Don't blame the drugs

A century ago alcohol was the prevailing demon substance. Prohibitions on drug use were few, jails were not full of drug users, and drugs derived from coca, cannabis, and poppy were in wide use by the public. Reputable doctors, scientists, and poets, along with less well known people, used these drugs in ways similar to use of caffeine and nicotine today, such as the physician who continuously used morphine for 62 years. For the most part people used these drugs without them affecting their life or functioning, their use ebbing and flowing among periods of non-use.

Popular patent medicines of the time were likely to contain one or more of these psychoactive drugs. The manufacturer Parke-Davis had tincture of cannabis and 15 coca related products. The Bayer Company marketed a new product, diacetyl morphine, described as the “heroine” to treat both morphine addiction and cough and sold under the brand name “Heroin.” Coca-Cola originally contained cocaine and was a result of the temperance movement in the United States: with the growing threat to alcohol, the Atlanta based inventor John Pemberton removed the red wine from his popular “French Wine Cola,” added cocaine, and changed its name to Coca-Cola.

Richard DeGrandpre describes psychoactive drugs as “socially defined commodities” and not solely, as they are often portrayed, inherently powerful manipulators of our will and behaviour. He points out that “drug use and drug outcomes are ultimately artefacts of culture, not of the inherent pharmacological properties of drugs.”

Context, in other words, is everything. Take cocaine users out of their normal setting and place them in a controlled, blinded study: they can't differentiate injected cocaine from caffeine or even placebo. Mice, when isolated and given nothing to do, will self administer cocaine until exhaustion; when put in their normal habitat and given the option of food or cocaine they will choose food as their stimulus of pleasure half the time.

Each society allows drugs to unlock different forms of behaviour. The author gives the example of alcohol, explaining that we learn about drunkenness from our society and act accordingly: “Whisky in a pub in the Gorbals excuses hitting your friends with bottles; bloody Marys at a Chelsea party facilitate sexual advances towards other people's wives.”

The cult of pharmacology is not limited to illicit drugs. Cult behaviour also exists with legal drugs, largely driven by commercial interests. Barbiturates, initially marketed as safe and non-addictive, were developed to replace chloral hydrate. Meprobamate replaced the barbiturates, only to be replaced by benzodiazepines, which were much safer and, once again, initially thought to be non-addictive.

As the market matured and the dependence potential of benzodiazepines became known, a search for new drugs began. What I call “backward pharmacology” was used to develop the so called selective serotonin reuptake inhibitors (SSRIs). The search for SSRIs did not occur because serotonin deficit was known to be a cause of depression; rather, the drugs were developed and then a disease for their use had to be found—fluoxetine was initially investigated as an antihypertensive. It was only later that SSRIs were commercialised to fill the gap in the psychopharmacology market left by the growing negative connotations of anxiety and the changing medical opinion of benzodiazepines.

Firstly, however, the depression market had to be created. Depression in the United States in the 1950s and before was considered to be a rare disorder, with a prevalence of 0.005%. This now contrasts with a prevalence of 10% at the end of the 20th century. Given the difficulty in separating anxiety from depression, and given the negative connotations of anxiety, it was a relatively easy matter to develop this previously rare or perhaps unrecognised disease to create the market.

From “tonics” to anxiolytics to antidepressants, all of these classes of drugs initially received the imprimatur of the medical community. Once their use came to be associated with the lower socioeconomic classes—and newer, “safer” alternatives were marketed—they became vilified in the medical and lay media. The change in status from therapeutic agent to drug of abuse is one that is largely independent of the drug's pharmacology.

However, the fact is that alcohol or drug use does destroy the lives of users and those around them. And, indeed, many people have had their lives transformed through the use of anxiolytics or antidepressants. The price for benefit to some people or preventing harm to a few has been policies depriving the many.

The desire to alter state of consciousness has been present in nearly all cultures. Along with this desire has been the categorisation of drugs as “good” and “bad.” We now have a white market of legal (“good”) psychoactive drugs, a grey market of drugs used to alter consciousness but lacking a stamp of legitimacy to do so—alcohol, nicotine, caffeine—and a black market of (“bad”) psychoactive drugs.

DeGrandpre points out that these distinctions are largely based on cultural mores and not the pharmacology of the drugs. In the early 1900s the US Food and Drug Administration, in a prelude to prohibition, seized 40 barrels of Coca-Cola because the caffeine in it was reported to cause, at one girl's school, “wild nocturnal freaks, violations of college rules and female proprieties, and even immoralities.”

As I write this, though, a legal cup of caffeine sits next to my computer monitor. Meanwhile, in the mountains of Peru, workers are chewing coca leaves to get them through their day.

The theme of The Culture of Pharmacology is that our approach to psychoactive drugs, whether white market or black market, is “irrational and unpredictable, full of fear and loathing, with a strong theme of commerce running right through the center.” The book is well researched and documented and full of interesting facts. For many readers it will produce a whole new perspective that will have an impact when they reach for the prescription pad or a cup of coffee or disparaging the drug user on the street.

Context is everything. Take cocaine users out of their normal setting and place them in a controlled, blinded study: they can't differentiate injected cocaine from caffeine or even placebo.