America's Atered States

America's Altered States

"When does legal relief of pain become illegal pursuit of pleasure?"

By Joshua Wolf Shenk

My soul was a burden, bruised and bleeding. It was tired of the man who carried it, but I found no place to set it down to rest.

Neither the charm of the countryside nor the sweet scents of a garden could soothe it.

It found no peace in song or laughter, none in the company of friends at table or in the pleasures of love, none even in books or poetry.... Where could my heart find refuge from itself? Where could I go, yet leave myself behind?

St. Augustine

To suffer and long for relief is a central experience of humanity. But the absence of pain or discomfort or what Pablo Neruda called "the infinite ache" is never enough.

Relief is bound up with satisfaction, pleasure, happiness—the pursuit of which is declared a right in the manifesto of our republic.

I sit here with two agents of that pursuit: on my right, a bottle from Duane Reade pharmacy; on my left, a bag of plant matter, bought last night for about the same sum in an East Village bar from a group of men who would have sold me different kinds of contraband if they hadn't sniffed cop in my curiosity and eagerness.

This being Rudy Giuliani's New York, I had feared they were undercover. But my worst-case scenario was a night or two in jail and theirs a fifteen-year minimum. As I exited the bar, I saw an empty police van idling, waiting to be filled with people like me but, mostly, people like them, who are there only because I am.

Fear and suspicion, secrecy and shame, the yearning for pleasure, and the wish to avoid men in blue uniforms. This is (in rough, incomplete terms) an emotional report from the front.

The drug wars—which, having spanned more than eight decades, require the plural—are palpable in New York City. The mayor blends propaganda, brute force, and guerrilla tactics, dispatching undercover cops to call "smoke, smoke" and "bud, bud"and to arrest those who answer.

In Washington Square Park, he erected ten video cameras that sweep the environs twenty-four hours a day. Surveillance is a larger theme of these wars, as is the notion that cherished freedoms are incidental. But it is telling that such an extreme manifestation of these ideas appears in a public park, one of the very few common spaces in this city not controlled by, and an altar to, corporate commerce.

Several times a month, I walk through that park to the pharmacy, where a doctor's slip is my passport to another world. Here, altering the mind and body with powders and plants is not only legal but even patriotic. Among the souls wandering these aisles, I feel I have kin. But I am equally at home, and equally ill at ease, among the outlaws. I cross back and forth with wide eyes.

What I see is this: From 1970 to 1998, the inflation-adjusted revenue of major pharmaceutical companies more than quadrupled to $81 billion, 24 percent of that from drugs affecting the central nervous system and sense organs. Sales of herbal medicines now exceed $ 4 billion a year. Meanwhile, the war on Other drugs escalated dramatically. Since 1970 the federal antidrug budget has risen 3,700 percent and now exceeds $17 billion.

More than one and a half million people are arrested on drug charges each year, and 400,000 are now in prison.

These numbers are just a window onto an obvious truth: We take more drugs and reward those who supply them. We punish more people for taking drugs, and especially punish those who supply them. On the surface, there is no conflict. One kind of drugs is medicine, righting wrongs, restoring the ill to a proper, natural state.

These drugs have the sheen of corporate logos and men in white coats. They are kept in the room where we wash grime from our skin and do the same with our souls.

Our conception of illegal drugs is a warped reflection of this picture. Offered up from the dirty underworld, they are hedonistic, not curative. They induce artificial pleasure, not health. They harm rather than help, enslave rather than liberate.

There is some truth in each of these extreme pictures. But with my dual citizenship, consciousness split and altered many times over, I come to say this:

The drug wars and the drug boom are interrelated, of the same body.

The hostility and veneration, the punishment and profits, these come from the same beliefs and the same mistakes.

I. Before marijuana, cocaine, or "Ecstasy," before nitrous oxide or magic mushrooms, before I had tried any of these, I poked through the foil enclosing a single capsule of fluoxetine hydrochloride.

My drug story begins at this point, at the end of a devastating first year of college. For years, I had wrapped myself in an illusion that my lifelong troubles-intense despair, loneliness, anxiety, a relentless inner soundtrack of self-criticism would dissolve if I could only please the gatekeepers of the Ivy League.

By the spring of freshman year, I had been skinned of this illusion and plunged into a deep darkness. From a phone booth in a library basement, I resumed contact with a psychiatrist I'd begun seeing in high school.

I told him how awful I felt, and, after a few sessions, he suggested I consider medication. By now our exchange is a familiar one. This was 1990, three years after Prozac introduced the country to a new class of antidepressants, called selective serotonin reuptake inhibitors.

SSRIs were an impressive innovation chemically but a stunning innovation for the market, because, while no more effective than previous generations of antidepressants, SSRIs had fewer side effects and thus could be given to a much broader range of people. (At last count, 22 million Americans have used Prozac alone.)

When my doctor suggested I take Prozac, it was with a casual tone. Although the idea of "altering my brain chemistry" unsettled me at first, I soon absorbed his attitude.

When I returned home that summer, I asked him how such drugs worked. He drew a crude map of a synapse, or the junction between nerve cells. There is a neurotransmitter called serotonin, he told me, that is ordinarily released at one end of the synapse and, at the other end, absorbed by a sort of molecular pump. Prozac inhibits this pumping process and therefore increases serotonin's presence in the brain. "What we don¹t understand," he said, looking up from his pad, "is why increased levels of serotonin alleviate depression. But that's what seems to happen."

I didn't understand the importance of this moment until years later, after I had noticed many more sentences in which the distance between the name of a drug—Prozac, heroin, Ritalin, crack cocaine—and its effects had collapsed. For example, the phrase "Prozac eases depression," properly unpacked, actually represents this more complicated thought: "Prozac influences the serotonin patterns in the brain, which for some unknown reason is found to alleviate, more often than would a placebo, a collection of symptoms referred to as depression."

What gets lost in abbreviation—Prozac cures! Heroin kills!—is that drugs work because the human body works, and they fail or hurt us because the body and spirit are vulnerable. When drugs spark miracles—prolonging the lives of those with HIV, say, or dulling the edges of a potentially deadly manic depression—we should be thankful.(1) But many of these processes are mysteries that might never yield to science.

The psychiatric establishment, for example, still does not understand why serotonin affects mood.

According to Michael Montagne of the Massachusetts College of Pharmacy, 42 percent of marketed drugs likewise have no proven mechanism of action.

In Listening to Prozac, Peter Kramer quotes a pharmacologist explaining the problem this way:

"If the human brain were simple enough for us to understand, we would be too simple to understand it."

Yet pharmaceutical companies exude certainty. "Smooth and powerful depression relief," reads an ad for Effexor in a recent issue of The American Journal of Psychiatry. "Antidepressant efficacy that brings your patients back." In case this message is too subtle, the ad shows an ecstatic mother and child playing together, with a note written in crayon: "I got my mommy back."

The irony is that our faith in pharmaceuticals is based on a model of consciousness that science is slowly displacing.

"Throughout history," chemist and religious scholar Daniel Perrine writes in The Chemistry of Mind-Altering Drugs, "the power that many psychoactive drugs have exerted over the behavior of human beings has been variously ascribed to gods or demons." In a sense, that continues. "We ascribe magical powers to substances," says Perrine, "as if the joy is inside the bottle. Our culture has no sacred realm, so we've assigned a sacred power to these drugs.

This is what [Alfred North] Whitehead would call the 'fallacy of misplaced concreteness.' We say, 'The good is in that Prozac powder,' or 'The evil is in that cocaine powder.' But evil and good are not attributes of molecules."

This is a hard lesson to learn. In my gut, where it matters, I still haven't learned it. Back in 1990, I took the Prozac and, eventually, more than two dozen other medications: antidepressants, antipsychotics, antianxiety agents, and so on.

The sample pills would be elegantly wrapped. Handing them to me, the doctors would explain the desired effect—

this drug might quiet the voices in my head;
this one might make me less depressed and less anxious;
this combination might help my concentration and ease my repetitive, obsessive thoughts.

Each time I swelled with hope. I've spent many years in therapy and have looked for redemption in literature, work, love. But nothing quite matches the expectancy of putting a capsule on my tongue and waiting to be remade.

But I was not remade. None of the promised benefits of the drugs came, and I suffered still. In 1993, I went to see Donald Klein, one of the top psychopharmacologists in the country. Klein's prestige, underscored by his precipitous fees, again set me off into fantasies of health. He peppered me with questions, listened thoughtfully.

After an hour, he pushed his reading glasses onto his forehead and said, "Well, this is what I think you have." He opened the standard psychiatric reference text to a chapter on "disassociative disorders" and pointed to a sublisting called depersonalization disorder, "characterized by a persistent or recurrent feeling of being detached from one's mental processes or body."

I'm still not certain that this illness best describes my experience. I can't even describe myself as "clinically ill," because clinicians don't know what the hell to do with me. But Klein gave me an entirely new way of thinking about my problems, and a grim message.

"Depersonalization is very difficult to treat," he said. So I was back where I started, with one exception. During our session, Klein had asked if I used marijuana. Once, I told him, but it didn't do much. After he had given me his diagnosis, he told me the reason he had asked: "A lot of people with depersonalization say they get relief from marijuana."

At that time, I happened, for the first time in my life, to be surrounded by friends who liked to smoke pot. So in addition to taking drugs alone and waiting for a miracle, I looked for solace in my own small drug culture. And for a time, I got some.

The basic function of antidepressants is to help people with battered inner lives participate in the world around them. This is what pot did for me.

It helped me spend time with others, something I have yearned for but also feared; it sparked an eagerness to write and conjure ideas—some of which I found the morning after to be dreamy or naive, but some of which were the germ of something valuable.

While high, I could enjoy life's simple pleasures in a way that I hadn't ever been able to and still find maddeningly difficult. Some might see this (and people watching me surely did) as silly and immature. But it's also a reason to keep living.

Sad to say, I quickly found pot's limitations. When my spirits are lifted, pot can help punctuate that. If I smoke while on a downward slope or while idling, I usually experience more depression or anxiety. Salvation, for me at least, is not within that smoked plant, or the granules of a pill, or any other substance.

Like I said, it's a hard lesson to learn.

To the more sober-minded among us, it is a source of much consternation that drugs, alcohol, and cigarettes are so central to our collective social lives. It is hard, in fact, to think of a single social ritual that does not revolve around some consciousness-altering substance. ("Should we get together for coffee or drinks?")

But drugs are much more than a social lubricant; they are also the centerpiece of many individual lives. When it comes to alcohol, or cigarettes, or any illicit substance, this is seen as a problem. With pharmaceuticals, it is usually considered healthy. Yet the dynamic is often the same.

It begins with a drug that satisfies a particular need or desire—maybe known to us, maybe not. So we have drinks, or a smoke, or swallow a few pills. And we get something from this, a whole lot or maybe just a bit. But we often don't realize that the feeling is inside, perhaps something that, with effort, could be experienced without the drugs or perhaps, as in the psychiatric equivalent of diabetes, something we will always need help with.

Yet all too often we project upon the drug a power that resides elsewhere. Many believe this to be a failure of character. If so, it is a failure the whole culture is implicated in.

A recent example came with the phrase "pure theatrical Viagra," widely used to describe a Broadway production starring Nicole Kidman. Notice what's happening: Sildenafil citrate is a substance that increases blood circulation and has the side effect of producing erections in men. As a medicine, it is intended to be used as an adjunct to sexual stimulation. As received by our culture, though, the drug becomes the desired effect, the "real thing" to which a naked woman onstage is compared.

Such exaltation of drugs is reinforced by the torrent of pharmaceutical ads that now stuff magazines and blanket the airwaves.

Since 1994, drug-makers have increased their direct-to-consumer advertising budget sevenfold, to $1.2 billion last year. Take the ad for Meridia, a weight-loss drug. Compared with other drug ads ("We're going to change lives," says a doctor pitching acne cream. "We're going to make a lot of people happy"), it is the essence of restraint. "You do your part," it says in an allusion to exercise and diet. "We'll do ours." The specific intent here is to convince people who are overweight (or believe themselves to be) that they should ask their doctor for Meridia.(2)

Like the pitch for Baby Gap that announces "INSTANT KARMA" over a child wrapped in a $ 44 velvet jacket, drug ads suggest-or explicitly say-that we can solve our problems through magic-bullet consumption. As the old saying goes, "Better living through chemistry."

It's the job of advertisers to try every trick to sell their products. But that's the point—drugs are a commodity designed for profit and not necessarily the best route to health and happiness. The "self help" shelves at pharmacies, the "expert only" section behind the counter, these are promised to contain remedies for all ills. But the wizards behind the curtain are fallible human beings, just like us.

Professor Montagne says that despite obvious financial incentives, "there really is an overwhelming belief among pharmacists that the last thing you should do for many problems is take a drug. They'll recommend something when you ask, but there's a good chance that when you're walking out the door they'll be saying, 'Aw, that guy doesn't need a laxative every day. He just needs to eat right. They don't need Tagamet. They just need to cut back on the spicy food.'" It is hard to get worked up about these examples, but they point to the broader pattern of drug worship. With illegal drugs, we see the same pattern, again through that warped mirror.

Not long after his second inauguration, President Clinton signed a bill ear-marking $195 million for an antidrug ad campaign—the first installment of a $1 billion pledge. The ads, which began running last summer, all end with the words "Partnership for a Drug Free America" and "Office of National Drug Control Policy."

It is fitting that the two entities are officially joined. The Partnership emerged in 1986, the year basketball star Len Bias died with cocaine in his system and President Reagan signed a bill creating, among many other new penalties, mandatory federal prison terms for possession of an illegal substance.

This was the birth of the drug wars' latest phase, in which any drug use at all—not abuse or addiction or "drug-related crime”—became the enemy.(3)

Soon the words "drug-free America" began to show up regularly, in the name of a White House conference as well as in legislation that declared it the "policy of the United States Government to create a Drug-Free America by 1995."

Although the work of the Partnership is spread over hundreds of ad firms, the driving force behind the organization is a man named James Burke—and he is a peculiar spokesman for a "drug free" philosophy.

Burke is the former CEO of Johnson & Johnson, the maker of Tylenol and other pain-relief products; Nicotrol, a nicotine-delivery device; Pepcid AC, an antacid; and various prescription medications.

When he came to the Partnership, he brought with him a crucial grant of $ 3 million from the Robert Wood Johnson Foundation, a philanthropy tied to Johnson & Johnson stock. Having granted $ 24 million over the last ten years, RWJ is the Partnership's single largest funder, but the philanthropic arms of Merck, Bristol-Myers Squibb, and Hoffman-La Roche have also made sizable donations.

I resist the urge to use the word "hypocrisy," from the Greek hypokrisis, "acting of a part on the stage." I don't believe James Burke is acting. Rather, he embodies a contradiction so common that few people even notice it—the idea that altering the body and mind is morally wrong when done with some substances and salutary when done with others.

This contradiction, on close examination, resolves into coherence. Before the Partnership, Burke was in the business of burnishing the myth of the fiber-drug, doing his best—as all marketers do—to make some external object the center of existence, displacing the complications of family, community, inner lives.

Now, drawing on the same admakers, he does the same in reverse. (These admakers are happy to work pro bono, having been made rich by ads for pharmaceuticals, cigarettes, and alcohol. Until a few years ago, the Partnership also took money from these latter two industries.)

The Partnership formula is to present a problem—urban violence, date rape, juvenile delinquency—and lay it at the feet of drugs.

"Marijuana," says a remorseful-looking kid, "cost me a lot of things. I used to be a straight-A student, you know. I was liked by all the neighbors. Never really caused any trouble. I was always a good kid growing up. Before I knew it, I was getting thrown out of my house." This kid looks to be around seventeen.

The Partnership couldn't tell me his real name or anything about him except that he was interviewed through a New York drug-treatment facility. I wanted to talk to him, because I wanted to ask:

"Was it marijuana that cost you these things? Or was it your behavior while using marijuana? Was that behavior caused by, or did it merely coincide with, your marijuana use?"

These kinds of subtleties are crucial, but it isn't a mystery why they are usually glossed over. In Texas, federal prosecutors are seeking life sentences for dealers who supplied heroin to teenagers who subsequently died of overdose. Parents praised the authorities. "We just don't want other people to die," said one, who suggested drug tests for fourth-graders on up. Another said, "I kind of wish all this had happened a year ago so whoever was able to supply Jay that night was already in jail."

The desire for justice, and to protect future generations, is certainly understandable. But it is striking to note how rarely, in a story of an overdose, the survivors ask the most important question. It is not: How do we rid illegal drugs from the earth?(4) Despite eighty years of criminal sanctions, stiffened to the point just short of summary executions, markets in this contraband flourish because supply meets demand. Had Jay's dealer been in jail that night, Jay surely would have been able to find someone else—and if not that night, then soon thereafter.

The real question—why do kids like Jay want to take heroin in the first place?—is consistently, aggressively avoided. Senator Orrin Hatch recently declared that "people who are pushing drugs on our kids ... I think we ought to lock them up and throw away the keys."

Implicit in this remark is the idea that kids only alter their consciousness because it is pushed upon them. Blaming the alien invader—the dealer, the drug—provides some structure to chaos.

Let's say you are a teenager and, in the course of establishing your own identity or quelling inner conflicts, you start smoking a lot of pot. You start running around with a "bad crowd." Your grades suffer. Friction with your parents crescendos, and they throw you out of the house.

Later, you regret what you've done—and you're offered a magic button, a way to condense and displace all your misdeeds. So, naturally, you blame everything on the drug. Something maddeningly complicated now has a single name.

Psychologist Bruce Alexander points out that the same tendency exists among the seriously addicted.

"If your life is really fucked up, you can get into heroin, and that's kind of a way of coping," he says. "You'll have friends to share something with. You'll have an identity. You'll have an explanation for all your troubles."

What works for individuals works for a society. ("Good People Go Bad in Iowa," read a 1996 New York Times headline, "And a Drug Is Being Blamed.")

Why is the wealthiest society in history also one of the most fearful and cynical.

What root of unhappiness and discontent spurs thousands of college students to join cults, millions of Americans to seek therapists, gurus, and spiritual advisers?

Why has the rate of suicide for people fifteen to twenty-four tripled since 1960?

Why would an eleven- and a thirteen-year-old take three rifles and seven handguns to their school, trigger the fire alarm, and shower gunfire on their schoolmates and teachers?

Stop searching for an answer. Drug Watch International, a drug "think tank" that regularly consults with drug czar Barry McCaffrey and testifies before Congress, answered the question in an April 1998 press release: "MARIJUANA USED BY JONESBORO KILLERS."(5)

II. In 1912, Merck Pharmaceuticals in Germany synthesized a type of amphetamine, methyl-enedioxymethamphetamine, or MDMA.

It remained largely unused until 1976, when a bio-chemist at the University of California named Alexander Shulgin, curious about reports from his students, produced and swallowed 120 milligrams of the compound. The result, he wrote soon afterward, was "an easily controlled altered state of consciousness with emotional and sensual overtones."

Shulgin's immediate thought was that the drug might be useful in psychotherapy the way LSD had been. In the two decades after its mind-altering properties were discovered in 1943 by a chemist for Sandoz Laboratories, LSD was widely used as an experimental treatment for alcoholism, depression, and various clinical neuroses.

More than a thousand clinical papers discussed the use of LSD among an estimated 40,000 people, and research studies of the drug led to some extraordinary advancesincluding the discovery of the serotonin system. When LSD experiments were restricted in 1962 and again in 1965, Senator Robert Kennedy held a congressional hearing.

"If they were worthwhile six months ago, why aren't they worthwhile now?" he asked officials of the Food and Drug Administration and the National Institute of Mental Health. "Perhaps to some extent we have lost sight of the fact that [LSD] can be very, very helpful in our society if used properly."

The answer to Kennedy's question was that LSD had leaked out of the universities and clinics and into the hands of "recreational users."

It had crossed the line that separates good drugs from bad. LSD was outlawed three years later. In 1970, when a new law devised five categories, or "schedules," of controlled substances, LSD was placed in Schedule I, along with heroin and marijuana. This is the designation for drugs with no accepted medical use and a "high potential for abuse." In 1986, MDMA would be added to that list of demon drugs.

The question is: How does a substance get assigned to that category? What separates the good drugs from the bad?

In the nineteenth century, now-illegal substances were commonly used in medicine, tonics, and consumer products. (The Illinois asylum that housed Mary Todd Lincoln in the 1870s offered its patients morphine, cannabis, whiskey, beer, and ale. Sigmund Freud treated himself with cocaineand, for a time at least, praised it effusivelyas did William McKinley and Thomas Edison.)

A new era began with the federal Pure Food and Drug Act of 1906, which required the listing of ingredients in medical products. Then, the 1914 Harrison Narcotic Act, ostensibly a tax measure, asserted legal control over distributors and users of opium and cocaine.

On the surface, this might seem progressive, the story of a still-young nation establishing commercial and medical standards. And there was genuine uneasiness about drugs that were intoxicating or that produced dependence; with the disclosure required by the 1906 act, sales of patent medicines containing opium dropped by a third. But the movement for prohibition drew much of its power from a far less savory motive.

"Cocaine," warned Theodore Roosevelt¹s drug adviser, "is often a direct incentive to the crime of rape by the Negroes."(6) As David Musto reports in The American Disease, the prohibitions of the early part of the century were all, in part, a reaction to inflamed fears of foreigners or minority groups.
Opium was associated with the Chinese.
In 1937, the Marihuana Tax Act targeted Mexican immigrants. "I wish I could show you what a small marijuana cigarette can do to one of our degenerate Spanish-speaking residents," a Colorado newspaper editor wrote to federal officials in 1936.
Even the prohibition of alcohol was underlined by fears of immigrants and exaggerations of the effects of drinking. On the eve of its ban in 1919, a radio preacher told his audience, "The reign of tears is over. The slums will soon be a memory. We will turn our prisons into factories, our jails into storehouses and corncribs. Men will walk upright now, women will smile and the children will laugh. Hell will be forever for rent."

But the federal authorities, temperance advocates, and bigots had reached too far. Whereas alcohol (like coffee and tobacco) has been a demon drug in other cultures, in Western societies its use in medicine, recreation, and religious ceremonies stretches back thousands of years. Most Americans had personal experience with drink and could measure the benefits of Prohibition against the violence (by gangsters and by Prohibition agents, who, according to one estimate, killed 1,000 Americans between 1920 and 1930) and the deaths by "overdose."(7)

After Franklin Roosevelt lifted Prohibition, subsequent generations knew that the drug, though often abused and often implicated in crimes, violence, and accidents, differs in its effects depending on the person using it. With outlawed drugs, no such reality check is available.

People who use illegal drugs without great harm generally stay quiet.

Alcohol also can be legally used in medicines, such as Nyquil, or used medicinally in a casual waysay, to calm shattered nerves. Demon drugs, on the other hand, are prohibited or seriously limited even in cases of exceptional need. Forty percent of pain specialists admit that they undermedicate patients to avoid the suspicion of the Drug Enforcement Administration. Their fear is justified: every year about 100 doctors who prescribe narcotics lose their licenses, including, in 1996, Dr. William Hurwitz, a Virginia internist whose more than 200 patients were left with no one to treat them.

One of these patients committed suicide, saying in a videotaped message, "Dr. Hurwitz isn't the only doctor that can help. He's the only doctor that will help." Chronic pain, mind you, doesn't mean dull throbbing. "I can't shower," one patient explained to U.S. News & World Report, "because the water feels like molten lava.

Every time someone turns on a ceiling fan, it feels like razor blades are cutting through my legs." To ease such pain can require massive doses of narcotics. This is what Hurwitz prescribed. This is why he lost his license.

But at least narcotics are acknowledged as a legitimate medical tool. Marijuana is not, despite overwhelming evidence that smoking the cannabis plant is a powerful treatment for glaucoma and seizures, mollifies the effects of AIDS or cancer chemotherapy, and eases anxiety. The editors of The New England Journal of Medicine, the American Bar Association, the Institute of Medicine of the National Academy of Sciences, and the majority of voters in California and six other states (plus the District of Columbia) are among those who believe that these uses of marijuana are legitimate.

So does the eminent geologist Stephen Jay Gould. He developed abdominal cancer in the 1980s and suffered such intense nausea from intravenous chemotherapy that he came to dread it with an "almost perverse intensity." "The treatment," he remembers, "seem[ed] worse than the disease itself." Gould was reluctant to smoke marijuana, which, as thousands of cancer patients have found, is a powerful antiemetic.

When he did, he found it "the greatest boost I received in all my years of treatment." "It is beyond my comprehension," Gould concluded, "and I fancy myself able to comprehend a lot, including much nonsensethat any human person would withhold such a beneficial substance from people in such great need simply because others use it for different purposes."

This distinction between "people in great need" and those with "different purposes" is crucial to the argument for the medical use of marijuana.(8) Like Gould, many who use marijuana for medical reasons dislike the "high." Many others don't even feel it. But it is a mistake to think that the reason these people can't legally use marijuana is simply that other people use it for purposes other than traditional medical need. Because the very idea of "medical need" is constantly shifting beneath our feet.

I do not have cancer or epilepsy, or a disabling mental disorder such as schizophrenia. The "other purposes" Gould refers to are, in many ways, mine. The qualities of my suffering are (to simplify) anxiety, numbness, and anhedonia. If these were relieved by a legal drugin other words, if a pharmaceutical helped me relax, feel more alive, have funI would be firmly in the mainstream of American medicine.

This is my strong preference. But when I returned to see Donald Klein this past summer, hoping that new medications might have emerged in the last five years, he told me that "there are lots of things to try but there's only marginal evidence that any of them would do any good."

He also made it clear that I shouldn't get my hopes up. "What you have," he said, "is not a common condition, and it¹s almost impossible [for pharmaceutical companies] to do a systematic study, let alone make money, on a condition that¹s not common."

And so, yes, I turn sometimes to marijuana and other illicit substances for the (limited) relief they offer. I don't merely feel justified in doing so; I feel entitled, particularly since, every year, the pharmaceutical industry rolls out new products for pleasure, vanity, convenience.

When Viagra emerged, it was not frowned upon by the authorities that lead the drug wars. Instead, President Clinton ordered Medicaid to cover the drug, and the Pentagon budgeted $ 50 million for fiscal 1999 to supply it to soldiers, veterans, and civilian employees. Pfizer hired Bob Dole to instruct the nation that "it may take a little courage" to use Viagra.

This is a medicine whose sole purpose is to allow for sexual pleasure; it was embraced by the black market and is easily available from doctors, including some who perform "examinations" via a three-question form on the Internet. But Viagra's legitimacy was never questioned, because it treats a disease—erectile dysfunction. Before Viagra, when the only treatment options were less-effective pills and awkward injection-based therapies, this condition was referred to as impotence.

The change in language is interesting. The "dys" sits on the front of dysfunction like a streak of dirt on a pane of glass. At a level more primal than cognitive, we want it removed. This is what we do with dysfunctions: we fix them. Impotence, on the other hand, meaning "weakness" or "helplessness," is something we all experience at one time or another. Applied to men "incapable of sexual intercourse, often because of an inability to achieve or sustain an erection," the word carries a sense of something unfortunate but part of living, and particularly of growing older.

Thus the advent of Viagra does not simply treat a disease. It changes our conception of disease. This paradigm shift is a common occurrence but is below our radar.Hair loss becomes a disease, not a fact of life. Acid indigestion becomes a disease, not a matter of eating poorly.

If these examples seem to make light of the broadening of disease, the ascent of psychopharmaceuticals makes the issue urgent. Outside the realm of the tangibly physical, the power of drugs and drugmakers is far greater.

What we now know as "anxiety disorder," for example, existed only in theory from Freud's time through World War II.

Xanax & Prozac

In the early 1950s, a drug company polled doctors and found that most had no interest in a medication that treated anxiety.

But by 1970, one woman in five and one man in thirteen were using a tranquilizer or sedative, and anxiety was a mainstay of psychiatry.

The change could be directly attributed to two drugs, Miltown and Valium, which were released in 1955 and 1963, respectively.

The successor to these drugs, Xanax, introduced in 1981, virtually created a disease itself.

Donald Klein had already proposed the existence of something called "panic disorder," as opposed to generalized anxiety, some twenty years before. But his theory was widely refuted, and in practice panic anxiety was treated only in the context of a larger problem.

Xanax changed that.

"With a convenient, effective drug available," writes Peter Kramer, "doctors saw panic anxiety everywhere." Xanax has also become the litmus test for generalized anxiety disorder. "If Xanax doesn't work," instructs The Essential Guide to Psychiatric Drugs, "usually the original diagnosis was wrong.(9)

This is not to say that all specific disorders are arbitrary, just that there is a delicate line to be drawn. "The term 'disease’—and the border between health and disease—is a social construct," says Steven Hyman, director of the National Institute of Mental Health.

"There are some things we would never argue about, like cancer. But do we call it a disease if you have a few foci of abnormal cells in your body, something that you could live with without any problem? There is a gray zone. With behavior and the brain, the gray zone is much larger."

To Hyman's observation, it must be added that, whereas vague dissatisfactions make money for psychic hot lines and interior decorators, diseases make money for pharmaceutical companies.

What Peter Kramer calls psychiatric diagnostic creep is not an accident of history but a movement engineered for profit.We have only begun to grapple with the consequences.

The example of Prozac has been chewed over, but it's worth chewing still more, because it is so typical of a new generation of drugs, which are being used to treat debilitating conditions and also by people with far less serious problems. With Lauren Slater, author of the fine memoir Prozac Diary, we have a case anyone would regard as serious.

Suffering from obsessive-compulsive disorder, severe depression, and anorexia, she had been hospitalized five times, attempted suicide twice, and cut herself with razors. Prescribed Prozac in 1988, she found the drug a reprieve from a lifetime sentence of serious Illness—“a blessing, pure and simple," she writes.

The patients described in Peter Kramer¹s Listening to Prozac are quite unlike Lauren Slater. They share, he writes, "something very much like 'neurosis,' psychoanalysis's umbrella term for the mildly disturbed, the near-normal, and those with very little wrong at all."

The use of Prozac for these patients is not incidental; they make up a large portion, probably a wide majority, of people on the drug. (One good indication is that only 31 percent of antidepressant prescriptions are written by psychiatrists.)

Throughout his book, Kramer flirts with "unsettling" comparisons between Prozac and illegal drugs.

Since Prozac can "lend social ease, command, even brilliance," for example, he wonders how its use for this purpose can "be distinguished from, say, the street use of amphetamine as a way of overcoming inhibitions and inspiring zest."

The better comparison, I suggested in a conversation with Kramer, is between Prozac and MDMA. Both drugs work by increasing the presence of serotonin in the brain. (Whereas Prozac inhibits serotonin¹s reuptake, MDMA stimulates its release.) Both can be helpful to the seriously ill as well as to people with more common problems.

Most of the objections to MDMA

that it distorts "real" personality,
that it rids people of anxiety that may be personally or socially useful,
that it induces more pleasure than is natural

have also been marshaled against Prozac.

Both these drugs challenge our definitions of normalcy and of the legitimate uses of a mind-altering substance. Yet Kramer rejects the comparison. "The distinction we make," he told me, "is between drugs that give pleasure directly and the drugs that give people the ability to function in society, which can indirectly lead to pleasure.

If the medication can make you work well or parent well, and then through your work or parenting you get pleasure, that's fine. But if the drug gives you pleasure by taking it directly, that's not a legitimate use." (Viagra, because it allows men to experience sexual pleasure, falls on the side of legitimacy. But, Kramer said, a drug that directly induced an orgasm would not.)

The line between therapeutic and hedonistic pleasure, however, is awfully hard to draw.

I think of a friend of mine who uses MDMA a few times a month. His is a textbook case of "recreational" use. He takes MDMA on weekends, in clubs, for fun. He is not ill and is not in psychotherapy. But he will live for the rest of his life in the shadow of a traumatic experience, which is that for more than two decades he hid his homosexuality.

Some might say the drug is an unhealthy escape from "the real world," that the relaxation and intimacy he experiences are illusory. But these experiences give him a point of reference he can use in a "sober" state. His pleasure from the drug is entirely socialbeing and sharing and loving with other people.

Is this hedonistic?

"I found it astonishing," Kramer writes of Prozac, "that a pill could do in a matter of days what psychiatrists hope, and often fail, to accomplish by other means over a course of years: to restore to a person robbed of it in childhood the capacity to play."

Perhaps I would find restrictions on MDMA more reasonable if they at least carved out an exception for therapeutic use. Keep in mind, that's where this drug started. After Shulgin's experiment word spread, and thousands of doses were taken in a clinical setting.

As with LSD, MDMA was seen not as a medicine but as a catalyst to be taken just a few times—or perhaps only once—in the presence of a therapist or "guide."

The effects were impressive. Many users found their artifice and defenses stripped away and long-buried emotions rising to the surface. The drug also had the unusual effect of increasing empathy, which helped users trust their therapista crucial characteristic of effective healingand also made it useful in couples therapy.

In a collection of first-person accounts of therapeutic MDMA use, Through the Gateway of the Heart, published in 1985, a rape victim described working through her fears. Another woman described revelations about her son, her weight problems, and "why angry men are attracted to me."

I can hear the skeptics shuffling their feet, wanting data from double-blind controlled trials. But MDMA research never reached that stage. Mindful of what had happened with LSD, the therapists, scientists, and other adults experimenting with MDMA tried to keep it quiet. Inevitably, though, word spread, and a new mode of use sprang up—at raves, in dance clubs, in dorm rooms. An astute distributor of the drug renamed it Ecstasy to emphasize its pleasurable effects. ("'Empathy' would be more appropriate," he said later. "But how many people know what that means?")(10)

As the DEA moved to restrict MDMA, advocates of its medical use flooded the agency with testimony, pleading for a chance to subject the drug to methodical study. The agency's administrative-law judge, Francis Young, saw merit in this argument. In a ninety-page decision handed down in 1986, he recommended that the drug be placed in Schedule III, which would allow for it to be prescribed by doctors and tested further. Young cited its history of "currently accepted medical use in treatment in the United States" and argued that "the evidence of record does not establish that ... MDMA has a 'high potential' for abuse."

DEA officials overruled Young and placed MDMA in Schedule I, with the assurance that its decision would be self-fulfilling. A Schedule I substance cannot be used clinically and can be studied only with great difficulty. So medical use is essentially forever impossible. That leaves illicit use, which, by one common definition, is the abuse for which Schedule I drugs have a "high potential."

Since then, government-funded researchers have sought to document MDMA's dangers. Here we come to the truth about the line and how it is maintained. With rare exceptions, everything we know about legal drugs comes from research sponsored by the pharmaceutical industry.

Naturally, this work emphasizes the benefits and downplays the accompanying risks. On the other hand, the National Institute on Drug Abuse, which funds more than 85 percent of the world¹s health research on illegal drugs, emphasizes the dangers and all but ignores potential benefits.

One recent NIDA-funded study on MDMA was widely reported last fall. Dr. George Ricaurte found, in fourteen men and women who had used MDMA 70 to 400 times in the previous six years, "long-lasting nerve cell damage in the brain." Specifically, Ricaurte found decreases in the number of serotonin-reuptake sites.

The study begs three major questions.

First, do its conclusions really reflect the experience of heavy MDMA users? British physician Karl Jansen reports that he referred MDMA users who had taken more than 1,000 doses and that "they were told by Ricaurte that they had a clean bill of health" but were excluded from his study.

Second, should the brain changes Ricaurte found be called "damage," given that a number of psychiatric medications, Prozac and Zoloft among them, decrease the number of serotonin receptors by blockading them?

As psychopharmacologist Julie Holland writes, "This could be interpreted as an adaptive response as opposed to a toxic or damaged¹ response."

Third, do Ricaurte's findings have any bearing on the use of MDMA in therapy, which calls for a handful of doses over many months?

In this climate, it's hard to know. Charles Grob, a psychiatrist at Harbor-UCLA Medical Center in Los Angeles, has been trying to restart MDMA research for eight years. He received FDA approval to conduct Phase I trials on human volunteers, to see if MDMA is safe enough to be used as a medicine.

But even with his impeccable credentials, the backing of a prestigious research hospital, and an extremely conservative protocol, involving terminal patients, Grob has faced a seemingly interminable wait for permission to begin Phase II, in which he would study efficacy. Grob's struggle explains why he has little company in the research community.

"When you have a drug that's popular among young people," Grob says, "that's the kiss of death when it comes to exploring its potential utility in a medical context."

There is another "kiss of death": lack of interest from industry. I asked Lester Grinspoon, a professor of psychiatry at Harvard Medical School, who led the legal challenge to the DEA's scheduling decision, whether he had approached drug companies about supporting the effort.

"We didn't even consider it," he said. "No drug company is going to be interested in a drug that's therapeutically useful only once or twice a year. That's a no-brainer for them."

"Legal medications are the principal cause of between 45,000 and 200,000 American deaths each year," Shenk notes. "Marijuana, though not harmless," he adds, "has never been shown to have caused a single death."

Profits Not Cures

When you see the feel-good ads from the Pharmaceutical Research and Manufacturer's Association with the tag line "Leading the way in the search for cures," keep in mind that cures—conditions in which medication is no longer required—are not particularly high on the pharmaceutical companies' priority list.

Market potential isn't the only factor explaining the status of drugs, but its power shouldn't be underestimated.

The principal psychoactive ingredient of marijuana, THC, is available in pill form and can be legally prescribed as Marinol.

A "new" creation, it was patented by Unimed Pharmaceutical and is sold for about $ 15 per 10-mg pill.

Marinol is considered by patients to be a poor substitute for marijuana, because doses cannot be titrated as precisely and because THC is only one of 460 known compounds in cannabis smoke, among other reasons.

But Marinol's profit potential—necessary to justify the up-front research and testing, which can cost upward of $ 500 million per medication—brought it to market.

Opponents of medical marijuana claim that they simply want all medicines to be approved by the FDA, but they know that drug companies have little incentive to overcome the regulatory and financial obstacles for a plant that can't be patented. The FDA is the tail, not the dog.

The market must be taken seriously as an explanation of drugs' status. The reason is that the explanations usually given fall so far short.

Take the idea "Bad drugs induce violence."

First, violence is demonstrably not a pharmacological effect of marijuana, heroin, and the psychedelics.

Of cocaine, in some cases. (Of alcohol, in many.) But if it was violence we feared, then wouldn't we punish that act with the greatest severity?

Drug sellers, even people marginally involved in a "conspiracy to distribute," consistently receive longer sentences than rapists and murderers.

Nor can the explanation be the danger of illegal drugs.

Marijuana, though not harmless, has never been shown to have caused a single death. Heroin, in long-term "maintenance" use, is safer than habitual heavy drinking.

Of course, illegal drugs can do the body great harm.

All drugs have some risk, including many legal ones. Because of Viagra's novelty, the 130 deaths it has caused (as of last November) have received a fair amount of attention. But each year, anti-inflammatory agents such as Advil, Tylenol, and aspirin cause an estimated 7,000 deaths and 70,000 hospitalizations.

Legal medications are the principal cause of between 45,000 and 200,000 American deaths each year, between 1 and 5.5 million hospitalizations. It is telling that we have only estimates.

As Thomas J. Moore notes in Prescription for Disaster, the government calculates the annual deaths due to railway accidents and falls of less than one story, among hundreds of categories. But no federal agency collects information on deaths related to legal drugs.

(The $ 30 million spent investigating the crash of TWA Flight 800, in which 230 people died, is six times larger than the FDA's budget for monitoring the safety of approved drugs.)

Psychoactive drugs can be particularly toxic.

In 1992, according to Moore, nearly 100,000 persons were diagnosed with "poisoning" by psychologically active drugs, 90 percent of the cases due to benzodiazepine tranquilizers and antidepressants.

It is simply a myth that legal drugs have been proven "safe."

According to one government estimate, 15 percent of children are on Ritalin.

But the long-term effects of Ritalin—or antidepressants, which are also commonly prescribed—on young kids isn't known.

"I feel in between a rock and a hard place," says NIMH director Hyman. "I know that untreated depression is bad and that we better not just let kids be depressed. But by the same token we don't know what the effects of antidepressants are on the developing brain.... We should have humility and be a bit frightened."

These risks are striking, given that protecting children is the cornerstone of the drug wars.

We forbid the use of medical marijuana, worrying that it will send a bad message.

What message is sent by the long row of pills laid out by the school nurse, or by "educational" visits to high schools by drugmakers?

But, you might object, these are medicines—and illegal drug use is purely hedonistic.

What, then, about illegal drug use that clearly falls under the category of self-medication?

One physician I know who treats women heroin users tells me that each of them suffered sexual abuse as children. According to University of Texas pharmacologist Kathryn Cunningham, 40 to 70 percent of cocaine users have pre-existing depressive conditions.

This is not to suggest that depressed people should use cocaine. The risks of dependence and compulsive use, and the roller-coaster experience of cocaine highs and lows, make for a toxic combination with intense suffering.

Given these risks, not to mention the risk of arrest, why wouldn't a depressed person opt for legal treatment?

The most obvious answers are economic (many cocaine users lack access to health care) and chemical.

Cocaine is a formidable mood elevator and acts immediately, as opposed to the two to four weeks of most prescription antidepressants.

Perhaps the most important factor, though, is cultural.

Using a "pleasure drug" like cocaine does not signal weakness or vulnerability.

Self-medication can be a way of avoiding the stigma of admitting to oneself and others that there is a problem to be treated.

"It's the job of advertisers to try every trick to sell their products. But that's the point—drugs are a commodity designed for profit and not necessarily the best route to health and happiness."

Is Illegal Drug Use a "Disease"?

Calling illegal drug use a disease is popular these days, and it is done, I believe, with a compassionate purpose: pushing treatment over incarceration.

It also seems clear that drug abuse can be a distinct pathology.

But isn't the "disease" whatever the drug users are trying to find relief from (or flee)?

According to the Pharmaceutical Research and Manufacturer's Association, nineteen medications are in development for "substance use disorders."

This includes six products for "smoking cessation" that contain nicotine. Are these treatments for a disease or competitors in the market for long-term nicotine maintenance?

Perhaps the most damning charge against illegal drugs is that they're addictive. Again, the real story is considerably more complicated. Many illegal drugs, like marijuana and cocaine, do not produce physical dependence. Some, like heroin, do.

In any case, the most important factor in destructive use is the craving people experiencecraving that leads them to continue a behavior despite serious adverse effects.

Legal drugs preclude certain behaviors we associate with addiction—like stealing for dope money—but that doesn't mean people don't become addicted to them.

By their own admissions, Betty Ford was addicted to Valium and William Rehnquist to the sleeping pill Placidyl, for nine years. Ritalin shares the addictive qualities of all the amphetamines.

"For many people," says NIMH director Hyman, explaining why many psychiatrists will not prescribe one class of drugs, "stopping short-acting high-potency benzodiazepines, such as Xanax, is sheer hell.

As they try to stop they develop rebound anxiety symptoms (or insomnia) that seem worse than the original symptoms they were treating."

Even antidepressants, although they certainly don't produce the intense craving of classic addiction, can be habit forming.

Lauren Slater was first made well by one pill per day, then required more to feel the same effect, then found that even three would not return her to the miraculous health that she had at first experienced.

This is called tolerance.

She has also been unable to stop taking the drug without "breaking up."

This is called dependence.

There are plenty of addicts who lead perfectly respectable lives,'" Slater's boyfriend tells her. To which she replies, "'An addict.... You think so?'"

Watch XANAX (ANXIOLYTIC ADDICTION & WITHDRAWAL)

Watch EX-PHARMACEUTICAL REP SPEAKS OUT video

Watch CHEMICAL IMBALANCE video

III. Brave New World, Aldous Huxley

In the late 1980s, in black communities, the Partnership for a Drug Free America placed billboards showing an outstretched hand filled with vials of crack cocaine.

It read: "YO, SLAVE! The dealer is selling you something you don't want.... Addiction is slavery."

The ad was obviously designed to resonate in the black neighborhoods most visibly affected by the wave of crack use. But its idea has a broader significance in a country for which independence of mind and spirit is a primary value.

In Brave New World, Aldous Huxley created the archetype of drug-as-enemy-of-freedom: soma. "A really efficient totalitarian state," he wrote in the book's foreword, is one in which the "slaves ... do not have to be coerced, because they love their servitude."

Soma—“euphoric, narcotic, pleasantly hallucinant," with "all the advantages of Christianity and alcohol; none of their defects," and a way to "take a holiday from reality whenever you like, and come back without so much as a headache or a mythology—is one of the key agents of that voluntary slavery.

In the spring of 1953, two decades after he published this book, Huxley offered himself as a guinea pig in the experiments of a British psychiatrist studying mescaline.

What followed was a second masterpiece on drugs and man, The Doors of Perception. The title is from William Blake:

"If the doors of perception were cleansed every thing would appear to man as it is, infinite—for man has closed himself up, till he sees all things thro' narrow chinks of his cavern."

Huxley found his mescaline experience to be "without question the most extraordinary and significant experience this side of the Beatific vision ... [I]t opens up a host of philosophical problems, throws intense light and raises all manner of questions in the field of aesthetics, religion, theory of knowledge."

Taken together, these two works frame the dual, contradictory nature of mind-altering substances: they can be agents of servitude or of freedom. Though we are deathly afraid of the first possibility, we are drawn like moths to the light of the second.

"The urge to transcend self-conscious selfhood is," Huxley writes, "a principal appetite of the soul. When, for whatever reason, men and women fail to transcend themselves by means of worship, good works and spiritual exercises, they are apt to resort to religion's chemical surrogates."

One might think, as mind diseases are broadened and the substances that alter consciousness take their place beside toothpaste and breakfast cereal, that users of other "surrogates" might receive more understanding and sympathy.

You might think the executive taking Xanax before a speech, or the college student on BuSpar, or any of the recipients of 65 million annual antidepressant prescriptions, would have second thoughts about punishing the depressed user of cocaine, or even the person who is not seriously depressed, just, as the Prozac ad says, "feeling blue."

In trying to imagine why the opposite has happened, I think of the people I know who use psychopharmaceuticals. Because I've always been up-front about my experiences, friends often approach me when they're thinking of doing so.

Every year there are more of them. And yet, in their hushed tones, I hear shame mixed with fear.

I think we don't know quite what to make of our own brave new world. The more fixes that become available, the more we realize we're vulnerable. We solve some problems, but add new and perplexing ones.

In the Odyssey, when three of his crew are lured by the lotus-eaters and "lost all desire to send a message back, much less return," Odysseus responds decisively.

"I brought them back ... dragged them under the rowing benches, lashed them fast." "Already," writes David Lenson in On Drugs, "the high is unspeakable, and already the official response is arrest and restraint."

The pattern is set: since people lose their freedom from drugs, we take their freedom to keep them from drugs.(11) Odysseus' frantic response, though, seems more than just a practical measure.

Perhaps he fears his own desire to retire amidst the lotus-eaters. Perhaps he fears what underlies that desire.

If we even feel the lure of drugs, we acknowledge that we are not satisfied by what is good and productive and healthy.

And that is a frightening thought. "The War on Drugs has been with us," writes Lenson, "for as long as we have despised the part of ourselves that wants to get high."

As Lenson points out, "It is a peculiar feature of history, that peoples with strong historical, physical, and cultural affinities tend to detest each other with the most venom." In the American drug wars, too, animosity runs in both directions.

Many users of illegal drugsparticularly kidsdo so not just because they like the feeling but because it sets them apart from "straight" society, allows them (without any effort or thought) to join a culture of dissent.

On the other side, "straight society" sees a hated version of itself in the drug users.

This is not just the 11 percent of Americans using psychotropic medications, or the 6 million who admit to "nonmedical" use of legal drugs, but anyone who fears and desires pleasure, who fears and desires loss of control, who fears and desires chemically enhanced living.

Straight society has remarkable power: it can arrest the enemy, seize assets without judicial review, withdraw public housing or assistance.

But the real power of prohibition is that it creates the forbidden world of danger and hedonism that the straights want to distinguish themselves from.

A black market spawns violence, thievery, and illnessesall can be blamed on the demon drugs. For a reminder, we need only go to the movies (in which drug dealers are the stock villains).

Or watch Cops, in which, one by one, the bedraggled junkies, fearsome crack dealers, and hapless dope smokers are led away in chains.

For anyone who is secretly ashamed, or confused, about the explosion in legal drug-taking, here is reassurance: the people in handcuffs are the bad ones. Anything the rest of us do is saintly by comparison.

We are like Robert Louis Stevenson's Dr. Jekyll, longing that we might be divided in two, that "the unjust might go his way ... and the just could walk steadfastly and securely on his upward path, doing the good things in which he found his pleasure, and no longer exposed to disgrace and penitence by the hands of this extraneous evil."

In his laboratory, Jekyll creates the "foul soul" of Edward Hyde, whose presence heightens the reputation of the esteemed doctor.

But Jekyll's dream cannot last. Just before his suicide, he confesses to having become "a creature eaten up and emptied by fever, languidly weak both in body and mind, and solely occupied by one thought: the horror of my other self."

To react to an unpleasant truth by separating from it is a fundamental human instinct. Usually, though, what is denied only grows in injurious power. We believe that lashing at the illegal drug user will purify us.

We try to separate the "evil" from the "good" of drugs, what we love and what we fear about them, to enforce a drug-free America with handcuffs and jail cells while legal drugs grow in popularity and variety. But we cannot separate the inseparable. We know the truth about ourselves.

It is time to begin living with that horror, and that blessing.

"Sad to say, I quickly found pot's limitations. When my spirits are lifted, pot can help punctuate that. If I smoke while on a downward slope or while idling, I usually experience more depression or anxiety."