When Joseph Califano uttered his famous declaration, the hope among many of us in healthcare was that it would help to refocus our attention on perhaps the most important driver of illness and societal dysfunction. Unfortunately, it did not and we still find ourselves mired in erroneous and inconsistent attitude, behavior and policy with regard to drugs, drug users and drug problems. A big part of the problem in my opinion lies in the attitudes that we have toward the drugs themselves but also toward the drug users, the drug suppliers and how we define the trouble with the individual drugs. We make a big mistake, again in my opinion, when we see the differences in drugs and the circumstances surrounding their use rather than the commonality that exists for all drugs. Let's take a closer look.
When I say "drugs", I mean all drugs. If you were thinking only about narcotics or cocaine or methamphetamine, etc. then you were already making the mistake I was describing above. To really understand and address the drug problem, we need to include all mind and mood altering substances. In no particular order, the drugs I think we should examine are: alcohol, marijuana, "hard drugs" i.e. narcotics, stimulants, sedatives, and hallucinogenics, tobacco, caffeine, prescription drugs and over the counter (OTC) drugs. This is likely to get confusing as there are many moving parts. I usually present the information as a table with the individual drugs on the horizontal axis and the societal attitude about the drug, the user/abuser, the pusher/supplier and the definition of trouble on the vertical. As you read, it might be helpful to fill in your own table as the information is pretty easy to see in that format.
Okay, let's start. Alcohol is seen by the larger society as acceptable. It's everywhere and it's legal. Restrictions on obtaining it or using it are very lax. The user of alcohol is also acceptable and the abuser is seen as sick. We cover treatment for alcohol trouble throughout healthcare. The pusher/supplier is seen as a businessman. Anheuser-Busch, Miller Brewing or the local craft beer maker are thought of as pretty good guys. Remember Pete Coors talking to us from the foothills of Colorado? He actually ran for the Senate in 2004. Not sure if that adds to the "good guy" image or not. The diagnosis of alcohol trouble or alcoholism is based either on the trouble caused by the drinking e.g. cirrhosis of the liver, heart disease, pancreatitis, lost job, etc. or the type of use e.g. drinks very heavily and often, gets "drunk". Whether we see ourselves or someone else as alcohol-troubled usually depends upon who in our lives is obviously in trouble themselves. So it could be our father or grandfather or uncle although women are just as troubled as men these days. Or else, it's the stereotyped older-than-we-are, down and out, unemployed, scruffy male.
Marijuana is interesting as our societal attitude about it has undergone, and is still undergoing, a significant shift. Once lumped in with the "hard" drugs, pot was pitched a few years ago as medicine and lately is being legalized as a "recreational" drug. In my view, our attitude about pot is decidedly mixed with proponents and opponents poised to scream at each other at a moments notice. So pot is either acceptable or unacceptable depending on your point of view. This ambivalence is expressed in policy as the drug may be legalized by an individual state but be illegal federally. The user/abuser of marijuana is again either OK or not OK depending upon your attitude about the drug itself. A "pothead" may be seen as sick and in need of treatment. The pusher/supplier is seen either as a benevolent green grocer/businessman or as an evil supplier of death and destruction, once again dependent upon how you view the drug itself. Trouble with marijuana is defined by use itself , if the drug itself is unacceptable, or by the trouble e.g. paranoia or the type of use e.g. "he's stoned all the time", "he's a pothead". Nobody I know in the substance abuse treatment community thinks marijuana is medicine. What we do think is that it is the best chemical demotivator on the market today.
Next, "hard" drugs. These are the substances most people think of when they hear the term "drugs". They are narcotics like heroin or oxycontin, stimulants like cocaine, crack or methamphetamine, sedatives like Seconal or hallucinogens like LSD or mescaline. Hybrids like MMDA or ectasy are also lumped into this category. Our societal attitude about these drugs is that they are unacceptable. The user/abuser of these drugs is unacceptable as well. They are the drug addicts who prey upon their families and larger society to support their habit. The pusher of these drugs is evil and the harshest legal penalties we have are reserved for them. We don't ask if there is trouble associated with using these drugs, we say using these drugs is trouble. The circumstances surrounding their use don't matter. Use alone matters. As we'll see later though, the circumstances do matter if the Seconal is picked up at a local CVS or is bought on a street corner. Same drug but everything about it and its use is looked at differently.
Next up, prescription and over-the-counter drugs. Acceptable does not begin to describe societies' attitude about these drugs. They are medicine for god's sake. What could be better. The user/abuser is a patient. They're hurting and need help. The pusher is a doctor and so is inherently a good person. If they get into trouble with any of these drugs, they are clearly victims of an unintended consequence. In primary care, these drugs include opiates like Oxycontin, stimulants like Aderrall, sedatives like Seconal and anti-anxiety agents like Xanax and Ativan. Because of the opioid crisis, our attitude about narcotics has changed a bit. Doctors who prescribe without much oversight have been called out, even charged with malpractice. Drug companies, never anyone's darlings, have been held responsible for the doctor prescribing, the pharmacy filling and the patient taking and overtaking the drug. OTC drugs are typically less abuseable but can contain ingredients that are habit forming like caffeine to keep you awake or alert, antihistamines to promote sleep or reduce anxiety and narcotic-like drugs in some cough preparations.
Tobacco contains the drug, nicotine. Our attitude about cigarette smoking, the most common way to ingest nicotine, has changed over time. In the 1930's, doctor's sometimes endorsed smoking cigarette on billboards. Over time, the health hazards of smoking became well-known and our societal attitude which had been largely acceptable morphed into something more mixed. Smoking is frowned upon in most circles but tolerated. The user is either OK or unacceptable depending upon the attitude toward the substance itself. Pipes or cigars and chews are also viewed in mixed ways. Some smokers are viewed as sick but usually because of the negative physical effects; others because of the way they use i.e. chain smoking. The pusher is either a businessman or a bad person, again depending on the attitude about the substance. Trouble is either the negative effects e.g. COPD, lung or throat cancer, etc. or the type of use e.g. chain smoking. Due to the curious settlement between the tobacco companies and most States about reimbursement for Medicaid costs, the tobacco companies fell on their sword and accepted financial responsibility for the illnesses caused by people using their products. In perpetuity no less. In return, the States agreed not to speak of tobacco and smoking ever again. As I indicated, our attitude about tobacco is very inconsistent. While smoking on airplanes or in restaurants is forbidden, smoking in movies seems to be as frequent as ever. In the recent COVID epidemic, an upper respiratory nightmare, I never saw any governmental attempt to reduce cigarette use, or alcohol use for that matter, despite near criminal sanctions for not wearing a mask. Smoking accounts for 450,000 deaths per year in the United States, second only to alcohol. Among younger people, vaping has become a viable alternative to cigarette smoking and can be used to ingest not just nicotine but other drugs as well.
Caffeine is an acceptable drug in our society but has run into some opposition in recent decades with the advent of decaffeinated coffees and soft drinks. The user/abuser is either OK or sick depending upon trouble or type of use. The pusher is a businessman and trouble is defined by negative effects e.g. agitation or type of use e.g. drinks 20 cups a day.
So we have looked at our societal attitudes about drugs of abuse and about some of the circumstances surrounding them. If you populated a table, it's easy to see the differences among the drugs and the differing attitudes that we have about who uses them, who supplies them and what constitutes trouble, attitudes that can differ even though it's the same drug e.g. oxycontin bought on the streetcorner or by prescription at CVS. Or in the case of alcohol and sedatives, they are the same drug in terms of action and metabolism so that when you use one of them, you are in effect using the other one as they are perfect substitutes. As enlightening as that can be, my hypothesis is that it is the commonality, not the differences, that we should be highlighting.
Why on earth do people use these drugs? That is the basic question we need to answer if we are ever going to make real headway in solving America's drug problem. Some might say: "it's because they're addicting". Guess what, only some of the drugs in our table are addicting, but all of them are habit-forming. Alcohol and the other sedatives like barbiturates and benzodiazepines (Valium, Ativan, Xanax, etc.) are addicting. Addiction means the drug has tolerance and a withdrawal syndrome. Tolerance means you need a higher doses over time to get the same effect and withdrawal means that the body needs the drug for cell metabolism and, without it, goes into a state of distress. Narcotics are also addicting. Stimulants like cocaine, caffeine or nicotine are not addicting. Neither are the hallucinogenics like THC or LSD. Except in the throes of acute withdrawal, addiction is not why people use the drug. And after a week or so of not using the drug, they're not addicted anymore but they are usually at great risk of using again. What then is the common reason that people use these drugs?
Simply stated, people use drugs to alter consciousness, i.e. to change the way they think and feel. If the drug doesn't alter consciousness, it has no potential for abuse. The desire to alter consciousness can sometimes be satisfied by other means. Meditation, vigorous exercise, gambling, even food can alter consciousness. But drugs do it more easily and more reliably for most people. Those of us in behavioral health are fond of finding psychological explanations for just about everything. When it comes to drug use, however, hypothesizing that a patient shoots heroin because they felt unaccepted by their parents twenty-five years ago is just wrong and worse can easily lead to very bad outcomes. The narcotic user, the cocaine snorter, the alcohol drinker, and the pot smoker do it today because they did it yesterday. And they'll do it tomorrow because they did it today. Effective treatment therefore has to focus on the drug use itself and requires a period of abstinence in order to get away from the confounding direct effects of the drug. Trying to make sense to a person under the influence of a consciousness altering substance is a colossal waste of time. Getting them away from the drug is the first and only order of clinical business. We do have to understand the differences among the drugs when we ask people to stop using them and to provide whatever support is needed for them to safely withdraw whether or not the drug itself meets the requirements for being addicting.
Our attitudes and policies about these drugs are sometimes illogical. For example, alcohol is a sedative drug. Seconal, a barbituate, is a sedative drug. They are for all practical biochemical pruposes the same drug. Alcohol can be purchased legally with an id. Seconal, on the other hand is a Schedule II drug, just like the narcotics, and is therefore among the most highly regulated drugs we have. Schedule II drugs cannot be prescribed over the phone, in some places have a special prescription pad, can only be ordered in a limited amount and cannot be refilled. Either we are dramatically over reacting to the dangers of barbiturates or we are just as underreacting to the dangers of alcohol. Remember if you are using one, you are using the other, perfect substitutes. If regulated by the FDA, alcohol would have to be classified as a Schedule II drug. Many primary care doctors are reluctant to prescribe anti-anxiety drugs due to their potential for abuse. Fair enough but those drugs are the minor leagues compared to alcohol and the other sedatives. If the doctor is going to be concerned about Valium or Xanax or Ativan, where is the comparable concern about alcohol? It's like being concerned about caffeine but not cocaine.
Opiate use and abuse has taken center stage in the war on drugs in the past few years. Once confined to urban centers, opiate use is now represented in all areas of American life. In 2021, there were a reported 80,000 overdose deaths. This is a staggering number given the attention that has been paid to the problem including the widespread availability of Narcan. For those who are not routinely willing to bet their lives seeking a more intense high, it is difficult to understand how a person can be saved from certain death on a Tuesday and be back using on a Wednesday. Well intentioned but ignorant politicians and regulators keep approaching this issue as if the overdose is simply an accident when in reality it is a conscious pushing the envelope to the point of breaking. As awful as the opioid crisis is, the continuing tobacco crisis dwarfs it each and every year. Lung cancer, emphysema, COPD, cardiopathy and stroke claim 450,000 American lives each year. Our national response both from a regulatory standpoint and that of healthcare is almost criminally negligent in my opinion. Though not technically addictive, cigarette smoking is regarded by most of us in the substance abuse treatment field to be the toughest to quit. See how many of clean and sober members at your next AA or NA meeting are smoking in the parking lot or lavatory. In the movies, smoking before sex, after sex, in celebration or to relax is presented convincingly to the audience as normal behavior by the hero or heroine. E-cigarettes and vaping are thinly veiled attempts to wash the stain of smoking from the American scene. What's worse is that they have become yet another vehicle for ingesting more drugs.
When I taught a class of substance trouble in the 80's and 90's, I predicted that our mixed attitude about marijuana would be resolved in legalization. I wish I had been wrong. Marijuana is no more medicine than is heroin, cocaine or LSD. There is plenty of trouble associated with the use of pot. Psychologically, it is perhaps the most powerful demotivator in the drug universe. It is also a self-centering drug, focusing the user's attention inward and creating a drug-induced cloud between the user and the world around them. It appeals especially to the socially inhibited and of course over time increases social isolation. A room full of pot smoking people is not a group, it's a room full of pot smoking individuals. We're seeing the effects more clearly now that pot has been legal in some States like Colorado for a number of years. Poor productivity, lowered academic performance and DWI are some of the significant consequences of legalization.
Because alcohol is so pervasive in our culture and because it wreaks havoc on every organ system of the body, calculating the real cost of using it in economic or medical terms is virtually impossible. At one point, many of us in the field just made an assumption that about half of all human trouble was alcohol-related. Divorce, job loss, depression, violence, crime, myriad health conditions= 50%. Was true then, still true today although other drugs might also be involved. When you hear of an unruly passenger on an airplane, think alcohol. When someone decides to take on the State police from their living room, think alcohol again. And when you do think about alcohol, put it in a brown paper bag. It helps to see things more clearly that way.
I hope this exercise has been useful to you. As my blogs go, it is lengthy but really we're just scratching the surface. Our attitudes about drugs, users, pushers, etc. determine what we see and how we see it. And as long as we see some drugs as inherently good e.g. prescriptions and some as inherently bad, we'll continue to stumble. I've learned a little trick to help me see more clearly. When someone tells me why they're using a drug, I substitute another drug and see how it sounds. "It's been such a tough day, I need a drink." Try: "It's been such a tough day, I need a Valium or a Seconal or my crack pipe." See if it raises any questions. And remember: It's Still Drugs, Stupid!