January 22, 2007

Opiates of Choice

"When I ask heroin addicts why they started taking heroin, most of them reply with one of two answers. These are: "I fell in with the wrong crowd" and "heroin's everywhere".

"When I reply that it is odd how I meet many people who fell in with the wrong crowd, but I never under any circumstances meet any member of the wrong crowd itself, who must therefore be lurking permanently out of my sight and hearing, the addict who has attributed his addiction to his fortuitous acquaintance with the wrong crowd smiles, or even laughs, knowingly.”

[We might also add: heroin is not “everywhere”; as with any drug, whether licit of illicit, you have to devote some time and make some effort to “find” it. Even migraine tablets require a trip to the chemist.]

And further on:

"In other words, the whole apparatus of care, doctors, nurses, psychologists, social workers, counsellors, serves not to alleviate suffering but to create and exacerbate it. (I cannot resist quoting a law first enunciated by Colin Brewer about modern society: "Suffering increases to meet the means available for its alleviation.")

From The Australian - Edited extract from Romancing Opiates: Pharmacological Lies and the Addiction Bureaucracy, by Theodore Dalrymple. Dalrymple has worked as a prison doctor and as a psychiatrist in a general hospital in a British slum.

(Yes, yes, I know I covered this back in June 06 - see, this is how long it takes for O/S books to finally be released on our shores – Breaking the spell – Poppycock.)

Elsewhere in the same newspaper (can’t link it), some quotes were obtained to vigorously refute Dalrymple’s insights:

From Luke Davies, prize-winning author of Candy:

“I make the point in Candy that the physical stuff is kind of horrendous [though he admits that the physical side does take less time to recover from than the flu] - but it doesn’t even touch the sides of the spiritual despair, which is the driving force that keeps the addiction going – the horror at the pointlessness of existence.”

Oh dear. Where does one go with such self-justifying drivel? If we follow this to its logical conclusion, then we should all be daily and frequent heroin users. Alternatively, we would have to believe that only society’s most sensitive, angst ridden souls become addicts. [Insert vigorous derisive *snort*] Is the pointlessness of existence a greater horror than any number of actual horrors we could list? Nuh, I don’t think so. Besides, real spiritual despair leads to many things, many horrors in and of itself, but a clear beaten path to drug addiction is not, invariably, inevitably, or compulsorarily, one of them.

Drug treatment expert, Richard Mattick, offered his condemnation, saying that heroin addiction:

“kills hundreds of people in Australia each year” and that Dalrymple’s comments were “unhelpful because they send the message to ordinary people that opiate dependence isn’t a serious problem.”

No, that’s not what Dalrymple is arguing at all. He’s arguing that giving up the dependence isn’t a serious, or even medical, problem. He’s arguing that giving up opiates is easier than recovering from the flu, which is a real medical condition. He’s arguing that those deaths are, in fact, 100% avoidable. Although that last point has always been a tad self evident.

Dalrymple, says of the supporting industry for opiate users, and their gratitude for such:

“Any aid to the perpetuation of the state of daydreaming is … greatly appreciated.”

The extract is an interesting read, as I imagine would be the entire book. If nothing else, an alternative view will shake up the tired old mantras, maxims and aphorisms, for at least five minutes, before all will return to routine.

20 comments:

  1. As far as I can tell, Caz, Dalrymple's controversial views haven't really attracted all that much attention or debate anywhere yet, which is pretty remarkable given some of the evidence he claims to back up his view. (For example, that most addicted soldiers returning from Viet Nam had no great problem with dropping the habit when they had to.)

    I would like to see those who disagree with him actually engaged in meaningful debate, but it doesn't seem likely to happen.

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  2. Totally agree Steve, hence my after thought at the end ... a five minute *debate*, at best, seems on the cards.

    Let's not forget that this book was released at least 6 mths ago O/S.

    Falling on deaf ears so far, other than a few token articles.

    I think that's unfortunate.

    Wouldn't you think that those with a vested interest - the users and the supporting infrastructure, the politicians, the families, the friends, and so on - all those people who claim to be so worried, so compassionate, and often, so professional, would take an eager interest in new thoughts on this? After all, nothing else works, ever. Wouldn't you think this would at least pique there interest sufficiently to want to examine the implications, with a significant degree of honesty? Even if that might cause some short term pain, short term blows to the ego and unhelpful entrenched thinking.

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  3. As a bit of side issue, I once had an argument with a thoroughly left-wing friend over my suggestion that the movie Pulp Fiction would encourage drug experimentation because the characters who used it were portrayed, perhaps not as the brightest people, but as very cool dudes nonetheless. (I was particularly offended by the romantic glow of the close up of the flame under the spoon during the drug taking scene.) My friend scoffed and thought this was a ridiculous suggestion. They mostly end up dead, after all.

    Fast forward some time, and blow me down but Phillip Adams on Late Night Live said that friends of his who work with addicts and homeless people blamed the movie for a surge in heroin use! It's one of the very few times in my life I have felt vindicated in an argument by Adams.

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  4. Now that’s quite fascinating to me Steve, as I’m very fond of all Tarantino films – I own most of them.

    Thing is: Uma Thurman looked absolute shit for at least half of her storyline. I would have thought anyone with a brain would have found the drug use component of the film salutary and off-putting.

    I’ve seen the film many times and have never felt so much as a minor twitch of inclination to run out and become a heroin user (so that I can be that cool too).

    Strange to me that anyone would be so malleable, susceptible, gullible … or stupid. It’s an ugly and brutal depiction, rather than glamorous.

    So, the question is: did crack use in the US surge thanks to Whitney Houston? Rhetorical, but I promise I'm not being facetious.

    I expect the use of black tar heroin increased in large part thanks to Robert Downey Jr.

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  5. Caz, to people like you and me it is surprising that anyone tries such dangerous drugs, isn't it? It's therefore no argument to say "well of course it didn't influence me." I think you agree on that much anyway.

    I don't care for Tarantino, but I won't argue about that for the moment.

    But with Pulp Fiction, I thought it was pretty clear that the John Travolta and Uma characters were played for a certain dark coolness. Sure, on an intellectual level the danger and risk taking involved were shown, but at an emotional level I could imagine wannbe-cool-even-if-is-dangerous young minds potentially being influenced. In fact, at a certain level the risk might be part of the appeal for some. (Uma does make a remarkable recovery anyway.) It's also pretty clear that risk taking is not taken all that seriously by many people, given that smoking still exists.

    But as I said, my natural enemy Adams is on my side in this one, so I must be right!

    Also, hearing about celebrities who use drugs is never going to be as influential as a fictional film which semi-glamorises it (whether that was the intention of the film or not).

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  6. Another interesting thought, that is, the proposition that glamorised fiction is a greater influence rather than celeb airheads or rocks stars. I expect I’ve always assumed the opposite (rather subconsciously), but have never really given it much thought. I suspect that the gaggle of young female US celebs, whether drunk, drugged, dazzed is a non-fiction example that many young lasses consider worthy of emulation and aspiration.

    Mind and emotion altering substances have been with us since the dawn of time, in every land and every culture and every era. I understand people trying drugs … or some … which is no different to someone trying different alcoholic drinks, or drug hopping with GPs. But picking and choosing what to try, and picking and choosing to pursue or not pursue particular courses of action are indicators to the future, yes? It’s not as though anyone could claim ignorance of what they are getting themselves into. (A bit like all those books that continue to come out: OMG no-one ever told be that giving birth / raising children was this painful / difficult. Huh? WTF?)

    Besides, anyone whose only problem in life is “spiritual angst” or the “horror of the meaningless of existence”, is doing it easy, they don’t need constant doses of the world’s best known pain killer.

    I’ve always found it a most curious thing. Can you imagine the outcry if gov’t introduced free whisky for alcoholics, or a measured daily dose of crack cocaine? So, the difference is ….?

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  7. Well, there is and isn't a difference. The reason why Dalrymple's book hasn't made much of a splash is basically that he only tackles half the argument.

    As someone who has worked in this sector, around policy, I can assure you that most people in said sector recognise that physical addiction is only one component of addiction (I've heard qualified people more than once say that, physically, cigarettes are more addictive than heroin.

    However, Dalrymple completely ignores the _psychological_ component of drug addiction.

    It's not coincidence that most people with addiction problems come from very low socio-economic brackets and have an insanely high incidence of childhood abuse in the backgrounds. In essence, people take drugs because they are unhappy, and drugs make them happy for a short while.

    Dalrymple (I've actually read a few of his pieces now), seems to imply that - because the physical aspects of withdrawal can be overcome - the only thing holding people with drug addiction back is their base nature or something. I refute that wholeheartedly.

    The reason why we have thing like methdone clincs in Australia is because, empirically, they have been proven time and time again to reduce drug use, abuse, and the associated crime and lifestyle problems associated with drug addiction. Zero tolerance, on the other hand, has been demonstrated as one of the _worst_ things you can do to reduce drug dependence.

    The reason why we don't give alcoholics free whiskey is because they can buy it from the store themselves, and that alcohol addiction - though far and away the most damaging and prevalent drug addiction in Australia - is socially far more acceptable than others.

    That said, there are a number of medications that alcholics can be prescribed to help cope with their addiction, so the methadone analogy doesn't really hold up.

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  8. Interesting Patrick, particularly given that the author has worked in prisons and lower socio-economic areas. That’s a core part of his knowledge and expertise on the matter.

    The only committed heroin users I’ve met are the middle-class raised, with no trauma to draw upon, all gainfully employed as university lecturers, hospitality staff or whatever.

    Question: what comes first, the drug abuse, or being in a very low socio-economic bracket? After all, it takes a lot of money to become and remain an addict. An association between two factors does not a causal relationship make.

    Besides, the author doesn’t ignore the psychological effect, at least not by my reading. He’s saying the whole thing is overblown.

    Still, no one can answer the question: why do all people using opiates not become physically & psychologically addicted? Why are opiates an indulged and pampered medical situation, but not cocaine and crystal meth, both of which are far more physically addictive (by my understanding)?

    In Canada, only during the last year or so, the very worst off and very costly – health wise – homeless alcoholics were identified, housed and provided with daily alcohol. The cost has been proven to be far less, and the health of the formerly homeless alcoholics far better, that was previously the case, or could ever have been achieved without the program.

    Surely, surely it’s time we started thinking much more widely and more honestly about these things?

    No medical professional I have ever known (personally) has ever bought into the “poor helpless heroin addict” line,; it’s something over which they sigh heavily, or worse, snort with disdain. They don’t speak out though.

    Given that you have some experience in all of this, you'd know too that methadone is more addictive than heroin, and most of the time is used as a stop-gap until the user has access / money for heroin. It's supplementary.

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  9. Hmmm...

    Most chronic users of heroin ARE socially marginalised and deal with
    issues such as homelessness, mental health issues, abuse and crime. The fact the users you know are middle class doesn't have a bearing on this - they are a definite minority.

    The chicken before egg argument vis socioeconomic levels is kinda pointless I think. For some people, drugs ruin their lives, for many others
    their lives are already in ruin and drugs help them get from day to day.
    There is clear evidence that abuse, social isolation and poverty are
    determinants for drug abuse.

    Regarding methadone, it has been proven to be a hugely successful public health
    initiative, reducing death, crime and assisting people to get their lives
    back together. It's certainly not ideal as an addiction of sorts is maintained,
    but surely the focus should be on reducing harms? (Which, I should add, always has and always will be government policy [harm minimisation], because it works. Tough On Drugs is pure rhetoric)

    There aren't really a lot of other options, and this is why Darymple shits me. Basically the only other option is shut down treatment facilities and let people die? (And they do, sans facilities.)

    The other options is to take the US route and lock them all up, which wastes billions on overcrowded jails where most offenders (predominately black) are incarcerated for non-violent drug offences.

    If there was an effective pharmacotherapy for speed and cocaine, it would definitely be used. But sadly there isn't an equivalent maintenance treatment like methadone for these other drugs. Basically, to oppose methadone means that you also object strongly to nicotine patches, because they operate under the exact same theory as methadone.

    "and most of the time is used as a stop-gap until the user has access / money for heroin. It's supplementary."

    I'm gonna need to see a reference on that one. But above that - keeping a user away from heroin so they can spend their money on things like food for themselves and dependents, even if only for a couple months is still a net positive, a reduced harm.

    I can't help but think you woudl feel differently, Caz, if you're daughter developed an addiction.

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  10. Hmm, wierd hard returns there. Sorry!

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  11. Ah, Patrick - what on earth leads you to believe that I have a "just say no" or "war on drugs" mentality?

    Let's start chatting about the MILLIONS of people across the country on prescription drugs, shall we? Many of questionable efficacy, and even more highly questionable diagnostic and prescriptive value - or what can be called diagnostic creep, but is actually a surge.

    The difference between millions of people drugged up on Prozac (for example) when they don't need it, and any other drug user would be .... ?

    I would suggest that all drugs be decriminalized (not legalized), but that's an impossibly hard call to implement; the ramifications would be monumental, not just culturally and socially, but for global economics - which would collapse. I also don't ever see it happening, not in my or anyone else's life time.

    The chicken before egg argument vis socioeconomic levels is kinda pointless.

    Whoa! So, you're not a scientist then! But that's okay, most of us aren't. :-D

    Can't agree with your dismissal of the importance of cause & effect though.

    There is clear evidence that abuse, social isolation and poverty are
    determinants for drug abuse.


    Not entirely, because the drug trade would not contribute anywhere nearly as much to the global economy if only the poor were buying drugs, or were the majority buyers. Besides, try telling that to all the merchant banker cocaine users, or young and cashed up Ecstasy users. The bulk of drug users never come to the attention of any authorities, legal or medical or social.

    Heroin is actually on the decline (here at least, also in British studies), it's not "fashionable" at the moment; hasn't been for years, yet it still gets most of the attention. Drugs, like everything else have fashion cycles, periods of time where some drugs are much cooler than others. Which is also why new "styles" of drugs are introduced to the market and productized, just like any other consumer product.

    Your last comment is a cop-out, resorting to emotional shaming / blackmail, over a hypothetical. Besides, you don't know what any individual - on a blog, or in your real life - has first hand experience of in relation to this or any other topic - so it's always high risk to toss in that sort of comment in lieu of compelling argument.

    Besides, I have every sympathy for all families trying to cope with a drug addicted family member, for a myriad of reasons I won't list, but you'd never catch me criticizing any course of action or coping mechanism that families use - even if seemingly stupid - if you're not in their shoes, you've got no clue, is my thought on that matter. I have no difficulty in appreciating that drug abuse ruins the lives, happiness and wellbeing of entire families.

    Having crapped on at length, I will reiterate that I do genuinely and vigorously believe that discussion and action on drug use and abuse needs to be opened up. It has been a closed shop for decades. How many more decades do we leave it closed?

    Your blanket rejection to the ideas presented by Darymple is not significantly different to the trillions of people who automatically reject any suggestion that we could free up police around the world and empty out jails, and free up trillions of tax dollars for more valuable things, if only some changes were made to drug laws and accessibility.

    Long day, I’m tired and grumpy and need food.

    (PS – my daughter is not a drug user; I’ve tried more drugs than she has, at least as far as I’m aware. FYI.)

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  12. BTW - something I'd like to see even more than drug reforms, something I feel very strongly about: heroin should be freely and liberally available to people who are dying in pain. I'd very much like to see that, but, it won't ever happen either.

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  13. Oh, it wasn't my intention to offend you there, Caz, not at all. I'm sorry if I have.

    The reason why I blanket dismiss Darymple is because he is wrong. Flat out, pure and simple wrong.

    All his anecdotal evidence doesn't mean shit - in fact, all the anecdotal evidence in the world doesn't mean shit, and that's why he pisses me off. Crap like, "All the abc's I've ever met are xyz" has no place in policy debate.

    Not entirely, because the drug trade would not contribute anywhere nearly as much to the global economy if only the poor were buying drugs, or were the majority buyers.

    But they are. Again, this isn't an opinion, but an established fact. Drug research does highlight all users because they do representative research on it - they have the money for this because governments are prepared to pay to tackle this problem, so the information is all there.

    A good analogy is the casino - sure, most of the people who go to the casino aren't problem gamblers, but those guys only drop six hundred bucks a year - problem gamblers drop 20 grand, or more.

    I do agree with you that media tends to focus on one drug over another, but I would disagree that heroin is getting all the press, quite the contrary. Methamphetamines (ice, et al) are getting all the press these days, but it's not such a bad thing; the sector has been talking about methamphetamine as a growing problem for the last seven or eight years, so the papers are just slow to catch up! That said, alchohol does remain the most major drug problem in Australia by far.

    I agree with you that there should be debate about drug policy, and there is very vigorous debate - in the sector. Unfortunately, drug-taking is a process that seems to get very politicised for one reason or another, and so best practice (which is harm minimisation) doesn't always get the guernsey it deserves.

    That said, the last thing the debate needs is someone like Darymple, effectively going around saying that it's the fault of drug addicts if they can't kick a habit, demonising them, and characterising them in that age-old cliche of crafty, selfish and ultimately wayward children, who will simply straighten up and fly right if you spank them hard enough. And why? Cause he's met some drug addicts who acted like that in front of him. That is piss weak; it's like a climate change denialist using a cold day in summer to deny global warming.

    The sad thing is, fringe weirdoes like Darymple get a lot of coverage for their views, partly because there's no one else in the sector prepared to argue it, and partly because their controversy makes good copy.

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  14. Not at all Patrick - no offence taken, not for a second.

    One of the great failings of blogging (versus the many positives) is the difficulty of tone, meaning and intent. With light topics it's not generally a problem, but with big messy topics, it can be very easy to FAIL to convey our emotional and intellectual intent (at least for me).

    This topic, for example, would be even more complicated, yet easier to debate, verbally, over a very large drink or ten, for five or six hours.

    I think it's a very worthy subject for debate and discussion, and it's one I take quite seriously (even if it may not seem that way at times).

    Will have to get back to your other thoughts when I'm feeling refreshed.

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  15. I like Dalrymple.

    Anecdotal evidence has some weight. Sure, if you wanted information about heroin use, you shouldn't just go to a story that a friend of a friend of a friend tells. But anecdotal evidence from a clinical expert with years of experience? That's perhaps worth paying a little time to.

    In this case, I'm not sure how much it matters anyway. I've read a little bit of Dalrymple, too, and he doesn't really use anecdotes in his articles to make specific medical points. Indeed, most of his anecdotes consist of discussions he has with patients; they seem to be included as part of an ongoing philosophical inquiry on the part of Dalrymple into the existence of human nature and human troubles. He seems to be making a point more about the human will, about morality, and about conscience, which may not be things you can classify or measure in an experimental situation.

    I don't get the sense that Dalrymple is blaming drug users for their circumstances. He observes, yes, and carries on a philosophical dialogue which has implications for the lives of addicts. But blame? Not sure about that. So I agree with Caz: at the very least he challenges our egos, shows lazily-held opinions for what they are, and articulates an argument with powerful implications for medicine and society at large.

    (/End pompous rant)

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  16. I appreciate Patrick’s view, and it sounds as though he has first hand knowledge of the daily struggle that users experience. I’ll admit that I’m surprised by his outright rejection of Dalrymple's ideas. Again though, Patrick is coming at it from a particular knowledge base and context which, of course, colours his view.

    Still, I really do like the challenge that Dalrymple throws up. I am so tired of stale thinking on this and every other significant area of life, whether culture, economics, the universe; things that ultimately effect every single one of us.

    Dalrymple, to me, is like a platinum invitation to start thinking anew! YEAH! Except that no one RSVPed. So much for innovation, being open minded, investigative, curious, willing to persist and tease away at big things, not to settle.

    And you’re quite right Tim. I really like that the that he is discussing the higher concerns of existence (apart from sex and death), and that he does accept the connection between drug abuse and the questions around the meaning of life, and so on. Without reading the book, I can’t make any assumptions, but I suspect it would be worth reading the full teasing out of his path of thought and how he arrives at his broader conclusions. It is, as you suggest, far more philosophical than judgmental or punitive.

    Damn it, I’m nearly convincing myself to buy the book!

    Another thing: Dalrymple is accutely aware that heroin users are smart enough to be on the inside of the joke with him; they collude with him - they know it and he knows it. It's an intriguing dynamic.

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  17. Yeaaaaahhh, but it's all bullshit Caz!

    It's one thing to talk about the philosphy of existence, etc. but that is not going to help people who are victims, directly and indirectly, of drug abuse.

    Anecdotal evidence is total bullshit, Tim, in any context. It is a contradiction of terms, no matter who it comes from.

    Personally, I don't care about Dalrymple's philosophy. His facts are wrong, and he makes dangerous generalisations that have been proven time and time again to be untrue.

    If he wants to make a philosophical debate, that's fine, but he shouldn't frame it around information that is misrepresentative - and also he definitely shouldn't conflate those debates with policy, which is what he does in the pieces that I've read.

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  18. I think any aspersions on the use of anecdotes is getting a bit off track, within the context of this writing. He has spent years, or decades, working with addicts, at the down and out and criminal end of the spectrum. The use of anecdote is very effective for engaging an audience. People don’t relate to collated statistics or clinical observations. He uses anecdotes for illustration, and so as to present real people, for the edification and engagement of the reader. It’s not trickery. People really only ever relate to other individuals. No one relates to a statistical average, or vague ponderous analysis of data. His anecdotes would be a collation of millions of interactions with addicts, not a few weeks spent with a couple of addicts he ran into on the tube one day.

    Did you ever read “The Band Played On”? A ripper novel. Yet it was fact based, turned to fiction style, with goodness knows how many thousands of invented conversations. As an approach to conveying the politics at the beginnings of the HIV / AIDS era, and the internal workings and jealousies of medical science, it was a ripper yarn, all done without telling any lies.

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  19. I actually SHOULD go and buy the book Patrick, as I don't have a handle on how he thinks policy should be handled. I'd be interested to see what he concludes, and without solid information, have no idea whether I would agree with him or not. I can very easily envisage that I would enjoy his discussion, but not agree with where that leads him, or conclusions he makes overall.

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  20. LOL Never read Plato, Patrick: he based his whole career around anecdotes!

    When it comes to asking and answering precise scientific questions about physical conditions, then anecdotal evidence is next to useless - it's true. I was a member of The Australian Skeptics for several years, and they have heaps of examples of how medical frauds, con men, conspiracy theorists, ufologists and the like get away with lying by the use of anecdotal evidence. I just don't think that's what Dalrymple does here.

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