The NS Essay - Good drugs, bad drugs

Joshua Wolf Shenk on the fractured logic behind America's war on narcotics

To suffer and long for relief is a central experience of humanity. But the absence of pain or discomfort or what Pablo Neruda called "the infinite ache" is never enough. Relief is bound up with satisfaction, pleasure, happiness - the pursuit of which is declared a right in the manifesto of our republic. I sit here with two agents of that pursuit: on my right a bottle from a pharmacy; on my left a bag of plant matter bought last night, for about the same sum, in a New York bar from a group of men who would have sold me different kinds of contraband if they hadn't sniffed cop in my curiosity and eagerness. This being Rudy Giuliani's New York, I had feared they were undercover.

Fear and suspicion, secrecy and shame, the yearning for pleasure, and the wish to avoid men in blue uniforms. The drug wars - which, having spanned more than eight decades, require the plural - are palpable in New York City. In Washington Square Park Giuliani erected ten video cameras that sweep the environs 24 hours a day.

Several times a month I walk through that park to the pharmacy, where a doctor's slip is my passport to another world. Here, altering the mind and body with powders and plants is not only legal but even patriotic. Among the souls wandering these aisles, I feel I have kin. But I am equally at home, and equally ill at ease, among the outlaws. I cross back and forth with wide eyes. What I see is this. From 1970 to 1998 the inflation-adjusted revenue of major pharmaceutical companies more than quadrupled to $81 billion, 24 per cent of that from drugs that affect the central nervous system and sense organs. Sales of herbal medicines now exceed $4 billion a year. Meanwhile the war on other drugs escalated dramatically. Since 1970 the US federal anti-drug budget has risen 3,700 per cent and now exceeds $17 billion. More than 1.5 million people are arrested on drug charges each year, and 400,000 are now in prison. These numbers are just a window on to an obvious truth: we take more drugs and reward those who supply them; we punish more people for taking drugs and especially punish those who supply them.

The drug wars and the drug boom are interrelated, of the same body. The hostility and veneration, the punishment and profits, come from the same beliefs and the same mistakes.

To the more sober-minded among us, it is a source of much consternation that drugs, alcohol and cigarettes are so central to our collective social life. It is hard to think of a single social ritual that does not revolve around some consciousness-altering substance. ("Should we get together for coffee or drinks?") But drugs are much more than a social lubricant - they are the centrepiece of many individual lives. When it comes to alcohol, cigarettes or any illicit substance, this is seen as a problem. With pharmaceuticals it is usually considered healthy. Yet the dynamic is often the same.

It begins with a drug that satisfies a particular need or desire - maybe known to us, maybe not. So we have drinks or a smoke or swallow a few pills. And we get something from this, a whole lot or maybe just a bit. But we often don't realise that the feeling is inside, perhaps something that with effort could be experienced without the drugs or, perhaps, as in the psychiatric equivalent of diabetes, something that we will always need help with. Yet all too often we project upon the drug a power that resides elsewhere. Many believe this to be a failure of character. If so, it is a failure in which the whole culture is implicated. A recent example came with the phrase "pure theatrical Viagra", widely used to describe a Broadway production starring Nicole Kidman. Notice what's happening: sildenafil citrate is a substance that increases blood circulation and has the side effect of producing erections in men. As a medicine, it is intended to be used as an adjunct to sexual stimulation. As received by our culture, though, the drug becomes the desired effect, the "real thing" to which a naked woman on stage is compared.

Not long after his second inauguration, President Clinton signed a bill earmarking $195 million for an anti-drug ad campaign - the first instalment of a $1 billion pledge. The ads, which began running last summer, all end with the words "Partnership for a Drug Free America". The driving force behind the Partnership is a man named James Burke - and he is a peculiar spokesman for a drug-free philosophy. Burke is the former CEO of Johnson & Johnson, makers of various over-the-counter and prescription medications. The philanthropic arms of other pharmaceutical companies, such as Merck, Bristol-Myers Squibb and Hoffman-La Roche, have also made sizeable donations.

I resist the urge to use the word "hypocrisy", from the Greek hypokrisis, meaning the acting of a part on stage. I don't believe James Burke is acting. Rather, he embodies a contradiction so common that few people even notice it - the idea that altering the body and mind is morally wrong when done with some substances and salutary when done with others. The Partnership's formula is to present a problem - urban violence, date rape, juvenile delinquency - and lay it at the feet of drugs. "Marijuana," says a remorseful-looking kid, "cost me a lot of things. I used to be a straight-A student, you know. I was liked by all the neighbours. Never really caused any trouble. I was always a good kid growing up. Before I knew it I was getting thrown out of my house."

This kid looks about 17. The Partnership couldn't tell me his real name or anything about him except that he was interviewed through a New York drug-treatment facility.

In the 19th century now-illegal substances were commonly used in medicine, tonics and consumer products. A new era began with the federal Pure Food and Drug Act of 1906, which required the listing of ingredients in medical products. Then the 1914 Harrison Narcotic Act, ostensibly a tax measure, asserted legal control over distributors and users of opium and cocaine.

On the surface this may seem progressive, the story of a still-young nation establishing commercial and medical standards. And there was genuine uneasiness about drugs that were intoxicating or that produced dependence; with the disclosure required by the 1906 act, sales of patent medicines containing opium dropped by a third. But the movement for prohibition drew much of its power from a far less savoury motive. "Cocaine," warned Theodore Roosevelt's drug adviser, "is often a direct incentive to the crime of rape by the Negroes." As David Musto reports in The American Disease, the prohibitions of the early part of the century were all, in part, a reaction to inflamed fears of foreigners or minority groups. Opium was associated with the Chinese. In 1937 the Marijuana Tax Act targeted Mexican immigrants. "I wish I could show you what a small marijuana cigarette can do to one of our degenerate Spanish-speaking residents," a Colorado newspaper editor wrote to federal officials in 1936. Even the prohibition of alcohol was underlined by fears of immigrants and exaggerations of the effects of drinking. On the eve of its ban in 1919 a radio preacher told his audience: "The reign of tears is over. The slums will soon be a memory. We will turn our prisons into factories, our jails into storehouses and corncribs. Men will walk upright now, women will smile and the children will laugh."

But the federal authorities, temperance advocates and bigots had reached too far. Whereas alcohol (like coffee and tobacco) has been a demon drug in other cultures, in western societies its use in medicine, recreation and religious ceremonies stretches back thousands of years. Most Americans had personal experience with drink and could measure the benefits of Prohibition against the violence (by gangsters and by Prohibition agents, who, according to one estimate, killed 1,000 Americans between 1920 and 1930) and the deaths by "overdose". After Franklin Roosevelt lifted Prohibition, subsequent generations knew that the drug, though often abused and often implicated in crimes, violence and accidents, differs in its effects depending on the person using it. With outlawed drugs no such reality check is available. People who use illegal drugs without great harm generally stay quiet.

The editors of The New England Journal of Medicine, the American Bar Association, the Institute of Medicine of the National Academy of Sciences and the majority of voters in California and six other states are among those who believe that the uses of marijuana are legitimate. So does the eminent geologist Stephen Jay Gould. He developed abdominal cancer in the 1980s and suffered such intense nausea from intravenous chemotherapy that he came to dread it with an "almost perverse intensity". "The treatment," he remembers, "seem[ed] worse than the disease itself." Gould was reluctant to smoke marijuana, which, as thousands of cancer patients have found, is a powerful anti-emetic. When he did he found it "the greatest boost I received in all my years of treatment". He went on: "It is beyond my comprehension . . . that any humane person would withhold such a beneficial substance from people in such great need simply because others use it for different purposes."

This distinction between "people in great need" and those with "different purposes" is crucial to the argument for the medical use of marijuana. In common with Gould, many who use marijuana for medical reasons dislike the "high". Many others don't even feel it. But it is a mistake to think that the reason these people can't legally use marijuana is simply that other people use it for purposes other than traditional medical need - because the very idea of "medical need" is constantly shifting beneath our feet.

I do not have cancer or epilepsy or a disabling mental disorder such as schizophrenia. The "other purposes" Gould refers to are, in many ways, mine. The qualities of my suffering are (to simplify) anxiety, numbness and anhedonia. If these were relieved by a legal drug - in other words, if a pharmaceutical helped me relax, feel more alive, have fun - I would be firmly in the mainstream of American medicine. This is my strong preference. Meanwhile I turn sometimes to marijuana and other illicit substances for the (limited) relief they offer. I don't merely feel justified in doing so; I feel entitled, particularly in that the pharmaceutical industry rolls out new products every year for pleasure, vanity, convenience.

When Viagra emerged it was not frowned upon by the authorities that lead the drug wars. Instead President Clinton ordered Medicaid to cover the drug, and the Pentagon budgeted $50 million for 1999 to supply it to soldiers, veterans and civilian employees. Viagra's legitimacy was never questioned because it treats a disease - erectile dysfunction. Before Viagra, when the only treatment options were less-effective pills and awkward injection-based therapies, this condition was referred to as impotence. The change in language is interesting. The "dys" sits on the front of dysfunction like a streak of dirt on a pane of glass. At a level more primal than cognitive we want it removed. This is what we do with dysfunctions: we fix them. Thus the advent of Viagra does not simply treat a disease. It changes our conception of disease. Hair loss becomes a disease, not a fact of life. Acid indigestion becomes a disease, not a matter of eating poorly.

Prozac is typical of a new generation of drugs being used to treat debilitating conditions and also by people with far less serious problems. In Lauren Slater, author of the fine memoir Prozac Diary, we have a case anyone would regard as serious. Suffering from obsessive-compulsive disorder, severe depression and anorexia, she had been hospitalised five times, attempted suicide twice and cut herself with razors. Prescribed Prozac in 1988, she found the drug a reprieve from a lifetime sentence of serious illness - "a blessing, pure and simple", as she wrote. The patients described in Peter Kramer's Listening to Prozac are quite unlike Lauren Slater. They share, he writes, "something very much like 'neurosis', psychoanalysis's umbrella term for the mildly disturbed, the near-normal, and those with very little wrong at all". The use of Prozac for these patients is not incidental; they make up a large portion, probably a wide majority, of those on the drug.

Throughout his book Kramer flirts with "unsettling" comparisons between Prozac and illegal drugs. Since Prozac can "lend social ease, command, even brilliance", for example, he wonders how its use for this purpose can "be distinguished from, say, the street use of amphetamine as a way of overcoming inhibitions and inspiring zest". The better comparison, I suggested in a conversation with Kramer, is between Prozac and Ecstasy. Both drugs work by increasing the presence of serotonin in the brain. Both can be helpful to the seriously ill as well as to people with more common problems. Most of the objections to Ecstasy - that it distorts "real" personality, that it rids people of anxiety that may be personally or socially useful, that it induces more pleasure than is natural - have also been marshalled against Prozac. Both of these drugs challenge our definition of normality and of the legitimate uses of a mind-altering substance. Yet Kramer rejects the comparison. "The distinction we make," he told me, "is between drugs that give pleasure directly and the drugs that give people the ability to function in society, which can indirectly lead to pleasure. If the medication can make you work well or parent well, and then through your work or parenting you get pleasure, that's fine. But if the drug gives you pleasure by taking it directly, that's not a legitimate use."

In the Odyssey, when three of his crew are lured by the lotus-eaters and "lost all desire to send a message back, much less return", Odysseus responds decisively. "I brought them back . . . dragged them under the rowing benches, lashed them fast." "Already," writes David Lenson in On Drugs, "the high is unspeakable, and already the official response is arrest and restraint." The pattern is set: since people lose their freedom from drugs, we take their freedom to keep them from drugs. Odysseus's frantic response, though, seems more than just a practical measure. Perhaps he fears his own desire to retire amid the lotus-eaters. Perhaps he fears what underlies that desire. If we even feel the lure of drugs, we acknowledge that we are not satisfied by what is good and productive and healthy. And that is a frightening thought. "The war on drugs has been with us," writes Lenson, "for as long as we have despised the part of ourselves that wants to get high."

This article first appeared in "Harper's"