Drug addicts need tough love
In the fable of the frog and the scorpion, the frog gives the scorpion a ride on his back across a river. Midstream the scorpion stings the frog, dooming both of them. When the hapless frog asks why he did it, the scorpion replies, "I am what I am." As a parable about the difficulty of changing human behaviour, this fable fits the script for modern science. Lately, many neuroscientists have delighted in telling us that we are no different from insects or any other animal. Bad habits have become either incurable brain diseases or evolutionary destiny. And people are like the rats in the 1980s drug education pamphlets: they will suck on a cocaine bottle until they die.
Amidst the clamour that drug abuse is a disease and addicts are helpless victims, Theodore Dalrymple, the British conservative cultural critic, has taken on the medical establishment.
Dalrymple (the nom de plume for Dr Anthony Daniels) recently retired from his day job as a psychiatrist in Great Britain. In his spare time, he has also managed to be a prolific writer and chronicler of the descent of Western culture through the lens of his medical experience. Last year, in a new book, Romancing Opiates: Pharmacological Lies and the Addiction Bureaucracy, Dalrymple once again examined a frequent target of his pen, the therapeutic priesthood. Like the liberal who turns conservative after being mugged, his experience in treating hundreds of addicts changed his views on drug abuse. Romancing Opiates is a bracing rebuke of current popular views regarding substance abuse, in particular the Queen of Addiction, heroin. Dalrymple pierces the fog surrounding addicts and so-called treatment. Balancing scepticism and hope, he dumps New Age Compassionate Conservatism in favour of old time Tough Love.
Dalrymple repudiates his youthful dalliance with the "Standard Orthodox View". The current head of the National Institute on Drug Abuse, Dr Nora Volkow, promotes a familiar version of this pop orthodoxy with a science versus superstition story in a booklet from the National Institute, Drug Abuse, Drugs, Brains and Behavior –The Science of Addiction. Volkow informs us that:
"Throughout much of the last century, scientists studying drug abuse laboured in the shadows of powerful myths and misconceptions about the nature of addiction. When science began to study addictive behaviour in the 1930s, people addicted to drugs were thought to be morally flawed and lacking in willpower. Those views shaped society's responses to drug abuse, treating it as a moral failing rather than a health problem, which led to an emphasis on punitive rather than preventative and therapeutic actions."
For her, imaginary demons and spirits have been replaced by imaginary moral character and will power. In the therapeutic world, punitive can never be preventive.
But Dalrymple challenges Volkow’s picture of addiction in the opening of Romancing Opiates:
"Man is the only creature capable of self destruction, and only man decides in full consciousness to do what is bad, even fatal, for him. Freud’s death wish may be mere speculation, an abstract construct conjured from air, but no one with the slightest acquaintance with the human race could possibly conclude that human beings always pursue their own best interest by means of rational calculation. The primrose path to perdition never ceases to attract... Romancing Opiates draws the appropriate conclusion from this: that addiction to opiates is a pretend rather than a real illness, treatment of which is pretend rather than real treatment."
Dalrymple supports his hypothesis by demolishing the accepted orthodoxy about narcotic and other addictions. Opiate withdrawal is not hell on earth. Heroin addicts can simply stop. And treatment is not really treatment. Bottom line: it’s the people not the drugs, nor the brain.
He is abrupt but right. Narcotic withdrawal doesn’t even merit medical monitoring. Heroin addicts sometimes just quit. According to addiction experts like Stanton Peele, patterns of narcotic use vary over time, including switching between drugs, abstinence and prolonged sobriety. Dalrymple also cites a largely ignored study of Vietnam veterans which showed that only one in eight opiate addicts continued their addictive behaviour when they returned to the United States.
The book has had few reviews in the press. But late this summer, a conservative magazine on technology and society, the New Atlantis, published a blistering attack on Dalrymple’s tough love. The author, Lee Harris, is an American essayist not involved in the addiction industry who responds as a shocked layman to Dalrymple's politically incorrect assertions. As a compassionate conservative, Harris echoes the common view that tough love is cruel because it mistakenly blames the addict and not the drug. He finds Dalrymple's arguments compelling but he is troubled by his conclusions. By stigmatising addicts and "making him face the harmful consequences of his behaviour", he does more harm than good.
But isn’t stigmatisation unavoidable? Addicts are stigmatised by their behaviour. Lying and stealing don’t win too many friends. Harris finds Dalrymple’s belief that addicts are moral agents cruel because they aren't moral beings "like you and me". To support his argument, he cites Aristotle's belief that some human beings are "natural slaves" because they are unable to master their weaknesses. Harris blames the modern drug epidemic on the failure of people to believe that "certain substances are inherently destructive of our strength of will." Amazingly, Harris considers that his assertions are not stigmatising.
The difference between Dalrymple’s and Harris’ psychologies of free will and of pharmacological determinism is most evident in their approach to "harm reduction". Both men show the consistency of their psychological theories. For Dalrymple, tough love is needed and harm reduction strategies such as clean needle distribution and subsidised tattoos for jail inmates (as long as the tattoos aren’t racist -- even bureaucrats have their limits) are infantilising. Harm reduction is the soft bigotry of low expectations.
Harris considers enabling drug abuse and protecting junkies from harmful consequences the best one can do for those who are "hopelessly addicted". It is unclear how far he would take his appeasement. After harm reduction becomes established as a strategy, the bottom line sinks lower and lower. Needle exchange programs haven’t been very successful and have left parks littered with exposed needles. Consequently some municipalities, mainly in Europe, opened injection rooms. Even San Francisco health officials are pushing for heroin injection rooms. Are public crack houses next? Maybe. The mayor of Vancouver has called for "inhalation rooms".
What appears compassionate may do more harm. Injection rooms keep dealers employed and addicts homeless. The managers of the Vancouver injection room considers their 800 overdoses a success since no has died… yet.
Harris shows little interest in any tangible benefits from these programs. He even concedes that harm-reduction "may do little good for the addicts but at least it preserves the humanity of society". Does offering a place for people to get high make us more humane than running soup kitchens as our grandparents did? For Harris and many others, the false alternatives are either do something or nothing.
Dalrymple’s solution is to shut down clinics claiming to treat addicts. By this he means, stop treating drug abuse as a medical illness. Hence, close up those methadone programs. Two American psychiatrists, Sally Satel and Frederick Goodwin have argued that compulsory residential treatment and legal supervision have been very successful in reducing drug use and illegal activity among participants. Over the last few years, several studies have shown that addicts will maintain sobriety for rewards. Instead of enabling addiction and keeping dealers employed, Satel and Goodwin recommend "enlightened coercion".
Compassion without hope is merely demoralisation and surrender. Addicts aren’t rats in a cage. They still have a choice. Dalrymple’s prescription of tough compassion united with truth and hope could turn victims into victors.
Theron Bowers MD is a Texas psychiatrist.
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