………………
There are things we believe we know. Accepted truths that can’t be wrong. We see the evidence of these truths daily. These are the things we don’t need a citation for, the words we don’t list in the table of definitions, the questions we don’t even need to ask. But what if we have been fooled? What if everything we are sold to believe about drugs is, at some level, wrong?
There are some accepted truths that I question, in order to challenge my students. Here is one example:
Me: “What is a drug?”
5th year Med student: “Uuurgh! We all know what a drug is.”
Me: “So then tell me…”
Google kicks in. The class frantically searches “What is a drug…”
Student: “A drug is… drugs are chemical substances that affect or alter the physiology when taken into a living system. They can either be natural or synthetic.”
Me: “What about food…”
Frantic typing.
Students: “Except food!”
Me: “What about magic mushrooms? What about coffee? Sugar?”
Student: “A drug is an illegal substance that some people smoke, inject, etc. for the physical and mental effects it has (Oxford learners).”
Smug smile…for a second.
Me: “So Cannabis is no longer a drug in South Africa, Canada and parts or Australia? Which scientific body decided that?”
Student: “I’m sorry, but I didn’t come to this class to discuss philosophy. I came here to learn how to treat drug addicts!”
“Well, if there are no drugs, how can there be drug addicts?”
Here are some quotations, by people far smarter than me, from my course material.
From an interview with Jacques Derrida:
“…there are no drugs ‘in nature.’ There may be natural poisons and indeed naturally lethal poisons, but they are not as such ‘drugs.’ As with addiction, the concept of drugs supposes an instituted and an institutional definition: a history is required, and a culture, conventions, evaluations, norms…There is not in the case of drugs any objective, scientific, physical (physicalistie), or ‘naturalistic’ definition …the concept of drugs is not a scientific concept, but is rather instituted on the basis of moral or political evaluations: it carries in itself both norm and prohibition…it is a decree, a buzzword.”
“Whatever the origin of the U.N. Drug Treaties, and whatever the official rhetoric about their functions, the best way to look at them now is as religious texts… Books by Andrew Weil, Norman Zinberg, and Lester Grinspoon have been listed on drug warrior websites in the U.S. as ‘dangerous’ while ‘concerned’ citizens are encouraged to demand their removal from local libraries. The more detail in which the heresies are spelled out, the more the security of the Faith is established.”
“1. ‘Drug’ (as well as ‘narcotic,’ and similar terms…) does not denote a scientific or pharmacological category. It points, rather, to a category that reflects how a society has decided to treat a substance… 2. The category to which a substance is assigned affects how people who ingest that substance are treated and that, in turn, affects what the substance in question does to and for them. 3. Therefore, the solution to the problem is to redefine the phenomena involved. But this simple solution is not available because the power to define is concentrated among people [with] no incentive to take that easy step.”
“The belief in drug-induced addiction has acquired the status of an obvious truth that requires no further testing. But the widespread acceptance of this belief is a better demonstration of the power of repetition than of the influence of empirical research, because the great bulk of empirical evidence runs against it. Belief in drug-induced addiction may have deep cultural roots as well, since it is a pharmacological version of the belief in ‘demon possession’ that has entranced western culture for centuries.”
“Romantic love is an addiction. It’s a very powerfully wonderful addiction when things are going well and perfectly horrible when things are going poorly.”
Let’s believe that we know what a drug is. When you take a drug, there is no consistent outcome. Sure, the pharmacology may result in a similar biological effect. Opioids = analgesia. Amphetamines = energy. However, the perception, experience, meaning and impact are unpredictable. As Zinberg has shown, the drug effect shifts according to:
• Drug (dose, purity, method of use etc.),
• Set (beliefs about the drug, individual vulnerabilities and biology, drug expectation, the current state of mind etc.), and
• Setting (where we take a drug, who we are taking it with, who may be watching us, and even the legal status of the drug).
A person can reach a relatively stable outcome through consistent quality and learning. Still, the next person may have a very different outcome. With a different mind-set, in a different setting, everything can change.
How we define drugs has little to do with pharmacology or with potential harms – it has everything to do with the constructs around the drug. These can change with context. Colonel Peter Demitry described amphetamines as “the gold standard for ‘anti-fatigue.’ We know that fatigue in aviation kills … This is a life-and-death insurance policy that saves lives … This is a common, legal, ethical, moral and correct application” [quoted in War and drugs (Bergen-Cico 2015)]. Yet, in 2006, the United States Attorney General proclaimed methamphetamine to be “the most dangerous drug in America.” The drugs so described are almost identical, and they are currently prescribed to children to treat attention deficit disorder and obesity.
We need to stop thinking of drugs in terms of “harm.” If prohibition were about harm, free climbing would be illegal; paracetamol would require a prescription; alcohol would be banned, and LSD and psilocybin would be readily available. At the wrong dose, in the wrong combination with other drugs, most foods and drugs can cause harm under the wrong circumstances.
So what is this all about? What informs our constructs? As Cohen and others suggest, drug policy is more belief or religion than science. The only U.N. Convention to call something ‘evil’ is the Single Convention on Narcotic Drugs. 
Addiction is described as an evil that must be combated at all costs. The term evil suggests what the real issues are: the mystical experience, the internal resolution of suffering, the feeling of power that challenges church and state. We can feel ‘fine’, but never ‘better’.
You cannot point out that, for some people, using an unregulated street drug that will cause certain eventual death may be useful in the moment. The priests of prohibition are horrified and appalled at such a sacrilegious 
suggestion. It is unacceptable that a homeless person who is HIV and HEP C positive, is hungry and cold and has no prospects for the future, can inject heroin, using a blunt needle, through the crust of a septic abscess, and instantly find themselves lying simultaneously in the arms their (imagined) mother and lover.
We applaud the extreme sportsmen but deplore the pursuit of dopamine through chemical means. The relentless pursuit of money is called determination; the relentless pursuit of comfort through drugs is called “addiction.” We let people suffer the misery of cluster headaches rather 
than allow them to find relief in psilocybin. All because they may experience a non-state/church-sanctioned mystical experience. Governments let people suicide from pain, and let people who use unregulated heroin die from fentanyl poisoning while prescribing (the more dangerous) methadone instead. The prohibitionists would rather have someone die “clean” than live “dirty”.
Evolution has ensured that we pursue survival by any means: falling in love, searching for connection, attachment and belonging, and searching for mystical experiences that transcend our mortality. The mechanisms of determination, motivation and “addiction” are all inseparable parts of being human. They are framed as positives until they offend someone’s moral sensibilities or can be used to demonize a particular group.
Once the label of “addict” is used, the prophecy starts to fulfill itself. Most middle-class people who use drugs only develop a serious problem once they get caught using drugs. People keep drug use hidden. To be labelled a user of heroin is a shame few can tolerate. A sex worker becomes a junkie whore to 
her colleagues when they discover she uses heroin. We know that if young people use cannabis, the best if not only predictor of future criminality, incarceration and violence is whether or not they get caught. The remedy is worse than the problem.
I admire Carl Hart, whom I consider a friend. He gained his place in academia through one of the few ways a kid from the Ghetto stands a chance of escaping the realities of life as an African American — military service. He became the first tenured African 
American Professor of Sciences at Columbia. His research and data turned him into an advocate for developing a better response to problematic drug use. Recently Carl Hart outed himself as someone who uses drugs. No doubt he will feel an immediate backlash. Ultimately, I believe people will pretend he never mentioned his drug use. It is easier to ignore the facts than to confront the accepted “truths” about drugs and addiction.
From grade one, they taught us: there is no such thing as controlled drug use. People who use drugs cannot sustain their work, meaningful relationships or financial commitments. We have to believe that drugs are dangerous, drugs are demons, drugs cause the breakdown of communities, and we must strive for a drug-free world. Later we realize it’s just not true. We should have a fit of righteous anger for being denied coca tea for a mild boost of energy, the joy of MDMA-assisted couples therapy, the mystical experience and the resolution of existential angst through psilocybin. We might also admit that our myths have caused great harm. I mourn the friends who have died inexcusable deaths.
Ultimately there are no good or bad drugs. One person’s poison is someone else’s salvation. In a rational world, there are plants and medicines and molecules that we can use with purpose, informed by knowledge, wisdom and experience, to find comfort, transcendence, temporary relief, joy, belonging and ourselves. In a rational world, there are no drugs at all.
And if there are no drugs at all, what the hell are we treating?
Informed by unparalleled neuroscientific insight and written with his usual flare, Marc Lewis’s The Biology of Desire effectively refutes the medical view of addiction as a brain disease. A bracing and informative corrective to the muddle that now characterizes public and professional discourse on this topic.” —Gabor Maté, M.D., author of In The Realm of Hungry Ghosts: Close Encounters With Addiction
I am sorry but to me this is just playing with words and trying to be clever. As the father of a son addicted to alcohol, then marijuana, then oxycontin, then fentanyl, and always to adrenalin and who has not been in trouble with the law apart from the loss of his license but who has been struck down by acute necrotizing pancreatitis from over-consumption of alcohol and is now still fighting for his life I find it almost offensive that someone will debate the labelling of harmful drugs. Of course drugs are harmful if misused and so is alcohol and so is food. Please use your collective expertise to find a way to identify and treat people who are likely to be harmed by drugs or alcohol so that communities are not destroyed and millions of people’s lives ruined. The despair so many parents face while watching their loved ones die a slow and painful death makes this playing with words disrespectful. Sorry, but I am hurting.
I am sorry for your suffering. it is because of the deaths of many friends and the deaths of the children of friends (some who’ve lost more than one) that I do the work I do. This is so much more than semantics. Without a radical change in our understanding of drugs, we will never find meaningful solutions. There is a follow-on piece that will explain how re-thinking can result in effective interventions and solutions.
Hi Bruce and others. This comment is an attempt to capture some of my thoughts about the controversy that’s been stirred, and I expect will continue to be stirred, by Shaun’s post. Bruce, like others, I feel badly for you and your family. There is nothing quite so painful as watching our children suffer…and being unable to to do much of anything to help. But what I’m saying here is not just a response to your comment and your tragedy; it’s more general than that. Please read on and you’ll see what I mean.
I knew that Shaun’s post would invoke a lot of astonishment, counter-argument, and even anger. That was inevitable. I also wondered if some readers would be so turned off as to divest from this blog forever. But I hoped it would attract others — or even the same readers in a different mood. Attract them, not necessarily because they agree with everything Shaun has to say, but because they recognize his viewpoint as legitimate in its own right…because of how articulate, coherent, and forceful it is, despite the swirling sea of controversy out of which it arises.
I think Shaun’s post marks an exciting moment in the evolution of this blog. There are strong feelings, like loss, anger, fear, and/or shame, on BOTH sides of the debate. It’s hard for anyone who’s lost a loved one to a drug overdose or other drug-related tragedy to hear “there are no bad drugs” or “‘addiction’ is a construct that has more to do with moralistic propaganda than reality” or “the idea of ‘drugs’ as currently used is a container without meaning” [note: these are my paraphrasings, not Shaun’s words]. But — and here’s the kicker — Shaun has also lost people he was close to: “I mourn the friends who have died inexcusable deaths.” So, he’s not unaware of the tragedy that can result from the use of powerful drugs (in the context of the present “prohibitionist” culture), and he’s experienced this tragedy himself.
It seems to me that very similar events can lead to, or more likely reinforce, radically different perspectives or beliefs, even core beliefs: on drugs, drug use, and drug policy.
I’m not going to try for some glib resolution. In one sense, I’ve been wrestling with such issues throughout the ten-year history of this blog. I don’t agree with everything Shaun says or implies…but I do agree with a lot of it. And by “agree” i mean…what, exactly? I get his points and his perspective, I see them as valid, I’m still thinking about them. Intuitively I accept some, reject others, and I’m still agonizing over what’s in the middle. I see Shaun’s viewpoint as worth airing in its strongest form — I wouldn’t have published it if I didn’t. Yet I believe it’s essential to further explore the implications of this position — a position that’s more extreme than “harm reduction” — already pretty radical as seen from the mainstream. I think we need to explore these ideas further, extend them, unfold them, and try to integrate them into our own viewpoint. That way, perhaps, our perspectives will knit into a comprehensive philosophy — one that makes sense to those at both ends of the ideological spectrum.
Re this last point, one more word. Take a construct like “racism,” as used in the Anglo-American world. Two hundred years ago, there was no doubt about white supremacy. A hundred years ago, the dominant culture began to see that there was another perspective, as we (we?!) recognized the contributions of black thinkers and teachers, as well as black entertainers and athletes. Fifty years ago, in my youth, ideas like “Black Power” (part of which evolved into BLM), were considered highly radical. For much of the dominant culture, such ideas seemed like a slap in the face — wtf are you guys talking about?! You really believe that this is a legitimate position? And now (here’s a sideline) my literary agent tells me that I’d have a much better chance of publishing my latest book if I were black, or gay, or trans, or ideally all of the above. He said this half in jest, but it reflects a reality. Viewpoints as to what’s acceptable, even desirable, are changing so fast, that what were once highly controversial positions are now accorded not only legitimacy but also respect and optimism. Of course we don’t know where all this debate and struggle and propaganda, and the DEMAND to be treated fairly, voiced by formerly fringe elements…we don’t know where it’s all going to land, if it ever does land. But even 20 years ago we would never have predicted that a black man would soon become a two-term president of the US, better liked by a huge chunk of the population than the white guys who came before and after him. All I’m saying is that what look like wild, irrational, fringe perspectives at one time can often merge with more dominant, cherished perspectives, and change them, even trounce them, in fundamental ways, in just a few short years.
First, for Bruce: I am so very sorry for your son and your family. Necrotizing pancreatitis is life-threatening, as you said. My own son has OD’s 5-8 times and is, cliche as it sounds, living in my basement. 24 years old, smart…but no college, no military, and no regular job, while watching his siblings move on and experience the world. Yeah, no,…..drugs are real and they ruin or shorten millions of lives a year…no matter the definition
I, too, agree that the author is just playing with words. There is a big difference between some aging hippie smoking pot once in a while and the life-destroying effects of the street drugs (and alcohol) that people abuse. And so what if methamphetamine has legitimate uses? Back in 2006 –before opioids took over the scene — it was a scourge; destroying lives and families (and causing many grandparents to have to raise their grandchildren)
I would agree that it’s drug abuse, and not drug use, that is the problem….but you can’t use heroin “once in a while.” Maybe some rare individuals can, but the Russian Roulette aspect of it is too high a risk.
Marc, this last year, I’ve gotta wonder if you are just finding a way to justify a return to using drugs.
p.s. Bruce, when your son recovers, if he is so inclined, there is a well-written book by Rich Roll called Finding Ultra, which is a biographical narrative of a man who overcame his alcoholism and became sober and an extremely fit endurance athlete.
There are a huge number of heroin users that do not suffer significant medical consequences. Diamorphine (heroin) is not a particularly harmful drug. But unregulated heroin is. People in heroin prescribing programmes do really well on long-term injectable heroin. Most find stability and employment and lead fulfilling lives.
Again, it is not the drugs themselves that cause the majority of consequences, it is the response, stigma, rejection and systemic violence against drug use that cause the vast majority of negative consequences.
I certainly do not work with “aging hippies”. I work with mainly street dwelling people who inject drugs. These are not semantics, they are critical and fundamental faults in our thinking that cause deaths.
In the last three years more than 100 people I know, and can name, have died from violence against them because they are drug users, or drug-related unattended medical needs, including TB, HV and HCV, or poisoning related to contaminated drugs. I don’t have time for theoretical arguments… unless they can impact policy and save lives. The way we understand drugs defines the way we respond.
Hi Marie.
I think we have to put data before opinions. Apparently some people CAN use heroin recreationally. And the same may be true for other hard drugs. But yes, there are risks, and those risks are much greater for some people than others. For example, I would continue to restrict the use of hard drugs for children and teens. For sure. Like you, I see “addiction” as a real phenomenon and a real danger, and this may be where I differ from Shaun and Carl Hart. I’m aware of the neurocognitive changes that accompany addiction, whether to substances or behaviours. I’m old-fashioned enough to believe “better safe than sorry” when it comes to my own kids. And I know that drug use often exacerbates existing problems. But drugs — call them what you will — can also help…and that’s a big part of Shaun’s message. Another big part is that opinions can be far more damaging than substances.
Personally, I think that injecting drugs is way too risky for anyone. And it’s not necessary. People can experience drug effects using natural modes of ingestion. But as to whether heroin, for example, is so risky that it should be forbidden, regardless…I’m not so sure that’s helping anyone. Particularly because putting the cookie jar on a higher shelf generally makes it more attractive.
While I’m a firm supporter of decriminalization, I’m still undecided about aspects of legalization. Legalization may or may not increase access, but it definitely increases a society’s capacity to regulate what might be more dangerous if left unregulated.
Shaun thank you a very illuminating and much needed form of discussion.
Indeed!
Why are oxycodone, morphine and other chemicals prescribed by our health care “systems” to remedy disfunction, and restore function, but heroin is described as “evil”?
Heroin could easily be used in the same way as those other chemicals.
One of our most pervasive addictions in North America today does not involve the consumption of any substance what-so-ever…..gambling.
Modern societies, including Canada, are recognizing that the most socially destructive element of addiction is the criminalization of the behaviors.
I’m inclined to see this discussion as more than just word play. It is a way to refine the discussion about addiction treatments. Gambling is legal, it does not involve consumption of a “drug” but it is as destructive as any other “substance abuse”. What is it that we are actually treating??
Shaun, thanks for this work.
It can’t be said enough…
This isn’t abstract philosophy or semantic trickery (two things I’m accused of daily), this is ground truth and first-principles reasoning.
It’s both life-engancing and life-preserving.
Keep going!
Hi Zach. Good to hear from you! I just wrote a lengthy comment, which I put in a separate window…right at the top for now. But I just want to mention that this started off as a “reply” to you. Then it seemed more general and less of a response to you per se…so I moved it to its own spot. Thanks for the trigger!
You got it!
Great to hear from you as well 🙂
It’s such a huge can of worms. Substance abuse, compulsive gambling, over-eating, sex addiction, QVC, self mutilation, it’s all related to a sense of being disconnected from something bigger than ourselves. At least that’s my understanding of it, from everything I’ve read and observed in my own experience. ‘Addiction’ is a symptom of a deep sense of ‘not enough-ness’. You could point to societal dysfunction, early childhood trauma, the loneliness of living in a hyper-individualistic culture, mass consumption of meaningless shit, doing work that’s unfilling, etc.
Wonderful post Shaun and thank you for publishing it Marc! Yes, problematic drug use causes tragedy. So does any other behavior that causes tragedy! As Stanton Peele points out, the number of “crimes of passion,” especially women killed by men, are huge. Domestic violence has taken the lives and/or spirits of many women I know, but beating one’s wife or partner is not fought with the zeal of the “opioid epidemic” or any War on Drugs. The neurochemicals that cause rage have not been outlawed, and the outcomes of that rage when they occur in the home are rarely punished. Or just the every day cruelty of one human being against another, or against animals.
Focusing on the drug is a great way to distract attention from all the factors that lead to harmful behaviors. Poverty, lack of hope, lack of connection, lack of access to basic needs… these things all make something that predictably makes you feel good, even if temporarily, very attractive. I’ve tried to quit drinking while living in relative economic security and while living without knowing how I was going to pay my rent. It went a lot better (and abstinence from alcohol is my choice, for reasons of health specific to my brain chemistry, not any sort of moral conviction) when I could pay the bills.
In six years of work with people trying to change their drinking, I have seen a lot more harm done by shame than by alcohol. I encourage people who do not gravitate toward the label “alcoholic” (which some seem to enjoy, and I respect their choice, but most do not find empowering), to avoid it if they can. Avoid so-called treatment, avoid labels, and find habits that make you feel better than drinking more than you really want to. Then move on with your life – while you still can! I can say from experience that once that label takes hold, it can take longer to deprogram from the feelings of shame and worthlessness implied by the label than it takes to recover from any physical effects of alcohol.
I’m so grateful for the evolving work all of you are doing.
Hi April,
Good to see you here. it’s been a while since we last corresponded. We are both on similar pages. your comments are spot on. the important thing is a personal choice – abstinence or conscious and purposeful drug use are both viable options and a person can have different choices for different drugs, life circumstances and be the better off for those choices.
Shame is indeed deadly. There needs to be more research on the consequences of “shame” – I think Howard Becker’s work on labelling and his seminal “Becoming a Marihuana User”, as well as Goffman’s work on stigma, should be revisited because they are just as relevant today as when first published.
Hi Shaun
Great to hear you! Hope all is well. I’m gonna mess with you just a little and turn your own declamation back on you because I know you’re a good sport!
Shame is not deadly per se… shame, the universal mammalian emotion that is both self- and co-regulatory and pervades human culture (potential embarrassment, humiliation to regulate group behavior, etc.). It keeps us motivated to do the things we like, and recognizing the boundaries of safety, satiety and dangerous excess. But “toxic shame,” or un-anchored, groundless shame? The kind of shame that causes people to feel responsible for horrible deeds they can’t remember they never did?… Due to some developmental disruption, chaotic parenting or trauma? … Or being conditioned that hiding from shame feels safer than reaching out for help? That can definitely be deadly. “Substance misuse” (which I think I’ve heard you use) is a much more accurate label—a more accurate depiction of what is actually happening for preventive educational purposes. I have a friend who occasionally comes to my groups and says ALL addictive behavior is gambling, because all addictive habit behaviors involve riskfully playing the odds to greater or lesser degrees with dramatic consequences.
m
Thank you for your post, Shaun, which I imagine took a lot of experience, discussion and courage. In the 21st century, my belief and observation is that we are having to reimagine our futures away from incessant consumption – and the 24/7 production – which enables it, as individualised cultures are truly making people sick. Physically and mentally.
I grew up with Eric, a younger brother who didn’t fit in. He was a great risk taker, zany, creative and never worked hard. Fun was his middle name. As such, he became our dad’s scapegoat. Fast forward to 12, a disastrous emigration to South Africa and it was almost inevitable that Eric would tip over into addiction. He did manage harm reduction, when he lived with our mother, after dad’s death. He caused no end of problems, to be frank, and essentially sold out of life at 16. Rehabs? Nothing helped. He made us despair and made us very angry, often. But I stayed in touch with him over the years, because he was still my brother.
I latterly developed my own problems with addiction: alcohol. I recognised it became a problem as I was checking out of life and latterly, wanted to end it.
I’ve been talking to people the past 10 years about family addiction: EVERYONE is ashamed of it, and 1 in 2 families I know have problems – it’s massive. After I quit drinking, I’ve been helping people to quit drinking, which has created real meaning and purpose in my life. (Unpaid.)
What does it mean to be human? We all search for our own kind of meaning, as Viktor Frankl so beautifully wrote. How do we balance the spirit (and need to reach altered states where life is much more peaceful, interconnected and loving – as Nature is) with the need to operate in a consumer culture? Can we move to safe rooms where people use, in community, in safe ways, and there medics close by to help? Should all festivals test for drugs, not just Covid, from now on. I like the idea of labs testing pills to check for purity, before people ingest them. Will pubs stock a proper range of alcohol free options, or arrange a taxi home for people who’ve clearly had enough?(always think about domestic violence here……)
It’s important that people who choose to use also have meaning in their lives. They need community and a reason for cutting down, if not cutting out. Families, too, need to be considered in all of this. I know my dad probably died 10 years before he would have normally, with all the stress. My mother died early too. That makes me very sad. I also reflect on the note Eric left when he committed suicide, 12 years ago: “Sorry for all the pain I caused.”
The whole needs to be considered i.e. families and communities. Spaces for people to get well, to discern a new purpose and to follow that purpose with every fibre of their being. Low rent/cost housing, good public transport, and a recognition that caring jobs are much more important than financial markets. Some countries, like Portugal and New Zealand are working towards it. The Puritanical English and American societies seem largely agin it. Condemnation and stigma just worsen the whole, sorry mess.
It’s spiritual, social, economic AND political. We do need debate, and that will take 2-3 years. It can’t be shut down….
https://transformdrugs.org/blog/former-new-zealand-prime-minister-welcomes-proposal-for-regulating-stimulants
Hi Annette,
Thanks for your heartfelt comment. You have some great ideas in here. Transform is fantastic. I have had many conversations with Steve and others. I really enjoy Prime Minister Helen Clarke’s discussions – I have had the good fortune having conversations with Helen and others at the Global Commission on a few occasions.
Madame Ruth Dreifuss, a colleague of Helen’s at the global Commission is also a strong voice and in her one-year term as the president of Switzerland introduced heroin-prescribing and they haven’t looked back. In her words, the biggest problem now is supplying injectables to old age homes.
I’m sorry for the loss and difficulties you’ve had to suffer.
Thanks to everyone for your insightful and meaningful comments. I will respond either in part two or as I get the opportunity.
Shaun I agree with your words 100 percent …I too work with the homeless and downtrodden and the neglected of society …after 30 yrs of listening to these people …
what I see is:
Classifying illegal drugs as “bad “ fuels the addiction more… leads to more deaths in the long run… leads to having to rely on more risky behaviors like prostitution and stealing to keep chronic habits going…Makes people chose between a “normal lifestyle” and the “drug lifestyle” …. and when a person chooses the “drug lifestyle” over family they often can’t come back from the pain and the family can’t forgive. And criminality of drugs causes more problems that people often can’t come back from…
I’m for legalization of drugs after seeing some people get psychosis from the chemical heroin out there. Scary stuff. Anyone can put anything in the unregulated drugs.
Why does a person get to go to a bar and get a requested drink in a clean glass ? How come sitting in a bar is an “acceptable” lifestyle… heck it’s “cool” to go to a bar. But snorting heroin alone in your room is “devilish”? And even if you request heroin you have no idea what’s in it…
We labeled cocaine and heroin and marijuana “morally”bad … but they were a drug just like the others on this planet.
It’s our response to drugs that causes the problems and ultimately causes the deaths.
But who the hell is going to listen to me? This is not just my opinion this is based on 30 years of observation of how the shame of illegal drugs in society and the lack of regulation destroys people not the actually drug.
I often hear people say that famous line… if you don’t stop drugs it’s either death or incarceration or institutions…. society created these options not the drugs.
Thanks for sharing this!
I disagree with Shaun and here are my reasons based on the twenty plus years of treating patients impacted by drugs and alcohol.
I was at a meeting, and a passionate believer in harm reduction told the group in great sincerity a real-life example of harm reduction. A street prostitute, a heroin user would come to the outreach center to pick up a supply of syringes and condoms. He asked the audience rhetorically if there was anything wrong with this approach? I applauded his passion and complimented him for helping this person and asked him if he could do anything more for her. He gave me a confused look.
I told him: “Have you considered telling this person about treatment options”. If she ever wanted to get off heroin, she could receive buprenorphine and other medications to get off the heroin. She could receive psychiatric care and other services. The State of Missouri even provides safe housing. She could receive all these services at no cost. She could contact my clinic when she is ready. Now this center is the biggest referral source for my clinics in St Louis. Most of the patients coming to this center to pick up syringes, condoms and naloxone were not aware about top quality care at no cost!
Shaun describes in his blog a homeless person injecting heroin through an abscess. If my outreach person had seen this homeless person covered with abscesses, injecting heroin with a blunt needle he would have offered him medical treatment to get off heroin, and antibiotics for the abscesses and a host of other services, all at no cost. If he were reluctant to seek help, my outreach employee would have left a business card and told him to call when he was ready. He would also have arranged to drop off syringes and naloxone.
Frankly, I am baffled at the shrill voices advocating for safe injection facilities, legalizing drugs like heroin, meth and cocaine as deep gestures of compassion. This misplaced compassion can end up doing more harm. The present opioid epidemic started with a ‘compassionate’ gesture to treat chronic pain sufferers with opioids. Before long tens of millions of patients went to doctors for a prescription of heavy- duty opioids like oxycodone and hydrocodone. This was de facto legalization of opioids. What followed next. The Mexican narco mafia flooded the US with cheap heroin and there were calls for legalizing heroin. Why stop at heroin. The Chinese saw a huge market opportunity to smuggle fentanyl into the US and I have heard calls to legalize fentanyl. Where do we stop? We are seeing analogs of fentanyl being smuggled and there is huge increase in meth and cocaine smuggling. Do we throw open our borders for an open season for drugs?
When drugs use increases, more patients are going to seek help. Where is the help? Why have we not mobilized treatment services to meet the demand? We have medications like buprenorphine, methadone and naltrexone that can help patients. How have we reacted? By placing restrictions on using these meds, particularly methadone and buprenorphine. The Biden Administration did the right thing by removing restrictions on prescribing buprenorphine. This would have gone a long way in helping patients obtain buprenorphine. Within days, those restrictions were re-instated. Who was behind this move? It is worth reading the letter sent to the US Govt. http://www.aatod.org/wp-content/uploads/2021/02/data2000.letter.coalition.pdf.
Let us not delude ourselves by believing that foods, drugs, behaviors are the same. The basic principle of good and bad is applicable here. There is a saying in one of the Indian languages that roughly translates as: Too much ambrosia can turn into poison. Even the food meant for gods can turn toxic. In medicine we strive to use medicines with low or no abuse potential. This is not always possible. In such cases the drugs have to be used with caution. The restrictions on opioids, however imperfect, make complete sense to me.
Percy,
you are creating a straw man argument and are wrong about harm reduction. What I do agree on is low threshold access to methadone and buprenorphine, but also diamorphine. Naltrexone is suitable only for a tiny percentage of people and can be a very dangerous route to follow as a first or even second-line option.
Here is where I disagree:
1. “Harm reduction” in your use of the word does not simply hand out needles and syringes to people. It offers a complete continuity of services, including abstinence options.
2. If you want to talk anecdotes, I have a talk called “the best photo I ever took”. It’s David’s feet in a pair of shoes. 18 months prior he could not even fit his swollen and septic leg into the leg of a pair of tracksuit pants. I thought he would lose his leg. He refused to go to the hospital. Why? Because he knew that he would be denied real pain treatment – paracetamol doesn’t cut it for a heroin-dependent person. Long story short, David’s leg was saved through compassion and care- he needed no treatment. Just compassion, a space to feel safe and someone to show that they cared. He is now employed at a palliative care centre for street people. He was on methadone, which we also offer, alongside buprenorphine. No need for a business card, because we see the service users daily. That is what harm reduction is.
3. The opioid crisis did not start with compassionate prescribing. It started with an economic crisis that robbed people of their hopes and dreams and psychosocial integration. Combined with rampant capitalism that includes the end-user marketing of drugs, more people found meaning and mental analgesia in their drugs. Then CDC started cutting supplies of prescription opioids, an act that has proven to be callous and deadly. And then total inaction when fentanyl hit the scene. ( I’ll deal with this in the next post).
4. Last time I checked fentanyl is legally prescribed in the US.
So, “harm reduction” offers most of what you do, but also offers services to people who aren’t interested in stopping to use, people who find meaning and comfort in their drugs. What we usually forget is that people seldom have a drug problem, they have drug solution.
Shaun,
I wish the harm reduction advocates in the US were as open minded. The goal of harm reduction in the US is keeping patients alive and reduce the risk of infections. The primary tools are syringes and the distribution of naloxone and giving patients information on treatment centers that offer buprenorphine and methadone. Our harm reduction advocates will be very interested in the various tiers of harm reduction practiced in South Africa, especially abstinence. I believe harm reduction should progress towards harm elimination and harm avoidance which is what you are practicing. Any information you can send would be most appreciated.
It was despicable on the part of companies like Purdue Fredrick to promote highly addicting and dangerous drugs like Oxycontin to vulnerable people who had lost their jobs and source of livelihood. Getting patients addicted to opioids, benzodiazepines and other drugs is no way to address the despair of unemployment and poverty. I disagree with the argument that restrictions on opioids led to the present problem of heroin and illegally manufactured fentanyl flooding the US.
Greedy drug companies capitalized on the desperation of patients addicted prescription opioids. Methadone, a dangerous drug as you write in your blog, was promoted as a safe and less expensive opioid for the treatment of chronic pain. A drug company even introduced a higher dose of methadone – 40 mg and patients started dying in droves. The DEA forced the manufacturer to withdraw this dose.
Fentanyl, a super powerful drug has been used in anesthesia and hospitalized patients for over 30 years with minimum issues of diversion, abuse etc. Once again, greedy companies introduced fentanyl formulations for the treatment of terminal cancer pain and shamelessly promoted the drug for chronic pain. The CEO of one these companies, Insys Therapeutics is serving a six-year jail sentence. Several drug companies, drug wholesalers and even marketing consultants have paid fines in the billions of dollars. Mexican drug dealers introduced heroin long before the tightened restrictions on prescription opioids.
We are told, sometimes by highly influential people that the best way to end the scourge of drug addiction is to legalize drugs like heroin, cocaine, meth and regulate the use and marketing. Regulation is a slippery slope and easily thwarted by greedy companies driven by profits. We saw the regulations on opioids in place for decades unravel before our very eyes and cause so much destruction and sorrow. All it took was a letter published in a medical journal, taken out of context stating that opioids are safe for the treatment of chronic pain. The mess we have with medical and recreational marijuana should give us further pause. Do we really want to legalize heroin, cocaine, meth and fentanyl?
I have strongly supported decriminalizing drug possession but opposed drug legalization on the grounds that drug legalization impacts poor people disproportionately.
I look forward to continuing the dialog.
Percy, I have to butt in here. You do sound rather extreme. Regarding the legalization of marijuana, what mess are you talking about? Since marijuana was legalized in Canada, just over two years ago, the stats show the following:
“…many feared that youth use would also rise. Early indications from this NCS study suggests use among Canadian youth has not increased. This accords with the Colorado experience—the first to legalize non-medical cannabis…”
“Legalization raised concerns about increased use among drivers. According to the NCS, the likelihood of reporting driving after cannabis use did not change with legalization. For example, in 2019, 13.2% of cannabis users with a valid driver’s license reported driving within two hours of using cannabis—unchanged from 2018.”
(https://www150.statcan.gc.ca/n1/pub/82-003-x/2020002/article/00002-eng.htm)
Cannabis use among adults (age 25 plus) has increased, but not by a huge amount. But so what? These people are less likely to drink alcohol and more likely to divulge use of a legal substance that was previously illegal. Cannabis use is certainly safer than excessive alcohol consumption. So what “mess” are you talking about?
Also, really? — you want to prohibit the use of powerful opioid painkillers for terminal cancer patients? To my mind, this is a perspective that hurts rather than helps. What exactly is the point of intensifying pain for people who have a rather small chance of becoming addicted before they die?
The “problem” is not simply legalization. The problem is legalization in a deeply flawed system where moral presumptions, economic disparities (as Shaun mentions), and archaic legal distinctions make indefensible categorizations of what’s okay and what’s not, and then persecute, isolate, or jail those who are caught outside the resulting structure.
Why did I bring up the ‘mess’ issue with marijuana legalization? Unlike the US each state and even individual counties can decide on legalization which again falls into medical and recreational use. Not all states are uniformly in favor of legalization.
The US has a peculiar mind-set of turning loopholes into big business. Many states have legalized marijuana under strict controls. There is an elaborate and costly process involved in securing a license. The entire marijuana industry is dominated by for-profit companies. A new issue has arisen about Black entrepreneurs not getting a share of these lucrative licenses. There are a whole set of other issues. Marijuana being smuggled into neighboring states; illegal preparations like hashish oil being produced and sold as vaping cartridges; marijuana edibles getting into the hands of children and last but not the least, illegally grown marijuana being sold on the streets.
The cost of producing marijuana will go down dramatically and consumption will increase. Larger for-profit publicly traded companies with formidable marketing prowess may decide to get into the business and lobby to weaken the licensing requirements and commoditize the product. Why not sell marijuana preparations at gas stations and convenience stores? Back to my contention – price and access are the two biggest factors driving habits and addictions. This is what I call the ‘mess’. The enclosed scholarly paper is worth reading.
https://www.sciencedirect.com/science/article/pii/S0955395921000608?via%3Dihub
I am in no way advocating for the prohibition of powerful opioid analgesics. They are indispensable in the treatment of post-surgical acute and terminal cancer pain. These patients did not have any issues obtaining these drugs. There is also a group of patients with legitimate chronic pain who do well on powerful opioids. Sadly, patients with legitimate chronic pain have difficulty obtaining opioids. Drug companies like Insys Therapeutics obtained FDA approval for fentanyl formulations to treat cancer pain and illegally promoted them for ‘chronic’ pain. The company admitted doing this. Rogue pharma companies find ways to thwart FDA approved indications. I would recommend reading White Market Drugs – Big Pharma and the Hidden History of Addiction in America by David Herzberg.
I spent 18 years with Big Pharma and ran smack into Big Treatment. Both have their overt and hidden agendas driven by a profit motive.
Percy,
what you are describing is not a drug problem, it is a problem of capitalism. The spurious belief that we live in a meritocracy, that free-markets work, that wealth flows downwards (it’s called trickle-down not flood-down for reason), and that everyone is responsible for their circumstances is misguided at best.
Pharma is going to capitalise on every loophole. that is what large corporations with shareholders demanding dividends do. At a billion dollars per drug no one can afford to develop a drug that satisfies an acute condition. They need chronic illness. They need everyone to be sick, and people to feel “fine” but never “better”. These are not drug problems, although they may well lead to drug problems.
Big treatment is the same – the so-called evidence-based treatments are anything but evidence-based. “Keep coming back” is their mantra. “if it doesn’t work, it’s because you ain’t working it” is their absolution.
You say: “The goal of harm reduction in the US is keeping patients alive and reduce the risk of infections.” It is a noble cause, and we know that the vast majority of people will resolve their issues with drugs without treatment. If they stay alive long enough. So I would rather see a focus on keeping people alive, compassion and care than a focus on abstinence-based “treatment” that will keep you beholden for life. A system that labels you as someone with a disease (brain or otherwise), incapable of autonomous choice, trapped in a pay-per-hour system.
Prisoners become patients-become-prisoners. “The myth of treatment: Pathologization in the pursuit of profits” is the working title of an upcoming book I am co-authoring.
I have written about the way harm reduction has been high-jacked by the set of “comprehensive” harm reduction interventions described by the WHO et al: https://shaunshelly.medium.com/has-harm-reduction-lost-its-soul-bf5ef200e068
The last thing I am is a neo-liberal free-market capitalist or Libertarian. I believe in decriminalisation of all drug possession. I believe that legal regulation has a lot of potential problems and needs to be carefully tested in each context. I also believe that any model of legal regulation must include the current sellers of drugs. The drug economy plays a critical role in many communities, and without it, they will suffer even more. Further, poor regulation will mean that poorer communities will be vulnerable to exploitation and harsher penalties while the rich get high with impunity – A Brave New World as described by Huxley will be the reality.
Hello Percy
You write: ‘Our harm reduction advocates will be very interested in the various tiers of harm reduction practiced in South Africa, especially abstinence’. Please explain?
The problem is the “treatment field” is told to look at causes of addiction through the binoculars of society. And it’s a very narrow view of the addiction problem. Society doesn’t want us to question this view… it’s much easier to label “good and bad” than really look at the truth of society and have to say oh shit this is complex. And we find ways to protect the binoculars, even feel safe with them on our neck. Even tell ourselves it’s a play with words and semantics to stay with society’s view. Humans don’t like uncertainty. They like binoculars.
And to add to that, we have the binoculars the wrong way round! The view is myopic. If we stepped back, we would see the big picture, and as Marc and I have discussed many times, we would see fractals. The repetitive pattern repeating on different scales.
Why if confrontation and punishment on an individual level fail, do we try it at a community and systemic level?
We love dichotomies and nosology – everything must have a place and a label. I believe we find balance by embracing all points of the scale completely. Then we can find a place of equilibrium that doesn’t elevate one reality or suppress another. But this is uncomfortable because things change, and we need to hold apparent contradictions and shift positions, as new facts emerge, to maintain a balance.
Yes you are right we have the binoculars the wrong way!!! Thanks for your insight. It’s so refreshing!
Shaun, thank you for this work. I think it is wonderful and I agree with you, completely. And of course I can understand the resistance to this discussion, especially by those who have had to face the heartbreak that does legitimately come from a loved one’s addiction problems. But if we can’t discuss the nuance, we can’t hone the problem down to a workable solution. If we keep using broad strokes to “fight” addiction–strokes that were largely informed by archaic drug laws, so many will miss out on finding healing. At either the personal or collective level, addiction needs to be healed, not fought.
Thanks, I appreciate your comment.
Hi, I’m just tacking this on here, journalist Michael Moss on the science of making people addicted to processed food: https://www.nytimes.com/2013/02/24/magazine/the-extraordinary-science-of-junk-food.html
Hi Karen. There’s lots of action on this stuff in the business world. But most of it seems to be motivated by profit-based strategies to get people addicted to products. I was recently asked to join a board to lend a neuroscience perspective to an addiction-for-profit advisory group. It gives me the creeps!
People try to commodify every other human activity. Commodification of addiction treatment has been a thing for a while now… Maybe they’re trying to reverse engineer the commodification of addiction? jk