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High Society: How Substance Abuse Ravages America and What to Do About It, by Joseph A. Califano Jr., New York: Public Affairs, 270 pages, $26.95 The Cult of Pharmacology: How America Became the World's Most Troubled Drug Culture, by Richard DeGrandpre, Durham, N.C.: Duke University Press, 294 pages, $24.95 On the opening page of High Society, which aims to explain "how substance abuse ravages America," Joseph Califano declares that "chemistry is chasing Christianity as the nation's largest religion." Although it is not always easy to decipher Califano's meaning in this overwrought, carelessly written, weakly documented, self-contradictory, and deeply misleading anti-drug screed, here he seems to be saying that opiates are the religion of the masses. Americans, he implies, are seeking from psychoactive substances the solace they used to obtain from faith in God, and better living through chemistry is nearly as popular as better living through Christ. That claim, like many Califano makes, is unverifiable, and it does not seem very plausible. Americans may be less religious than they used to be, but large majorities still say they believe in God and identify with specific faiths, making the U.S. much more religious than other Western countries, which tend to have substantially lower drug use rates. Although Americans have a bewildering array of psychiatric medications to choose from nowadays (with permission from a doctor), they smoke a lot less than they did in the 1960s and drink less than they did a century ago, when they also could freely purchase patent medicines containing opium, cocaine, and cannabis. If the devout are less inclined than the doubters to use mood-altering drugs, how is it that mostly Mormon Utah leads the country in antidepressant prescriptions? And if chemistry and Christianity are locked in competition, what are we to make of Jesus' water-into-wine miracle, or of the Native American Church, Uniao do Vegetal, and other groups that combine Christianity with psychedelic sacraments? Already I have put more thought into the alleged connection between faithlessness and drug use than Califano did. And so it is with the rest of the book. A proper debunking would require more than the 186 pages of text that Califano, a domestic policy adviser to Lyndon Johnson and secretary of health, education, and welfare in the Carter administration, squeezes out of conversations with politicians and old reports from the Center on Addiction and Substance Abuse (CASA), the prohibitionist propaganda mill he founded and heads. Although CASA brags about its affiliation with Columbia University, the school has less cause to be proud of that relationship, given the center's sloppy research and hyperbolic rhetoric. In a 2002 report that attracted wide publicity, CASA issued "a clarion call for national mobilization" against "America's underage drinking epidemic," claiming that "Children Drink 25 Percent of Alcohol Consumed in the U.S." Not only did these "children" include 18-to-20-year-olds (a.k.a. "adults"), but it turned out CASA's estimate was off by a factor of more than two. Yet Califano is worth taking seriously. He is a leading exemplar of the moralistic pseudoscience that Richard DeGrandpre dissects in The Cult of Pharmacology, an insightful, historically informed critique of the ideas that guide the war on drugs. DeGrandpre, an independent scholar with a Ph.D. in psychopharmacology and a former fellow at the National Institute on Drug Abuse, decries "the modern mythologizing of drugs as angels and demons" that underlies our "bewildering and often brutal differential system of prohibition." Califano, by contrast, is committed to defending the arbitrary distinctions built into our drug laws. Califano, who since his time in the Carter administration has railed against cigarettes with all the zeal you'd expect from a former three-pack-a-day smoker, is perceptive enough to recognize that legal drugs are not necessarily angels. When he talks about the promiscuous use of stimulants to control inattentive, unruly schoolchildren or the routine prescription of mood-altering drugs to smooth "the changing moods that mark human nature," he sounds a bit like DeGrandpre, who wrote a book called Ritalin Nation and is unsparing in his criticism of the psychiatric profession and the pharmaceutical industry. What Califano fails to understand is that every drug, regardless of its current legal status, is potentially an angel or a demon. DeGrandpre builds upon the insights of the alternative medicine guru Andrew Weil, who first made his name with books about drugs and altered states of consciousness. "Any drug can be used successfully, no matter how bad its reputation, and any drug can be abused, no matter how accepted it is," Weil wrote in his 1983 book From Chocolate to Morphine (co-authored by Winifred Rosen). "There are no good or bad drugs; there are only good and bad relationships with drugs." While Califano acknowledges the importance of context in determining what constitutes abuse of alcohol and prescription drugs, he insists that any use of currently illegal drugs is abuse by definition. "Drugs are not dangerous because they are illegal," he says. "They are illegal because they are dangerous." This line, popular among drug warriors, misconstrues an argument against prohibition. The point is not that prohibition causes all the hazards associated with drug use but that it compounds those hazards by exposing users to the unreliable quality, unpredictable doses, and violence of the black market (not to mention the risk of arrest). Leaving aside the question of how prohibition makes matters worse, it is untenable to argue that illegal drugs are uniquely dangerous, since every potential problem they pose is also posed by alcohol, a substance that Califano says he does not want to ban. The argument that drugs "are illegal because they are dangerous" is especially hard to make with respect to marijuana, which is by far the most popular illegal intoxicant, one that half of American adults born after World War II have tried. The worst risk that marijuana smokers face is getting arrested, a fact Califano tries to obscure through the time-honored prohibitionist tactics of focusing on children, conflating correlation with causation, and obscuring the distinction between short-term and long-term effects. In the 1980s, Califano says, "we seemed to discover" (an odd but appropriate way of putting it) "that marijuana might not be as benign as kids and permissive parents thought." How could smoking pot be no big deal in the '60s and '70s, when the baby boomers were in high school and college, then suddenly become a big deal in the '80s and '90s, when their children were? Might this shift reflect the natural tendency of parents to be alarmed by their children's rebellious behavior, even when it's no worse than what they themselves did without regret as teenagers? Of course not. Califano wants parents to know there's a firm scientific basis for their hypocrisy. "Today's teens' pot is not their parents' pot," he explains. "It is far more potent....The average levels of THC jumped from less than 1 percent in the mid-1970s to more than 7 percent in 2005." Since the potency threshold for distinguishing cannabis from a placebo in experiments is roughly 1 percent, Califano is in effect asserting that people who smoked pot in the '60s and '70s generally did not get high as a result. If so, it's hard to fathom how "pot was becoming the hottest high on college campuses" by the end of the '60s, as Califano reports elsewhere in the book. In fact, as sociologist Lynn Zimmer and pharmacologist John P. Morgan show in their 1997 book Marijuana Myths, Marijuana Facts, claims that Mom and Dad's pot was indistinguishable from ditchweed are based on low-quality, nonrepresentative samples that probably lost their THC content while in storage. Even if average THC content has not risen seven-fold (or 30-fold, as drug czar John Walters claimed in 2002), it no doubt has increased significantly as marijuana growers, especially indoor growers in the U.S., have learned to produce a better product. The average THC concentration of seized cannabis tested by the University of Mississippi's Potency Monitoring Project (which relies on "convenience" samples that are not necessarily representative of the national supply) more than doubled between 1983 and 2006, from a bit under 4 percent to 8.5 percent. But the stronger pot is, the less people tend to smoke. Since the possible respiratory effects of smoking are the most serious health risk associated with marijuana, higher THC content makes marijuana less dangerous, not more so. But "today's marijuana is addictive," Califano says, warning that "10 percent of those who try it will get hooked at some point in their lives." Even taking that number at face value, it is about one-third lower than the lifetime addiction rate for alcohol, based on data from the National Comorbidity Survey. Implicitly conceding that cannabis itself is not very dangerous, Califano makes much of marijuana's status as a "gateway drug," a substance that people tend to try before they use other illegal intoxicants. According to a CASA analysis of survey data from the early 1990s, he reports, "twelve-to seventeen-year-old children who used marijuana were eighty-five times more likely...to use cocaine." That impressive-sounding "risk ratio" reflects the fact that people very rarely use cocaine without trying marijuana first. Although he repeatedly cites such numbers as a reason to prevent people from trying marijuana, Califano concedes that "gateway statistical relationships do not necessarily establish causality," and he quotes the Institute of Medicine's take on the issue, which does not suggest that marijuana pharmacologically causes people to seek "harder" drugs: "People who enjoy the effects of marijuana are, logically, more likely to be willing to try other mood-altering drugs than are people who are not willing to try marijuana or who dislike its effects. In other words, many of the factors associated with a willingness to use marijuana are, presumably, the same as those associated with a willingness to use other drugs." Perhaps sensing that the gateway argument is not generating enough alarm, Califano warns that marijuana "adversely affects short-term memory, the ability to concentrate, emotional development, and motor skills." By throwing in "emotional development," he falsely implies that the memory, concentration, and motor skill impairments, which are short-term effects of intoxication, are permanent disabilities caused by smoking one joint too many. Speaking of old prohibitionist tricks, Califano is not above scare tactics reminiscent of the "reefer madness" claims that Federal Bureau of Narcotics Director Harry J. Anslinger promoted in the 1930s. "Recent studies indicate that marijuana use increases the likelihood of depression, schizophrenia, and other serious mental health problems," Califano writes. These studies do not show that smoking pot makes you crazy; they show that people who smoke pot, especially if they do so at early ages and in large amounts, are more likely to have "serious mental health problems." In other words, these studies find associations, which, as Califano notes vis-a-vis the data on gateway drugs, "do not necessarily establish causality." It could be that people with psychological problems are especially attracted to marijuana because it makes them feel better, or because they tend to act out or take risks; early use of marijuana could be a marker for psychological problems rather than a cause of them. Having failed to explain why people should be arrested for producing, selling, and possessing marijuana when they are free to produce, sell, and possess alcoholic beverages, Califano goes on to note that all those arrests (about 830,000 in 2006 alone) don't seem to have accomplished much. "From 1993 to 2005," he writes, "a 107 percent increase in marijuana arrests was accompanied by a 100 percent increase in marijuana users." Califano concludes that "something more is needed": harsher penalties, mandatory anti-drug classes, and forced "treatment" for pot smokers. More generally, although he claims to be recommending a "dramatic shift," even a "revolution," in drug policy, Califano actually wants to maintain the status quo, except with more drug treatment and better anti-drug classes. (He correctly notes that DARE, the most popular such program in American schools, "has been repeatedly found worthless.") Califano wants to force "treatment" on people who use politically incorrect intoxicants even though he concedes "there have been few independent systematic evaluations of substance abuse treatment effectiveness." The techniques that have not been proven effective through rigorous independent evaluations include the religiously oriented 12-step programs that Califano nevertheless wants to compel drug users to attend. While Califano seems to favor mandatory treatment rather than jail for drug users, he says people "who dealt drugs but didn't use them belong in prison -- and for a long time." Contrary to conventional wisdom in the drug business, then, it may be a good idea to sample your own product, so you can benefit from Califano's curiously compartmentalized compassion. Lest you think that Califano, a big-spending liberal Democrat, favors unproven demand-side measures at the expense of futile supply-side measures, he can also sound like the most clueless get-tough Republican, confident that we can seal our borders against the flow of drugs Americans want if only we put our minds to it. "We must mount a far more effective effort to block entry of illegal drugs into the United States and to eliminate production within the country," he writes. "This under-taking demands the kind of attention we have committed to keeping chemical, biological, and nuclear weapons out of our nation. Marijuana, cocaine, heroin, Ecstasy, and other illegal drugs have demonstrated a far deadlier capability for mass destruction." Califano, who worries that "sensational media coverage" causes "popular concerns and parental fears about substance abuse" to "ricochet from drug to drug," does not exactly strive for a restrained tone himself. Blaming cocaine for inciting "paranoia and violence," he says the smokable version "flooded inner-city neighborhoods and kicked off a harrowing crack-related crime tsunami." To support this claim, he cites page 245 of Paul Gahlinger's Illegal Drugs: A Complete Guide to Their History, Chemistry, Use, and Abuse. But Gahlinger says nothing about a "harrowing crack-related crime tsunami." As DeGrandpre notes in The Cult of Pharmacology, Califano's image of crack-crazed criminals was debunked more than a decade ago by the U.S. Sentencing Commission. "The media and public fears of a direct causal relation between crack and other crimes do not seem to be confirmed by empirical data," the commission said in 1995. "Studies report that neither powder nor crack cocaine excite users to commit criminal acts and that the stereotype of a drug-crazed addict committing heinous crimes is not true for either form of cocaine." So-called crack-related violence was in fact prohibition-related violence, arising from conflicts among black-market participants. Other Califano claims are absurd on their face. In his lexicon, if a single teenager reports seeing a fellow student buy, use, or possess alcohol or other drugs at his school, that is enough to render the school "drug-infested." In a 1999 report CASA said "teens who smoke marijuana are playing a dangerous game of Russian roulette," an activity in which there is a one-in-six chance of instant death on each turn. Three years later it likened underage drinking to "a deadly round of Russian roulette." In High Society, Califano trots out the metaphor for another purpose. "Russian roulette is not a game anyone should play," he informs readers, just in case they were considering it as an alternative to checkers. "Legalizing drugs not only is playing Russian roulette with children; it is also slipping a couple of extra bullets into the chamber." Meaning that if drug prohibition were repealed, half of America's children would die? Califano is on even shakier ground when he suggests that the classical liberal philosopher John Stuart Mill would have approved of drug prohibition, since "Mill's conception of freedom does not extend to the right of individuals to enslave themselves," and "drug addiction is a form of enslavement." We can be pretty sure Mill would not have endorsed drug prohibition on this ground, since he didn't. In fact, he vigorously opposed alcohol prohibition as a clear violation of individual liberty. But maybe Mill was wrong. Could drug addiction really be a form of slavery? According to Califano, it's actually a "chronic, relapsing disease" similar to "diabetes or high blood pressure." Which is not to say that it's strictly a biochemical phenomenon. Addiction research, Califano says, "is also psychological, emotional, and spiritual research, since this complex disease has elements of dysfunction in all these areas." Califano's fondness for Alcoholics Anonymous and likeminded groups makes sense, since he, like them, views drug abuse as a medical problem with a spiritual solution. Does it matter that Califano chooses to call drug abuse a disease? I think it does, since a disease is something that happens to people, not something that they do. It follows that the choices made by people whom others identify as addicts need not be respected, since they are not really choices at all. DeGrandpre quotes Alan Leshner, a former director of the National Institute on Drug Abuse, who declares "Addiction is not a voluntary circumstance. It's not a voluntary behavior. It's more than just a lot of drug use. It's actually a different state...a state of compulsive, uncontrolled drug use." DeGrandpre doesn't buy it. "The vast literature on careers in drug use flatly contradicts this perspective," he writes in The Cult of Pharmacology. He summarizes that literature, showing that addicts commonly drift into and out of heavy use, stop or moderate their consumption on their own, and "mature out" of supposedly permanent addictions. Even the animal experiments prohibitionists cite to demonstrate the irresistible power of certain chemicals, DeGrandpre notes, actually show that drug use is "sensitive to the context in which it occurs." When lab animals are kept in stimulating environments along with other animals, they are much less inclined to consume drugs than when they are isolated in boring environments and hooked up to a catheter. Human drug use shows even more variation. A patient in pain or a soldier at war can use a strong narcotic for particular reasons and give it up without much trouble once those reasons no longer apply. A happy person can take or leave the same drug that a miserable person turns to every day. A person who uses a drug to excess during an especially troubled period may find that he can use it in moderation after his situation improves. Given these differences, it makes little sense to talk about a drug's "addictiveness" as if it were a chemical property. "Used for different reasons, taken in different forms, and at different doses, the same drug can serve dramatically different ends," DeGrandpre observes. "Drugs, their users, and the context of use all come together to produce drug outcomes." Since expectations affect the drug user's experience, DeGrandpre provocatively but plausibly argues, the belief that a substance is powerfully addictive can become a self-fulfilling prophecy. "The massive use of opiates in the nineteenth century did not translate into widespread dependence and addiction," he notes, but that was before opiates, especially heroin, acquired a reputation as irresistible and inescapable. He suggests this "placebo script," together with prohibition and the concomitant shift in the user population from middle-class women to young men at the margins of society, made opiates look more addictive. Likewise, says DeGrandpre, exaggerating the power of nicotine (as Califano routinely does) "teaches [smokers] that it is impossible to quit." DeGrandpre persuasively debunks "the two core ideas of the disease model: that use leads inevitably to addiction and that addiction, without 'treatment,' guarantees lifelong use." But those two ideas can be separated, as illustrated by the history of thinking about alcohol abuse. As the sociologist Harry G. Levine noted in a 1978 Journal of Studies on Alcohol article, "the idea that drugs are inherently addicting was first systematically worked out for alcohol and then extended to other substances. Long before opium was popularly accepted as addicting, alcohol was so regarded." This was the idea that drove the temperance movement's transition from moderation enforced by self-discipline to abstinence enforced by law: If alcohol was inherently addicting, voluntary temperance was a dangerous illusion. After the repeal of Prohibition, the view of alcoholism as a disease caused by alcohol gave way to a view of alcoholism as a condition that makes it impossible for certain susceptible individuals to drink moderately. Whatever its scientific weaknesses, this A.A.-promoted version of the disease model does not demand abstinence from all and is therefore much more compatible with a legal market in alcoholic beverages than the earlier versions. Califano seems to accept the A.A. model of alcoholism, which concedes that most people are capable of drinking moderately. While "Just Say No" is the message children should receive with regard to illegal drugs, he says, "The message for alcohol use is more complex: No for children and teens, moderation for adults." He never explains why "moderation for adults" is not a valid approach to, say, marijuana. The belief that certain drugs are irredeemably evil and that the current version of the Controlled Substances Act has inerrantly identified them betrays a lack of historical understanding. Heroin originally was sold as a substitute for codeine and a cure for "morphinism." Cocaine was touted by Sigmund Freud as a nonaddictive all-purpose tonic. After these drugs were demonized, DeGrandpre notes, psychoactive pharmaceuticals such as meprobramate (Miltown), amphetamines (Benzedrine, Dexedrine, Methedrine), barbiturates (Ambutal, Nembutal, Seconal), methaqualone (Quaalude), and the benzodiazepines (Librium, Valium, Xanax, Ativan, Halcion) followed "the same cycle of medical hype, vast nonmedical use, and new and 'unexpected' problems of dependency." DeGrandpre argues that SSRI antidepressants such as Prozac are undergoing a similar re-examination. The government's own legal distinctions belie the idea that drugs can be neatly separated into good and bad categories. "Even methamphetamine, [which] drug czar Barry McCaffrey called 'the worst drug to ever hit America,' was dispensed to children by prescription until the end of the century," DeGrandpre notes. Children diagnosed with attention deficit disorder (ADD) continue to receive Ritalin, a drug whose pharmacological action is very similar to cocaine's, as teenagers who crush and snort their friends' prescription pills have discovered. "If Ritalin could legally be given to millions of American children despite the fact that its effects were indistinguishable from cocaine['s] when taken in comparable doses and via the same route of drug administration, then popular and scientific beliefs concerning these two drugs in the twentieth century were nonsensical," DeGrandpre writes. "Either cocaine is not the inherent demon drug it was made out to be, or Ritalin is incorrigibly evil and corrupting." The story of pharmaceutical fashions that DeGrandpre tells highlights a fact that the psychiatric iconoclast Thomas Szasz has long emphasized: Drug prohibition is built on a foundation of mandatory prescriptions. Although Califano seems to believe Ritalin is overprescribed, he presumably would say that giving it to a child based on a valid ADD diagnosis is a legitimate use, while snorting it for fun is not. Likewise, amphetamines can legally be used with a doctor's prescription to treat obesity, relieve depression, and keep narcoleptics and military pilots awake. But in the government's view (and therefore in Califano's view), if people use amphetamines on their own for essentially the same purposes -- to lose weight, boost their moods, or stay alert -- they are guilty of drug abuse (although I guess that was not true until 1954, when prescriptions were first required for amphetamines). In such cases, the difference between use and abuse lies not in the drug's chemical structure or even in the user's goal. What matters is the spell scrawled by a government-appointed medicine man who can transform demons into angels with the stroke of a pen. Reason Senior Editor Jacob Sullum is the author of Saying Yes: In Defense of Drug Use (Tarcher/Penguin). |
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