In discussing the last post with my daughter, she asked why alcohol doesn't fall under the authority of the FDA. The answer is actually a complicated one but boils down to the way alcohol is viewed by our society. It is not uncommon to see or hear the phrase "alcohol and drugs". Since alcohol is indeed a drug, the phrase is akin to saying about a comparison: "it's like apples and apples", rather than apples and oranges. The more enlightened among us may use AOD, meaning alcohol and other drugs but the need to separate alcohol from other drugs is the real issue. Simply put, our culture does not see alcohol as a drug and therefore we do not see distillers and brewers the way we see pharmaceutical companies and we don't see bartenders as pushers and liquor stores as pharmacies. We have a similar issue with tobacco although the tobacco settlement acknowledged nicotine as an "addicting" substance but stopped well short of providing any actual regulation of its use. Marijuana has gone through an interesting and predictable process from the evils of "Reefer Madness" through quasi-medicine to recreational drug-- accent on the recreational.
Having taught a college course first in alcohol trouble and later substance abuse, I came to believe that there is great commonality among drugs and that the differences are more due to societal attitudes than to biochemistry. To that end, I developed a table of substances with the various substances in the vertical columns and our societal attitudes about the substance, the user/abuser, the manufacturer and/or pusher, and how trouble with the substance is defined. For example, so-called hard drugs--heroin, cocaine, meth, downers-- are unacceptable to society, the user/abuser is unacceptable, the pusher is evil and use alone defines trouble. Prescription drugs on the other hand are thought to be acceptable. They're medicine for god's sake. The user is OK and the abuser is sick. The pusher, the DOCTOR, is good and trouble is defined by the trouble caused by the drug use. The opiate crisis has changed our societal attitudes a bit so that we look at the pharmaceutical company as a business but one with responsibility and the prescriber, the DOCTOR, can be seen as compromised if he/she profits from the prescription. Interestingly, if the prescription drug is obtained on the street corner from a pusher rather than from CVS, then it is considered a hard drug and everything and everyone involved is unacceptable. Remember the very same drugs sold on the street corner can be found on the shelves of CVS and Walgreens. How the user obtains them determines how we see them and how we treat them. If they are pushed by the DOCTOR, then even if they are abused, we see the abuser as sick. If the abuser buys them on the street corner, we might put them in jail and we certainly will put the seller/pusher in jail. In fact, the harshest mandatory sentences were for selling drugs.
Let's look at alcohol. As a society, we think that alcohol is fine. The third of Americans that don't drink might object for themselves but, since the Noble Experiment failed, they are probably not going to try to tell you what to do. The user is a hale-fellow-well-met or a connoisseur or a good ol' boy or girl. A good person, not a druggie. The abuser is sick and needs help. The pusher is a businessman and may even be a loving steward of a centuries old recipe. Certainly, not like the guy on the street corner. Heck, he may even be the friendly bartender you can confide in. Pete Coors is no criminal. Trouble is defined by the trouble that results from use or the type of use e.g. "he drinks like a fish". For the life of me, I do not understand why the States or lawyers have not gone after the distillers and brewers. Alcohol causes all manner of medical problems including cancer, diabetes, heart disease, cirrhosis of the liver and organic brain syndrome to name only a few. If pharmaceutical companies can be held responsible for people abusing a drug that requires a prescriber, how can the manufacturer of alcohol that doesn't require an intermediary escape responsibility? The only answer I can come up with is that no one wants to rock the alcohol boat even though there are untold billions at stake.
Caffeine has never been seen as a true drug of abuse although the movement decades back toward decaffeinated beverages did acknowledge some problems associated with its use. The drug is therefore considered acceptable as is the user. The abuser is sick and needs help. No one I know wants to hold Starbucks responsible for people who ingest too much caffeine as we clearly do not see it as a significant contributor to severe illness or disease even though it raises blood pressure and taxes the heart.
Since I developed the attitude table, society has changed the way it looks to some degree at tobacco/smoking and to an even greater degree about marijuana. As a result, we have mixed feelings about the users/abusers and pushers of these substances. There are still segments of our society that see smoking as an individual right and others who see marijuana as a benign substance and the green grocer as providing a needed service. As I indicated in the first blog, money is very much at the root of these more permissive attitudes and creates a conflict of interest for governmental agencies that is inescapable. We use drugs because they alter consciousness. If the drug does not do that, then we don't use it. That commonality helps us to understand the user and underlies effective treatment. I want all of you who reads this to examine your own attitudes about all drugs to see if you are seeing clearly. Most of us are not because we look at the circumstances of the use-- where did the person get the drug, why do they say they are using it-- rather than seeing the common reason for the use, namely alteration of consciousness. As Secretary of HEW, Joseph Califano, said decades ago: It's Drugs, Stupid". It was true then and it's true today.