried to come.”
And so, when she woke up bleeding from numerous cuts after a binge and read a suicide note she didn’t remember writing, she went to school. She was glad to be alive. “It was terrifying that I could do something like that and have no control over it,” she says.
Her injuries turned out to be more bloody than dangerous, but Tina was afraid the cuts might get infected. “I wasn’t going to show my mom because she had no idea I was cutting myself,” she says. When she got to school, her English teacher helped clean her up, as she sobbed and told her what had happened.
Even then, Tina’s abstinence didn’t start immediately. While she didn’t have another severe relapse, she did on several occasions take a few hits off a joint or have a drink. Now, however, she’s nearly two years sober. “I’m starting college in the fall,” she says, adding that it was the whole school and the 12 Steps—not any one person—that helped her the most.
During her relapses, however, she also benefited from the school’s harm reduction philosophy. “They’d sit me down and say, ‘Whenever you’re ready, we’re here,’” she says, adding that she thinks it is “so sad” that some schools expel people much more rapidly.
Stacy, who is now 24, also attended Northshore, but her recovery took a different path. Depression runs in her family—and she wound up misusing Ritalin that was prescribed to her when nothing else worked for her chronic fatigue.
When she took too many pills while out on a day pass from McLean Hospital, where she was being treated for depression, she was transferred from the depression unit into one focused on substance problems. From there, she went on to residential treatment—and then Northshore.
Stacy did not find the 12 Steps especially useful, although she did go to meetings in treatment and have a sponsor. “I never officially went through the 12 Steps,” she says. “It’s not forced on people. It works great for some people, but I definitely think it’s dangerous when you try to put all these different people in one box and say this is the only way you can get better.”
Stacy also says that she didn’t want her entire identity to be focused on recovery. “I got sober at 17,” she says. “If I wasn’t sober, I wouldn’t be all the things that I am, so I think that’s the foundation, but there’s more to life than this.” After graduating from American University, she’s joined the Peace Corps, which had been a dream for her since childhood.
For his part, Liam is attending William J. Ostiguy High School in downtown Boston, where about 40% of the school’s roughly 80 students suffer from opioid addictions like he does. Principal Roger Oser says, “We’re abstinence-based, not harm reduction,” and unlike at Northshore, the in-school programming at Ostiguy does include required 12-step components. But even here, alternatives like SMART Recovery can be used instead of attending outside 12-step meetings and relapse does not automatically lead to expulsion. Some students take medications like Suboxone, but because of their age, the plan is for detox, not maintenance.
“There’s no boilerplate [recovery path] that the student has to follow,” says Oser, adding that, “in early recovery, relapse is often part of the experience.”
Liam, who is a senior, has been drug-free since September and is still also attending the treatment center that referred him to the school. Growing up in a family dominated by addiction, he was hooked on heroin by 17. His opioid use started with prescription pain medication—but he never got it from doctors. “I knew people who sold drugs,” he says, describing how he supported his habit by stealing and dealing.
While his parents’ addictions initially helped enable his own, when they watched him go from an academic success and “good kid” to a thief and dealer, they knew they, too, had to change. Both successfully detoxed last August and now father and son sometimes speak together at 12-step meetings. Ostiguy, he says, “is giving me a life that I never had. I went from literally having nothing to having my whole life in eight months.”
All of the students I spoke with emphasized the sense of community, even family, they felt in their recovery school. Each described behavior that is highly uncharacteristic in many high schools: being able to go to teachers with emotional problems and feeling safe enough to share pain with peers in groups at school.
The schools also recognize that teen drama and heartbreak is part of growing up—so they don’t make unrealistic rules like banning relationships. But all of them are also small enough—typically less than 100 students, often only 30 or 40 or fewer—to provide highly individualized attention to each student. Because students feel so free to share with teachers and even principals, when a breakup, relapse or other emotional event is going on, it’s typically not long before the adults are aware of it and can offer help if needed.
While relapse is recognized as a common issue in recovery, one thing the schools show no tolerance for is bullying. “We have six kids who are openly gay and three transgender kids, and we will not tolerate bullying or abuse,” Lipinski says. (The high proportion of LGBT youth in recovery schools reflects the fact that rates of substance use disorders are two to three times higher in this group, a link associated with stigma related to gender and sexual orientation.)
This inclusive philosophy is echoed by Oser and by Rachelle Gardner, the principal of Hope Academy, a recovery school in Indiana. Since the feeling of being in a safe community is critical to the success of these schools, bullying and violence threaten the entire project. As a result, disciplinary measures tend to focus on restorative justice—making amends to the community—rather than punishment. However, assaulting other students or using drugs on campus tends to result in immediate referral to treatment or expulsion if treatment is rejected.
While drug tests are administered in most recovery schools, a positive result does not necessarily mean return to treatment or expulsion—relapse is not seen as an occasion for punishment, but as a sign that more support is needed. And the more honest the student is about the circumstances of the relapse, the less likely he or she is to be asked to leave the school.
Of course, some parents fear that the stigma associated with addiction might harm these students’ chances of college admission, but so far that hasn’t proven to be a problem. All of the schools, however, see themselves as schools, not treatment—and they do their best to emphasize academic achievement.
“I’m doing this because no one else fucking is,” says the always frank Kristen Johnston of her quest to bring a recovery school to New York. “I partied in high school like a rock star and I was a functional addict for many years, but the bottom line is that those were years of sorrow, misery and hell. I would really love to be able to give kids the ability to have the good part of that life, not the bad part.”
*Names changed to protect privacy.
The following article first appeared on Substance.com.
Journalists are no less likely to take drugs than anyone else—indeed, in my admittedly anecdotal experience, they’re more likely to use. You’d think that this would make us especially skeptical both about federal policies that failed to prevent our own drug-taking and about extreme claims about drug users.
But the press may actually be one of the biggest obstacles to reform. Instead of asking tough questions, reporters tend to simply parrot conventional wisdom—and reinforce the idea that the drug war is the only way, even when drug warriors’ claims contradict the evidence of the writers’ own lives.
In the last month alone, we’ve seen several particularly egregious examples of mindless reporting—including one that is explicit in propping up longtime racist stereotypes about drug users. If we want better care—and, especially, less incarceration—for addicted people, we can’t just sit by while the media stirs up frequent drug panics. If we don’t challenge the stale formula that “crackdowns” are the best response to drug-related harm and that “typical drug addicts” are black, reform will remain marginal, at best.
Let’s examine the problem in some recent stories. Here’s NBC, in part of a network-wide series on heroin. In a lead-in to a video report headlined “Will the Rise of Heroin Mean the Fall of Pot?” (see the video below) the website says:
In the 1960s, the wide acceptance of marijuana paved the way for a heroin problem in America and the War on Drugs. Today, with two states legalizing marijuana, could this happen again?
Reread that first sentence: “The wide acceptance of marijuana paved the way for a heroin epidemic” is a claim that is stated as fact. But is it true? The report provides no sources or statistics—and while it’s obviously an argument that some anti-drug conservatives have long made, the claim is not backed by strong scientific or historical evidence. And it’s certainly not widely accepted enough to be stated in a way that implies causality and “objective” truth. Whether the intent is to bolster the long-debunked “gateway” theory that marijuana puts users on the road to heroin hell or to claim that relaxing laws on one type of drug use inevitably produces increases in them all, it’s simply not an accurate statement of fact.
Just because A follows B, it doesn’t mean that A caused B—and there were many other things besides a liberalization of attitudes toward marijuana going on in the 1960s and 1970s. In the video, however, the narrator says:
American drug culture is always in flux. A decade ago, even two years ago, marijuana was banned and heroin was an out-of-sight small problem. Now marijuana is sold like beer and heroin is ravaging a whiter, younger, more suburban crowd. But hold on a minute, haven’t we seen this episode before? In the late 1960s, reformers launched a massive push for the acceptance of marijuana. We ended up with a heroin plague….As marijuana acceptance spread, heroin pushed out of the ghetto and into white suburbia and the armed forces.
Note the sly mention of “the armed forces.” Do you notice anything missing? If you are of a certain age or just even have a rudimentary knowledge of history, you might recall that there was a little war in Southeastern Asia going on during these same decades, one that was opposed by some of the same people who wanted marijuana reform. And while this could, of course, be sheer coincidence, that conflict took place in an area of the world quite relevant to the supply of heroin. It seems that NBC, however, didn’t think Vietnam was worth mentioning—perhaps because including it would make viewers question its entire thesis connecting marijuana to heroin.
The narration continues, describing how President Richard Nixon made political hay by declaring war on drugs:
[This] allowed President Nixon to treat numerous middle-class concerns—crime, race riots, braless women, dirty-haired kids—as one addressable issue: drug abuse.
As the word “crime” is spoken, a clip of a black man appears, followed by one of black rioters. While earlier in the piece, the narrator noted that “more than 80% of the new mainliners, just like today, were white,” it apparently never doubted that viewers would share its own assumption that most heroin addicts are black. If heroin “pushed out of the ghetto” on the wings of marijuana in the 1970s, are we to conclude that the war on drugs worked, and did so by cracking down on pot? What, then, would account for the “heroin chic” epidemic of Nirvana’s 1990s, which occurred before marijuana legalizers gained any victories and which wasn’t black, either?
There’s another critical element missing from this story, perhaps even more important. That is, the big increase in prescription painkiller misuse since the introduction of Oxycontin in 1995 and the crackdown on prescribing in recent years. Several studies showdirect links between moves to make pain drugs harder to get or more difficult to misuse and increases in heroin use and overdose rates. And yet NBC blames heroin on marijuana.
Ok, I’m not going to pick on this pathetic excuse for “journalism” any further. You could argue that it’s just one misstep, and not representative.
Unfortunately, the release of a study last week purporting to show that casual marijuana use causes brain damage shows that this is not an isolated incident. Here are just some of the headlines, as gathered by one of the few skeptical articles, written by John Gever forMedPage Today:
“Marijuana News: Casual Pot Use Impacts Brains of Young Adults, Researchers Find” (The Oregonian)
“Study Finds Brain Changes in Young Marijuana Users” (Boston Globe)
“Casual Marijuana Use Linked to Brain Changes” (USA Today)
“Even Casually Smoking Marijuana Can Change Your Brain, Study Says” (Washington Post)
“Study Finds Changes in Pot Smokers’ Brains” (Denver Post)
“Recreational Pot Use Harmful to Young People’s Brains” (Time)
So, what’s the problem here? Although the press release that accompanied the study implied otherwise, the research itself is completely mischaracterized in these stories.
For one, it doesn’t really include “casual” marijuana smokers—the average marijuana smoker smokes once a month, while the 20 who participated in the study typically smoked 11 joints a week. Second, it doesn’t show that marijuana “changes” the brain—the methods used by the authors can’t determine whether marijuana caused the brain differences it found between users and nonusers or whether those brain differences cause people to like to smoke cannabis.
Finally, as I pointed out in the Daily Beast, the study doesn’t show that even this level of use is “harmful.” The participants were only included in the research if they were not experiencing signs of addiction, psychiatric disorders or any other detectable drug-related problem. In other words, they were normal—so it’s not even clear whether the brain changes that were detected are at all meaningful. As Carl Hart, a Columbia University associate professor of psychology and psychiatry, told me, there are detectable brain scan differences between men and women, but we don’t call women “impaired” as a result.
The New York Times saw “Negro Cocaine ‘Fiends’” fit to print. Photo via
While the media does seem to be improving in some ways—now, in our heroin panics, we do get coverage of overdose prevention and calls for evidence-based treatment like maintenance—these examples show that journalists still have a long way to go.
Of course, sensationalist coverage of drugs has been with us perhaps as long as we’ve had journalists—it has certainly accompanied every single drug policy debacle, from the initial criminalization of narcotics to the “Reefer Madness” that led to the crackdown on pot in the 1930s to the mandatory minimum insanity of the 1980s cocaine era. But drug panics don’t just sell newspapers or get ratings or clicks—they are clearly linked repeatedly to both racism and bad policy decisions.
As a reminder, here’s a New York Times headline from 1914, the year federal drug prohibition was enacted: “Negro Cocaine Fiends Are a New Southern Menace.”
Perhaps 100 years later, we can finally learn our lesson and not repeat history again. Perhaps in 2014, reporters and editors can show a bit more skepticism—so that the headlines and articles they write will not be as ignorant and inflammatory as the Times’. Then, for perhaps the first time ever, we might actually get intelligent drug policy.
In a better world, there would be no conflict between abstinence-based treatment and harm reduction: As in other types of medicine, addiction care would occur on a continuum. Just as you don’t see cancer doctors blogging that radiation is a “con” and only chemo should be used in all cases, you wouldn’t see addiction counselors making a similar case that abstinence should always be used, never maintenance.
Unfortunately, thanks to the likes of Bob Forrest, that’s not the world we live in. Forrest, who identifies himself on his website as the “longtime partner of Dr. Drew,” now runs his own treatment program, Acadia Malibu. It’s hard to believe, but yes, a man who worked on Dr. Drew’s Celebrity Rehab actually advertises this fact to sell addiction services—despite the show having a mortality rate of nearly 13% among its “patients.”
Forrest opposes maintenance treatment—even though three of the five patients who died after their season on the show lost their lives to opioid overdose or its complications, which could have been prevented if they had been given support for maintenance, rather than told abstinence is the One True Way.
Nonetheless, here’s what Forrest—after noting, “I thought of calling this blog ‘The Open-Minded Report’”—writes about harm reduction:
“It’s a con in my opinion. I have seen the suffering and degradation it causes: the confusion it brings to the 12-step community about who is sober and who is not; the irrational fear of detox, where the list of medications designed to help you avoid actually experiencing any withdraw symptoms grows longer and longer every year; and just generally, the lies and danger and horror it is causing. The medical profession and pharmaceutical industries drive the use of Suboxone and Subutex. This is code for ‘profitable to doctors and drug companies.’”
Nearly everything about this paragraph is wrong. For one, if harm reduction—by which he means opioid maintenance here—is a “con,” why is it endorsed by every major public health organization that has investigated the issue, from the Centers for Disease Control and the National Institutes of Health in the US to the National Institute for Health and Care Excellence in the UK and the World Health Organization?
Why does the Cochrane Collaboration—an independent organization widely viewed as producing the highest-quality evidence on which to base medical decisions—say this about methadone: “It retains patients in treatment and decreases heroin use better than treatments that do not utilize opioid replacement therapy,” while concluding of 12-step programs that “no experimental studies unequivocally demonstrated the effectiveness of AA or [12-Step Facilitation] approaches for reducing alcohol dependence or problems”?
And why does research show that patients who leave methadone treatment double their risk of dying—and quintuple their risk of overdose death if they are injection drug users? Why do studies consistently find death rates among addicted people in methadone treatment to be about one-quarter or one-third the rate of those not on maintenance? Even if Forrest relies only on anecdote, not data, his own experience with Celebrity Rehab deaths clearly bears this out.
OK, so it’s clear that Forrest is on the fringes here, ignoring both an overwhelming international consensus on best practices and the evidence of his own eyes. Let’s move on.
Is there any truth to the idea that maintenance treatments are simply a profit center for doctors and drug companies? While some money is being made, a look at the actual history of maintenance makes evident that if this is a pharma conspiracy, it’s an extremely strange one, because the US government basically had to pay drug companies to participate in it.
Let’s start with methadone. It’s a generic drug, long off patent and therefore definitely not of current interest to Big Pharma. As an addiction treatment, methadone was developed by Vincent Dole and Marie Nyswander of Rockefeller University in the mid-1960s—starting with money scraped together mainly from the government of New York City, not drug companies.
At first, virtually all methadone treatment was funded by the federal government as an anti-crime measure—and while there certainly have been unscrupulous providers, that’s linked far more to the stigma of addiction, and the lack of oversight of the care addicted people actually get for the money spent on us, than to any drive for pharmaceutical profit related to selling methadone.
What about Suboxone? It, too, was first studied as an addiction treatment, by the government—in fact, there was so little commercial interest in it that the National Institute on Drug Abuse had to push the FDA to give it “orphan” status in order to get the company that now makes it to enter the market. As Nancy Campbell writes in Discovering Addiction: The Science and Politics of Substance Abuse Research, “Lack of coordination between public and private interests delayed development far longer than the notoriously slow FDA approval process. To bring ‘bupe’ to market, NIDA worked to stimulate private interest.”
In other words, we have Suboxone despite the disinterest of pharma in the addiction market—not because it saw dollar signs when it looked into our eyes. While Reckitt Benckiser did ultimately profit from the drug, this is not a scandal like the overselling of antipsychotic medications, for which every single manufacturer has paid at least multimillions, and sometimes billions, of dollars in fines for misleading marketing. Indeed, it’s an example of a drug that is doing precisely what a drug is supposed to do: restoring health more often than harming it.
Of course, it’s not completely wrong to say that there is an excess of shady doctors in the Suboxone business—but again, the reason for this is that addicted people are, to put it mildly, not popular with physicians. Those who have the choice not to work with us generally make that decision whenever they can—because of both the stigma and the legal scrutiny that maintenance treatment for addiction brings.
All of this is not to say that everyone who has ever had an opioid addiction should be on maintenance: I am personally an example of someone who is not. But good medical practice is about finding the right treatment for the right person—not prescribing the same therapy at the same dose for every patient with every variant of the disorder in which you supposedly specialize.
Finally, I have to add that it’s laughable that someone like Forrest would claim that maintenance proponents are scaring people away from abstinence by raising fear about withdrawal—when on Celebrity Rehab, patients were brutally detoxed in the most uncomfortable way possible.
Need I remind him that one person who later died of an overdose actually became psychotic during withdrawal on the show and another, who later committed suicide, suffered a seizure? Actual experts say that neither symptom should have been allowed to emerge in appropriate medical treatment with slow, careful detox—but this is the picture of withdrawal that the supposed abstinenceadvocate presented to the world.
There’s truly no need for abstinence and harm reduction advocates to be at each other’s throats: Both forms of treatment are needed and belong in the continuum of care. Not every person addicted to opioids needs lifelong maintenance—but some do; likewise, while some people benefit greatly from 12-step participation, others don’t. We can, and should, all get along here, to paraphrase Rodney King, another patient who died after Celebrity Rehab.
While there is room for many different approaches in addiction treatment, we’ve got to start being intolerant of this absurd and often deadly intolerance.
The following originally appeared on Substance.com:
For anyone interested in addiction and drug policy, the last year or so has been the most fascinating period in recent memory. Having kicked heroin and cocaine in 1988 and written about the subject ever since, I can’t remember a time when public opinion and actual policy have changed so quickly—and in such a rational direction.
I’m not just talking about marijuana—although the fact that the Obama administration has allowed two states (Colorado and Washington, as of January 1) to legalize the recreational use of marijuana is a seismic shift. Six other states are considering either recreational or medical marijuana legalization. Internationally, Uruguay has also legalized, and Mexico has a decriminalization bill in the works.
A US congressman recently ridiculed the nation’s deputy drug czar for his failure to admit the obvious—that marijuana is less harmful than methamphetamine—when, previously, few politicians would publicly do anything except thunder about the evils of marijuana as a “gateway drug” while pushing for longer sentences, harsher penalties and increased “antidrug” spending. Being seen as “soft on drugs” was viewed as a political death sentence in the Clinton and Bush years.
But today, even the staunchly prohibitionist Smart on Marijuana (SAM) claims to support cannabis decriminalization: a stance that was seen as tantamount to promoting drug use just a few years ago. Although what SAM actually seems to favor is coerced treatment or “education” for marijuana possession rather than full decriminalization, the fact that almost no one seems to think locking up marijuana users and saddling them with criminal records is a good idea anymore is an incredible reversal.
Indeed, SAM’s Kevin Sabet and Patrick Kennedy seem to be nearly the only people willing to go on TV or be quoted by the media as firmly opposing what’s going on in Colorado and Washington. Former drug czar Barry McCaffrey no longer accepts TV requests because, he told the Washington Post, the networks “only wanted a rented idiot general who didn’t understand that marijuana was harmless and filling America’s jails.” He’s still anti-marijuana, but he says, “the opposition has gone silent.”
There were some despicable and reactionary attacks on Philip Seymour Hoffman’s character, but virtually no one called for a crackdown on dealers and users or for more policing.
And when columnists David Brooks of The New York Times and Ruth Marcus of the Washington Post recently editorialized against legalizing weed, the nearly universal response was not just disagreement but ridicule. In the past, it was the legalization side that was marginalized.
Only a few years ago, in fact, the position of the “very serious people” (the phrase Times columnist Paul Krugman has popularized regarding the upholders of questionable conventional wisdom) was to occasionally decry the excesses of decades-long mandatory minimum sentences for nonviolent drug offenders, while failing to even question whether incarcerating people for drug use is a good idea in the first place. Now, the once-radical view that criminalizing drug possession is harmful is starting to dominate, at least with regard to marijuana. Even Sue Rusche, who helped found the parents’ movement against marijuana in the ’70s, now doesn’t believe criminal penalties for drug use are effective.
Views on addiction are changing as well. While the endless debate over whether addiction is a disease, a bad habit or a moral failing continues, even treatment providers who have defined themselves by the 12 Steps are no longer insisting that this must be the only route to recovery. Hazelden, the founder of the Minnesota Model, which once banned coffee during rehab because it is a drug, began offering opioid maintenance with Suboxone last year. That’s basically the rehab equivalent of the Catholic Church allowing the use of contraception—and it is a profound step toward treating addiction as an actual disease in which scientific evidence, not “treatment philosophy,” determines practice.
In addition, more people are coming around to the view that 12-step programs, while useful as support for many, should be an adjunct to treatment—not treatment itself. (Incidentally, this would be the case if people actually followed the 12 Traditions and never got paid for doing 12-step work. The industry couldn’t function without the thousands of low-paid counselors whose prime qualification is their own recovery and who spend much of their therapy hours trying to get patients to get with the program.)
The Affordable Care Act (“Obamacare”) and its unprecedented requirement for parity of treatment for addiction and other mental illnesses with physical disorders is another profound change, as is the DSM-5’s controversial new view of drug problems as a spectrum, rather than “addiction” being distinct from less severe drug misuse.
The response to the tragedy of Philip Seymour Hoffman’s death has also been markedly different from drug war tradition. While there were some despicable and reactionary attacks on his character, virtually no one called for a crackdown on dealers and users or for more policing. Instead, the media focused on how Hoffman’s death might have been prevented, asking whether access to the overdose reversal drug, naloxone, should be increased and whether Hoffman should have been given maintenance treatment.
In other words, harm reduction. While for years, drug warriors like McCaffrey and Sabet fought against maintenance, needle exchange and other harm reduction policies—and even opposed the use of that phrase in official policy documents—harm reduction has finally come out of the closet.
Hazelden, which once banned coffee during rehab, began offering opioid maintenance with Suboxone last yea—the rehab equivalent of the Catholic Church allowing contraception.
In the early ’90s, at the height of the AIDS epidemic, needle exchange advocates had to fight with treatment providers, parents of addicted people and others who should have been natural allies in protecting addicted people from their high risk of HIV infection. Today, the governor of Maine’s opposition to expanded access to naloxone is denounced by parents of overdose victims and rejected by the Office of National Drug Control Policy itself. Indeed, the drug czar’s office now claims to be doing “drug policy reform,” which may stick in the craw of those who have been doing that work for years, but is, at least in the case of advocating naloxone, accurate.
In the coming months, I’ll be covering these issues for Substance.com, exploring their potential for both positive and negative outcomes for people with substance use disorders. While I believe that almost all of these changes are positive, it’s important for people who advocate new ways of doing policy to be aware of the pitfalls of going too far and to adjust their approach to deal with the changing situation they face. Some past attempts to liberalize drug laws have been met with a harsh backlash when predicted benefits were not as great as promised or when harms were dismissed rather than addressed.
Drug policy is complex, as is addiction: Both involve not just biology and psychology, each of which is staggeringly complicated, but also culture and fashion. It’s clearly the case that incarceration doesn’t treat or prevent addiction; it’s also true that commercial interests like the alcohol and tobacco industries can exacerbate it. There is no perfect solution here, only ways of balancing risks and benefits, which may vary from substance to substance, from person to person, from social class to social class, from country to country and in countless other ways.
What Most People Think They Know About Marijuana Is Unscientific, Paranoid and Even Racist Propaganda
This article first appeared at The Fix, with coverage on addiction and recovery, straight up.
Everyone thinks they know something about drugs—whether from personal experience or from 8th grade prevention classes or simply because the media presents so many stories about them. Unfortunately, most of what people think they know is inaccurate, and comes from years of government war-on-drugs propaganda, with little understanding of itsmedical and historical context.
Take some of the recent absurd anti-marijuana columns and tweets from some of the backbones of the media establishment: the New York Times’ David Brooks, Ruth Marcus of the Washington Post and Tina Brown, former New Yorker editor and founder of the Daily Beast.
Both Brooks and Marcus told stories of their own youthful pot smoking—neither of which seems to have led to any lasting negative consequences as is the case for the overwhelming majority of marijuana users. Yet both claimed—without apparently understanding that relying on a single study that has been questioned in a follow up by the same journal is not accurately reporting “fact”—that marijuana definitively lowers IQ.
And neither mentioned the elephant in the room: the fact that marijuana laws are mainly enforced against black people and that arresting millions and saddling them with criminal records hasn’t prevented around half of the adult population (white and black) from trying weed. It has, however, meant that black people have reduced opportunities to get jobs with organizations like the Times or the Post while Brooks and Marcus never faced arrest.
Conveniently, the columnists also left out the fact that countries like Portugal that have decriminalized marijuana (or countries like Holland that tolerate some commercial sales of marijuana) actually havelower rates of youth drug use than we do.
Meanwhile, Tina Brown also tweeted that marijuana makes people stupid and legalization will reduce our ability to compete with China. Suffice it to say that she has little evidence for such a claim—one might argue based on equally flimsy data that it enhances creativity and popular culture, which is one of our true strengths—but that wouldn’t sound appropriately “serious.”
And right there is the problem: columnists and journalists who write about drugs rarely question conventional wisdom or go beyond cherry-picking of data to support what they already “know.”
But why are we so gullible in this area, when reporters are supposed to be skeptical? One reason has got to be the fact that over the last 40 years, the government has spent billions of dollars on advertising and even planted media articles and messages in TV shows aiming to get us all to “just say no.” While these campaigns are often ineffective at preventing use, they do seem to work at clouding perception.
And the truth is seen as immaterial in the drug war. Written into the job description of the “drug czar” by Congress is that whoever heads the Office of National Drug Control Policy (ONDCP) must “take such actions as necessary to oppose any attempt to legalize the use of a substance (in any form)” that is currently illegal, regardless of the facts. When asked about its distribution of “misleading information”—by a Congressman, in fact—ONDCP cited this provision to justify doing so, saying that this is “within the statutory role assigned to ONDCP.” In other words, they have to lie.
Rare is the journalist who will admit to having fallen for this outright propaganda, which is why last year’s confession by CNN’s chief medical correspondent Dr. Sanjay Gupta that he was wrong about marijuana was so stunning.
On CNN’s website, he wrote:
I mistakenly believed the Drug Enforcement Agency listed marijuana as a schedule 1 substance because of sound scientific proof. Surely, they must have quality reasoning as to why marijuana is in the category of the most dangerous drugs that have "no accepted medicinal use and a high potential for abuse."
They didn't have the science to support that claim, and I now know that when it comes to marijuana neither of those things are true. It doesn't have a high potential for abuse, and there are very legitimate medical applications.
The truth is that our perceptions of marijuana—and in fact all of our drug laws—are based on early 20th century racism and “science” circa the Jim Crow era. In the early decades of the 20th century, the drug was linked to Mexican immigrants and black jazzmen, who were seen as potentially dangerous.
Harry Anslinger, the first commissioner of the Federal Bureau of Narcotics (an early predecessor of the DEA), was one of the driving forces behind pot prohibition. He pushed it for explicitly racist reasons, saying, “Reefer makes darkies think they're as good as white men,” and:
"There are 100,000 total marijuana smokers in the U.S., and most are Negroes, Hispanics, Filipinos and entertainers. Their Satanic music, jazz and swing result from marijuana use. This marijuana causes white women to seek sexual relations with Negroes, entertainers and any others."
The main reason to prohibit marijuana, he said was “its effect on the degenerate races.” (And god forbid women should sleep with entertainers!)
Although it sounds absurd now, it was this type of propaganda that caused the drug to be outlawed in 1937—along with support from the Hearst newspapers, which ran ads calling marijuana “the assassin of youth” and published stories about how it led to violence and insanity. Anslinger remained as head of federal narcotics efforts as late as 1962, whereafter he spread his poisonous message to the world as the American representative to the U.N. for drug policy for a further two years.
Before marijuana was made illegal, the American Medical Association’s opposition to prohibition was ignored, as was an earlier report on marijuana in India by the British government, which did not find marijuana to be particularly addictive or dangerous. That “Indian Hemp Drugs Committee” reporthad concluded way back in 1894 that, “The moderate use of hemp drugs is practically attended by no evil results at all.”
Pundits and columnists who make pronouncements about marijuana’s dangers seem willfully ignorant of this history, which is easy to check via any online search engine. Its seems unlikely that Brooks, Marcus and Brown would want their names associated with a law that is both explicitly racist in intent—and continuingly racist in outcome.
But until we treat drug issues as medical and scientific questions, we will be doomed to continue this bigoted legacy—and we will not be able to treat addiction as the health issue that it is.
So, just say know when it comes to drugs—and be sure what you know is based in science, not ancient biased nonsense. (Though, on second thought, Anslinger may have had a point about the inadvisability of sexual relations with entertainers, particularly musicians.)
For a weekly roundup of news and developments in the drug reform movement and the injustices stemming from prohibition, sign up to receive AlterNet's Drugs Newsletter here. Make sure to scroll down to "Drugs" and subscribe. Also, please check out the new AlterNet Drugs page on Facebook. Thanks for reading!
The following first appeared on The Fix:
Glee star Cory Monteith’s tragic death on July 13 was preventable. Now that more details have emerged about what led up to his fatal alcohol and heroin OD, that conclusion is inescapable. As a adolescent, he was sent to many potentially traumatizing “troubled teen” schools—and as an adult, he received addiction treatment that did not follow government guidelines for effective care and did not provide potentially lifesaving harm reduction information.
Meanwhile, the media is doing its usual best to obscure the problem and keep stereotypes about addiction alive. Portraying Monteith as the “new face of” and pretending as though the drug hasn’t long been used by both celebrities and the middle class, the networks and online media are recycling the idea that heroin is just starting to escape the ghetto and affect people who don’t look like an addict “should.” That’s not news.
But what is important—and is not getting enough attention—is the fact that Monteith has just joined fellow heroin addict Kurt Cobain as yet another famous and beloved victim of tough love and, as Anne Fletcher wrote in The Fix on Monday, anti-maintenance stigma.
Monteith’s history with ineffective and harmful anti-drug programs started almost as soon as he began using, at 13. Between that age and 16, he attended some 12 different schools, including several aimed at “troubled teens,” a phrase that has become shorthand for harsh programs that we now know can backfire.
During the years when he was locked inside troubled teen programs—1995-1998—tough love reined. Tactics were aimed at “breaking” youth through physical and emotional abuse—everything from solitary confinement, punitive restraint and sleep and food deprivation to public humiliation like wearing signs saying, “I am an asshole,” being made to dress in drag and being forced to scrub bathrooms with the same toothbrush you must later use to brush your teeth.
For a sensitive and depressed adolescent, these tactics are counterproductive. They can exacerbate any pre-existing mental illness, a condition of virtually all addicts whose use starts in pre-adolescence like Monteith’s. They can worsen the odds of relapse. Most perversely, they can turn a mild drug misuse problem into a chronic addiction.
So, this is the initial instance where tough love was likely to have harmed the future star. And it probably did so in two ways. First, by the damage itself that comes from harsh treatment. And second, by creating a fear of treatment as disrespectful and even brutalizing.
None of the “care” Monteith received as a teen “stuck.” And while the first “my way or the highway” intervention he got at 19 did initiate a period of sobriety, it was almost certainly his discovery of his talent as an actor at this time rather than anything he experienced in rehab that sustained it. Paradedescribed Monteith’s first experience in front of a camera (in the role of a man contemplating suicide) as “life altering.” The actor told the magazine that it was the first time he’d felt the joy of “working hard and being good at something.”
Fast forward to 2013. Ryan Murphy, the co-creator of Glee, learns that Monteith is using again—and probably, that opiate use was involved.
As Deadline Hollywood reported:
“As soon as I heard what was happening, when we had two episodes left to go, I brought him to my office where we had the intervention,” Murphy said. “He said he wanted to finish the rest of the season, and I said absolutely not. We were not going to put a stupid TV show before his sobriety. I assured him he was not fired, that his job was secure, that he would leave today. He went with a whimper and not a bang and it was very emotional. On one hand, he was thrilled that people wanted to take care of him, though he also felt shame and regret. We had experts in the room and tried to let him know this was a disease. It was a tough and very emotional day and the last thing he said before he left was, ‘I want to get better.’ And I believed him.”
Apparently, these “experts” suggested Eric Clapton’s Crossroads rehab in Antigua, an old-school program that does not “believe in” using medications to treat opioid addiction, despite all the data favoring them as lifesaving for people whose problems involve heroin or painkillers. Murphy implies that Monteith was in another rehab (reportedly Betty Ford) that “didn’t work”—but that after the second program, “all indications were that he’d gone through the Steps.”
We all know what happened next. Although the intervention did get him into treatment—unlike the one conducted on [Kurt] Cobain, which was followed directly by his suicide—Monteith followed the pattern of the 90 percent of opioid addicts who are coerced into 12-step recovery and denied an adequate period of maintenance treatment: He relapsed.
He also followed two other predictable and dangerous patterns.
First, the risk of overdose is highest in the initial few months after being in rehab or any other situation where a period of abstinence has occurred. After a complete detoxification, a person’s tolerance drops precipitously—meaning that the dose they took before treatment without even getting very high may now be potentially fatal. The first two weeks following prison, for example, were shown by one study to carry a greater than 120-fold increased risk of overdose death; that extreme risk elevation holds for whenever the person first uses again after a period without opioids.
Second, the vast majority of “opioid overdoses”—overdoses involving drugs like heroin or Vicodin—are not accurately characterized by that name. Instead, they are really “opioid mixture overdoses,” typically including an opioid and other depressants like alcohol and/or benzodiazepines like Xanax and Valium. Opioids are the drug that most often makes these mixes turn deadly—but only one third or fewer of so-called opioid overdoses involve those drugs by themselves.
Monteith took the deadliest possible combination—alcohol and heroin, whose actions to slow breathing are not additive but multiple—at the deadliest possible time. He was likely not informed about the risk because abstinence-focused rehabs typically don’t provide harm reduction advice. He certainly was not provided with maintenance medication like methadone or buprenorphine that can dramatically reduce that risk; he may not even have know that maintenance was an option—just as Cobain was told he could not take any more opioids, even for his chronic pain. Nor, apparently, were Monteith or his loved ones given naloxone, which can reverse opioid overdose, or instructed on how to use it.
In no other type of treatment are FDA-approved medications seen as appropriate to withhold—without even informing the patient of their existence. No cancer center in the US provides only chemo while refusing to inform patients about radiation treatment or putting it down as something “we don’t believe in here” because it is “cheating” rather than “real recovery.” But the equivalent is done in addiction treatment—even for celebrities—every day. If we don’t want to keep losing patients, we’ve got to actually treat addiction like a disease, by providing evidence-based treatment, not just repeating faith-based philosophies.
Ryan Murphy has said that Glee will soon return and will deal with Monteith’s death in its storyline. “What we’ve been talking about in the writer’s room is that maybe the way we deal with this tragedy might save the life of someone,” he told Deadline Hollywood. If he really wants to do that, Murphy needs to fire his current “experts” and learn the truth about addiction.
Denying people access to maintenance care costs lives—and so does failing to provide harm reduction information and tools like naloxone to reverse overdose. The 12 Steps and abstinence are not the only way. If Glee can teach this, Monteith’s death truly could prevent thousands of others—and help finally bring addiction treatment into 21st-century medicine.
What is the most dangerous activity you can engage in? If you guessed doing illegal drugs, you would be wrong. Extreme sports like big wave surfing, heli-skiing, cave diving, white-water rafting and mountain climbing all have a higher rate of risk to life and limb. Yet the question of a ban on these behaviors beloved by "adrenaline addicts" is viewed as ludicrous, even when the risk of death, say, in climbing Mount Everest once (until recently, about 1 in 3) is greater than the annual risk of dying from heroin addiction (around 1% to 4%).
Or consider mundane activities like driving: Car accidents are responsible for 1% of annual deaths nationwide. Cigarettes and alcohol do at least as much, if not more, harm to each user than heroin or cocaine. Alcohol, cocaine and heroin have a 3% to 15% rate of addiction, depending on how it is measured—and tobacco's rate is higher. Yet the risks don't align well with their legal and social status, especially when you consider that marijuana is safer than any of the legal drugs.
The reasons for this inconsistency around risk are complicated. Driving has huge personal and economic benefits. Risky sports are seen as noble challenges that foster the human will toward exploration, adventure and growth. When it comes to nonmedical drug use, however, discussion of benefits tends to be either dismissed as delusional or stifled in favor of “risk” talk.
I mention these facts not to promote drug use. That I feel compelled to immediately include such a disclaimer underlines my point: Our values shape our perception of risk and the way we make drug policy. If we recognize only the risks and ignore the benefits, we fail to understand that the real problems are addiction and harm—not the substances themselves and the people who use them.
For instance, when we talk about the “epidemics” of Oxycontin, methamphetamine or heroin, we rarely acknowledge that the majority of users never become addicted: Over the course of a lifetime, only about 10% to 15% ever get hooked. That risk is not insignificant: Few people would fly on a plane that crashed every tenth flight. But focusing on use as the main factor in addiction obscures what is actually at stake.
There are, decade after decade, headlines about the fall of one drug and the rise of another. Yet the overall rate of people with addictions remains fairly constant. Although population differences and other variables make the numbers hard to compare exactly, a large national survey in 1990 found a 3.6% rate of illegal drug problems (DSM-defined “abuse” or “dependence”) in people ages 15 to 54 during the previous 12 months. The most recent National Survey on Drug Use and Health, which includes people from age 12 to those in their 80s or older, found a 2.5% rate of abuse or dependence in 2011. While that rate may seem much lower, the difference is probably due to the later survey’s inclusion of people over 55, who are numerous and had a 2011 addiction or drug misuse rate of a mere 0.8% or less. It is worth noting that 1990 was the peak of fears about a non-ending crack epidemic; by contrast, today, while there are concerns about growing prescription opioid addiction, the actual rates have been steady since 2006.
Now, this fairly constant long-term rate of drug use problems isn’t the end of the story. There are periods when dangerous drugs like opioids that have serious effects on people’s health replace the use of comparatively low-risk ones like marijuana. Similarly, addiction rates can sometimes change dramatically—for example, populations with a high exposure to early-life trauma are more likely to become addicted than those who have happier childhoods. Fashions can also pull large groups of people to use at dangerous levels (alcohol and cigarettes in the Mad Men era, for example, or the coke-happy early ‘80s).
What the real prevalence of addiction does signify, however, is that a policy of prevention that focuses mainly on a particular trending drug isn’t likely to solve the problem. If 10% to 15% of people are at high risk for addiction because they have significant life problems like mental illnesses or social or economic dislocation, fighting one drug will generally steer many of them to another drug while deterring those who wouldn’t have suffered harm anyway. And if the drug we spotlight as the current “bad guy” is in fact less harmful than some of the alternatives, we will only increase harm rather than reduce it.
The other problem is that targeting use itself alienates the majority of recreational users who don’t have problems—and makes anti-drug campaigners appear to be opposing pleasure rather than danger. (AA did itself an enormous favor when it chose to avoid claiming that alcohol is inherently problematic for everyone—but instead sought to fight alcoholism.) Similarly, campaigns against drunk driving have been effective because they don’t stigmatize drinking, but fight alcohol-related harm. Indeed, their most effective component was the creation of the “designated driver,” which solves the practical problem of transportation for a group that wants to drink and gives an important social role to someone who is abstaining, either permanently or temporarily.
The media often implicitly endorses an abstinence-only line. Last week’s New York Times report was a classic example of inaccurate anti-pleasure fear-mongering. Headlined “Designated Drivers Often Drink,” it said that a study found that “only” two-thirds of young designated drivers in Florida had no alcohol in their blood and another 17% had less than 0.05. In other words, 82% of designated drivers were safe to drive even under the most stringent standards, which is hardly a result indicating a “really ineffective” policy, as an “expert” source claimed. Indeed, the rate of drunk-driving deaths has fallen dramatically since the designated driver policy was introduced.
Unfortunately, those who have focused on illegal drug issues have tended to seek to stamp out drugs, not addiction. Consider the original name of the Partnership for a Drug Free America (now Partnership at Drugfree.org) and the Drug Free America Foundation, to take just two. By trying to eradicate drugs themselves, they have, intentionally or otherwise, allied themselves with political forces that not only stigmatize addiction as criminal behavior but use drug policy to send unrelated political messages. Two recent, widely praised books—Michelle Alexander's The New Jim Crow and David Musto's The American Disease, make a powerful case that American drug policy originated in racism. Cocaine, for instance, was banned first by state laws due to fears that it literally made black men impervious to bullets and caused them to rape white women; opium was banned in the states in part because of panic that it would allow Chinese men to rape white women.
Anti-drug organizations have therefore denied themselves the clarity of purpose that tends to make activism effective. By only fighting “drugs,” such advocates tend to undermine any claims they make of addiction being a disease, particularly when they highlight the use of marijuana. Consider that if you tried to fight alcohol by highlighting drinking as a disease: It just doesn’t work.
Although most users can easily think of someone who has gotten into trouble with cannabis, they also know from personal experience that such people are the exceptions, not the rule, just as with alcohol. The same goes for opioids, methamphetamine and cocaine, although this fact is widely obscured because many people who really like the drugs immediately realize their risk and avoid regular use.
To truly take on addiction, then, we need to focus on why some people have serious problems with them. There can be reasons to also focus on a particular drug or risk—for example, the overdose risk of opioids—but to deal realistically with the fact that people have always sought (and probably always will seek) chemical pleasure, we need to find effective ways to manage this human desire instead of ignoring it.
That means fighting addiction and drug-related harm—and facing inconvenient truths, such as the fact that addiction risk increases with poverty, unemployment and trauma. Addressing drug dangers is, of course, less simple than declaring “war on drugs.” But it has the benefit of suggesting measurable and attainable goals—with some of these efforts already shown to help the people the drug war has most harmed.
Maia Szalavitz is a columnist at The Fix. She is also a health reporter at Time magazine online, co-author, with Bruce Perry, of Born for Love: Why Empathy Is Essential—and Endangered (Morrow, 2010), and author of Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids (Riverhead, 2006).
The crimes are heinous: murdering a pizza deliveryman for his uniform, then wearing it to shoot down Colorado’s state prison chief; hiring a hit man to kill your parents; stabbing both of your grandfathers to death. Besides the horror, these recent homicides share a surprising common element: In each case, the alleged or convicted perpetrator had been sent to an unregulated tough-love camp known as Paradise Cove.
Evan Ebel, the 28-year-old ex-con who is now notorious for the Colorado killings and the high-speed Texas car chase and shootout that ultimately led to his own death in March, attended at least two such programs, including Paradise Cove. His parents apparently sent him there around age 12 because they were concerned about his destructive behavior and suspicious that he was using hard drugs and alcohol.
But Paradise Cove was anything but paradise for the boys who attended. The Samoa-based camp was part of a “troubled teen” chain—variously known as the World Wide Association of Specialty Programs and Schools (WWASP), Teen Revitalization Inc., and Youth Foundation Inc.—that has had over a dozen of its programs (including Paradise Cove) closed down following reports of abuse. Former participants link at least 11 suicide or overdose deaths as well as three homicides to this particular camp—and many more to the network overall. Although apparently not using the WWASP name these days, the same high-level management is still involved in residential youth programs today, mainly in Utah.
The boys at Paradise Cove slept in straw-roofed huts on mats on a concrete floor. To prevent escapes, fluorescent lights burned all night, attracting mosquitos. Flip-flops were the only shoes permitted—another security measure—but these were rapidly destroyed by the sharp coral beaches where the boys exercised and worked. The cuts that resulted attracted flies and infections. “They’d just swarm on you,” Paul Richards, who attended Paradise Cove in 1997, told me for my book on troubled teen programs, Help at Any Cost.
Breaking any of the program’s strict rules—for example, sitting in the wrong position or talking out of turn—resulted in severe, escalating punishment. Beatings by staff were common. But the worst consequence was “The Box,” a three-foot-square windowless, wooden hut with a concrete floor, where teens were made to stay for days to months, subsisting on rice and water. Sometimes, they were thrown in hog-tied and left for hours. Other times, they were made to kneel or sit in stress positions, which rapidly became agonizing.
“You’d have to sit cross-legged with your hands on top of your head with your elbows sticking out,” says Bill Boyles, who attended Paradise Cove from 1997 through 1999 and is now an activist with theCoalition for the Safe and Ethical Treatment of Youth. “It’s ridiculously uncomfortable on concrete in the hot summer sun in the tropics and they wouldn’t let you take a shower.” (A website calledWWASP Survivors advocates for people who attended WWASP-related camps and serves as a watchdog over the "troubled teen" industry in general. Bill Boyles runs the Paradise Cove Survivorswebsite, which vividly details the brutal, squalid conditions at the camp.)
Unlike Ebel, Boyles had not been sent because of aggressive behavior—he was moody and had refused to go to school, but did not take drugs or commit crime. Paul Richards, who attended at the same time as Boyles, had been a straight-A student and star high school basketball player. In both cases, their main problem had been not getting along with their parents, but Paradise Cove accepted any child a parent labeled as troubled, so long as the tuition was paid.
“Therapy” at Paradise Cove consisted primarily of emotional attacks. “They just circle you up and they all start yelling at you at the same time and say how shitty a person you were…[things like] ‘You’re worthless, you’re pathetic, you’re a piece of shit, you’re a compulsive liar and nobody likes you,’” Richards told me.
“Ebel was extremely quiet, kept to himself,” says another former Paradise Cove resident, “Andrew” (not his real name), who is concerned that media coverage has portrayed teens sent to Paradise Cove as beyond help. “The realistic view is that if one was ‘troubled’ when they arrived in Samoa, they left as a basket case, and if one was a basket case when they arrived, they left as a [disaster],” Andrew says.
Paradise Cove was shut down by the Samoan government in 2000, after a report by the US State Department found “credible” allegations of “beatings, isolation, food and water deprivation, choke-holds, kicking, punching, bondage, spraying with chemical agents, forced medication, verbal abuse and threats of further physical abuse.”
Boyles says that the worst thing about the program was that the constant threat of emotional and physical violence numbed teens to the suffering of others. At one point, for example, a rumor spread that if a boy died, the program would be shut down and all of the boys would get sent home. En masse, the teens decided to cause such a death.
They chose the smallest, youngest boy to be their victim. Although stories differ as to whether they attempted to drown or stab him, the plot was known by dozens of boys and no one tried to stop it. Fortunately, the boy survived—not surprisingly, he later developed PTSD. But the incident showed that the teens involved were so desperate to leave and so accustomed to violence that committing murder seemed a reasonable means of escape.
“I would say not necessarily that it makes you more violent, but when you’re around that level of brutality and violence as a kid, you get inured to it,” Boyles says.
“Ebel was one of us,” Andrew says. “His mind might have been so distorted when he left that there was no path back to sanity. I don't condone his last actions that later led to his demise, but I, and most of us from the Cove, understand his thoughts and empathize with him.”
In the weeks before he died, Ebel sent a friend what has been described as a suicide note, attributing his anger to having spent years in solitary confinement during 11 years in prison for robbery and for attacking a prison guard. The letter, described by the friend who received it, said Ebel felt “ruined” and was “consumed” with rage and a need for “vengeance.” (According to several "alumni," the routine cruelty at Paradise Cove bred in some boys a deep resentment against their parents for sending them there.)
Ebel's history raises questions like, If he had received proper psychological treatment—rather than the abuses of Paradise Cove—would he even have committed the robbery that sent him to prison? And how did his lockdown at Paradise Cove affect his ability to stay out of solitary in prison or endure it once imposed?
Two other recent killings also have links to Paradise Cove. Chris Sutton, a deeply troubled young man from Miami, spent three years in the program after first threatening to kill his parents when he was 16. At 25, he actually hired a hit man to do the job—killing his mother and blinding his father in 2004. He tried to use the abuse at Paradise Cove in his defense, but was convicted in March 2011 and sentenced to life in prison.
Joshua Lambert, a 31-year-old Washington man who attended the camp when he was 15, confessed to stabbing both of his grandfathers to death in 2011. He is acting as his own attorney and claiming an insanity defense (he was diagnosed with anti-social personality disorder), in the bizarre case where he went from one house where he bound his great-aunt in duct tape and killed one grandfather, and then went to his mother’s home to kill the other grandfather.
“It was the worst time of my life,” Lambert said of being at Paradise Cove in his local paper, theWhidbey Times. He added, “It does make it easier to be in jail. I remember being sent to jail when I was 18 and thinking it was so much nicer than Paradise Cove.”
Any abuse the perpetrators suffered—at "troubled teen" camps or in prison—certainly does not excusetheir horrendous crimes. Still, it seems likely that such brutal behavior-modification camps can exacerbate tendencies toward violent crime—in the same way that child abuse, domestic and neighborhood violence do.
For its part, WWASP has always insisted that it is not abusive and that the teens who had bad outcomes are liars who were simply beyond help. WWASP's Ken Kay has called the allegations “ludicrous” and claims that, as of 2010, WWASP existed “only on paper” to defend against related lawsuits.
Although no one knows how many boys did time at Paradise Cove—Boyles estimates around 2,000—the number of homicides, suicides and overdoses that have been reported (the actual number is unknown) is excessive, even among troubled kids sent for treatment.
Two additional factors also make the numbers seem disproportionate. First, like Richards and Boyles, many teens sent to the camp were not involved in crime or drugs beforehand. Second, almost all of the teens had either wealthy or middle-class parents, since tuition ran at least $3,000 a month and boys stayed for at least 18 months. It was not covered by insurance.
US regulators have generally failed to stop tough treatment that is reportedly over the line from being imposed on youth, in part because no reliable follow-up studies have been done to see if these programs actually make people worse or simply don't help. Two Government Accountability Officeinvestigations and two sets of congressional hearings several years ago demonstrated the lack of oversight, fraudulent marketing practices and deadly outcomes that have been reported in connection with many troubled teen programs. But legislation intended to help has never made it through Congress. While a bill to regulate these programs and ban abusive tactics was re-introduced this month by Rep. George Miller (D-CA), it is unlikely to progress given the general gridlock. Previous versions of the bill did pass the House twice, but stalled in the Senate.
If studies proved that these tactics increased addiction, suicide and violent behavior—as seems likely—it would be impossible to argue that any claimed benefits outweigh the risks. Such data could perhaps finally persuade Congress to regulate anyone who incarcerates teens for profit, no matter what they label their "program." And we could finally stop programs like Paradise Cove from preying on American kids and parents.
Drug addicts and alcoholics are surprisingly conservative when it comes to psychiatric medications. We’re willing to try virtually anything to get high—but when it comes to taking drugs to get better, we tend to get all “Just say no.” For me, this tendency led to years of suffering before I finally had no choice other than to try antidepressants.
Part of the problem can be attributed to widespread skepticism about these medications, which is prevalent in some 12-step programs. This fear has two facets: the first, a justified anxiety based on historical claims about certain medications not being addictive, which later proved false; the second, a more problematic moralizing that use of medication to “fix” an emotional or mental problem is somehow “cheating.”
The issue of AA members telling people to stop taking—or advising them never to try—psych meds became so acute by the early ’80s that a 1984 conference-approved document, “The AA Member and Other Medications,” explicitly warns against “playing doctor” and states starkly:
AA members and many of their physicians have described situations in which depressed patients have been told by AAs to throw away the pills, only to have depression return, with all its difficulties, sometimes resulting in suicide.
Although I attended 12-step groups daily for the first five years of my recovery from cocaine and heroin addiction, I never thought that I bought into the extreme anti-drug line. Indeed, I handed out that pamphlet to many people who had been reprimanded for sharing, or felt otherwise beleaguered, about taking medication—and yet I resisted it for myself.
And so I continued going to meetings and trying to get on with my life, even as I wrestled with feelings of self-hatred and anchorless fear. I’d spend hours on the phone, analyzing tiny incidents of social rejection, thereby ruining the friendships I actually had but felt I didn’t. I tried talk therapy, but several years of ruminating about my childhood didn’t change much.
Throughout this time, my mid-20s, my career was taking off and I’d managed to sell my first book. At the lowest points of my life, work was the one area of life where I’d always felt good about myself. But when the publisher killed the book, I found myself paralyzed by apprehension.
I thought the problem might be the structurelessness of my freelance life, so I got a job. When even working on an AIDS documentary—something that normally would have energized me—didn’t change the state of deadness and dread, I knew I had to try something else, especially when I found myself unable to stop crying at the office.
The next day, I managed to get myself to a psychiatrist, who rapidly prescribed Zoloft. It turned out to be lucky that I took the oblong blue pill for the first time on a weekend. Several hours later, I experienced an oddly familiar sensation.
It was a feeling in the pit of my stomach that things were about to get weird—the vaguely nauseous lurch I’d often experienced after taking acid, right before the drug kicked in. Soon, as with LSD although less intensely, I was seeing multidimensional red and green geometric shapes if I looked at anything bright for too long.
Concerned, I called my psychiatrist, and she said it would pass and that I should take my next dose on time, but halve it. And indeed, the hallucinations soon diminished to the point where I felt normal enough to go back to work on Monday. Ironically, I missed my colorful visions: although the hallucinations hadn’t lifted my depression, they had at least distracted me from it.
I had never before been consciously aware of the minute bursts of pleasure until they’d leached away—and now suddenly returned.
For about 10 days after first taking Zoloft not much changed. I didn’t relapse; I went to meetings. I did the bare minimum necessary to get through the day. This was not helped by the fact that after my office-crying incident, one of my bosses responded cruelly. I tried to explain what was wrong with me, saying I was seeking help. She barked, “Don’t bring it to the office.”
Then one morning, something changed. I noticed it when I was writing an op-ed and found myself pleased by a line that I had written. It was no great ecstasy, but it was striking all the same. I actually felt…good. That’s when it hit me: This drug is working and I am going to get better.
What I hadn’t realized until that moment was that pleasure had disappeared from my life. I knew something was wrong, of course, but I had never before been consciously aware of the minute bursts of joy that I had typically gotten from my work and my interactions with people until this pleasure had leached away—and now suddenly returned.
That moment and those that followed helped me recognize a fundamental truth about my addiction: It had largely been driven by an inability to take pleasure in emotional support. The reason I seemed insatiably needy was that I didn’t see or feel the love around me. I always needed more support because I couldn’t truly take in what I had.
Twelve-step programs had taught me that my perceptions of social rejection might be misguided and that when I walked into a room and thought everyone wanted me to leave, that was my interpretation, not necessarily what the data suggested. But they couldn’t teach me to experience emotional connection that I wasn’t physically—chemically—capable of feeling. When even work no longer provided satisfaction—when whatever brain chemicals that had allowed that last pleasure broke—everything had collapsed. And by boosting dopamine, serotonin or some type of nerve growth factor—as current theories of antidepressant action suggest—the Zoloft solved the problem.
One study of the effects of these antidepressants shows that almost immediately after you first take them, you start to perceive emotional expressions in faces more accurately—and the better you get at recognizing happy faces, the greater the improvement in your symptoms. It may be that the time it takes for the drugs to kick in is the time it takes you to really take in these smiles and warmth that you have missed. It may also be that when you can feel pleasure again, you are better able to see it in other people.
Regardless, this experience taught me that simply changing your thinking often cannot solve serious problems; a change in brain chemistry is needed. And that’s not an ignoble shortcut. We cheer new medications that make recovery from cancer or heart disease possible, why should someone already cursed with depression or addiction have to do more and more “hard work” to overcome it if an easier, softer way does work? While opposition to medication has certainly mellowed in the 12-step world—to the point where Hazelden itself now offers maintenance medication for opioid addiction, when once it wouldn’t even permit Prozac—there is still lingering discomfort, if not stigma.
I’ve taken antidepressants for around 20 years. The drugs have dramatically improved my relationships, ending the days when I needed so much reassurance that no one could stand it. Now I get to support other people. By turning down the volume on negative emotions, they have also allowed me to be sad when it is appropriate—not when I watch AT&T commercials. Incidentally, the fact that the drugs have worked for me in this way also shows that I am not simply having a placebo effect: In their ability to lower emotional over-responsiveness, studies have shown that serotonin antidepressants like Prozac and Zoloft have dramatically better effects than placebo.
While they don’t work for everyone, the widespread notion that these antidepressants have no pharmacological effects—or only negative ones ("they "turn you into a zombie," etc.)—has been debunked by more than two decades of research. For many people, including a surprising number of 12-step members, these drugs improve or regulate mood to a very significant degree—and that can be exactly what a person needs to do the work of recovery. But because these medications alter brain chemistry, they can also have undesirable side effects. These can be truly terrible: The wrong drug for the wrong person can absolutely be worse than doing nothing.
For me, however, the only thing I regret about taking medications for depression is not having done so sooner—in fact, I wonder if I might have skipped addiction entirely had these drugs been available during my teens. Of course, your mileage may vary, but I encourage everyone who is struggling in recovery to consider the possibility that drugs can help as well as harm. And whatever you do, make sure it truly works for you. Don’t settle for any treatment—whether medication, talk or support group—that doesn’t allow for the full return of joy.
t is far easier for Americans to buy a gun than to get treatment for mental health or addiction, let alone for both. Our nation's lack of these services is getting an unusual amount of attention right now in the fierce debate about gun control following December's mass shooting at a Newtown, Conn., elementary school. Yet some of the measures being proposed—and passed—are less about treating a vulnerable population and more about a heavy-handed attempt at regulating them. This poses a serious threat for almost half of all people who were or are addicts, as that's the percentage who have depression, anxiety or some other "mental illness."
The debate over how to reduce gun violence is portrayed by the media as polarized, pitting those who support gun rights against those who support gun control. In fact a majority of Americans, and even many gun owners, support a more balanced approach and agree that modest measures to restrict access, such as universal background checks and bans on high-functioning magazines like 15- or 30-round devices, are in order. And all sides agree that such measures should include better screening of mentally ill people who have a history of violence.
President Obama has proposed stricter regulations on not only the people who buy guns but on the guns themselves, such as a ban on assault weapons. But at his State of the Union speech last week, the high point was his emotional appeal to Congress simply to allow a voteon gun control legislation, period. That voting on, rather than passing, a new gun law appears to be the best that reform advocates can hope to achieve makes plain who is winning this debate: the hardcore minority of gun rights adherents, led by the NRA’s Wayne LaPierre, who argue that the main cause of the rising trend in gun violence and mass murders is untreated mental illness. Their advocacy for stricter regulation of these people is already being written into new legislation in even the most liberal states.
Recovering from mental health and substance abuse disorders is difficult enough as it is, with proper and affordable treatment often stymied by a combination of poor access, diagnoses that address substance abuse while ignoring co-occurring mental illness, and the general stigma associated with both diseases. This is why these reporting provisions of state gun control proposals have mental health and addiction advocates digging in for a fight.
But it’s David versus Goliath. The mentally ill, not being a rich and powerful lobby like the NRA but rather a vulnerable and stigmatized minority, are an easy target. And yet an enormous one: annually about 25% of Americans over the age of 18 suffer from a diagnosable mental illness, a total of almost 60 million people.
There is little evidence that focusing attention on mental illness as a cause of gun violence will have any but marginal effects, according to both public health and firearms experts. For one thing, a person with a diagnosis of mental illness is five times more likely to be the victim of violence than to be the perpetrator, experts say. Only 4% of people who commit violence are mentally ill; those who are violent tend to suffer from bipolar disorder, schizophrenia or some other serious problem. According to a large study by the National Institute of Mental Health’s Epidemiological Catchment Area (ECA), 16% of people with a serious diagnosis commit violence, compared to 7% of people with no mental illness.
Addiction and mental health issues tend to go hand in hand—far more often than is generally recognized. According to the just-released 2011 survey by the Substance Abuse and Mental Health Services Administration (SAMHSA), 42% of the 19 million American adults with a substance abuse disorder had a co-occurring mental illness in 2011. By contrast, 17% of Americans without a substance abuse disorder had a mental illness. And the stark difference also holds on the other side of the equation: Adults with a mental illness are three times more likely to abuse drugs or alcohol than adults without a mental illness.
These disturbing public health trends become literally life and death issues when you consider the very strong link between substance abuse and violence. According to the Psychiatric Times, up to “75% of those who begin addiction treatment report having engaged in violent behavior (e.g., physical assault, mugging, attacking others with a weapon and suicide).” The ECA study found that substance abusers with no mental illness diagnosis were almost seven times more likely than nonaddicts to be involved in a violent act. As for people with co-occurring disorders, most studies have found that a diagnosis of mental illness had no measurable effect on the rate of violence by substance users.
Throw a gun into the mix, and you get a status quo in which close to 20,000 Americans commit suicide and another 11,000 are murdered with a firearm every year. Among people with addiction, mental illness or both, the split between suicide and murder is 55% and 45% respectively. And recovering addicts are particularly susceptible to depression and thoughts of suicide, with alcohol and substance abusers four times more likely to have given serious thought to taking their own life in the past year than nonabusers.
Kurt Cobain could be the posthumous poster boy for the most serious gun danger facing people with co-occurring disorders. In the twilight of his 27-year life, the Nirvana front man, who had a diagnosis of bipolar disorder, was in a continual fight with heroin and alcohol addiction. The allure of that quick fix dogged him right up until the day in Seattle when he put a shotgun—one he had bought out of state—in his mouth and ended his life. The rock star's tragedy spoke to the silent struggles suffered by millions of recovering addicts every day.
But as so often on Capitol Hill, reality must yield to politics in partisan battles over policy, dinging the likelihood of an actual solution to actual problems. From the get-go, the NRA’s LaPierre has pursued a take-no-prisoners strategy, vowing retribution on any legislator who votes for increased controls, even background checks. His own proposal? To establish a “national registry” of people with a mental illness while adamantly opposing a national registry of gun owners—or even a universal background check for all gun purchasers.
In early January, New York state governor Andrew Cuomo, one of the nation’s most progressive presidential aspirants, signed a sweeping gun law that includes a provision requiring mental health professionals to inform their county directors of any patient who exhibits “harmful thoughts” to self or others. If the police are informed, they can then void the patient’s Second Amendment rights. A month later, a Georgia senate health committee unanimously passed legislation allowing licensed mental health professionals—including ordinary counselors—to involuntarily commit patients they deem potentially dangerous (to themselves or others) to an institution for 72 hours.
In reality, almost all mass shootings are done in family or workplace contexts by a perpetrator with no mental illness—or an undiagnosed and untreated one. “Most of these killers are young men who are not floridly psychotic,” Michael Stone, MD, a clinical psychiatry professor at Columbia University and an expert on mass murderers, told The New York Times. “They tend to be paranoid loners who hold a grudge and are full of rage.”
A paranoid loner is unlikely to end up in the office of a psychotherapist, while the people in treatment—now possibly coming under tighter surveillance—pose little risk except to themselves. If anything, mental health experts say, stricter regulation will discourage a paranoid-loner type from even considering treatment.
Fixating the gun violence debate on the issue of mental illness may have emerged as a tactic to change the subject from gun control, but it could do a lot of real-world damage. It threatens to intensify the stigma surrounding the mentally ill by popularizing the false notion that they are violent—and this goes double for people with a dual diagnosis.
f the New York state law is any indication, the provisions are likely to be written so vaguely as to only stoke the fears of someone who is in, or who needs, treatment. Questions like whether you will end up in the state’s criminal background check database, whether prospective employers will have access to this information, and whether a diagnosis can ever be expunged following treatment could have a chilling effect on addicts—especially those who use an illegal substance—with a dual diagnosis.
That's bad news for recovering addicts in need of mental health treatment, who already tend not to receive care. The 2011 SAMHSA numbers show that less than a third of Americans with a substance abuse disorder received any mental health care at all. An additional 4% received such treatment in rehab. A mere 7% of addicts accessed both mental health care and rehab services. While laws such as the one in New York are intended to preserve public safety, they might have the adverse effect of instilling mistrust between patients and their doctors, exacerbating this public health crisis even further. And the worse the substance abuse, the worse the co-occurring mental illness and risk of suicide.
President Obama's gun-control proposal is relatively uncontroversial as far as its provisions for reporting mental health status to background check databases, as those laws are already on the books (though poorly enforced). But the president's insistence that mental health care providers "get in the game" when it comes to reporting potentially violent individuals has already become a sticking point for doctors—not to mention a needless obstacle to addicts who genuinely want to recover from their illnesses. The president has insisted that such provisions will not violate patient privacy, and are only meant to target truly risky individuals. Current and prospective mental health patients had better hope he is right. Otherwise, they face a healthcare landscape in which they're discouraged from talking about, say, thoughts of finding happiness at the end of a warm gun.
With the news last week of country star Mindy McCready’s suicide by gun, the death toll among Dr. Drew’s Celebrity Rehab patients now stands at five, giving the show an unusually high mortality rate of nearly 13%. But what’s even more disturbing is that most of those deaths—possibly even McCready’s—might have been prevented if the program had utilized treatment practices proven to be most effective.
Although Dr. Drew appears to truly believe in what he does, addiction experts say that the treatment philosophy and policies demonstrated in his show and public statements often do not reflect the best evidence-based practices. His rejection of maintenance treatments, use of punitive detox practices and humiliating therapy and insistence that people cannot truly recover without complete abstinence through 12-step programs reflect the conventional wisdom of the 1980s, not the data of the 21st century. Indeed, Celebrity Rehab’s treatment—leaving aside the massive confidentiality violation of being televised—diverges dramatically from the National Institute on Drug Abuse’s (NIDA)Principles of Drug Treatment, a guide that lays out standards for the best addiction care.
Take the harsh way McCready was treated during her detox on season three of Pinksy's show, which premiered in 2010. As the cameras rolled, the country star began shaking and making involuntary movements. Her roommate, Mackenzie Phillips, simply laughed at her, apparently buying into the stereotype that addicts who seem ill must be faking it. But as Phillips belatedly realized that the seizure was all too real, the cameras continued to roll. She raced around, screaming and searching for a nurse; nearly a minute goes by with no one stopping the production to help. Instead, the cameraperson actually zoomed in as McCready shuddered and shook.
Prior to treatment, McCready admitted to drinking and taking benzodiazepines (anti-anxiety drugs like Valium and Xanax)—both of which can cause withdrawal seizures if patients aren’t adequately medicated during detox. Indeed, withdrawal from benzodiazepines and alcohol—unlike methadone or heroin withdrawal—can be fatal because these seizures can progress into a condition called status epilepticus.
Charles O’Brien, MD, PhD, is the director of the University of Pennsylvania’s Center for Studies in Addiction. He has developed drugs to treat dependence to alcohol, opioid and cocaine, done pioneering research into the clinical aspects of addiction and the neurobiology of relapse, been a longtime advisor to the government on drug policy and is widely seen as one of the top treatment experts in the world. He says that the death rate from such seizures can be as high as 10%. “If you properly medicate, you can usually prevent seizures,” O’Brien tells me. (To be fair, McCready had also suffered a previous head injury, which could also have caused the seizures.)
Seizures and other behavioral consequences of Pinsky's tough-love, no-medication, abstinence-only approach make for high drama, which is why some detractors have argued that Celebrity Rehab may put entertainment ahead of the most effective treatment—and even safety. For his part, Pinsky argues that drama is the only way to attract viewers. He told The New York Times in response to criticism of such practices by other addiction specialists that “the problem with my peers is they don’t understand television…you have to work within the confines of what executives will allow you to put on TV.”
Sadly, that’s not the only way in which the show fails to provide evidence-based treatment. Consider what happened to former Alice in Chains bassist Mike Starr, who, under the current standard of care, probably should not have been detoxed at all, let alone as rapidly as was done on the show. In 2011, he died of an overdose of unspecified prescription opioids.
In the first episode of season three in 2010, Dr. Drew notes that withdrawal symptoms vary but that Starr is “in for a painful and even dangerous journey.” Starr was withdrawing from methadone, which he had been taking for 10 years to treat heroin addiction, a not insubstantial period of time.
Most experts say that methadone detox, done slowly, even after decades of use, needn’t be either extremely painful or dangerous, merely unpleasant and at times seriously uncomfortable. But Starr was withdrawn quickly, producing pain—and drama. He vomits voluminously at one point, leaving the puke to fester overnight when no one comes to clean it up. Sanitation issues are not the main problem, however.
O’Brien says that allowing people to suffer by abruptly stopping methadone is unethical. “It's a moral thing, and it doesn’t have anything to do with recovery,” he says. “Why should we be sadistic and want people to suffer just because they’ve become addicted? There’s not a shred of evidence that it’s good. This has absolutely no benefit.”
On day two of Starr’s detox, Pinsky describes his withdrawal as “so bad that he’s becoming confused, paranoid and rageful.” However, the doctor apparently does not slow the detox process to ease these symptoms. Indeed, as Starr kicks things, curses at the staff, makes obscene gestures and demands the cameras be turned off, the production continues, ignoring what appears to be a removal of consent to tape.
By day four, Starr has broken a lamp and refuses to get out of bed. Dr. Drew considers sending him to a lockdown psychiatric center, describing the musician as “overtly psychotic, a complication of his methadone withdrawal.”
However, psychosis is not considered a symptom of methadone withdrawal, according to O’Brien. “If someone becomes psychotic during withdrawal, it might be underlying schizophrenia,” he says, explaining that many people with addictions also suffer other psychiatric conditions. “We have seen people who are doing well on methadone go to pieces when they are taken off abruptly,” he says. “That’s why you take them off slowly. The best way is long-term detox over months as an outpatient.” That is, not 21 days’ inpatient like Dr. Drew’s program—and probably not at all if the patient does poorly without the drug.
Celebrity Rehab also reinforces negative stereotypes and myths about addiction—primarily the idea that abstinence through the 12 Steps is the only hope for recovery. That idea may have been deadly for Starr and some of the other patients, like bodybuilder and actor Joey Kovar, who overdosed on opioids last year, and actor Jeff Conaway, who died of pneumonia that was probably sparked by an opioid overdose in 2011.
For one, Pinsky’s repeated insistence that abstinence through 12-step programs is the only way to recover is a fundamental deviation from evidence-based best practices. In a voiceover on the show, Pinsky says, “12-step meetings are the cornerstone of recovery. Therefore, attendance is mandatory.” He also states, “Without 12-step, in my experience, there is no possibility of recovery."
In a statement a spokesperson for the National Institute on Drug Abuse (NIDA) disagreed, saying, “Different treatment approaches are needed for different people, since not everyone afflicted with addiction responds to the same intervention.”
Indeed, it’s not clear why a methadone patient like Starr should have been encouraged to stop that medication at all. Studies have shown conclusively that methadone reduces opioid use, cuts death rates and lowers crime: it is at least as effective as abstinence-based treatment on these measures, and in some cases, more so.
While some methadone patients can achieve lasting abstinence, the risk of relapse and resulting death by overdose is extremely high. As a result, expert advice is generally to support attempts at abstinence but not to disparage maintenance or oppose a return to it if the patient isn’t doing well.
In fact, a 2007 consensus statement convened by a panel of experts by the Betty Ford Center—not exactly a hotbed of support for non-abstinence treatments—recognized that people on stable maintenance should be seen as being in recovery, just like those in 12-step programs. The experts wrote, “formerly opioid-dependent individuals who take…methadone as prescribed and are abstinent from alcohol and all other nonprescribed drugs would meet this consensus definition of sobriety.”
This is apparently news to Dr. Drew, who tells patients that “methadone takes your soul away,” which can’t mean that he thinks methadone is consistent with sobriety. When questioned about this statement, he told VH-1, “If you get enough for it to work, you’re just on the couch. You can’t do anything.”
“That’s completely false,” O’Brien says. “We’ve had people on methadone going back to school, practicing law. There's hard evidence that methadone saves lives and probably a lot of souls, too.”
Pinsky discourages not only methadone but also maintenance with buprenorphine (Suboxone, Subutex), which is also consistent with sobriety if used as prescribed, according to the Betty Ford consensus. Indeed, Hazelden itself—the originator of the 28-day abstinence-based model on which Dr. Drew’s program is based—has recently begun offering buprenorphine maintenance. It had found that too many people were dying of overdose following treatment, so it changed its practices based on the data. Three of the five deaths following Celebrity Rehab have involved opioid relapses that might have been prevented by maintenance.
But Dr. Drew insists—again contrary to NIDA guidelines—that buprenorphine “is supposed to be a medication for outpatient detox,” not a maintenance drug. NIDA says, “Buprenorphine has been approved to treat opiate addiction, reducing withdrawal symptoms and preventing relapse without producing euphoria or sedation.”
Still, on an episode of Sober House 2, a counselor can be seen taking buprenorphine away from Starr, calling it “the root of all evil.” While Starr had been using crack and other substances as well as his maintenance drugs, experts say that he could have been detoxed from them while on methadone or buprenorphine.
“Where I get really annoyed is when people say that they ‘don’t believe in’ medication or that it’s ‘against my philosophy,’” O’Brien says. “That’s not scientific. Maintenance has saved thousands of lives. People who have this prejudice are engaging in unethical behavior.”
And sadly, the deviations from recommended treatment on Celebrity Rehab don’t stop there. In episode two of season three, McCready and fellow patient Dennis Rodman were taken for brain scans, purportedly to show them how much their addictions have damaged their brains and the harm that will result if they relapse.
“We do a lot of research with brain scans but we don’t claim this has any role in treatment at the present time,” O’Brien says. There’s no way currently of knowing what the scans really mean for recovery. However, on Celebrity Rehab, patients are told that their brains are damaged. The intention is apparently to use fear of the negative consequences to strengthen their resistance to relapse. But this exposure to their own brain damage could make them hopeless about their ability to avoid relapse instead.
If someone were providing care on national TV for years that was as far away from what experts recommend for any other condition, it wouldn’t take a journalist to bring the misleading claims to the experts for debunking, especially after someone dies. But addiction still isn’t really seen as a disease where research evidence should determine the best treatment. Instead, it’s a matter of “philosophy” and faith. You can say, “Methadone steals your soul,” and still get a national TV show and be quoted every time a celebrity relapses—and no one even reports until after a death that all of the major bodies on addiction medicine disagree.
While the choices that McCready, Starr and others made after leaving treatment are clearly their own and cannot simply be blamed on any treatment provider, insistence that a return to any form of maintenance treatment is a failure and that there are no alternatives to the 12-step program of abstinence certainly does not offer hope to patients. If they begin to find the pain unbearable and do not find the steps useful, they may believe they have nowhere else to turn but back to drugs.
And giving people punitive treatment—the way Dr. Drew does in detox—may be part of why they drop out or fear seeking additional help. McCready, for example, was apparently seriously reluctant to get psychiatric help for depression following the recent death of her son’s father, even when Dr. Drew urged her to hospitalize herself. And apparently she left that treatment early, against medical advice. In several decades of research, not one study has supported the confrontational approach over a more empathetic style.
Dr. Drew responded to McCready’s death and the criticism of the show in a call-in appearance on The View last week. He said, “In a weird way I wish I could claim more responsibility for this. The reality is, though, I haven’t seen Mindy, say, in years. I’ve talked to her occasionally, and we've been friendly, but I've not been her doctor in years. I wish some of [the Celebrity Rehab clients] would stay with us. Some of them do, and some of them are sober, but some go on their own way and cut their own path. And I wish I could be more responsible for them."
He could start by practicing more responsible addiction medicine.
Maia Szalavitz is a columnist at The Fix. She is also a health reporter at Time magazine online, and co-author, with Bruce Perry, of Born for Love: Why Empathy Is Essential—and Endangered (Morrow, 2010), and author of Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids (Riverhead, 2006).
The media seems to have three modes of action when it comes to psychoactive drugs: intense promotion of advances and benefits; general disregard; and full-on panic about negative effects, including potential for misuse and addiction. During both the benefits and the risks periods, many myths and misinformation are disseminated. But between these bouts of euphoria and panic, there is little coverage at all, especially of addiction. This up/down/off pattern does a disservice not only to people suffering from addiction, but to those with other diseases as well.
Right now, we seem to be moving from a period characterized mainly by disinterest into one of attention and fear. Though we’ve never returned to the peak freak-out of the late ‘80s and early ‘90s—in 1989, a Gallup poll found that Americans viewed drugs as the number one problem threatening the nation, eclipsing even the economy during a recession—we have seen brief but blinding spotlights on Oxycontin, methamphetamine and now prescription drugs more generally.
A recent front-page New York Times story on Adderall addiction is suggestive of the new turn. After years of focusing on these drugs primarily to ask whether they enhance cognition, or allow people to cheat in school by faking ADHD, the article puts them front and center; it tells story of a college student who faked the disorder and the physicians who enabled him to continue getting the drug, despite desperate warnings from his parents about his addiction. Over the course of several years, he became psychotic and ultimately committed suicide.
That Adderall, an amphetamine drug, can be addictive and can sometimes cause mental illness and suicidality is no surprise. If the Times searched its own archives, it would see several earlier periods of promotion of speed as a cognitive enhancer and study aid, followed by hysteria over psychosis and addictions. (Indeed, way back in 1937, the paper of record called it “high octane brain fuel”). And anyone old enough to remember the ‘60s probably recalls the admonition “Speed Kills.”
Why can’t we recognize that a drug can simultaneously benefit some people and harm others? Why do we swing from seeing particular drugs as panaceas to viewing them as the devil’s own poison?
Part of it stems from “generational forgetting”—a well-documented condition that prevails when the addicts of one era have aged out or died and those who saw the damage done are also past their youth. When America was still in a frenzy that the ‘80s crack epidemic would continue escalating until every last youth was a glassy-eyed zombie, the younger siblings of crack addicts were already observing the devastations of the drug and choosing a different, less demonized high—often marijuana, sometimes opioids. Crack use fell rapidly.
That was far from the first time that an epidemic had burned itself out. Epidemics are inherently self-limiting because once the use of a particular drug is widespread, its dangers become obvious to everyone—and because when a culture becomes familiar with a drug, it develops ways to minimize harm. For example, our long-term relationship with alcohol has produced bans on drunk driving; price, sales, and advertising restrictions; and advice on moderation, like alternating alcoholic drinks with water or soft drink—not to mention AA.
Unfortunately, this can also create the impression that panic is productive as a way of changing behavior, when it actually contains the seeds of the next epidemic. Since the new generation is not using the previous one’s “demon drug,” it thinks its own drug use is not going to become a problem. Indeed, the newly popular drug appears to be safe, beneficial, fun—at least, that’s generally how the media tends to portray legal drugs when first on the market. Of course, during the early stages of addiction, it does seem like everything’s under control.
And so, the early ‘70s fears that heroin was the worst drug imaginable made cocaine, by comparison, seem benign to those who used it in the ‘80s. But while the coke generation tended to avoid heroin, it had also missed the nation’s ‘60s bout with stimulants, which had informed the succeeding heroin-preferring group.
Every 10 years, the nation shifts from a "stimulant" decade to a "depressant" one: the speed-loving ‘60s, the ‘70s heroin wave, the coke-snorting ‘80s, the Kurt Cobain junky ‘90s, the methamphetamine ‘00s.
Although a crude metric, this pattern suggests that every 10 years, the nation shifts from a stimulant-dominated decade to a depressant drug-of-choice one: the speed-loving ‘60s, the ‘70s heroin wave, the coke-snorting ‘80s, the Kurt Cobain junky ‘90s, with some prescription opioids on the side. By the ‘00s, it was on to methamphetamine.
Because our attention span seems limited to one demon drug at a time, we create easy rationalizations for new generations of addicts who are not, after all, using the evil substance highlighted by the media during their childhood. We start by focusing on the fashionable drug’s benefits—an emphasis often encouraged by the drug company's marketing—and then turn on it, seeing only the risks. (When first marketed in 1895, heroin was advertised by Bayer as less addictive than morphine.) As a result, we are unable to break out of these cycles.
Through all of this, we miss the realities of addiction, which depend less on particular drugs than on people’s need for relief, and the particular relief available when they are young and most prone to start using. Addicts do follow trends, but they also find the drugs that most suit them: Use of multiple substances is more the rule than the exception.
In the end, we damage both the addicts, when we are promoting the drugs and ignoring the risks, and the people who benefit—ADHD patients using stimulants, say, and pain patients using opioids—when we focus on the harms. We continually speak past each other: the people who see addiction as the worst fate while ignoring the suffering of those who benefit from medications vs. those who value the benefits dismissing the risks of addiction.
None of this is helped, either, by the demonization of addiction and addicts. Panic promotes harsh treatment of drug addiction; in fact, it is often sowed and spread by people with a political agenda that is implicitly or explicitly racist and involves fears of “contamination” of mainstream (read: white) America by minorities or “aliens” who use drugs.
The nation’s history of drug criminalization illustrates this point: Cocaine was made illegal due to fears related to black men using it; opium was banned because of its association with Chinese railroad workers; reefer madness was spurred by its connection to Mexicans and blacks. We continue to lock up black and brown people for their involvement with drugs, while whites are more likely to get “treatment, not punishment.”
Moreover, the vast majority of scare stories also involve the spread of the drug into the middle class. So, for example, in the Times piece we get a doctor saying, “Drug addicts don’t look like they used to,” as an explanation for why a nice white college kid can successfully lie about ADHD to feed his addiction. Addicts are never “people who look like us.”
If we’re ever to break out of these cycles and deal effectively with addiction as a health issue, we have to learn to live with complexity and contradiction. The same drug that is a lifesaver for me can kill you—and addiction is a perennial problem, not just one that surfaces with the popularity of specific drugs. To appropriately treat addiction, we need to recognize the racism that has marred our drug policy—and also see that while addiction does hit the poor the hardest, the middle class isn’t exactly immune.
It may make a sexier story to pretend that a drug trend is unprecedented and to disregard the phases of love and hate we go through with psychoactive drugs. But it does a disservice both to those who struggle with addiction and to those who need potentially addictive drugs as medical treatment when we focus only on risk or only on benefit and ignore the Janus-faced, double-edged sword of the substances we love to hate or hate to love.
Ah, ibogaine. It just so happens that ibogaine and I have a long history: though I never took it, I knew Howard Lotsof, the former heroin addict whose own recovery began in 1962, when he accidentally discovered that ibogaine can relieve heroin withdrawal. I wrote about ibogaine as a potential “alternative treatment” detox drug, in fact, in my first book, Recovery Options. As a fan of psychedelics who finds their therapeutic potential intriguing—and as someone who likes to see people in recovery advance the field—I’ve followed its highs and lows with great interest.
Anyone familiar with addiction is likely to be wary of brain-boosting drugs: we all know how chemicals that once seemed the answer to all our woes can become instead our biggest problem. But those of us who have also benefited from antidepressants and other mood-altering prescription drugs know, too, that the right drug in the right situation can be positively transformative—and that simply deciding that “all drugs are bad” can be counterproductive.
As technology advances, we’re increasingly faced with new drug issues that force us to examine and re-examine our values and our chemically malleable selves. With each Olympic games, we face new types of doping and tricky issues like why high-altitude training, which boosts levels of red blood cells just like “blood doping” does, is acceptable, but using drugs to achieve the same result is not.
The camp that supports removing the ban on safe doping in sports does so based on several claims. These include: that they maintain a level playing field because all athletes have equal access to the boosters, that permitting enhancers would allow it to be monitored for safety and that certain performance-enhancing drugs, like steroids, blood boosters and growth hormones, mimick the body's natural processes.
Soon, undoubtedly, too, someone will select an embryo for in vitro fertilization (IVF) that has genes linked with athletic prowess. That seems less natural than allowing talent to emerge through training, but nonetheless doesn’t involve truly artificial manipulation like genetic engineering or cloning.
In the not-too-distant future, we’ll likely also have to ask: is implanting a gene already found in athletes who came by it naturally “cheating”—and if so, why is it OK for those born with that advantage to use it but not OK for others to acquire it? After all, simply taking steroids or “smart drugs” doesn’t guarantee performance: if you sit on the couch and don’t train or study, you’re not going to have the skill or knowledge it takes to compete and the same is true for genetic endowments. (So-called smart drugs may enhance cognition, memory, wakefulness and other brain functions.)
Already, our attitudes around performance-enhancing drugs are highly dependent on context. For example, a recent study found that college men judge a hypothetical sprinter who wins a race because he takes steroids more harshly than they do a student who uses a friend’s Ritalin to boost his exam performance. The rationale? Sports are a zero-sum game: if I win, you lose. But my high test scores in class don’t necessarily influence yours: we can both do well even if a curve is applied.
When it comes to consideration of widespread use of drugs that improve mental clarity, it can be quite difficult, in fact, to make a rational case against them, provided that the side effects aren’t dire. For example, who wouldn’t want scientists to find a cure for cancer more quickly or for policy makers to become smarter to find better solutions to social problems?
Of course, this immediately becomes a question of values: would a “smart drug” also produce smarter criminals—or would it make them less impulsive and thereby more likely to choose the straight and narrow? We want our friends to become smarter, but not necessarily those with whom we disagree.
The best case against smart drugs involves fear of pressure to use them “because everyone else is”—but again, if the benefits outweigh the risks, why would this be bad? Alternatively, there are worries about the poor being left behind as the rich, who can afford to buy cognitive enhancers, gain ever greater advantages for themselves and their children. However, we certainly don’t deny the rich every other advantage for this reason.
The questions become even thornier when we consider drugs that might, say, vaccinate against addiction or aggression or envy. Would our kids lose some of their free will if we vaccinated them so that smoking would never bring pleasure and cocaine would carry no kick? If we had an anti-violence drug, would we even use it for fear that it would neutralize our animal flight-or-fight response enabling chemically unenhanced enemies to take advantage of us?
The ability to regulate ourselves with drugs produces multiple conundrums because altering the defaults on the way we make choices inevitably changes who we are. This is why addiction itself is so frightening: although we’re already limited in controlling “what we want to want,” addiction insidiously places one desire above all others. But if a drug allowed us to choose what we want to be passionate about, how would we even know what that should be?
Existing “smart drugs” like Ritalin and amphetamines are marred both by their addiction potential and by the fact that their effects aren’t especially large and only enhance certain types of learning. Indeed, some research suggests that they actually impair the performance of those who are most intelligent, working best on B and C students, not those already getting As.
Oddly, the same drug may help people with ADHD less likely to yield to unwise impulses, while making those who are addicted to it more likely to make ill-advised choices. Both phenomena seem to reflect the idea that there’s a “sweet spot” in the brain’s dopamine system: run it too low and attention and memory may be impaired, but elevating it too high also causes problems.
But if effective drugs are developed that fight the ordinary cognitive decline that can come with aging—not just frank disease states like Alzheimer’s— they may well improve intelligence generally and it would be nearly impossible to prevent “off label” enhancement use. Indeed, we’re already far more lenient with drugs we see as productivity tools than we are with those we see as offering unearned pleasure. While some doctors will freely admit to prescribing Ritalin, Provigil and amphetamines to buoy up busy executives, they would be targeted for prosecution if they confessed prescribing Valium or opioids for mere relaxation.
The idea of cognitive enhancement allows us to consider drug policy issues afresh and to examine the often hidden-values questions in arguments that are framed as being simply about risks. We tolerate far greater risks in the quest for knowledge and what we view as personal growth than we do in the quest for pleasure. This is why dangerous expeditions like mountain climbing that are far riskier than most drugs are not seen as simply selfish indulgences. It’s also why many people see psychedelic drugs as being wrongly classed among drugs thought simply as "meaningless" pleasures.
Pharma will not shy away from cognitive enhancers if it can market them as fighting aging—and if we allow plastic surgery, it becomes bizarre to ban improving the mind as well. The chemicals that can change us may be sitting on lab shelves right now: those of us who know both the highs and the lows of pharmaceutical experience need to think hard about how the world can best deal with them to maximize the benefits and minimize the unintended negative consequences.
Narconon, the Scientology-affiliated rehab is under investigation by the state of Oklahoma, following three patient deaths within the last nine months. Last Wednesday, the inquiry into the July 19 death of 20-year-old Stacy Murphy was expanded to include the April death of 21-year-old Hillary Holten and the October death of 32-year-old Gabriel Graves. The state district attorney has asked the sheriff’s department to deepen its investigation.
The involvement of law-enforcement agencies—not simply regulatory authorities—suggests the possibility of criminal charges against those involved with the deaths. The facility, Narconon Arrowhead, is located near Canadian, Oklahoma. It is not only licensed by the state and listed on the federal addiction program locator, but also accredited by CARF, an organization that claims on its website to “focus on quality, results” in certifying treatment programs.
The 2009 death of 28-year-old Kaysie Dianne Wernick, who was transferred from Narconon Arrowhead to a nearby hospital while suffering a respiratory infection, resulted in an out-of-court settlement of a civil negligence lawsuit, the terms of which have not been disclosed. There have been three other deaths at that Narconon facility alone since 2005. Over the years, as The Fix has reported, numerous deaths and many lawsuits have been linked to the international Narconon program.
Oklahoma assistant district attorney Richard Hull told the Tulsa Worldthat, “After looking at the [earlier] report and additional witness statements, the District Attorney’s Office has requested the Sheriff’s Office to further investigate,” and that full autopsy and toxicology reports have not yet been received. A spokesperson for Narconon Arrowhead told Alcoholism and Drug Abuse Weekly that program staff found the deaths “deeply saddening” and their loss “has taken an extreme emotional toll on us as well.” Narconon representatives have also told the media that they are cooperating fully with the investigation.
As The Fix reported earlier, the Narconon program is based on Scientology founder L. Ron Hubbard’s “Purification Rundown,” which was originally devised as part of the process required for conversion into Scientology. It involves taking high doses of vitamins and spending four to five hours a day in 150-degree saunas. This is believed to “detoxify” the body and remove drug “residue” that Hubbard claimed was responsible for craving.
There is no scientific evidence, however, that drug “residue” causes craving or that mega-doses of vitamins and marathon super-hot saunas are effective elements in addiction treatment. Indeed, for people who are medically fragile or who have recently taken certain classes of drugs including alcohol, amphetamines and cocaine, intense heat without breaks for relief could potentially lead to hyperthermia, which can be deadly. One study found that 25% of deaths in saunas were associated with alcohol or stimulant use.
Narconon also shares Scientology’s fierce opposition to psychiatry and the use of psychiatric medications, meaning that even if the rest of its methods were evidence-based, it would not be able to effectively treat half of all people with addictions who suffer from co-existing conditions like depression, nor would it utilize the state-of-the-art treatments that include medication. The belief that all psychiatric conditions can be treated via Hubbard’s techniques would not seem to support effective screening and referral for care for these disorders.
In fact, when Narconon was originally fishing for official and popular support to build Narconon Arrowhead rehab in the late 1980s, the Oklahoma State Board of Mental Health flatly denied approval, pointing out that there was no credible evidence that the program (which also included indoctrination in the teachings of Hubbard) was effective for chemical dependency and that evidence-based effective addiction treatment suggests that, on the contrary, Narconon is very unlikely to work. Nonetheless, Narconon purchased tribal land, without disclosing its ties to Scientology (its typical MO), and got the rehab up and running. Eventually, despite a flurry of negative publicity, it was able to win state-board approval.
Although each Narconon is, at least on paper, independently owned and operated, the Church of Scientology holds the license. Many, if not most, of the staff at the several dozen Narconon rehabs worldwide are Scientologists, and according to many former patients, the implicit goal of the Narconon treatment program is to turn addicts, who may pay tens of thousands of dollars for their rehab stay, into Scientology converts.
All of which raises the question: how on earth has such a program managed to be licensed in numerous states, listed on federal registries of addiction treatment and even accredited by organizations that are supposed to ensure quality and high standards of care?
Narconon is, to some extent, a special case in the rehab industry. As a de-facto extension of Scientology, it can deploy all of that organization’s infamously sophisticated strategies against opponents, including extreme litigiousness and PR and, reportedly, even threats of violence against whistleblowers.
Yet in a larger sense, Narconon’s decades-long viability as a legitimate rehab comes down to the ongoing belief that faith-based treatments, while not permitted as primary care in the rest of the medical system, are acceptable for addictions. There is no other disease or disorder for which a Scientology-based treatment that has been thoroughly discredited by science could win such acceptance. There is no other medical condition for which faith-based programs from multiple religions that also “pray away the gay” are considered part of mainstream care. There is no other medical condition, in fact, for which prayer and meeting are seen as a main element of recovery.
While for mental illness, use of punitive measures like restraint, isolation, humiliation and corporal punishment have long been dismissed as barbaric, even late into the 20th century these were regular features of addiction treatment—and some programs still rely on them, particularly those aimed at teens. One reason that they have been so difficult to root out is that faith, not evidence, remains an acceptable basis for treatment models.
If we are to improve addiction treatment, faith-based care should be as unacceptable as the primary treatment as it is for cancer or heart disease. And that means that supporters of twelve-step programs will have to make some big changes. If addiction is a disease, meeting and prayer can be viewed no longer as treatment for it but merely as adjuncts to care—as they are for other medical conditions. If addiction is a disease, twelve-step material cannot be used in rehab itself— referrals to meetings can be made, information can be provided, and even onsite meetings made available, but counseling can’t consist of use of the steps. That’s just not how medicine or mainstream psychology is practiced.
As with other conditions, the spiritual aspects of the problem—for those who find them important or believe they exist at all—need to be kept separate from medical and psychological care. Otherwise, there will be no way to prevent religious ideas from being sold as treatment: if rehabs can sell programs based on the confession, surrender and faith aspect of AA, why shouldn’t they be able to sell Scientology?
And if they can sell Scientology, why not any belief about treatment anyone wants to promote? There’s no way to set standards of care when your treatment relies on a higher power: if God, why not Xenu?
Some will argue that twelve-step facilitation—a manualized treatment that involves introduction to the steps and encouragement of participation in the program—has been shown in some studies to be as effective as more standard “evidence-based” programs like motivational interviewing and cognitive behavioral therapy. They will point to research showing that those who do affiliate with AA or NA do better in the long term than those who do not.
But that doesn’t make AA a type of medicine any more than depression recovery through social support is a type of medical care. The mind and body are not separate, and belief certainly can play a role in healing. That doesn’t mean the main medicine for any disorder should be faith. If we continue to allow this, we shouldn’t be surprised when people die in addiction treatment. Medicine itself only advanced and stopped killing more people than it helped when it began to rely on data rather than faith: we need to hold addiction care to this standard, too.
While use of prescription opioids for cancer and other end-of-life pain is increasingly accepted, if you are going to suffer in agony for years, rather than months, mercy is harder to find. Indeed, it seems a given by the media that because addicts sometimes fake pain to get drugs, doctors should treat allpatients as likely liars—and if a physician is conned by an addict, the doctor has only herself to blame.
But do we really want our doctors to treat us as if we were guilty until proven innocent? Do we really want the routine use of invasive procedures—ranging from nerve conduction tests to repeated scans and surgeries—to “prove” we’re really hurting? And do we actually want physicians to be held responsible for the actions of a patient who dissembles and does not take drugs as prescribed?
The answers to these questions are at the heart of the bizarre way we view synthetic opioid medications and the suffering of the 116 million Americans who have moderate to severe chronic pain, according to Institute of Medicine estimates.
In recent weeks, for example, New York Sen. Charles Schumer, anti-drug abuse advocates and reporters have inveighed against the potential FDA approval of an experimental opioid painkiller called Zohydro—professing to be horrified by the introduction of a new class of “100% pure” hydrocodone "superdrugs" that they have already dubbed "the next OxyContins." And many states are weighing laws like one now in place in Washington state, which limits the doses of opioids that can be used by chronic pain patients.
When people consider the use of these medications in chronic pain, addiction fears are typically the first thing that comes up. Moreover, media coverage rarely includes the perspective of pain patients— or does so only to knock those who advocate for access to opioids as pawns of the pharmaceutical industry.
If the press—often quoting leading public health officials like Dr. Thomas Frieden, the director of the CDC—is to be believed, the US is in the throes of an “epidemic” of prescription painkiller abuse. Frieden even claimed at a recent press conference on opioid-related deaths that doctors are now more responsible than drug dealers for America's addiction problems. "The burden of dangerous drugs is being created more by a few irresponsible doctors than drug pushers on street corners," Friedman said.
However, the opioid issue looks very different when you examine the numbers closely. For one, the rates of Americans addicted to OxyContin, Vicodin, percocet, fentanyl and other products in our synthetic narcotic medicine cabinet are not rising. In fact, they have been steady at 0.8% since 2002, according to the government's own statistics.
Moreover, fewer than 1% of people over 30 (without a prior history of serious drug problems) become an addict while taking opioids; for chronic pain patients who are not screened for a history of previous drug problems, the addiction rate is 3.27%. That means, of course, that more than 96% do not become addicted.
Yet these statistics usually go unmentioned in media accounts because they do not confirm the preferred panic narrative. Also left out is the fact that around 80% of Oxy addicts (a) did not obtain the drug via legitimate prescription for pain and/or (b) had a prior experience of rehab. Their contact with the medical system—if any—was not what caused their addictions.
So, the first thing the public really needs to know about what doctors call “iatrogenic addiction” is that it is extremely rare. If you’ve made it out of your 20s without becoming an addict, the chances that you will get hooked on pain treatment are miniscule—and even young people are not at high risk in most medical settings.
Nonetheless, the media continue to love them some “innocent victims”—and the real story of not-so-blameless drug users who move from heavy drinking, cocaine use and marijuana smoking to prescription drug abuse is just not as compelling. This, sadly, only contributes to the delusion that anyone who is treated for chronic pain with opioids is at risk for drowning in the—gasp!—ubiquitous riptide of addiction.
The panic leads to policies that require pain patients to be urine-tested, to be called in to their doctors’ offices for random “pill counts” and to make frequent visits—all of which is not only humiliating but expensive and time-consuming. There’s little evidence that such policing prevents addiction or does anything else beyond inconveniencing and stigmatizing pain patients.
And indeed, the stigma of addiction is what’s behind the curtain here. Imagine suffering from incurable daily pain so severe that it feels like your legs are being dipped in molten iron or your spine is being scraped out by sharp talons. Even if you did, in a worst-case scenario, join the tiny percentage of patients who develop a new addiction and became obsessed with using opioids, would this really be worse, especially if you had safe and legal access to them?
Most of the physical and psychological horrors of addiction come with loss of control and with being unable to be present for family, work and friends. But pain can produce even greater dysfunction and emotional distance, and its ability to destroy relationships is at least as monstrous. Moreover, maintenance on opioids can typically stabilize people with addictions, without numbing or incapacitating them. So why do we panic?
In the absence of true pharmaceutical innovation (Zohydro and other "superdrugs" are mere purer versions of VIcodin without the acetaminophen ), opioids remain the only medications that can even begin to touch severe pain, though they are far from perfect. But since they rarely lead to addiction—and since addiction (or opioid maintenance treatment) may actually sometimes be the lesser of evils—does it really make sense to restrict and even deny their benefits to pain patients?
When the situation is considered rationally, our outsized fear of addiction has little to do with the reality of chronic pain. Instead, it’s about the way we see addicts: gun-toting robbers of Oxy from pharmacies and other scummy, lying, sociopathic criminals—people we don’t want to be around or become.
Even though readers of this site know that drugs don’t somehow “make” ordinary people into such demonic figures—and that addicts can also be as kind, compassionate and hard-working as anyone else— the stigma runs deep.
Much of it, I think, comes from the same evasion of responsibility that allows us to blame doctors for addictions. After all, it’s not doctors who tell their patients to inject or snort their oral painkillers, to drink while taking opioids, to take more than prescribed or to lie, cheat and steal to obtain them.
These actions are deliberately taken by drug seekers. Doctors don’t “make” anyone make the ongoing choices that lead to impaired self-control. While trauma histories, psychiatric disorders like depression and/or genetics do make some of us more vulnerable to taking this path, no one can force us to do it. And if we see doctors—or, for that matter, dealers—as having “caused” our addictions, we open ourselves up to be dehumanized and stigmatized.
That is because if we are seen as incapable of making good choices, how can we expect respect for our desires and preferences? If we can’t control ourselves, why shouldn’t we be incarcerated to protect others from our actions? After all, when the public sees us as mindless zombies, their response is not sympathy for our supposed powerlessness but fear and disgust at our imagined violence.
Even the overdose issue is mismanaged due to our hatred of addicts. Overdoses have now overtaken car accidents as a leading cause of accidental death, but it's unclear how much of this increase is due to the actual rise in the use of opioids and how much to medical examiners simply attributing more deaths to these drugs since they are now found in more dead people. What is clear is that most of these deaths occur in the context of drug abuse—95%, according to one study of one of the hardest-hit states. A large number of these deaths could be prevented by providing the antidote to opioid poisoning, naloxone, with prescriptions for the drugs. But because we want the wages of sin to be death, however, drug warriors have largely prevented funding for programs to broadly distribute that lifesaving medication.
The opioid problem is really the stigma of addiction writ large. Consequently, if we want to stop getting in the way of access to painkillers for people who genuinely need them, we need to take responsibility for our own actions and help fight this stigma. No one but you can make yourself into an addict. But chronic pain can happen to anyone.
Additional research by McCarton Ackerman.
It's always difficult to know what to do when your child is at risk. But parents of children with drug problems are incredibly vulnerable. When a child has cancer, Mom and Dad tell the grandparents immediately, call Aunt Alice who used to work as a secretary at Sloan-Kettering or the Mayo Clinic, Google the scientific literature for the best treatments and generally mobilize their entire support system.
But parents of addicted kids tend to shamefully sneak searches online and then grab at the first referral they’re offered quietly, often ignoring clear red flags. In other words, they become easy prey for charlatans and worse.
Los Angeles Magazine recently ran a dramatic and poignant account by one such parent, Michael Angeli, the co-executive producer of Law and Order: Criminal Intent. The story illustrates why we need to educate parents about what to look for in treatment programs—and why professional standards should never be ignored.
Angeli’s son Bey apparently developed a marijuana problem so severe that his parents believed he required intensive treatment. They sent the 17-year-old to an unregulated “nonresidential” program, which, in California, requires no licensing and was under no government oversight.
“The House” was run by a charismatic ex-addict, Steve Izenstark, who was ultimately arrested—by an armed LAPD strike force—during a Family Night therapy session and charged with a litany of sex crimes: He had had sex with several of his teenage patients, which he labeled “intimacy therapy.”
Here’s how a 16-year-old victim described her experience in court testimony:
Q: Could you please tell us what [Steve] told you?
A: My goal…would be to be in love with him and want to have sex with him. And at that point, I’m at my intimate peak, and it’s my healthiest that I could be. And he would say no to having sex with me and I would be done with my intimacy therapy.
Q: Was there ever a time during this intimacy therapy where he put his penis into your vagina?
But such obvious sex crimes were far from the only boundary violations that occurred. When Angeli first visited the program, concerned about his son’s withdrawal and isolation, Izenstark writes: “Hey, don’t you worry about that, my friend,” Steve reassured me, “my friend” being one of his signature phrases. “Have you seen some of the girls around here? Have you? Huh? They’re drop-dead gorgeous.”
Angeli perfectly captures Izenstark’s chamelonlike personality:
He had a knack for being all things to all people: the dreamer, the drill sergeant, the world-weary mentor, the rebel pied piper, the vocation-devoted divorcé, the gentle soul, the gulag colonel. He reversed the weaving permissiveness of baby boomer parents and at the same time seduced them by tapping into the moldering resin of their counterculture youth with his shambling charm and his different-drum approach.
Before the arrest made the allegations public, Angeli’s son Bey himself had stayed over at the “nonresidential” program during nights when he was “in crisis,” even though such stays should have made the program subject to regulation.
“I have heard every bullshit story you can imagine, OK?” [Izenstark told Angeli.] “These kids will lie until they get tired of being busted for it or it’s too late and they’re thrown out of here, OK? Everybody who walks through that door lies.”
So, how did a rich, successful Hollywood producer fall for what is—to anyone who knows anything about treatment research—an obviously outdated scam? The problem is that much of what is portrayed in the media as “professional treatment” in shows like Celebrity Rehab and Intervention isn’t based on evidence of what works and can all too easily lead to boundary violations and outright abuse.
Take the notion that all people with drug problems are liars. While it is true that many addicted people do lie about their drug use to avoid being punished for it, most research finds that they are just as likely as anyone else to tell the truth when they feel safe doing so. For example, anonymous surveys of addicts about their drug use tend to line up closely with urine testing (this may not be the case for the significant minority of addicted people who also have personality disorders).
Why does this matter? If you label all your patients as liars, it is easy to dismiss their complaints and justify treating them in disrespectful, even humiliating ways. If teens tell their parents that they are uncomfortable with treatment, that’s just “druggie manipulation”; if they go to police or other authorities about the abuse, their stories are often dismissed for decades. In Angeli’s case, he kept his son in “treatment” for months after what he saw there had made him uncomfortable.
But Izentark made two mistakes rarely seen in abusive treatment: First, he got busted buying cocaine. Second, he hired a woman with actual psychology credentials who believed his victims’ accounts after she’d found he’d lied to her. That led to the court case that was his ultimate downfall.
Before that, though, many other red flags were clear. Angeli writes:
Bey had been at The House for about three months when I began to question Steve’s methods. Our health insurance had already declined to cover The House after Steve emphatically guaranteed the opposite. By then we’d learned that trying to get him on the phone was hopeless and that the messages my wife left rarely had an impact.
Once, Steve and I walked out of his office after a meeting just as some kids had finished cleaning the living room. It looked immaculate. “Didn’t I tell you to clean this pigsty up?” Steve growled, and the kids kept cleaning what was already clean. Later, when I took exception to his autocratic gruffness, we argued. As part of Bey’s therapy, Steve had him build a wall in The House’s backyard. When Bey finished, Steve ordered him to tear it down and reconstruct it on the other side of the yard, which Bey did without saying a word.
The first warning sign was the insurance question: lying to parents about a program being covered when it is not is obviously not a good sign. And although insurers will often do anything to avoid paying, sometimes they actually have sound, evidence-based reasons to reject a type of treatment. Second, professional programs do not ignore phone messages or require intensive efforts for parents to get through to key staff. But the most disturbing aspect of that description is the arbitrary exercise of power and forced, meaningless labor. Although many addiction programs still see their role as “breaking people down,” in order to fix them, there’s no proof that this helps anyone get better.
Making people feel powerless, and fostering blind obedience are, in fact, generally viewed as antithetical to promoting mental health: research shows that the “learned helplessness” that comes from having no control over your life can lead to depression and even post-traumatic stress disorder, not recovery. Indeed, creating learned helpless in animals by placing them under uncontrollable stress until they stop trying to escape is a commonly used experimental model of depression. (If a drug restores an animal's struggle to get free, it typically helps human depression, too.)
These methods are also harmful to program staff. They basically create conditions that encourage the abuse of power, even situations that can lead ordinarily kind people to behave poorly.
Consider what happened in just several days in the notorious Stanford Prison Experiment. There, ordinary young adults (prescreened to exclude psychiatric disorders) were asked to play the roles of guards and prisoners, in a mock jail in a university basement. Within days, the guards were humiliating the prisoners by making them urinate in buckets and forcing them to do meaningless tasks. The experiment got so far out of hand so fast that the researchers had to shut it down long before they’d intended.
A program with an unaccountable leader and a belief that “breaking people” will help them is a similar if inadvertent setup. With no checks and balances, counselors may easily come to believe they can do no wrong and that even sleeping with patients will help heal them. A race to the bottom typically ensures, as in the Abu Ghraib dynamic.
That may sound far-fetched, but it has happened literally thousands of times in “tough love” rehabs in the U.S. and around the world. Straight Inc. gagged teens with Kotex and put them through a “spanking machine” and restrained children until they urinated or soiled themselves repeatedly before it was finally shut down for intensive abuse in all seven states in which it operated during the ’80s and ’90s. Its offspring, KIDS, produced virtually identical abuse in three states. Both programs kidnapped teens and even some adults who tried to escape. Tens of thousands of teens (and their families) were harmed.
And as recently as 2009, the state of Oregon shut a tough-love boarding school, the ironically named Mount Bachelor Academy, which had been forcing girls to do lap dances as part of its humiliation-based treatment. The staff was so sure it was doing the right thing that they initially did not even outright deny some of its extreme tactics when state investigators paid a call.
How can parents avoid being taken in by these harmful programs? I have four recommendations that I am confident will help:
1. Do not rush into making a decision. Stay calm, no matter how nerve-wrung you may feel at the knowledge that your child needs detox and recovery. With rare exceptions, run from any program making threats your kid is at imminent risk of harm or death if treatment decisions aren’t made immediately. If someone is injecting drugs or actively suicidal, immediate hospitalization for safety may be necessary—but even then, there’s no reason to make instant decisions about long-term care.
2. Do ask people you trust about the situation—and read the scientific literature, not the popular stuff. If addiction is a disease, why would you leave its care to amateurs, rather than doctors? If an MD recommended treating your child’s cancer by having someone abduct them from their bedroom at 3 a.m. and put them in the woods for a month, would you even entertain the idea? Why should treatment for mental disorders be different?
3. Be aware that in the vast majority of cases—particularly for youth—treatment at home is at least as effective as (and far less risky than) residential rehab. The essence of the research on addictions and mental illness is that compassion, connection and kindness are what heals, not toughness. The entire mental health field has been moving away from inpatient treatment and toward “care in the community,” not because inpatient is more expensive (though it is) but because people are typically happier and healthier when treated at home, surrounded by loved ones. Compassion, connection and kindness are what heal, not toughness, according to the lion’s share of research on addictions and mental illness.
4. Be aware that any program that cuts your child off from you and the outside world, that sees its charges as liars and manipulators and that believes “toughness” is essential is basically a case of abuse waiting to happen. Establishing boundaries and clear rules without dehumanizing or humiliating people is possible. But doing so requires professionalism, critical thinking, oversight, checks and balances—none of which the con artists who run “tough love” programs have in stock when parents come running. This fact sheet from the Federal Trade Commission specifically for parents of troubled teens gives very helpful background information on the licensing, accreditation and other regulatory requirements that separate legit youth rehabs from the other kind.
When the Center for Disease Control and Prevention recently announced that one in ten Americans now takes an antidepressant—a 400% increase since 1988—there was a predictable media hand-wringing about "pill popping” and a rush to “quick fixes.”
â€¨â€¨What I always wonder when I hear these complaints is this: Have these people ever experienced depression themselves, or known someone who suffers from it? In over 20 years reporting on mental health, I’ve never actually come across a person whose first response to the slightest sadness was to seek medical help. (If you are or know of such a person, please do contact me—I’d love an interview).
â€¨â€¨In fact—and the research backs this up—most people with depression typically go untreated for years, or even decades, before finally getting treated. They often (as I personally did) tend to get lost in long, dangerous experiments in self-medication with legal or illegal drugs. Truth is, most people are reluctant to try antidepressants, rather than eagerly “ask their doctors” for the latest pill.
â€¨â€¨So why do we persist in believing that depression is over-medicated and everyone is popping Prozac like candy? The first reason is the cultural notion that mental illness should be rare.
Although we readily accept that pretty much everyone will suffer from physical illness from time to time, few seem willing to believe that mental disorders could be equally commonplace. Indeed, reports about the high prevalence of mental illness are typically met with accusations by Big Pharma of “disease mongering” (which, to complicate things, does occur).
â€¨â€¨When you think about it, however, why shouldn’t the brain be as illness-prone as the rest of the body? It is, after all, the most complex object in the known universe. The brain is better protected than other organs because of its vital importance, but to expect mental illness to be rare makes little sense.
The most recent national study finds that around 9% of Americans suffer depression at any given time. The new CDC study found 11% of us taking the drugs. That sounds like overmedication—except for the fact that other research finds that at least one out of five of these prescriptions are written for non-depressive disorders, ranging from pain to obsessive-compulsive disorder to menopausal symptoms.â€¨â€¨
Moreover, the same CDC study found that only one-third of people with severe symptoms of depression were taking medication.
â€¨â€¨The real problem is that depression is wildly complicated, our mental health care system is in shambles and the disease itself often prevents help seeking. â€¨â€¨
You feel hopeless and incapable of pleasure; you dread every social encounter. Simply picking up the phone to make the appointment feels impossibly challenging. Worse, even the slightest hint of rejection—like a brisk tone of voice on the phone—can send you spiraling into self-hatred and unreasonable terror.
No one wants to feel like this, and a large percent of people with addiction try to medicate it away. Our problem with depression is that culturally, we think “escaping” this way is wrong. We believe that God inflicts suffering deliberately as a punishment for sin—and, therefore, evading it without “hard work” is cheating.
â€¨â€¨It’s not. Why should you have to suffer or struggle or work more to recover when the disease itself is such agony? Why should those whose depression has often resulted from early painful life experience suffer not only from their memories, but also the illness it triggered?â€¨â€¨
Those who've never been afflicted with such trauma aren’t required to struggle with the "hard work" of therapy because they tend to feel alright. So why should the others have to suffer twice?
If a cancer therapy was devised today that did away with the agony of chemotherapy and radiation, we’d be dancing in the streets. So why do we treat the idea of “popping a pill” for depression, rather than crying in a therapist’s office, with such disdain?
The problem with using drugs to medicate away depression isn’t drug use itself; it’s the use of drugs that aren’t effective for that purpose. Since, however, “fun” drugs do lift mood, people seem to believe that all mood-lifting drugs must be “fun.” And, consequently, that those taking antidepressants must all secretly be addicts.
â€¨â€¨Of course, anyone who has taken antidepressants knows that the idea that they are “happy pills” is nonsense. The simplest way to explain the difference is this: I sometimes forget to take my Prozac. But I never forgot to take my heroin.
America’s ambivalent relationship with drugs and medication pushes us to ignore critical differences between drugs, while failing to appreciate useful similarities.
The following is an adapted excerpt from Born for Love: Why Empathy Is Essential—and Endangered (Morrow, 2010) by Maia Szalavitz and Bruce D. Perry, MD, PhD.
Teenage girls are not especially known for empathy. To adults, they often seem self-involved, moody and inconsiderate. Their obsessions with what seem like trivial social slights and their desperate yearning for status and friendships, however, may reveal important truths about the development of altruism in humans and the conditions under which children's brains evolved. And oddly, that stereotypical first job of a young girl -- babysitting -- may be the ultimate source of our ability to understand each other.
Here's how babysitting, teen cliques and empathy intersect. For centuries, human caring behavior was either ignored or dismissed. It was seen as mere self-interest; only occurring when, in fact, the goals of the self and the other happened to coincide, as in parenting. But recent research in neuroscience has complicated matters, showing that not only is altruism and a desire for fair treatment real, it shows up early in life and even in other species.
For example, chimps will protest when another ape is not rewarded equally for similar behavior, even rejecting their own treat. And children as early as 14 months will try, without prompting, to help adults having difficulty reaching an object that the child knows how to get.
How could this kind behavior evolve? The traditional explanation goes back to Darwin himself. He suggested that humans who were better at cooperating with each other would be much better at battling other groups, and therefore more likely to survive.
But this doesn't seem to account for the origin of altruism, for why people would have the inclination to connect with each other in the first place. Cooperation in battle may well have escalated the success of groups that stuck together -- but it doesn't explain why individuals would help at first. That's where babysitting comes in.
Anthropologist Sarah Hrdy is a key proponent of this new theory. In her recent book, Mothers and Others, Hrdy says, in essence, that an early human version of "daycare" -- not warfare -- drove the rise of human empathy. And, curiously enough, this may help explain why teenage girls are so obsessed with fitting in and forming tight cliques.
To explain her theory, Hrdy notes the dismal infant mortality rates that are seen where modern perinatal care isn't available. In prehumans, half of all children probably died before reaching puberty. Among the hunter-gatherer Mandinka tribe who were studied between 1950 and 1980, nearly 40 percent of all children were dead by age five.
Consequently, she argues, our species could probably not have survived at all -- let alone in numbers large enough to fight wars with each other -- if serious energy and attention wasn't devoted to childrearing. But Hrdy believes we have been misled about what early human childrearing was like. And this misunderstanding has kept us from recognizing the roots of empathy in childcare.
Great apes have traditionally been the model for early human parenting styles. Chimpanzees and orangutans infants are nurtured exclusively by their mothers, nursing from four to seven full years. In infancy, these little apes are in constant skin-to-skin contact with their mothers, day and night. But Hrdy thinks this breeding style of intensely possessive motherhood isn't ours.
Humans, instead, have traditionally shared the burden of baby care. Typically, a human birth prompts celebration. In most cultures, a welcome new baby is eagerly passed around among the waiting relatives. But among the great apes, a new baby that was passed around would soon be dead meat -- literally. The importance of helpers -- not just moms -- in human childcare was obscured by several things. For one, the people originally seen as the best model for early child-rearing practices -- the !Kung -- turned out to be rather unusual. !Kung hunter-gatherer mothers hold their children 75 percent of the time, These infants are either in a sling which allows them to nurse whenever they choose or strapped to their mothers' backs.
But babies in other hunter-gatherer groups and certainly modern babies spend far less time in this way. And researchers had previously ignored the fact that in the great apes, moms and babies touch 100 percent of the time -- while even among the !Kung, babies spend a full quarter of their time being held by others. In contrast, if a chimp takes another chimp's newborn, that baby is in great danger. Both males and even females can and will kill unrelated babies. This, needless to say, is rarely what happens when human beings hold infants.
Indeed, most human child abuse occurs among isolated, stressed caregivers -- not among those with many helpers. The ubiquity of the nurturing, protective reaction to babies suggests that early humans must have frequently cared for each other's children. That means that, unlike great ape mothers, human moms must have spent significant time out of skin contact with their infants, though they were likely nearby.
In fact, the presence of willing "babysitters" may have been even more important to early human survival than the closeness of a father. Among the Mandinka, for example, research found that having a maternal grandmother or older sister around cut a child's risk of dying young in half. But a father's presence made no survival difference at all?and a stepfather actually increased the child's mortality risk.
As a result, Hrdy argues that while fathers and nuclear families certainly matter, the role of extended family and friends in keeping children healthy has been overlooked. Cross-culturally, studies have found that poor mothers, single moms, teen mothers and mothers of premature babies have children that do significantly better on all measures -- academic, emotional and physical -- if they have extended family, particularly maternal family, nearby and participating in their lives. Like marmosets and some other small monkeys -- but unlike the great apes -- humans seem to be cooperative breeders. .
Consequently, cooperative breeding could have been a driving force in human evolution -- and here's why that matters for teenage girls. If having female relatives and friends was necessary for the survival of your children, being able to recruit such helpers would literally be a matter of life or death. As girls become ready for reproduction in adolescence then, building a network of female supporters would become almost as important as finding the right mate. Hence, social obsession.
From this perspective, the dramatic teenage world of cliques and BFF's and Queen Bees and Wannabes makes a lot of sense. Girls would need to learn to cooperate in small groups to achieve success as mothers. This cooperation wouldn't take place automatically -- like other skills, it would take practice and would involve inevitable mistakes and misunderstandings.
But how could cooperative breeding drive the development of empathy? For it to work, cooperative breeders need to share and babysit. These nurturing experiences could promote the survival of genes that increase helping across the board. A species in which cooperative breeding was important to survival would also tend to produce babies who were increasingly good at attracting helpers.
Increased cuteness would be one possible result. A more important outcome, however, would be enhanced survival of babies who are sensitive to emotional contagion and good at reading people. As these genes got selected, people in the groups which had them would become better and better at understanding and caring for each other -- producing a virtuous spiral of escalating altruism. Or at least, escalating altruism toward group members.
The same genes might later have allowed cooperation in warfare which would further select for them -- but they probably originated in the earliest versions of babysitting and daycare. If Hrdy is right, women, teenage girls and babies drove the evolution of the caring brain, not men at war. "Were it not for the peculiar combination of empathy and mind reading," she writes, "we would not have evolved to be humans at all."
Unfortunately, today we seem to be ignoring the important role of our extended families and friends, placing intense pressure on mothers and the nuclear family. Rather than seeing shared care as "natural," we harshly judge mothers who don't spend all of their time with their infants. We don't provide affordable, high quality daycare -- consideration of doing so, despite the fact that the majority of American mothers work -- isn't even part of the political debate. We ignore the help historically given to mothers by relatives and friends which is now rarely available, viewing motherhood in an isolated suburban home with a father who is absent for most of the day as "traditional."
We don't consider the fact that for most of human history, mothers worked with other mothers, with their youngest children around them. Intense attention has been given to the problems of working mothers, single parenthood and divorce -- yet virtually no one looks at the effects of the massive breakdown of extended family that has come with industrial and post-industrial society. When extended family and related social networks are studied, however, they show great benefits to children -- especially for single parents, but for two-parent families as well.
Shared care of children was probably the original cradle of empathy -- and early nurture is still critical to its development today. If we want a kinder culture -- and to protect our capacity to connect -- we have to do better for parents, babies and teens.
Adapted from Born for Love: Why Empathy Is Essential—and Endangered (Morrow, 2010) by Maia Szalavitz and Bruce D. Perry, MD, PhD. All rights reserved.
Until now, there has never been a feature film that takes us inside "tough love" teen programs like those headed by Romney financiers Mel Sembler and Robert Lichfield. The New York Times calls Nick Gaglia's indy production, Over the GW a "lean yet harrowing ... look at reprogramming that masquerades as rehabilitation." It is playing for just a short time here in New York City (details)-- and I urge everyone to see it, especially those whose lives have been touched by these monstrous "therapies."
The movie was based on Gaglia's own story. From 1997-1999, he attended the KIDS program in New Jersey, which was run by Miller Newton. Those who follow these issues will probably recall that Newton previously served as national clinical director for Sembler's Straight Inc. Despite having had to pay out over $10 million in settlements related to abuse he participated in and directed and admitting abusive practices to regulators, Newton still sits on an advisory board for Sembler's Drug Free America Foundation.
Gaglia discussed his experience with me recently. Just 25, the writer/director is beginning to hear from Hollywood -- the NY Post, NY Sun and Variety also took note of his debut film. Before being sent to KIDS, Gaglia had auditioned for and was accepted to New York's prestigious Professional Performing Arts School, whose notable alumnae include Clare Danes, Alicia Keys and Britney Spears.
But Gaglia had problems at home. Although he's still not quite sure why, he didn't want to go to school and simply couldn't communicate with his parents, who had divorced when he was nine. "I wanted to do what I wanted to do," he says. "I wanted my independence and they were getting in my way." Soon he was drinking and smoking pot daily-- and coming home late, smashing furniture and punching doors. Until after KIDS, he'd never even tried any other drugs.
When taken to the program, located near a major shopping mall just over the George Washington Bridge from his home, he was told by his parents that he'd be going shopping. "I tried to run away, but a group of five people grabbed me. I was a really skinny kid and I wasn't going to fight, I wasn't violent."
He was strip-searched by teenagers who were already inmates-- made to "chicken squat" naked in front of them. In the film, the violence and potential for abuse in having unsupervised adolescents do such searches is represented with the terrifying snap of a rubber glove and images of a naked boy, surrounded by bigger, tougher kids who are clothed.
What he doesn't show is the urine stains visible on the "clean" underwear he was given to replace the "druggy" clothes he was made to leave behind when admitted. When restrained on the floor, teens were not given access to the bathroom. "At my first group, there was a kid being restrained on the floor and his hands were soiled," he says.
"I was restrained over 100 times," he continues, detailing how fellow participants would throw him to the floor for "offenses" such as responding to being poked because he wasn't paying attention by trying to fend off the attack. These restraints could last hours-- with one person sitting atop the victim while others held down each limb. The most frightening part was fear of suffocation: sometimes the victim's mouth would be covered and his nose pinched close.
Writhing was interpreted as defiance. "One time I felt like I was five seconds away from dying," he says, "I have scars in my mouth which was bleeding. I was panicked and trying to communicate but they think you are resisting. What are you supposed to do?"
Grim as this material is, Gaglia represents only the barest outlines of it in the film: limited both by budget and by recognizing that if he did show the whole truth, he might make a movie that was unbearable to watch. He also avoided the trap of didacticism, which often mars attempts to tell these stories.
"I wanted the viewer to feel like he was sitting in that room," he says. "You don't know why your sister was there, you don't know what day it is, you don't know why they were doing certain things. And that's the way I directed the actors."
In fact, the actor who played the character based on Newton didn't even know that there was a real-life model for the story until later. "I told him to act as though he believed he was doing everything 'to help these kids,'" says Gaglia. The self-righteous rage and "ends justify the means" thinking that characterize the operators of tough-love programs comes through vividly.
Gaglia eventually managed to escape from KIDS by jumping out of a car stuck in traffic at the toll plaza of the GW Bridge. The program parents who were driving the car had childproof locks to prevent escape via the back doors-- but the front seat was empty, and Gaglia went for it. Fortunately, after getting the attention of the police, he was able to convince his own parents not to return him.
But, like many who left, he was at first terrified that the program's predictions of a future of "jails, institution or death" would come true rapidly because he'd left without completing it. And, again like many others, when that wore off, he began drinking more heavily and using harder drugs. "When the drunkest guys you know are saying 'Hey dude, you're drinking too much,' you start to think it's a problem," he says. Ultimately, he studied film at Hunter College and got back on course.
"I don't see how anyone who was in that kind of a situation for as long as I was could come out without post-traumatic stress disorder," he says. "I had nightmares all the time that I was back in."
I attended a screening recently for those who had been through KIDS and similar programs. I was struck by the age range: there were people from their mid-20's to their 40's who had suffered through years at KIDS. Though many were nervous that the film would trigger distressing memories, those I spoke with found that the film validated their experience. "More than anything, I made the movie as an homage to these people," says Gaglia, "We're all speaking with this film."
Let's hope that people who can prevent the abuse from continuing are finally listening.
Florida's Supreme Court has rejected an appeal from Richard Paey, a wheelchair-using father of three who is currently serving a 25-year mandatory prison sentence for taking his own pain medication. In doing so, the court let stand a decision which essentially claims that the courts have no role in checking the powers of the executive and legislative branches of government when an individual outcome is patently unjust.
Richard Paey -- who suffers both multiple sclerosis and from the aftermath of a disastrous and barbaric back surgery that resulted in multiple major malpractice judgments -- now receives virtually twice as much morphine in prison than the equivalent in opioid medications for which he was convicted of forging prescriptions.
He had previously been given legitimate prescriptions for the same doses of pain medicine -- but made the mistake of moving to Florida from New Jersey, where he could not find a physician to treat his pain adequately. Each of his medical conditions alone can produce agony. Paey has described his pain as constantly feeling like his legs had been "dipped into a furnace."
The Ivy-league educated attorney has no prior criminal convictions, and weeks of surveillance by narcotics agents did not find him selling the medications.
The Florida Court of Appeals had upheld his conviction -- despite the lack of evidence of trafficking and despite the fact that most of weight of the substances he was convicted of possessing (higher weights lead to longer sentences) was made up of Tylenol, not narcotics. The majority suggested that Paey seek clemency from the governor, claiming that his plea for mercy "does not fall on deaf ears, but it falls on the wrong ears."
In a jeremiad of a dissent, Judge James Seals called the sentence "illogical, absurd, unjust and unconstitutional," noting that Paey "could conceivably go to prison for a longer stretch for peacefully but unlawfully purchasing 100 oxycodone pills from a pharmacist than had he robbed the pharmacist at knife point, stolen 50 oxycodone pills, which he intended to sell to children waiting outside, and then stabbed the pharmacist."
But the Florida Supreme Court disagreed, letting the sentence stand, without comment. It released its cowardly decision in the media quiet of a Friday night. As Siobhan Reynolds, founder of the Pain Relief Network points out, "Where Florida stands now is that individuals have no recourse to the courts when the executive and legislative branches behave tyranically." Under the Constitution, the role of the judiciary is supposed to be to check the powers of the other branches -- not simply to defer to them.
Paey's only other alternatives now are an appeal to the U.S. Supreme Court or clemency from Governor Charlie Crist.
Writing in support of clemency, leading academic pain specialist Russell Portenoy, MD, said, "the information available indicates that any questionable actions [Paey] took, actions which led ultimately to his arrest, were driven by desperation related to uncontrolled pain."
He noted that such cases "may increase the reluctance of professionals to treat pain aggressively."
Portenoy wrote that despite the fact that Paey required high doses of opioids, those doses were "clearly in the range used by pain specialists in this country." He stressed that, "The number of pills or milligrams of an opioid required for analgesia says nothing about any of the negative outcomes associated with these drugs-including abuse, addiction and diversion-and reference to the amount of drug as evidence of these outcomes by regulators or law enforcement should not be condoned."
Unfortunately, across the country, pain patients are being undermedicated and doctors are going to prison because the Justice Department refuses to believe this.
People profess to be experts about addiction because they have personal experience with drugs or addicts; they think they know about opioid drugs because they've watched a few episodes of E.R. or been through DARE classes at school. The truth is that opioids are amongst the safest drugs known to humanity -- when given appropriately, they do not kill.
Unlike aspirin, Tylenol, Vioxx, Celebrex, Advil, Alleve and every other known class of pain medications, opioids do not harm any organs and there is no maximum dose once a person has become tolerant to them. People need to educate themselves about the complexities of how drugs, brains and settings interact before making policies about them that send people like Richard Paey to prison.
Governor Crist, please, do the right thing and send Richard Paey home.