Does one drug cause the user to be more annoying?

April 14, 2010

As a bit of a followup to the poll we ran on whether or not cigarettes make you high, I offer context and my thoughts. As of this writing, btw, the votes are running 44% “Yes”, 47% “No”, the balance “other” with a fair bit of commentary to the effect that “high” is not exactly the right description for nicotine.
For the background, we might as well start with the comment from SurgPA:

This started with an email from PalMD asking why doctors react much more negatively to narcotics abusers than alcohol or nicotine abusers. I hypothesized that most people view acute use of the various drugs differently. Specifically I suspected that most doctors’ gut reactions when seeing someone light a cigarette are qualitatively (and vastly) different from seeing someone shoot heroin (or snort crushed oxycontin). In short that we don’t see the act of smoking as an acute intoxication by a neuroactive substance, even if we understand it intellectually.

PalMD asked Why do doctors dislike narcotics abusers?

But narcotics are not the most frequently used addictive substances. For example, about a fifth of Americans smoke. But we as health care providers react differently to different kinds of substance use. I certainly cannot speak for all doctors, but narcotic abuse seems to push our buttons in a way that nicotine and caffeine (and even alcohol) don’t.
So I asked around to try to understand why so many of us have negative reactions to people with narcotic use disorders. After talking to a few professionals in person and via email one factor stood out: narcotic abusers often use health care providers to obtain their fix. Most of us don’t like being lied to or being involuntarily enlisted as a drug dealer.

Commenter Jon on PalMD’s thread hit very close to my take on this issue.

The cocaine and/or opiate abusers that I’ve known are much different socially that smokers and (usually) drinkers. They are generally more dishonest, manipulative, disengaged emotionally, and generally antisocial. Though, in my opionion, a lot of that difference is caused by the difficulty and danger of finding and paying for that next dose.

Let me expand, based on a number of comments I made off-line to PalMD and SurgPA. If the question is, why are those addicted to nicotine more palatable than those addicted to opiates (“narcotic” properly refers to the opiate class drugs, btw) and to a lesser extent alcohol, I point to three issues. Legality, acceptance that the drug is addicting and the impact intoxication has on behavioral function.
To start with the question of addiction, I could imagine that the nicotine dependent are least likely to deny their addiction relative to narcotics and especially alcohol. To themselves, to their family and to their medical care providers. This may be a function of age / generation but given the big tort fights, PR coverage, cancer messaging and agonist therapy marketing which all tell us that cigarettes are addictive, full stop, it is hard to imagine there are many people that debate nicotine dependence. In fact it really surprises people to see a paper like the Dierker and Donny (2007) one indicating that some 38% of individuals who have smoked at least 10 cigarettes per day for at least 10 years may not meet diagnostic criteria for dependence. (Another paper from this group describing the perhaps surprisingly low contribution of number of cigarettes smoked daily and the duration of smoking to dependence is here. )
This contrast with alcohol, for which we have much much more of an acceptance that there are social drinking patterns that are not, and never will be, a problem. The penetration of alcohol is nearly complete (upwards of 95% have at least tried it in the US population) and the repeat drinkers (weekly? monthly? however you construe it) are very salient to most observers. While the notion that alcohol does cause dependence is probably less controversial with its consumer base than, e.g. the cannabis user base, there is a great deal of understanding that addiction and dependence on alcohol are not inevitable.
Narcotics feature a bit of both- with one extra bonus factor. Remember that we’re talking about the user population that is interfacing with medical care providers. And as I said to PalMD and SurgPA it was my speculation that the legal status was a factor. I asserted that the fact that narcotics dependent folks are highly interested in scamming their medical providers for their fix was an important difference. Admittedly, since some of them started off with clinical pain management and these are pills instead of street drugs, perhaps there is a bit of denial of the dependence here. Sort of like the alcoholic. But the legality issue modulates how they have to interact with docs. I suggested that this amounted to having to lie to their care provider about all sorts of things about their health and daily lives. I concluded that this can’t help but be part of the problem; see this comment for additional support.
I also suspect that a higher order version of this dishonesty issue is at play in terms of the degree to which people dependent on the respective drugs walk around their normal lives concealing versus revealing their addiction.
This brings me to what I see as one important difference between nicotine and alcohol or narcotics is that it is not illegal or illicit or perceived as in anyway bad to be acutely intoxicated on nicotine in daily working and home life. In some senses this is the most specific point being addressed in the poll asking whether cigarettes get you “high”. Social perceptions are an important factor. Our good blog friend Anonymoustache was all over this in the comments at White Coat Underground. My formulation is that it is socially acceptable to be intoxicated on nicotine during the work day (ditto caffeine). Nobody has a problem (beyond second hand exposure issues) with a parent who is acutely nicotine intoxicated. It is not considered to make the person nonfunctional in any critical way. Therefore, there is less reason for a person to hide a nicotine addiction over an opiate, or more importantly alcohol, addiction. It is my speculation that this may shape their general honesty and skeeviness. Perhaps over time that may set up some distinct traits in a person.
So what I was getting at in my response to the medical care provider viewpoint is simple. I think that it is premature to ask if there is anything inherent about opiates that turn you into a jerk, or to assume that jerks are drawn to opiates over, say cigarettes or alcohol. We should rather ask questions about the situation of being dependent on various drugs. The social acceptability of using a given drug would seem to be a very critical determinant of the way the dependent individual interacts with others.

46 Responses to “Does one drug cause the user to be more annoying?”

  1. DuWayne Says:

    This is something that really kind of bites to the heart of the problem of addiction. I understand that these biases exist. Hell, I have my own reactions to specific types of drug addicts – tweakers and crackheads are very frustrating, for example. And they, no different than any other addict, are also human beings. Often very decent human beings underneath the behavior that surrounds their addiction. People often get bent on the sneaky/skeavy and forget – or simply don’t understand that that is not the whole of this person.
    I have known crackheads who I wouldn’t trust to leave a half smoked cigarette I set on an ashtray to smoke later, who are caring, normal human beings underneath that shit. I made friends with some of them during my insomnia walks in Portland and watched with horror as they descended into the worst of it – the loss of fine and even not so fine motor-control.
    The stigmas are brutal and dehumanizing. I have not plumbed the depths of acute opiate dependence or addiction, but I have my addictions and I have plumbed some pretty good depths of substance abuse. I know what it is like to have people look at you and know that they think you are sub-human – some of them probably do, others don’t. The important thing is how the addict interprets “the look.” And let me tell you – it really fucking sucks to be looked upon as garbage. It sucks to go into the ER with ribs that are broken from dry-heaving, dehydrated to the point that your skin is sallow and overhear a motherfucking doctor arguing with the resident caring for you that he shouldn’t give you the IV push of some pain killer or another that you didn’t even fucking ask for. And arguing this in front of you, like you aren’t even there.
    And I had it pretty good as far as substance abusers go. I was in a band, when I wasn’t the exotic hitchhiker, or the activist or the actor/poet who gets on St. Louis public radio a lot. I had my substance abuse problems, but I also had a rather large community of respect to balance out that shit. And eventually I came to terms with my problems and I have been managing them with increasing success ever since. I thankfully never managed to achieve acute dependence on many things.
    Unlike your average junkie, I am unlikely to die an actively using junkie – existing in a world full of people who I think think I am less than human – quite often thinking so correctly.


  2. leigh Says:

    first and foremost, i am definitely not a psychologist of any sort. this is just my random nonsense. i think if the acceptability of using a given drug is based on a social construct, it isn’t too surprising that addicted users are going to adapt to fit themselves into that construct however they need to. lying, manipulating, whatever.
    the interesting thing, i think, is the cognitive effect of the drug. (of course, i am slightly biased.) nicotine and caffeine tend to have some positive effects on cognitive performance- while if you compare to intoxicating doses of alcohol or opiates, you’re looking at an entirely different situation. just some food for thought…


  3. becca Says:

    “perceived as in anyway bad to be acutely intoxicated on nicotine in daily working and home life.”
    Perceived by whom?
    I know I am disgusted and appalled by people smoking in daily working and home life.
    “Nobody has a problem (beyond second hand exposure issues) with a parent who is acutely nicotine intoxicated.”
    FALSE. VERY, very, sadly and dangerously false.
    Both my parents were the 2-pack-a-day Camels unfiltered kind of smokers (and despite major respiratory consequences and attempts to reduce, no signs of truly giving it up). First, it’s next to impossible to separate out second-hand issues. My parents are very badly addicted; my mother spoke to me, with dread, about a planned visit in several weeks. The reason? My parents must refrain from smoking around their grandson. This does *not* familial harmony spread.
    Furthermore, if you’ve never had a very large, very enraged person puffing away while yelling at you, you do not think very much about nicotine and behavior. My favorite part was how he always insisted nicotine was calming.
    “It is not considered to make the person nonfunctional in any critical way.”
    Addiction fixates attention on the addiction; this necessarily takes away from empathy with others in times of conflict. A nicotine addicted parent is *inherently* less capable of functioning as an empathetic parent in certain situations (which may never come up, or may be painfully relevant).
    Keep in mind, I’m not arguing with you about general perceptions in nicotine vs. opiate addiction. I am simply sharing my thoughts about nicotine addiction, and letting you know that yes, DM, SOMEbody has a problem with nicotine addiction.


  4. Becca, would you be as appalled if the person was not smoking, but instead had a dozen nicotine patches under their shirt?


  5. Greg Laden Says:

    An excellent, almost anthropological, analysis of the situation. Very nicely done.
    Tobacco can get you high, by the way. I think the ambivalence in the data is a combination of two tings: Regular smoking of tobacco doesn’t do much … but a smoker who takes a couple of days off will get very stoned, for a while, with the first cigarette; and we westerners smoke weak tobacco, in a way that minimizes these effects. Try smoking the equivilant of cigar wrappings through a banana stem pipe with a bunch of Pygmies. You may not even need the pot they typically mix into it…
    By the way, I’m currently stoned on narcotics.* Am I being annoying? It’s OK, you can tell me.


  6. non3 Says:

    I’m just reading Thomas Szaszs Ceremonial Chemistry and it opened up a whole new look on this topic. Highly recommended!
    And @greg; i don’t find acute nicotine intoxication pleasant, the regular smoking pattern is pleasurable imho.


  7. Dude, I’m surprised the pygmies didn’t clog the stem.


  8. becca Says:

    @Cath the Canberra Cook- part of the reason smoking is so insidiously addictive is that it’s almost an ideal route of administration for a *quick* effect. Part of the *point* of nicotine patches is to reduce the ups and downs of mood associated with nicotine craving and use.
    So I would find it equally appalling if it made them as cranky as smoking, but one hopes that is less likely.
    @Greg- I don’t think they’re having the conversation about people who might be *less* annoying while on one drug. But it’s worth having.


  9. llewelly Says:

    For at least 40 years (and probably longer) the public has been bombarded with propaganda telling them that users of illegal drugs are immoral, dishonest, disgusting, and stupid people. This is sufficient to explain the negative attitudes of doctors, and other people to the users of illegal drugs. (It may be true that some drugs make people more dishonest, but there’s no evidence for that, and it isn’t necessary to explain widespread public perception of drug users.)


  10. Vicki Says:

    Another piece of this is that the person who is least likely to be visible as narcotics-dependent is the chronic pain patient who is managing to live a more or less normal life with the help of their medications.
    They probably don’t want their employers, neighbors, etc. to know that they get through the day with the help of narcotics. If they have a doctor who prescribes what they need, and it does the job without getting them high, the only people who have to know are their doctor and pharmacist. So, the rest of us don’t hear “narcotics dependency” and think about the person we know or work with, because we don’t know that they’re using more than ibuprofen and acetominophen to get through the days. We think about the people who aren’t coping, with the various stereotypes.
    And the doctor, if they’re reasonably empathic, also doesn’t think of that patient when they think about annoying narcotics addicts: because the annoyance isn’t the patient who comes in regularly, gets an exam, maybe also asks for help with a rash or for a DPT booster, and walks out with the same prescription every time. (Or, if that’s an annoyance, it’s because the doctor would like to be able to cure the problem, rather than just maintain things–as would the patient.)


  11. Greg Laden Says:

    Dude, I’m surprised the pygmies didn’t clog the stem.
    All the time. “Always have a spare plantain stem” is their motto.


  12. D. C. Sessions Says:

    Adding caffeine to the list of “addictive but socially acceptable” drugs, I see at least part of the pattern as having to do with the effects of acute use: caffeine and nicotine both leave the user quite functional (perhaps even more functional than baseline short of near-toxic overdose.) That means that they’re not perceived as a threat compared to drunk/stoned drivers, co-workers, etc.
    It also means that caffeine and tobacco addicts (by and large) don’t get into a downward spiral towards the gutter. Some of the negative perception undoubtedly comes from the poverty of alcoholics etc. and the distaste that people have towards its symptoms.
    That last, to me, is tied to the disconnect that people have between their impressions of Rush Limbaugh’s drug addiction and the derelicts they avoid on the street: Limbaugh has the money to avoid the trappings of “addiction.”


  13. Alex Says:

    Are there any drugs whose users should, simply by virtue of being users and irrespective of whether they are engaging in any conduct that harms others, be locked into cages alongside violent criminals?


  14. DrugMonkey Says:

    whoa, that is such a subtle, penetrating and insightful Socratic question Alex!11!


  15. SurgPA Says:

    @10 Vicki –
    One thing that is frustrating to those on the prescribing end is that many prescription-narcotic abusers are also relatively invisible; in fact they act a lot like the chronic pain patients you describe. I want to be empathetic toward my patients. I want to treat genuine pain (please note I’m not trying to differentiate pain I can explain physiologically from pain I can not, simply trying to differentiate pain from drug abuse, depressive symptomatology, etc.) But it can be very difficult initially to differentiate the “legitimate” chronic pain patient from the substance abuser, and you don’t have to treat very many of the former before you start to encounter the latter.


  16. Zeb Says:

    The questions you have to ask yourself which color every other question that you may ask about illegal drug use are:
    “Where does the money go”?
    “Why are the massive sums inherent in drug manufacture and supply forced into a hidden black economy”?.
    “Cui Bono”?
    Until those questions are asked and answered with a reasonable degree of accuracy, all other questions about drug use and attitudes to drug users simply skirt around the edges of the phenomenon


  17. Anonymous Says:

    “Are there any drugs whose users should, simply by virtue of being users and irrespective of whether they are engaging in any conduct that harms others, be locked into cages alongside violent criminals?”
    if someone is a tremendous threat to themselves then it might be worth it to lock them up at least for a brief period. for example a cutter who tends to go on escalating episodes cutting deeper and deeper every time.
    obviously treatment would be better but that was not offered 😉


  18. Alex Says:

    I’m less interested in subtlety and more interested in getting to the heart of the issue.


  19. DrugMonkey Says:

    Zeb, Alex-
    The questions you have to ask yourself which color every other question that you may ask about drug use are:
    Is it acutely harmful, either directly or indirectly, to the person or others?
    Does it cause harm with continued use?
    What factors cause people to continue to use it?
    Until those questions are asked and answered with a reasonable degree of accuracy, all other questions about public policy are opinion-making hand waving.
    Impact on health and well being is the heart of the issue.


  20. Alex Says:

    Harm to health and well being are not sufficient reasons to lock a person in a cage alongside violent criminals. Indeed, if you’re concerned about a person’s health and well-being, locking him in a cage at the mercy of violent criminals is the absolute last thing that you should do.
    I have loved ones who suffer from all manner of mental health problems, some of which make them potentially dangerous to those around them. Appropriate medication, therapy, support networks, these things are solving their problems. Knocking down their door, pointing guns at them, and dragging them to a cage with violent criminals, these things would NOT solve their problems.
    I’m deeply concerned with the health and well-being of others. So concerned that I make a point of not wanting them locked in cages alongside violent gangs.
    Also related: My grandfather was an alcoholic. He also grew up in a neighborhood run by the Mafia during the 1920’s. The harm that alcohol inflicted on him and his family does not in any way diminish the fact that undermining Al Capone’s business model was A Good Thing. In fact, I would argue that one of the best things about the 21st amendment is that alcoholics didn’t have to pursue their habits in venues run by gangsters.


  21. DuWayne Says:

    DM –
    I was all about the notion of getting on Zeb for his line in the sand approach, because frankly the notion that his is the only issue that can be addressed before any discussion can happen is absurd. Then I take and nap and here you are doing the same damned thing.
    Is it acutely harmful, either directly or indirectly, to the person or others?
    Does it cause harm with continued use?
    What factors cause people to continue to use it?
    Until those questions are asked and answered with a reasonable degree of accuracy, all other questions about public policy are opinion-making hand waving.

    Bullshit. There are a hell of a lot more questions that are equally important. And if you pay attention to what psychologists have to say about it, you might note that to a strong degree that last question – the key question there is never going to be answered in some all conforming standard, because all addiction is different and all addicts have a different relationship with their substances of abuse. Though if you want to get an idea, read my last response to PAL’s thread.
    As for the first question – we have an answer to how that works in the status quo. Of course drugs hurt the user. On some occasions they even hurt others. What you are ignoring is the immense damage that current policies are causing too – and that is neither opinion or irrelevant. The inherent damage caused by the war on drugs is absolutely an integral part of the equation.
    And the second question – yes it causes harm with continued use. As it stands the current policies also create significant barriers to discontinuing use.
    You seem to be trying to pretend that we aren’t dealing with the problems you are concerned about now. I should think you would be aware by now that we are and in very serious – as in causing our nation tens of billions every year with current policies. The hell we can’t have an informed policy discussion without handwaving and opinions. The status quo is bleeding us dry at the same time it is also hampering our ability to treat addiction reasonably. And at the same time it is interfering with the ability of people with legitimate medical needs for narcotic pain killers to get onto a reasonable pain management regimen without being stigmatized.
    Impact on health and well being is the heart of the issue.
    I am sorry DM, but it is not the governments job to waste billions that we don’t have, create unsafe neighborhoods for the impoverished by creating such a lucrative black market, all in the name of pretending we are concerned about the health and safety of people who might become addicted to drugs – many of whom are already addicted to those drugs. I have gone on at great length and presented compelling arguments. There are lawyers, judges, law enforcement officers, psychologists, psychiatrists, sociologists and yes, even doctors, getting louder and louder about this, because the evidence we have is that not only have current policies failed, they have created a clear danger to public health and safety.
    That is not handwaving and opinion – that is pure, unadulterated fact. Take a walk in a fucking ghetto neighborhood in a sizable urban center and tell me that they haven’t created that danger. Talk to any cop about what the majority of people in lock-up are there for and tell me they haven’t created a danger. Look at the statistics for both how much of your state budget goes to maintaining state prisons and then look at the statistics for what they are there for.
    I can tell you what you will find. In the ghetto neighborhood, you will find violence, the evidence of violence and if you ask anyone what that violence is about, they will say drugs and drug trade related crime. You ask a cop, he will tell you that most are there for drug crimes. You look at those state budget allocations going into prisons, you will see something nearing fifty percent – in my state it has been more than half. You look at what people are in for and significantly more than half are there for drugs or crimes relating to the illicit drug trade.
    Health and well being my hairy ass.


  22. Alex Says:

    The violence associated with underground markets, and the disparate racial impacts of policies to combat those markets, are absolutely crucial to this topic. If those topics aren’t on DM’s radar, perhaps I should do what is customary on the internet and make an observation about privilege.


  23. SurgPA Says:

    DuWayne & Alex
    Both of you are assuming a priori that the drugs in question are “bad”. Re-read your posts in the separate contexts of three different drugs. Caffeine, Marijuana, and Heroin are all psychoactive compounds – “drugs”, yet caffeine is generally considered to be relatively benign and heroin quite dangerous. Marijuana is controversial (see prior posts on this blog) with some feeling it is benign, others that it has some potential for dependence, abuse, adverse effect and impairment. Both of your comments are fairly accurate in the context of heroin, but ridiculous in the context of caffeine. I think DM’s point is that issues of public policy toward users of various substances can’t be addressed until his questions have been considered.


  24. DuWayne Says:

    SurgPA –
    I am going to be rather more sloppy than I should be right now and I am not going to actually provide the citations for what I am about to assert. I really do apologize for not doing so, but I have spent rather more time that in reasonable in this topic given the amount of work I have to do at the end of semester crunch and the fact that this has nothing to do with any of the papers I am working on. If my files were better organized I probably would have an easier time of it but they are not.
    Caffeine isn’t nearly so benign as it is generally thought to be. There was a study, IIRC conducted in Sweden, that concluded coffee that is of average coffee shop strength is, volume for volume as hard on the liver as alcoholic beverages containing 12% alcohol. There has also been a sharp rise in the number of young adults (16-21) admitted to ERs for caffeine overdose. And of course there has been serious problems with mixing energy beverages (and now candies and gum) and alcohol.
    But ultimately caffeine is rather irrelevant because it is not an illicit substance, or even particularly controlled (with some localized exceptions restricting sales of energy drinks).
    And my comment wasn’t meant to address just heroin. Or even cocaine and crack as well. It also addresses cannabis, LSD, MDMA and pretty much every other illicit drug. The only reason it doesn’t particularly address alcohol and tobacco, is because we are talking about illicit drugs.
    The problem with DM’s three questions, is that the first two have been answered with a great deal accuracy. Do we have every aspect of harm for every drug? No and there will probably always be more to learn. But we certainly can say with a great deal of accuracy that we have a more than adequate understanding of harm, for most drugs, to formulate public policy. We also have a great deal of statistical data for harms associated with prolonged use (though that is mostly in the context of substance use disorders). Again, enough to inform public policy. And for the last, the factors that cause people to use it, we have just about as much information as we are ever going to have. I.e. there are certain, general universals associated with addiction – but every addict and indeed every user (not all are addicts) has a different relationship with substance use. There are different factors that cause substance use disorders (see my last comment on the thread at Pal’s blog that is linked in this post) in different people.
    The bottom line is that DM’s questions have been addressed more than adequately to inform public policy. And the serious problem with DM’s questions is that they are incomplete. Especially when he then closes with the statement that the heart of this is the impact on health and wellbeing. Because it ignores the very serious impact that current policy has on health and wellbeing. Here are some facts about health and wellbeing in the context of substance use disorders;
    Fact – current policies are a clear danger to the health and wellbeing of people who have nothing to do with substance use – especially in locations that are rife with poverty. The illicit drug trade has a profoundly destructive effect on people who’s only “crime” is being financially disadvantaged.
    Fact – current policies make it far more likely that children raised in poverty are going to be at significantly higher risk for substance abuse problems with illicit drugs, than kids who are not.
    Fact – current policies make it significantly less likely that people with substance use disorders, who abuse an illicit drug significantly less likely to seek help – even if they are very aware they have a problem.
    Fact – current policies create ethical dilemmas for psychologists who are trying to treat substance use disorders, where the substance of abuse is an illicit drug.
    Fact – current policies have created a thriving black market that is a direct cause for the majority of violent crime in the U.S.
    Fact – current policies place non-violent offenders of said policies into institutions with violent and dangerous criminals. People who with the exception of their breach of drug laws, are otherwise entirely law abiding citizens.
    Fact – current policies have not stemmed the tide of substance use disorders involving currently illicit drugs. These problems still exist and will continue to exist regardless of drug policy.
    Fact – current policies foster profoundly negative stigmas about people with substance use disorders, just one of the ways that current policies interfere with the treatment of such disorders.
    Fact – current policies put people who are sick and who deserve compassionate and treatment for their illness in prison instead of into a doctor’s care.
    And just for you and your desire to treat people with pain, without dealing with non-pain related narcotic seekers;
    Legalization will make it quite possible for those seekers to find their drugs without forcing them to harass you and other doctors. It would be easy enough to formulate policies that will encourage patients with legitimate pain management needs to see you rather than self medicating, while preventing recreational drug seekers from harassing you.
    And of course the final fact I will address;
    Fact – current drug policy costs taxpayers across the U.S. tens of billions of dollars in expenditures and deprives us of massive tax revenues. Formulating a legalization, strict regulation model that sets aside a specific percentage of those tax revenues for addiction research and treatment, while setting aside more to compensate for the addition cost of healthcare incurred through the use of these drugs would be an unquestionable boon for the treatment of substance use disorders. It would also provide the opportunity to treat the underlying mental illness of the vast majority of people with comorbidity to their substance use disorder.


  25. DuWayne Says:

    It just occurred to me that I could have summed up the previous post rather more succinctly;
    Those questions and others have been considered and very strongly inform my position on drug policy. Not just my position on drug policy, but also the positions of a huge proportion of APA members who treat substance use disorders.
    And I forgot to address the “controversy” about cannabis. The controversy is honestly mostly about the science of cannabis and a lot of people who deny said science.


  26. SurgPA Says:

    @25 –
    So it sounds like you actually agree with DM’s statement, and your argument is that you have (at least for yourself) already addressed his questions. In terms of the legal vs illegal drugs, I guess I didn’t read his statement to be exclusive only to drugs that are currently illegal; the legality of individual substances seems fairly arbitrary and not based on a consistent rational evaluation of each drug.
    I absolutely agree with you about the cannabis “controversy.” Unfortunately, many of those trying to influence public policy (on both sides) don’t.


  27. DuWayne Says:

    The reason I focused on illicit drugs, was because that was the context of the response he was making. And I rather adamantly disagree with him both because the questions he poses have been exhaustively considered and because he ignores other critical components of what should be speaking to drug policy.
    I understand that there is still a great deal to learn about the overt harm caused by the use of various drugs – both in the short and longterm. But there are always going to be more questions and ultimately we already know a great deal about the harm caused – certainly enough to inform public policy.
    And the premise of his last question is inherently flawed. For the most part, we have a very solid understanding of the few universal aspects of what causes people to continue using a substance. We even have a very good understanding of many non-universal reasons that people initiate use and continue to use after initiation and develop substance use disorders. I will use myself and my own substance use disorder as an example.
    Excepting for the mechanical aspects of the underlying neurobilogical pressures, I can go into a fairly exhaustive and accurate assessment of my relationship with mind altering substances. I can explain exactly why I initiated use – what the driving force behind my desire to alter my mind those first few times. And I can explain in both colloquial terms and in terms of specific psychopathology terms. I can even explain it all to some degree in neurobiology terms. The psychosocial input into that relationship is far more complicated and I will admit that it is unlikely I could describe a completely comprehensive picture of my continued use, but I could provide enough information to help inform someone else about things they should watch for if they meet certain, specific risk factors.
    And I have sat down with and garnered enough information from other people with substance use disorders, trying to help others with addiction issues to provide similar assessments of what drove their initiation and sustained use. A few years more of formal education and I will be able to provide official diagnosis. But there are simply too many relative factors – including factors that are dramatically different from each other, to come up with a singular answer to that question. I mean the question DM is asking there is a lot like asking an oncologist what they think the cure for cancer will look like.
    I have repeatedly decried the absurdity of the lack of communication between people who perform the sort of laboratory research that DM engages in and people who actually treat addiction/are involved in psychological addiction research. And I think that DM’s general demeanor in this discussion is indicative of the need for such communication. DM seems to be so very hyperfocused on the hard science end, that he completely ignores the reality that people who are trying to treat addicts and the addicts themselves are dealing with. He is pretty free with his criticisms of fuckups that come out in the media and I honestly sometimes wonder if he believes that the efforts of those of us who trying very hard to fight this battle on the treatment end are unworthy of consideration.
    He is certainly very comfortable dismissing what we have to say about drug policy wholesale.


  28. Alex Says:

    Look, I’m fine with any drug policy that has the Taliban and the Mexican cartel lords sitting by the freeway off ramp with signs saying “Will work for food.” I suspect that any such policy will probably involve providing free, voluntary rehab for those suffering harms. And it will probably involve fewer non-violent people in prison.
    I think there are excellent, data-driven reasons to support such a stance, not to mention historical examples in favor of my stance. I freely admit to not being as knowledgeable about the detailed scientific data on harms for users as DM is, but I do know that the Mafia’s influence declined greatly in my grandfather’s neighborhood after the 21st amendment. It doesn’t take a rocket scientist, or a neuroscientist, to grasp that.
    DM focuses on a very specific aspect of the problem, mocks anybody who takes a stance contrary to his without understanding this particular aspect as well as he does, and ignores issues related to crime, law enforcement, foreign policy, race, and class. As per internet tradition, when somebody fails to give sufficient weight to issues of race and class, I shall point my fingers and shout “Privilege! Privilege!”
    I believe that at this point internet tradition dictates that DM must grovel.


  29. DuWayne Says:

    I would just like to make it clear, as I was a bit harsh in my assessment, that I like DM and have a great deal of respect for him. I have my areas of disagreement with him, but there are few bloggers I interact with who I would rather have the opportunity to meet with in person.


  30. Isabel Says:

    There is a pervasive myth, that forms the core of certain people’s arguments around here, that some other participants in the discussions have claimed that cannabis is completely benign. The single example I am aware of of this ever happening is a Rastafarian who blew in and out and left a single comment about a year ago.
    So I call bullshit.
    Specifically, I challenge the next person to make such an assertion to actually quote an example.
    And I predict that this comment will be answered with assertions that this has in fact happened, that I have even done it etc etc blah blah WITHOUT QUOTING ANY EXAMPLES – as usual.
    The ONLY time the words are used are in conjunction with the word relatively, as in “relatively benign compared to alcohol” a statement for which a ton of evidence has been provided. It is dishonest to twist other people’s words and it makes your argument seem weak, since it depends on twisting others’ words.


  31. Zeb Says:

    Thanks to duwayne and alex for their posts. its good to know that other people “get” the angle that I’m coming from.
    Note that my post referred specifically to the black market drug system
    “Impact on health and well being is the heart of the issue.”
    Impact on health and well being (both individually and socially) may be at the heart of our motivation in discussing this issue, but this is not the driver of the phenomenon.
    Find what drivers influence a phenomenon and we have a far better chance of influencing it. That is why I give the original questions that I posted primacy in this debate
    DM, the questions that you responded with are useful questions to ask, but in the context of the black market drug question they are in fact secondary or even tertiary. They will lead to strategys where we are forever trying to “catch up”. Thats because those who ultimately benefit from the drug black market will never ever consider those questions. Who the hell cares about a few toothless dead people way over there?…. I’m doing ok.
    Get my point?
    By the way, this point shouldnt be considered a line in the sand so much as the definition of the overall context. Ask yourselves any questions you please about these issues but at some point in order for the answers that you get to be meaningful they have to be considered in this context.
    Telling people to be naive about what drives the phenomenon that is influencing their lives so pervasively and profoundly is frankly asking for trouble.
    Given what I have seen over the years, what passes for a “war on drugs” might be better described as a “war on accountability” or a “war on transparency” or a “war on harm reduction” or even on my most cynical days as “The Proxy War on the Community At Large”
    Now that we have established an understanding of the wider context that our questions and answers will derive their meaning from, the strategy that will take us closer to the “social engines” that drive the problem is pretty simple. And just a hint about where this will likely NOT take you. Afghanistan and South America
    Here it is:
    Follow the money


  32. Alex Says:

    Given what I have seen over the years, what passes for a “war on drugs” might be better described as a “war on accountability” or a “war on transparency” or a “war on harm reduction” or even on my most cynical days as “The Proxy War on the Community At Large”
    I would add “war on minorities” given so much of the racial history behind drug prohibition. If DM is so concerned with the less privileged, and so aware of his own privilege, why does he mock anybody who opposes a racist policy like the drug war?


  33. Maia Szalavitz Says:

    The idea that “many opioid addicts started out as medical users” is a myth. The vast, vast majority of people addicted to painkillers (addicted, not dependent, and thank God the DSM is finally going to get rid of the term ‘dependence’ as a synonym for addiction– a mislabel that was hell for pain patients) were addicts long before they were ever pain patients (if they were ever pain patients at all).
    Fewer than 3% of people given opioids medically will ever develop addiction– and the vast majority of people who misuse opioids (even if they claim “my doctor made me into an addict”) can be found, on closer inspection, to have long prior histories of drug misuse.
    For example, studies find that 80% of Oxycontin addicts have taken cocaine. That’s more than 4 times the rate in the general population– so unless you believe that grandma is getting Oxycontin and loving it so much she’s going out and finding a coke connection to make up for all those years she missed out on being a dope fiend, the more plausible conclusion is that these addicts either have pain and got painkillers from a doctor (yes, addicts can actually suffer pain! it’s not all fake!) or were otherwise pre-existing hard drug users, not poor innocents “hooked” by evil pharma and docs.
    Yes, people with antisocial personality disorder are over-represented among opioid addicts– and that’s where we get the reputation of being “lying manipulative etc.” But the vast majority of people with antisocial personality disorder are not opioid addicts and the vast majority of opioid addicts (outside of criminal justice populations, which are obviously skewed) don’t have ASPD.
    The idea that certain types of drugs are associated with certain types of “bad people” is simply a creation of our drug laws. In the 1800’s, the most common opioid user was a middle class housewife.


  34. DuWayne Says:

    The idea that certain types of drugs are associated with certain types of “bad people” is simply a creation of our drug laws. In the 1800’s, the most common opioid user was a middle class housewife.
    Yes Maia, but you know who else was doing it don’t you? Actors, writers and even people who liked to DANCE!!!!1!11!! I mean sure, a middle class housewife at first. But the next thing you know they are sneaking out in the middle of the night to go dance and engage in SATANIC ORGIES!!!11!111!!!!
    Working as a handyman and remodeler, I often came across really old newspapers, because they used to put them under certain types of flooring. I scored a major cue one day, when I came across a rather long op-ed by a minister who was talking about the drug scourge and it’s attendant evils. His screed made Reefer Madness and other PSA’s from that time look sane. About the only thing I think might have been in his favor, was that it may not have been his own bullshit. He claimed to be talking about a young female parishioner who had ended up pregnant. I would assume she was a very imaginative young lady. The story was from the teens.
    I think that one of the best resources is the Consumers Union Report book on licit/illicit drugs from the early seventies. I actually had a hard copy of it at one time (totally great score – it was in on the cheap shelf of a used book store), but shed it when I moved out to Oregon. It can be found online at the Schaffer Library. The difference between opiate addicts pre-prohibition and post is very striking.


  35. Passerby Says:

    Interesting topic, obviously a powder-keg for polarizing opinion.
    Like Becca, I’ve known lifelong nicotine addicts, including one who is a senior biochemistry investigator with many liver P450 papers and more than a casual knowledge of the various molecular pathway effects of drug metabolism.
    This person will not give-up smoking – despite having a prior history of cancer. Never tried to quit; it’s simply not an option. He is also a low-key alcoholic.
    He is what I would call a soft-addict. He tried various recreational narcotic drugs as a kid, but has never become addicted to them.
    I used to believe that the underlying biochemistry behind addiction was relatively straightforward. This individual has lifestyle habits that might contribute to a cycle of self-harm and self-medication: poor sleep hygiene, very unhealthy diet, and longterm nutritional deficits that could be attributed to, or worsened by, nicotine addiction and alcoholism.
    But there is something I learned about him long ago, that he had personality traits that were (according to family) a throwback to a very cold, harsh and dictatorial grandparent – total lack of personal empathy and tendency towards self-serving manipulation, with a lack of demonstrated care if substance abuse habits harmed others.
    An excellent case of don’t-give-a-shit attitude: an truely manipulative and self-serving individual who smoked heavily around a wife with a family history of breast cancer for years. He fed her chocolate addition quite purposefully to quell her dislike of his smoking, continued to smoke in her face throughout her final years with terminal cancer, and was adamant that he his smoking had no physical association with the development of severe asthma in his grandchildren, whom they raised for quite a few years.
    This person also has very poor sleep hygiene and diet that of zero fruits and vegetables, heavy in saturated fat, salt and preserved meats.
    The association of personality traits with substance abuse has given me pause, because at one time, I would have asserted that the cart (addiction) came before the horse (personality tendencies associated with soft drug abuse).
    I dunno. Maybe low social feel good hormones drives a tendency towards trying continued use of addictive substances because they are common to a particular pattern of socialization (drinking and smoking at bars with friends), where it may facilitate social ease.
    I suspect they aren’t hooked unless these same substances boost flagging dopamine production (self medication). They are really hooked, however, if low natural dopamine levels are further skewed by substance feedback (the roller coast high and low). It’s a carrot and stick routine that has them constantly responding to ingrained environmental cues.
    I think DM has hit the vital spot in the argument, that we need to better understand the neurochemical deficits and personality traits that may contribute to substance abuse susceptibility. I don’t think one size fits all.
    Really good post, DM.


  36. Anon Says:

    I think MD’s don’t like certain types of drug abusers because anyone that shoots heroin/meth/smokes crack has no regard for their life. Docs are there to save lives, so when people are actively working against this, with no care on the world, this can be irritating, I am sure. I know this is a generalization, but after nearly a decade of daily H use (quit 8 years ago), I have found this to be a common denominator among abusers. BTW, most docs were very nice to me, I think it was because I was 100% honest and upfront with them. (hard not to be with the scars I’ve got :))
    “Normal” people smoke and drink, smoke pot. “Normal” people even get mixed up with pills, and even try cocaine in college. People who do the drugs that are known to be deadly and very addictive (meth, crack, heroin) are often outside of whats considered “normal”. Not always- but often enough to make it a generalization that most people believe. Its seen as the ultimate taboo to shoot drugs, only a little less to smoke crack/meth, the only people that take it that far are usually outcasts/rebels/etc- after all, you obviously don’t care for laws, social standards, or your own health and well being if you are spending your days doing these things…….
    Are narcotics users any more dishonest than normal people? Were they this way before they started, or just after? When I used every day, I never stole, lied for meds, or abused others. I had a job, and I worked hard at it, then spent what I had on my heroin addiction. From my experience of H users, it was about 70/30- 70% were sleazy thieves you couldn’t leave alone in your house, 30% were normal, ethical and worked all the time (at normal jobs) to support their addiction. Crack smokers were more like 90/10, meth was 90/15. I don’t know why the differences, but I thought I would add my experience, since it’s been extensive!
    One last note about annoying drug users- those that have internalized the 12 step philosophy are ALWAYS the WORST behaved. They have learned (been brainwashed) that they are “powerless” and “unable to control their use” without the grace of a “higher power”, and they use it as an excuse to go off the rails, often subconsciously. Its a philosophy that is not only not scientifically proven, but also dangerous to those who are exposed to it. Addicts without these beliefs were more able to modify their behavior, and didn’t go all the way “to bottom” before quitting.
    (Ok, off my soapbox now…..)


  37. DrugMonkey Says:

    Nice try Alex. Please show where I mock anyone for their opposition to any drug policy. If I grow frustrated with individuals expressing such viewpoints it is not for this that I criticize them. It is for their denial of the science, and sometimes their inability to discuss science independent of policy. A little thought experiment for you: Does Highly Allochthonous Chris have to discuss the inequities of building standards ever time he mentions plate tectonics?


  38. Passerby Says:

    >Does Highly Allochthonous Chris have to discuss the inequities of building standards ever time he mentions plate tectonics?
    This made me burst out laughing! Good point, although few of your readers will be regulars of Chris’ informative blog.
    Could have an interesting spin: we’ve seen 3 cases in as many months of large earthquakes destroying traditionally built and recently built structures that were ‘not to code’ – relatively earthquake proof. In each case, the poor were the worst affected.
    Despite the fact that the upper practical engineering design limit is MG 8.5-9, relatively few structures that employed regulated materials and structural reinforcement ‘to code’ suffered substantial damage in Chile. They learned their lesson in that very large mid-60s earthquake.
    Now, we have an interesting potential case, brought up by Chris, of Istanbul Turkey. Sits on major fault system that hasn’t released stress for many, many decades. Istanbul has a dismal building code history, with nearly 90% of structures ‘not to code’ because it has few warning signs of impending earthquake in recent decades. Istanbul also has a very large shanty-town on it’s outskirts. This is where many lives will be lost in the event of a moderately powerful earthquake (Mag 5-6).
    The region, and Turkey in particular, have suffered several warning earthquakes in this same 3 month period. It would be prudent to raise red flags now, before the worst happens and there is time to make some improvements that will save lives.
    But you know, I rather think it might fall on deaf ears, because Turkish civil engineers and geologists have given the same warning in the past. They were ignored.
    Officials that ignore warnings after several recent earthquakes in their country share the self-deception common to nearly all substance abusers: the worst will not happen here.


  39. SurgPA Says:

    @33- Maia wrote: “studies find that 80% of Oxycontin addicts have taken cocaine. That’s more than 4 times the rate in the general population– so unless you believe that grandma is getting Oxycontin and loving it so much she’s going out and finding a coke connection to make up for all those years she missed out on being a dope fiend…”
    Please don’t conflate correlation with causation. Or are you saying the 80% were cocaine addicts before they ever had oxycontin? The quote above could as easily be interpreted that oxycontin use leads to cocaine use as vice versa.
    “Yes, people with antisocial personality disorder are over-represented among opioid addicts”
    Is this really true? More so than people addicted to other substances? Because this might actually help explain the original question (over at PalMD’s WCU) “why do doctors dislike narcotics users?”. What are the rates of APD among opioid addicts, alcoholics, smokers, and non-abusers?


  40. Isabel Says:

    “Nice try Alex. Please show where I mock anyone for their opposition to any drug policy.”
    Calling the opposition the “legaleez it crowd” as if they are all stoned Rastafarians and slacker surfer dudes who spend all their time chanting inanely at smoke-ins and so on may be a gentle form of mockery, but it’s still mockery.
    “It is for their denial of the science”
    I already responded to this above
    “and sometimes their inability to discuss science independent of policy.”
    Ah, but YOU are usually the one to bring up policy right in your OP! My main objection, after all!


  41. DuWayne Says:

    SurgPA –
    I wouldn’t read much into a higher incidence of ASPD among opiate abusers – more accurately amongst people with any substance use disorder. The odds are pretty good that ASPD will either be removed from the new DSM, or the criteria will be significantly changed. I mean it is pretty fucking ridiculous, as you can apply it to most any person who had a particularly shitty childhood. And one of the potential diagnostic criteria is substance abuse problems.
    Not to mention that virtually all of the diagnostic criteria for ASPD are significant risk factors for substance use disorders.
    ASPD is basically a label to apply to people who had a crap childhood and who weren’t one of the lucky few who managed to pull out of it.


  42. SurgPA Says:

    Yes, I’m actually quite suspicious of her claim. I guess the incredularity of my reaction didn’t come through in my response.


  43. pttugas Says:

    The key is telling your body there won’t be any more famines. There are two primary ways of doing this:
    1. Eat real food. When you’re eating quality food and it’s assimilated efficiently, the body begins to receive what it needs to function at its best. This is one very important step in turning off the famine response. The presence of nutrient-dense food in the diet signals to the body that there is plenty of food available and there’s no need to pile on fat stores. Digestion is also an important part of this equation because you want to make sure the real food you eat is assimilated properly. Including raw and cultured foods in your diet on a regular basis can improve your digestive health and ensure you’re getting the most out of your food.
    2. Reduce stress. Another folly of modern society is the intense level of stress most of us are exposed to, often since very early childhood. Stress induces the famine response as much as dieting. After all, the body doesn’t distinguish between types of stresses; the same biochemical reactions occur whether you’re stressed by your work, a difficult marriage, lack of real food, poor sleep habits or any number of stressors. So it’s very important to address this and take the appropriate steps to reducing and managing the stress in your life. Read more about the stress connection to weight loss here and here and here.
    Without addressing these two components, a healthy body composition is virtually impossible to achieve. Plus, healthy food choices reduce stress, and reducing stress makes it easier to choose healthier food. So making one small change at a time really can add up, and the right choices will come more naturally over time. Granted, this involves patience and won’t produce results like “Lose 10 pounds in one week!” But it will set you on the path to lasting health.


  44. DrugAddictsRLosers Says:

    Drug addicts are disgusting scums of the earth. They make a mess out of everything. They’ll take ANYTHING you have that is of any value just to get their next high. I’ve known one whose beatne me up in the past just because I refused to give him any of my hard earn money so his low-life ass can get another hit. They take NO responsibility for their mess and drama! They are like CANCERS.

    Nothing but users, liars and deniers those hard core drug addicts. And they wonder why their family and friends walk away from them. Fed up and sick of their bullshit is why.


  45. DrugMonkey Says:

    So is it your opinion that they either 1) started as such “scum” or 2) are irretrievably lost? ’cause we still should try to help them, right?


  46. Sandra Watson Says:

    My son has an opiate addiction and is currently starting treatment. I definitely have something to add about behavior. When he is using opiates he has a severe inhibition of socially acceptable ways of behavior. I don’t mean the lying and manipulation that go with this kind of drug use. I mean an argumentative and aggressive attitude that one usually associates with over indulgence in alcohol. He becomes obnoxious and will get loud or fight over anything after the initial slowed down and falling over condition. About a half hour after he uses he becomes awake and aware but is an awful person and is just as rude as he can be. I cannot wait for his treatment (suboxone therapy) to begin as he is unbearable in his current condition. Im going to encourage him to get mental health counceling as well as I suspect he has co-occuring mental health problems along with the addiction.


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