I agree with Dalyrmple`s theory wholeheartedly. In my day if you were serious about giving something up, you simply went cold turkey. Sure it was tough for a while but you soon got over it. If you felt tempted, you`d go and mow the lawn for the old lady down the street. People were tough back then…

I doubt that mowing the lawn is going to fix up most druggies!That is a bit of a simplification. I am a child of the sex and drugs revolution and people I know have died of overdoses, and several people I know have had their lives or their kid’s lives wrecked by drug use.This interpretation of Dalrymple’s views( i haven’t read his book yet )ignores the very strong PHYSICAL craving of opiate addiction.
Most opiate users do tend to use various amounts- depending on supply-but after a short while they need a certain amount of the drug just to feel normal. That is the main argument in favour of legalisation . But if they want to get high they have to take more, and to get more they do what they always do , crime and prostitution.
Also, unlike going on the grog ,( which could take 20 years or a case of alcohol poisoning to kill you), a very small overdose of heroin can kill an intravenous user, even though they develop a tolerance.( This why punk rocker Sid Vicious died after coming out of gaol. he had been using a vast amount and straight away used the same quantity.) The same will happen iffor some reason the supply is more pure.And all this is beside the dangers of the needle itself.No wonder the probelm has been medicalised. it does have medical aspects, butin the end , not only supervision but 100% SUPPORT in the model of narcotics anon. is necessary. Acceptance that there might be failure is also necessary. 
But i think because the price of failure is so high, opiates (and also the new stronger hydroponic marijuanna) should remain illegal, and the best action is to interrupt supply.For those that say that doesn’t work it is interesting to note that since supply from Afghanistan has been interrupted, and less and less opium is produced and trafficked in Asia, heroin deaths in Australia have fallen dramatically .

Would this theory apply to Alcoholism as well? My assumption is yes, as it is a drug as well. This is something I have thought for years. Humans have struggled with self mastery and self respect--which seems to be the real problem.

Cool new insight, I think western society is just pampering drug addicts with injection rooms.  Very soon you will have to open conting rooms for pick-pockets.

Both sides are missing the point by ignoring research:  harm reduction works and tough love is a complete and utter failure if you actually look at the data.

It is conclusive:  needle exchange reduces HIV infections and drug use and even serves as an entry point to treatment and methadone is THE SINGLE MOST EFFECTIVE TREATMENT KNOWN for opioid addiction in terms of reducing *both* crime and chaotic drug use.  The Institute of Medicine-- hardly a liberal or radical organization-- and every other single medical body ever to look at the needle exchange data has come down in favor of it.  It may actually be the single most well supported public health intervention ever.

Tough love, on the other hand, has failed every time it has been studied.  In 4 decades of research, not a single study-- not one!!!-- finds the confrontational and humiliating counseling style of tough love to be effective and many find it harmful.  As leading addiction outcomes researcher William Miller of the University of New Mexico put it, the more the counselor confronts, the more the client drinks!!!!!

Both sides are arguing without looking at the data, which is a very silly thing to do!!!

Sally Satel, btw, works at a methadone program and Stanton Peele is a long term proponent of harm reduction!!!!!

I haven’t read “Romancing Opiates”, but it seems Dalrymple’s assertions are certainly worth consideration. However, let’s not be overly simplistic: “cold turkey” as a treatment option doesn’t work in every case. Neither do residential programs nor legal supervision. Furthermore, not all substances can be equalized in terms of physiological effect.

I work with a population of pregnant former heroin users. Going “cold turkey” could be fatal to the unborn child. These women are prescribed oral methadone as a means of reducing the risks associated with intravenous drug use, while avoiding the physiological withdrawal that could induce spontaneous abortion or premature delivery. Should we close up this methadone program?

Finally, Dr. Bowers please nota bene: “narcotic” is a precise term that refers only to opioids. Other substances, like marijuana and crack, do not actually fall into this category (except, perhaps, in American “legalese"). Your reference to narcotics in your essay would leave lay readers with an unclear understanding of the term.

I know Theodore Dalrymple exclusively through his column in the Spectator magazine where his Hogarth-like reflections on prison psychiatry ultimately numb through repetition. Sadly, his latest contribution seems no exception. Dalrymple blithely ignores inconvenient realities including a swathe of studies highlighting the neurobiological basis of addiction encompassing craving, physical dependence, and withdrawal, the high incidence of psychiatric comorbidity in drug-dependent populations, substantial evidence of biological cum constitutional vulnerability to drug dependence in many individuals, and so the list goes on. Moreover, some harm-reduction strategies such as methadone maintenance have a proven record in substantially reducing illicit drug use, unsafe behaviour, and drug-related crime. Methadone (like any strategy) is no panacea – the diversion of methadone into the black market is a case in point. However, complex problems call for nuanced responses – Dalrymple’s posturing polemic fails this test.

I remain a great fan of Theodore Dalrymple, and I agree with him that drugs are a choice people make, not some psychobiological destiny programmed in the womb for which they bear no responsibility. He’s also right that the horrors of opiate withdrawal have been grotesquely exaggerated, mostly, it seems, to give a little drama to Hollywood movis. Addicts are inherently boring people, so dramatists have to introduce a little horror into their stiflingly monochromatic lives somehow.

But the point is drugs are a choice, and if adult citizens want to blast their neurons with some toxic substance, whether it’s heroin, marijuana or 12-year-old single malt whisky, then I say let them. Legalize drugs, put the criminal cartels out of business and let the police busy themselves with protecting citizens’ safety and property rather than squandering their efforts in an unwinnable “war on drugs.” Arrest a dealer and you don’t take a drug merchant off the streets, you create a job vacancy in one of the most lucrative industries on the planet—a vacancy so attractive that people will fight and kill to fill it.

That industry is not going to go away. All we can do is decide who controls it—government, legitimate enterprise or criminal cartels. So far we’ve given the last group exclusive rights to the vast profits to be made. Hardly a wise choice. In the process we have managed to romanticize a pathetic behaviour.

Thanks for the responses. I want to focus on a few themes which I will break down in several posts.

Several ignored one of the main themes in the book and maybe not addressed adequately in my column. Many addicts want to get high and the desire isn’t reducible to pharmacology or neurobiology. Many accuse Dalrymple of oversimplification but I do find that many of my colleagues are as guilty of this in the public discussion of drug abuse. Anyone treating addicts are familiar with those addict who “just aren’t ready for rehab” This is a nice way of saying that some addicts want to continue getting high and don’t care if spouses, parents or therapist object. Anyone in groups with addicts must be on guard for the war stories.

I recall an interview with Danny Baldwin (an actor) They asked him about his 8 previous attempts at rehab.  I think that he gave an honest reply. “I didn’t want to quit.” The reporter ignored his statement and made a comment the his 8 previous rehab attempts proves how drug abuse is “resistant to treatment.”

Motivation has at least made a reappearance in the textbooks but it still seems like a dirty word in public discussions about addiction.

Second, is Methadone a successful treatment?

Keys words are successful and treatment.  I don’t think switching opiate addictions is a treatment, if the word has any meaning. How many would consider beer addiction a successful treatment for vodka addiction? I also don’t consider Methadone Maintenance a “treatment” since the methadone isn’t reversing any pathology and maintains the opiate addiction. Many addicts have told me that getting off methadone was harder than heroin.

Methadone offers two advantages. It’s dirt cheap and you don’t need a needle.  In a sense, Methadone was the first needle exchange program. A writer for the British Medical Journal sums up the problem with Methadone:

“The lethal dose of methadone is estimated at 50 mg for an opiate-naive adult.2 Nevertheless, many authorities recommend that methadone doses should be gradually increased to maintenance doses of 80-120 mg1—that is, twice the lethal dose for non-users. The greatly increased risk to users from methadone, particularly black market methadone, thus remains a major concern.”

The CDC reports that from 1999-2004 period, the number of poisoning deaths mentioning methadone increased 390 percent to 3,849.

Ultimately, I don’t think that any addiction is treated but instead “managed.” I think that we accept methadone management mainly because it’s very cheap and is beneficial for some; but rejected by many.

As far as success, Satel notes that among those on Methadone maintenance only 5 to 7 percent lead fully productive life and are otherwise drug-free may. As many as 35 to 60 percent also use cocaine or other illicit drugs or blackmarket sedatives.

Third, Tough love is not a treatment.
Maia Szalavitz said
“In 4 decades of research, not a single study-- not one!!!-- finds the confrontational and humiliating counseling style of tough love to be effective and many find it harmful.”

I would be surprised if such a study would even be approved for research. I was not proposing tough love as a treatment. I agree that therapist humiliating patients won’t bring about change but I don’t think that tough love is humiliation. Knowing many ex-addicts, I have found none who credit a therapist for getting them to stay clean or sober. On the other hand, many will credit AA, NA , etc who manages to balance firmness and flexibility.

Tough love is an approach which at least recognizes that the addict is a human being with competing motivations. Again, according to Satel, drug courts and other programs using some coercion have been more successful than public sector treatment programs.

The point of the tough love talk is a reminder that the legal systems is and always will have some role in managing drug addictions.

The other point about tough love is that at least in the US, publicly finance treatment programs have very limited slots. Most programs won’t pretend to treat those who are uninterested.

Several have said that harm reduction is a “proven” success. Well, we’ve gone from Methadone to clean needle to injection rooms. It never seems enough. Vancouver went to injection rooms because the needle program wasn’t working. 

That’s enough for now.

The unspoken premise of this article is that drugs should be illegal. I see no justification for it. The ‘War on Drugs’ is a monumental failure. The price of cocaine has gone down every year for the last 25 years. My twins, when they were in high school, would tell you that drugs were far more readily available than alcohol. Alcohol is legal and regulated, drugs are illegal and, effectively, unregulated.

Our present drug laws are the result of the excessive
moralizing of the twentieth century. I suppose it falls under the rule of unintended consequences. Those consequences include an enormous prison population and shootouts on our streets. Take the profit out of drugs and the crime rate will drop overnight. The same is true of sex slavery. Legalize and highly regulate prostitution and you can stomp out sex slavery. These things, of course, would require courage and I haven’t met many politicians who have an excess of that.

TB, you are completely missing the point on methadone and harm reduction.  *MORE* opioid addicts get their lives together on methadone than do from 12 step programs, proportionally.  This is hard for people to believe because methadone, unlike 12 step programs, retains the “failures” in treatment and reduces harm to them.

Whereas people who have no desire to stop using don’t usually continue going to 12 step meetings.  So, at meetings, you see mainly the successes, whereas at a methadone program, you’ll see more “failures” even though most of them are benefiting from treatment via reduced use and increased access to medical care.  And the successes will hide from media because being on methadone is seen, as you say, like substituting vodka for gin.

The problem is, that’s not an apt comparison.  Both vodka and gin cause ongoing impairment, but with opioids, tolerance produces a state where the person on a steady dose is not cognitively, emotionally or physically impaired.  This is why they can be on twice the dose that would kill non-tolerant people-- and NOT be impaired AT ALL.

Regarding the increase in methadone overdoses, if you look at the data, you’ll see that virtually all of that is related to increased use of methadone for pain treatment by doctors who don’t know how to use it appropriately and by diversion from pain patients, NOT from methadone clinics. 

Finally, regarding the expansion of harm reduction from needle exchange to injection rooms-- that isn’t done because needle exchange doesn’t work (it works rather spectacularly at reducing HIV-- for example, the UK which instituted it early had NO hetero epidemic and virtually no IV epidemic, but the US which instituted it late.... take a look at rates in minority communities and in communities late adopting needle exchange).

It’s because you expand successful programs-- does the fact that there are more Starbucks now signal failure?

Maia Szalavitz said:
“This is hard for people to believe because methadone, unlike 12 step programs, retains the “failures” in treatment and reduces harm to them.”

Seems like we are in agreement in regards to the limited success of Methadone as far as ending addiction, crime and unemployment. My comparison to alcohol was in the most limited sense in pointing out that Methadone does not reverse addiction.

In the big picture methadone doesn’t appear to have made much of dent in overall heroin use. Certainly, needle distribution programs can’t be the result of a successful methadone maintenance policy.

Retaining failures? Do you retain people who divert the methadone? What happens if the addict refuses to take the methadone at the clinic? Do you retain people with positive drug screens? These aren’t rhetorical questions. I’m just interested in what the feds allow.

Maia Szalavitz said:
“Regarding the increase in methadone overdoses, if you look at the data, you’ll see that virtually all of that is related to increased use of methadone for pain treatment by doctors who don’t know how to use it appropriately and by diversion from pain patients, NOT from methadone clinics.”

“Virtually all?” I would agree with most. I know that Methadone clinic have a lot more oversight than pain clinics. Still, I have found that opiate addicts love benzodiazepines and the combination is hard to balance.
Thank-you for your comments.

David Page and a few others call for legalization.

Well opiates are legal and regulated. As far as heroin or cocaine, what system do you envision? Would pharmacies distribute? Bars? Would the FDA be responsible for the safety of the drug?

Again, this is not a rhetorical question. I would be interested to hear from proponents of legalization about the system they would design.