Hidden Costs of Methadone Maintenance

    If addiction is a disease, and it is not at all clear that it is (I for one, remain unconvinced, which is one reason I oftentimes put "addict" in quotes), it is certainly not treated like any other disease. There is no known cure for opiate addiction, a relapsing-remitting disease. To be sure some addicts go into "spontaneous remission" or experience "natural recovery," most without any treatment whatsoever. When medicine is not able to cure disease, the next best thing is to reduce the harm of the disease by treating symptoms and doing everything possible to increase the patient's quality of life. In this context methadone could be considered a form of harm reduction, designed to make the symptoms of opiate addiction less burdensome to the individual and society.

    In addition to curing disease and palliating disease symptoms for which medicine currently has no therapeutic agents, medicine has also traditionally been used as a form of social control. Government control and medical controls have traditionally supported one another. Methadone maintenance, as a medical treatment, has aspects of both medicine and social control. Needless to say, the ethics of providing a medical service and the ethics of controlling people go by completely different rules. Methadone lies in between these two extremes, and as such is rife with paradoxes and contradictions.

Hidden Costs of Methadone

   The actual cost of methadone is very cheap. When bought in bulk (tens of thousands of mgs) the cost per dose is only pennies, pills for individual consumption only a few dollars. Methadone clinics charge between $10-15 dollars per day and may or may not be covered by insurance. The cost goes to paying for security guards, nurses, counselors and doctors. While not excessive, certainly no one is robbing banks to pay for their methadone, three to four hundred dollars per month can be a significant burden on poor people without health insurance. Some will say that since the addicts could find money to buy their black-market opiates, often at $100+ per day, they should be able to hustle up the cost of methadone. Such thinking is seriously flawed, do we really want people to commit crimes (petty theft like shoplifting, prostitution, low-level drug dealing) to be able to afford their medicine?

    Methadone clients have to go to a clinic everyday, where they might have to pass through metal detectors and wait, sometimes for hours under the watch of security guards, until they can see a nurse for their medicine. Counseling is also mandatory, regardless of whether the client wants it or not. One can only guess how efficacious forced therapy is, given that therapy usually requires mutual cooperation, understanding and trust.

    If diabetics had to go through such a routine they would be, rightfully, outraged. If methadone truly is a pharmaceutical treatment for a mental illness, why should patients suffering from this particular ailment not be able to get the medication from their primary care physician? If they desire to undergo counseling, they should be free to choose their own provider. Physicians may prescribe Prozac, Valium and a host of other psychotropic drugs, but methadone has its own series of restrictions. Of course these restrictions only apply to addicts, doctors are free to prescribe methadone for pain.

    Beyond the costs of the clinic, there is also the costs of transportation to and from the clinic. This is, of course, all born by the client. Also frequently overlooked is the opportunity costs of spending time traveling back and forth to the clinic, and wait time before dosing (which can range from minutes to hours). This has earned methadone maintenance the nickname "Liquid Handcuffs."

"What the [Baltimore] Sun utterly fails to recognize here is the human cost of seemingly benign regulations like limiting distribution of these drugs to special clinics and requiring that the addicts visit daily.

"For one, think about trying to hold down a job while having to make daily, sometimes lengthy visits to a clinic - a clinic typically located in a bad neighborhood that is usually open for only a few, fixed hours and that often makes you wait for your dose. You cannot go on a business trip, let alone a vacation. You cannot come in early or work late if you will miss clinic hours and you are literally tied to this daily visit no matter what else happens in your life or you will rapidly become ill.

"Such restrictions reduce the likelihood of addicts seeking treatment and succeeding at it if they do enter: Success in recovery is linked with employment (something you'd think everyone would want to encourage anyway). This is why allowing general practitioners to prescribe buprenorphine and let addicts take it home like any other prescription improves the odds of recovery. It also allows more addicts to get treatment, period."

-"The Wire V the Baltimore Sun: Which Covers Addiction Better?" by Maia Szalavitz

    Methadone does not work for everyone. How one defines success varies, but in my opinion the only measure that matters is quality of life. If an individual spends less time committing crimes to raise money, uses less "street" drugs, reconnects with family and community or gets a job following chronic unemployment, I would regard that as a success. Ideally once the client reaches a therapeutic dose they no longer require illicit opiates. Without having to spend most of each day trying to raise money to pay prohibition-inflated prices for opiates, and having to find a purveyor of said illicit opiates, the individual is then free to live a normal life. Unfortunately methadone is not well tolerated by everybody. Methadone is pharmacologically distinct from morphine-type opiates, including the most commonly "abused" opiates like oxycodone and heroin. While chemically distinct, methadone and morphine-type opiates are cross-tolerant, the dosages used at most clinics are high enough to "block" any attempts to use opiates. At this point many methadone clients turn to other drugs, the two most common being cocaine and benzodiazapines. When methadone is combined with benzodiazapines like valium or xanax, it provides an opiate-like high, though more sedated. Alcohol is also commonly used. When people turn to other intoxicants it can be debatable as to whether or not methadone is reducing drug harm.

    What happens when methadone doesn't work? If opiate addiction were like other diseases, the natural recourse would be to try a different medication. If methadone didn't work, other opioids could be tried. Again addiction is not treated like other diseases, the treatment "failures" are kicked out of the program. It is as though a easily cured patient is sick, a treatment resistant patient is a scoundrel and a malingerer.

Methadone is Substituting One Drug for Another

    One of the most common claims made against methadone is that it is just substituting one drug for another, and thus one addiction for another. Even in the drug treatment community, there is some debate as to whether addicts on opioid maintenance programs are truly "in recovery". The usual line by supporters of methadone is that there is a distinction between "addiction" and "dependence."

"This means that a person can be in complete recovery from addiction - in a stable job, supporting and loving a family, not taking any non-prescribed medications, appearing no different from anyone else - and still take methadone or buprenorphine. Addiction is not physical dependence on a drug. If it was, we'd have to consider all diabetics as "insulin addicts" and people who need antidepressants long-term as "antidepressant junkies."

"Instead, psychiatry defines addiction as compulsive use of a drug despite negative consequences. If the use isn't compulsive and the consequences are positive, the addiction has been resolved even if the physical dependence remains."

          -"The Wire V the Baltimore Sun: Which Covers Addiction Better?" by Maia Szalavitz



    It is hard to see how "compulsive use despite negative consequences" constitutes a disease state. Most heroin addicts use no more compulsively than tobacco addicts and few argue that constitutes a disease. According to such a definition, if a heroin addict is independently wealthy and is never arrested, or if another addict receives all their drugs through a prescription; that is, if they experience few negative consequences because they can afford the habit, are they not addicted? Moreover "compulsive" is inherently subjective, what may be a craving to one person could be conceptualized as a calling to another; few things in life have only positive consequences, each person weighs the possible positive and negative consequences of their actions and makes a choice according to their values and personal priorities. Drugs are no different, for some people drugs are their sole source of pleasure in this world. For some people the negative consequences are simply the price of admission to artificial paradise (the fact that prohibition makes these negative consequences far worse than they would be otherwise deserves to be repeated).

     In 2009 the New England Journal of Medicine published a research paper that showed that heroin was more effective than methadone for the treatment of opiate addiction. It is also more cost effective. I can't wait to see how the treatment industry is going to try to spin these results. If the same or better results as methadone maintenance can be achieved with regular doses of pharmaceutical heroin (known as HAT, heroin assisted therapy or heroin maintenance), one has to wonder if the negative consequences of dependence on black-market heroin has anything to do with the pharmacology of heroin and everything to do with the social circumstances surrounding heroin addiction (ie prohibition).


    I think the criticism of that methadone is a substitute for other opiates (eg heroin, oxycodone) is valid, though the assumption underlying this criticism is wrong. When methadone is criticized for being "just" a substitute for heroin, the implication is that addicts should not have access to drugs. Addicts are often accused of "escaping reality" through their drug use. This criticism is unevenly applied to only the "bad" (illegal) drugs. Persons taking antidepressants are not derided for an inability to "deal with reality," nor are they accused of chemical dependence. Nevertheless the belief that no one ought to use drugs to alter their consciousness is based on a religious ideal rooted in Christian tradition.

"No argument supporting the moral condemnation of drug use has had a stronger and more pervasive hold on the American popular imagination than the argument for protecting the perfectionist ideal of the person...The perfectionist ideal arose within the Radical Reformation and was carried to the United States by sects, such as the Quakers and Methodists, whose own moral conceptions appear to have decisively shaped the American conception of public morality...For the radical sects and their offshoots, all personal experience was considered religious; therefore, the state and quality of such experience was properly the subject of religious concern. The use of drugs, in particular alcohol, for nonmedical purposes, was thus eventually condemned." 

          SEX, DRUGS, DEATH, AND THE LAW: AN ESSAY ON HUMAN RIGHTS AND OVERCRIMINALIZATION. By David A. J. Richards. Taken from Chapter 4.

    It is my view that methadone maintenance is nothing more than a reinvention of the narcotic clinic model that evolved after the passing of the Harrison Narcotic Act in 1914. It has been known that when addicts are given stable, steady doses of opiates, they can live relatively normal lives. When deprived of a licit channel, what is at most a minor personal problem becomes a disaster for both the individual and society. The US government has always been hostile to the idea of narcotic maintenance, the last of the narcotic clinics were closed in the early 1920's. For methadone to be politically viable, it had to be sold as a treatment. The fact that a stable dose provides no euphoria is a selling point, since taking for drugs for pleasure is considered drug "abuse" (ie pharmacological masturbation), though from the user's perspective this is clearly a detriment.  

    It may seem that I am anti-methadone, nothing could be further from the truth. For many people methadone is a lifeline to normality. To cut off methadone access, or to limit the amount of time a patient may be on methadone, would be cruel. My problem with methadone is that it is over-regulated and administered in a way inconsistent with the treatment of other diseases. If opiate addiction is truly a disease, then it should be treated as such. Addicts should be given the full range of treatment options, including heroin. Ideology should yield to treatment outcomes.

"And yet here we are again, several decades later, engaging in the same misinformed debate, which often seems more about a puritanical vision of what’s “right” rather than what works. While it’s certainly possible for people with opioid addictions to thrive without maintenance—and while most of us prefer to be dependent on the fewest possible medications—there’s no need to stigmatize the treatment for those for whom it works.

"Type 2 diabetics who have conquered their disease through diet and exercise don’t go around calling those whose disease is more resistant “defective,” nor do they demand that insulin be pulled from the market or used only for limited periods of time in order to force those weaklings to recover more naturally. If they did, no one would listen. We know that personal experience doesn’t trump medical expertise and that medicine should be based on research, not anecdote."

          -How I learned to Stop Worrying and Love Methadone by Maia Szalavitz

Further Reading:

How I learned to Stop Worrying and Love Methadone by Maia Szalavitz

The Wire V. the Baltimore Sun: Which Covers Addiction Better? by Maia Szalavitz

Wire v The Media on Drugs II: You're Right, David Simon, We Suck by Maia Szalavitz

Dr. Drew Proves Once Again that He's an Asshole

Maia Szalavitz comes out swinging at "Dr". Drew in this expose of Drew's cruel, demeaning and unethical "treatment" for addiction. The mortality rate for patients treated at Drew's celebrity rehab? Nearly 13 freakin percent. "Dr." Drew is a 12-step fundamentalist who thinks methadone "steals your soul," and apparently sees no ethical problem with letting his patients suffer in order to increase ratings. Read the whole article by Szalavitz, some key paragraphs of which I reproduced below. Once again, "Dr." Drew proves he's an authoritarian asshole.  

"With the news last week of country star Mindy McCready’s suicide by gun, the death toll among Dr. Drew’s Celebrity Rehab patients now stands at five, giving the show an unusually high mortality rate of nearly 13%. But what’s even more disturbing is that most of those deaths—possibly even McCready’s—might have been prevented if the program had utilized treatment practices proven to be most effective.
"Although Dr. Drew appears to truly believe in what he does, addiction experts say that the treatment philosophy and policies demonstrated in his show and public statements often do not reflect the best evidence-based practices. His rejection of maintenance treatments, use of punitive detox practices and humiliating therapy and insistence that people cannot truly recover without complete abstinence through 12-step programs reflect the conventional wisdom of the 1980s, not the data of the 21st century. Indeed, Celebrity Rehab’s treatment—leaving aside the massive confidentiality violation of being televised—diverges dramatically from the National Institute on Drug Abuse’s (NIDA) Principles of Drug Treatment, a guide that lays out standards for the best addiction care.
[...]
"Seizures and other behavioral consequences of Pinsky's tough-love, no-medication, abstinence-only approach make for high drama, which is why some detractors have argued that Celebrity Rehab may put entertainment ahead of the most effective treatment—and even safety. For his part, Pinsky argues that drama is the only way to attract viewers. He told  The New York Times in response to criticism of such practices by other addiction specialists that “the problem with my peers is they don’t understand television…you have to work within the confines of what executives will allow you to put on TV.”
[...]
"O’Brien says that allowing people to suffer by abruptly stopping methadone is unethical. “It's a moral thing, and it doesn’t have anything to do with recovery,” he says. “Why should we be sadistic and want people to suffer just because they’ve become addicted? There’s not a shred of evidence that it’s good. This has absolutely no benefit.”
"On day two of Starr’s detox, Pinsky describes his withdrawal as “so bad that he’s becoming confused, paranoid and rageful.” However, the doctor apparently does not slow the detox process to ease these symptoms. Indeed, as Starr kicks things, curses at the staff, makes obscene gestures and demands the cameras be turned off, the production continues, ignoring what appears to be a removal of consent to tape.
[...]
"This is apparently news to Dr. Drew, who tells patients that “methadone takes your soul away,” which can’t mean that he thinks methadone is consistent with sobriety. When questioned about this statement, he  told VH-1, “If you get enough for it to work, you’re just on the couch. You can’t do anything.”
“That’s completely false,” O’Brien says. “We’ve had people on methadone going back to school, practicing law. There's hard evidence that methadone saves lives and probably a lot of souls, too.”
[...]
“Where I get really annoyed is when people say that they ‘don’t believe in’ medication or that it’s ‘against my philosophy,’” O’Brien says. “That’s not scientific. Maintenance has saved thousands of lives. People who have this prejudice are engaging in unethical behavior.”
[...]
"If someone were providing care on national TV for years that was as far away from what experts recommend for any other condition, it wouldn’t take a journalist to bring the misleading claims to the experts for debunking, especially after someone dies. But addiction still isn’t really seen as a disease where research evidence should determine the best treatment. Instead, it’s a matter of “philosophy” and faith. You can say, “Methadone steals your soul,” and still get a national TV show and be quoted every time a celebrity relapses—and no one even reports until after a death that all of the major bodies on addiction medicine disagree.

          Is Dr. Drew Too Dangerous for Prime Time? by Maia Szalavitz

The True Church

"This is the doctrine of the true church on the subject of opium: of which church I acknowledge myself to be the only member—the alpha and the omega: but then it is to be recollected that I speak from the ground of a large and profound personal experience: whereas most of the unscientific authors who have at all treated of opium, and even of those who have written expressly on the materia medica, make it evident, from the horror they express of it, that their experimental knowledge of its action is none at all."
-Thomas de Quincey "Confessions of an English Opium Eater"

    To be a member of the true church of opium one must be acquainted with opium, intimately. With due respect to the occasional user, the dabbler, and the chipper, that is the "recreational" users, one must have a large and profound personal experience opiates to be a member of the true church. In the second edition of the Confessions, de Quincey elevated himself to pope (consequently infallible). This article examines the religious or spiritual [1] aspect of opiate use and contrasts it with the medical or therapeutic use of opiates. For the purposes of this discussion, the occasional or "recreational" users are omitted.

 "One of the most important aspects of ceremonial drug use is that the desire for the drug is experienced as issuing from the very depth of the user; whereas, in the case of therapeutic use of drugs, the user experiences external necessity, or even compulsion, as the motive for drug taking. It is precisely this experience of an inner need or 'craving' that justifies our placing this behavior in the same class with other patterns of religious conduct and observance; what all these behaviors- that is, drug use recognized as religious, drug 'addiction' and habitual drug 'abuse'- share with other kinds of religious behaviors is the experience of a profound inner desire or urge, whose satisfaction gratifies the user's deepest sense of existence or being in the world. And herein, too, lies the reason why both the religious fanatic and the 'dope fiend' go to such great lengths to satisfy their desires; and why each feels fully justified in the moral righteousness of his conduct. This 'call' or 'craving'- which to the observer seems to come from without, from the voice of God or the lure of a drug, but which to the subject comes from within, from the recognition of the subject's 'calling' or from the conviction contrasted, if we are to appreciate its real import, with the universal human experience it opposes, and indeed tries to annihilate; namely, the experience of helplessness and powerlessness and of being manipulated by external agents and their hostile interests."

-Thomas Szasz, "Ceremonial Chemistry". p 40, from chapter on Communions, Holy and Unholy

    If Szasz is indeed right, we can make a distinction between two types of "addicts," the religious/spiritual  and the medical/therapeutic. The distinction can be elucidated by examining the motives of the individual. The medical user experiences an external need, be it pain or depression, and finds that the condition is relieved by the pain killing[2] and mood elevating properties of opiates. After the medicine is metabolized the individual finds that the symptoms recur, thus necessitating repeated dosing and setting up the conditions for dependence ("addiction"). When the original condition abates, the drug may be tapered and discontinued.
Superficially the medical and spiritual opiate "addicts" are indistinguishable. Without regular access to opiates they will exhibit similar drug-seeking behaviors [3].  Pain is a great motivator, to alleviate pain people will pay outrageous prices, both literally and metaphorically. Spirituality is similarly a great motivator, one does not need to look far to witness people making great sacrifices in the name of their religion. It is only by examining the motivations of the drug user does this distinction become clear.
    The religious "addict" uses the drug as part of a ritual, properly called in this context a ceremony. The motivation behind performing such a ceremony is to be whole. Similar to the religious Christian who does not feel "normal" without conversing with God in prayer, the religious opiate "addict" does not feel "normal" without performing their ceremony of opiate consumption. A pre-20th century conception of "addict" was not limited to drugs, but meant something closer to "fan" or "devotee." It is this conception of addiction that we then return to, the religious opiate user is addicted (devoted) to the ceremony of opiate consumption just as the Christian is addicted (devoted) to the ceremony of prayer. Both of these ceremonies are performed to make the individual feel whole.
    It should be noted that these views of addiction are not mutually exclusive. One can be (self-)medicating and participating in the religion of the true church of opium. This also explains the seeming contradiction of the individual who struggles for years to break the habit, then one day following a "moment of clarity" gives up the habit for good. The church is open to all races and creeds, and members are free to join or leave at their will. To the extent that Alcoholics Anonymous (AA) and its off-shoots (NA) work, and the evidence that they work any better than nothing at all is debatable, they work by substituting one religion for another.
     There are also people who, for whatever reason, perhaps for "gonzo" journalism or for "life experience," decide to addict themselves to heroin. Contrary to popular belief, this is not an easy task. Overcoming the nausea and vomiting takes time, and not everyone experiences intense euphoria, though opiates are generally experienced as pleasurable. Such people may then walk away from the "addiction" with the same nonchalance as they walked in. It is the people who experience heroin intoxication as feeling "normal," sometimes for the first time in their lives, who are at risk for "addiction."
    The "drug abuseologists" claim that opiate use, outside some very narrow parameters, is a disease. While claiming it is a disease (drug "abuse" or "addiction"), it is not treated like other diseases. It is treated like a moral failing and crime. Drug abuse can hardly be called abuse in the sense that it is used in other contexts (sexual abuse, child abuse), most drug use causes little to no harm to the users. As I have said before, drug abuse is a "wrongful custom" in the sense that it is drug use that deviates from cultural norms (why is tobacco smoking never call drug abuse?). In the case of opiates, especially heroin, users are not so much choosing the wrong drug as the wrong ceremony.
    This is evidenced by the ritual performed to make a drug holy, the physician's prescription. Whether a drug is holy (good and therapeutic), or unholy (bad and toxic) has little to do with the drug. After all heroin and percocet are, pharmacologically, more similar than dissimilar; and drugs do not work differently just because they come from a doctor. It is the physician's prescription that completes the ritual between what is therapeutic, and thus the correct ceremony, and what is drug "abuse," and thus the wrong ceremony. An example of this, also offered by Szasz, is Dr. Max Jacobson and President John F. Kennedy:

"Mutual friends introduced JFK to [Dr. Max] Jacobson during the 1960 campaign. The first shot elevated his mood. From then on, it was clear sailing. Miracle Max shot up the president before the Kennedy-Nixon debates, the major state addresses, and even the 1961 Vienna summit meeting with Nikita Khrushchev. Secret Service files and the White House gate log confirm that Jacobson saw JFK no fewer than 34 times through May 1962.

"Did Kennedy experience any of the impatience, irritability, and grandiosity, an exaggerated sense of personal power, that amphetamines so often produce? Clearly not: Kennedy's court historians maintain that his illnesses and drug use didn't affect his presidency. In any case, in June 1962, when Attorney General Robert Kennedy advised his brother to stop using Jacobson's concoctions, the president replied, 'I don't care if it's horse piss. It works.' "

          "Dr. Feelgood" William Bryk. The New York Sun Spt 20th, 2005 [Link]

      When a doctor injects amphetamines into the bloodstream of a powerful politician, it is ostensibly done for medical reasons. In this case the amphetamines were administered not for treatment of a medical disease (eg narcolepsy), but to enhance the performance of a healthy man. When a college student takes Adderall or Ritalin to improve their concentration in preparing for an exam, or a truck driver uses illicitly manufactured methamphetamine to remain alert for long periods of time, it is drug "abuse." The same basic drug, amphetamine, is being used for the same reason, to enhance performance. It is the physician's prescription that differentiates drug "abuse" from medicine. Clearly this is not defensible on pharmacological grounds.
The prescription is a magic ritual, one that sanctifies a behavior (drug taking) as being holy (healthy, medicinal), provided it is done under the auspices of the high priest (the physician) . While similarly self-medicating is declared illicit healing, particularly because it is done without the authority of the high priest (physician). Only a priest has the power to make ordinary water holy. Only a physician has the power to decide what drugs are therapeutic, and who gets what drug. The appropriate analogy is Holy Communion. To a true believer bread and wine is literally transubstantiated into the body and blood of Christ. The heathen observer sees only bread and wine. Similarly the "drug abuser" sees no legitimacy in the physician's prescription, the wine ("dangerous and addictive" drugs) is still wine, not the blood of Jesus ("therapeutic" drugs).
    If an individual asserts their will to circumvent the doctor's prescription and self-medicate with illicit opiates, this is drug "abuse." It matters not how knowledgeable the individual is, the individual may be a professor of pharmacology and know more about drugs than most doctors. We have taken the right to be sovereign over our own bodies, to decide for ourselves what drug or treatment is therapeutic, and given that authority to the medical profession and government agencies. Verily we have turned a fundamental human right into a crime.
     Heroin users are persecuted not due to the pharmacological properties of heroin (after all heroin rapidly converts to morphine, considered by the World Health Organization to be an essential drug), but because they are performing a heretical ceremony in a prohibited religion. This is what Szasz has called the "religious nature of the war on drugs." This also explains why drug legalization is opposed even after arguments in its favor have been refuted by logic, pharmacological and sociological research. It matters little that alcohol and tobacco are among the most toxic drugs regularly consumed, reason has never been successful in toppling religious belief.
      In a world where individuals are constantly reminded of their helplessness and powerlessness, of human fragility and mortality, people develop strong attachments to things which oppose these feelings. It is this strong attachment, or devotion, that is the meaning of "addiction." The number of things people may become "addicted" (devoted) to is truly immense. These attachments are expressed by certain ritual behaviors, rituals which may include certain chemicals we call drugs. By completing the ritual, it reinforces the individual's sense of belonging in the world. This is true of peyote and the Native American Church, Wine and the Christian ceremony of Holy Communion, Coca and the ceremonies of the indigenous people of South America; it is no less true of opiates and the modern day drug culture in the modern world.
    The war on certain drug users is a war on our right to self-medicate. The fact that a majority of Americans seem willing to concede that right in no way invalidates the the minority who choose to assert sovereignty over their bodies, minds and medical decisions. Fundamental human rights cannot be legislated away. The drug war is also a religious war, waged against chemical ceremonies deemed heretical. Because it is ostensibly waged in the name of public health, its religious nature has been obfuscated as much as possible. It is only when the arguments of the prohibitionists are refuted by logic that the true motivation behind the war on drugs becomes clear. Truly the only way to end such a conflict is to tolerate a diversity of spiritual views, and the associated chemical ceremonies each entails.

[1] I am using the words "spiritual" and "religious" more-or-less interchangeably in this article.

[2] Opiates do not so much "kill" pain as change the perception of pain. People on opiates will still experience pain, but it does not bother them. Opiates widen the emotional experience of pain, creating an emotional "distance" between the painful stimulus and the emotional response. This is also why people who have experienced horrific childhood abuse respond so well to opiates. There is a false dichotomy between physical pain and emotional/psychological pain, using opiates for the former is grudgingly accepted by the medical establishment, using opiates to treat the latter is considered drug "abuse" and to be exterminated with the full force of the state's medical and law enforcement apparatus.

[3] Such a person is in an unenviable position, taken advantage of by both criminals and quacks, all the while serving as a scapegoat for all of societies ills. In the words of Dr. Charles E. Terry, "That to supply this drug is not only necessary, but is vital, that to deny it is to cause a physical and possibly a moral wreck, while to heap contumely upon narcotic drug addicts as a whole is to drive them to the underworld for their supply, It never must be lost sight of that among the sufferers from this disease are numbered many of the highest intellectual types of men and women in the business and professional worlds..."

Catnip: Egress to Oblivion?

From the artist's site:

Cat­nip is all the rage with today’s mod­ern feline, but do we really under­stand it? 

Is it a source for harm­less kicks, or a poten­tially crip­pling addic­tion? Is it a tool to expand one’s con­scious­ness, or a down­ward spi­ral­ing path that can even­tu­ally lead to insanity? 

Once and for all the facts about this con­tro­ver­sial sub­stance are frankly dis­cussed, in the long-lost drug edu­ca­tional film that never-was, “Cat­nip: Egress to Oblivion?”. 

Chief of psychiatry
Catnip Crisis Center: Sishigan Michigan
DR. NEIL KIGHT, ESQ.
Author of “Looking Within: The Catnip Conundrum”

"Much of the progress made by the feline rights movement during the 1960s has now been effectively eroded. Catnip prohibition and the selective enforcement of herbaceous perennial laws have become the successor system to Jim Puss. They selectively target cats of all color, removing them from Felid society while barring them from the right to keep mice on the run, inspire us to dream up cool cartoon characters and teach us how to land on our feet." -Byddaf yn egluro

Further reading on catnip:

Catnip: Its uses and effects, past and present by Jeff Grognet [another link]

Thanks to anonymous commenter for the paper.

Drug War Sponsored Sexual Slavery in Afghanistan

Opium Brides, a PBS Frontline special. (running time 32:45)

From investigating the sexual abuse of young boys to embedding with a group of insurgents allied with Al Qaeda, veteran Afghan reporter Najibullah Quraishi takes FRONTLINE cameras where few Western journalists can go. 

Today Quraishi spoke with The World‘s Marco Werman about his latest journey — airing on FRONTLINE tonight — deep into remote Afghan countryside to investigate a horrifying sex trade: young girls kidnapped or traded to smugglers to meet the debts of impoverished opium farmers whose crops have been destroyed by the government. 

Quraishi met several girls who were taken from their families, an existing problem that he says has increased as a result of poppy eradication programs. The girls “are only nine, 10, 11 [or] 12 and used for manufacturing heroin, or immediately married to traffickers or sold in other countries, like Iran.” 

The smugglers are “very powerful and stronger than the Taliban and the government,” Quraishi tells Werman. 

Listen to the interview below for more about what Quraishi sees as the prospects for helping the young girls, and tune in to Opium Brides tonight for the full story of how young girls, and even boys, are paying the price for counternarcotics policy in Afghanistan.

Why Eradication Won't Solve Afghanistan's Poppy Problem, PBS Frontline 

[Note: I have reproduced a few paragraphs from this article below, but I highly recommend reading the whole article to get a sense of the corruption in Afghanistan's government and drug trade. The article begins in the 1980's, with the Soviet destruction of Afghanistan's traditional crops]

In Afghanistan in the mid-80s, the Soviet Army ended up adopting a “scorched earth” policy [to systematically destroy agricultural resources]. That is because while the Soviets were able to control the cities, they were never able to control the countryside. The insurgency was always [launching] attacks from the rural areas on the cities and generating instability. The Soviets tried military operations in the countryside, which didn’t control the problem, so ultimately, they decided to destroy the agriculture in the countryside with the idea that this would drive the rural population into the cities, which they could control. 

The effect was the complete collapse of the agricultural production of Afghanistan: the destruction of orchards, irrigation canals. The only thing the population could grow was opium poppy, which didn’t require [so much] irrigation, fertilizers or transportation, because Pakistani traders would come to the farm and pick up the opium. So this really unleashed the first systematic cultivation of opium poppy at the time. 

Between 2001 and 2004, the U.S. very much had a hands-off policy towards the opium poppy, partially because Northern Alliance warlords, [whom the U.S. was] using for intelligence and for direct military operations against Al Qaeda and the Taliban, were knee-high in opium poppy. … So the U.S. said the priorities are to defeat the Taliban, not their human rights problems or that they are peddling in the drug trade. 

The promise was that [poppy eradication efforts] would end corruption and bankrupt the Taliban.  Neither happened. Corruption kept increasing and increasing, and the Taliban became stronger and stronger, for a variety of reasons, [including] that the Taliban drew a lot of support from the poppy farmers who were outraged by the poppy eradication policy. 

The big change comes in 2009, when the Obama administration says, eradication is not doing what it promised. There is no decrease in corruption; in fact, there is a huge amount of corruption associated with eradication. It’s not bankrupting the Taliban; there is more poppy than there was a few years back, and it’s losing the hearts and minds of the population, and making counterinsurgency really difficult. So we are going to change policy. 

The U.S. government decided to defund the centrally led eradication force, which was the main unit that was eradicating. But the Obama administration wanted to compromise somewhat, and they said if the Afghan government, local governors, wants to do some eradication, that’s their choice. If the local provincial governors decide the want to eradicate, we will provide them assistance, both equipment and technical assistance. 

What often happens is that when the governors push ahead with eradication, they lose the support of the population; they do it at gunpoint, essentially. 

To some extent, many governors engage in eradication, but it’s often extremely limited — maybe a few hundred to a thousand hectares eradicated, on the scale of having 15,000 to 60,000 hectares cultivated. But they feel they need to throw some bone to the internationals who are demanding eradication, so they take either actors who are very weak — the poorest farmers who have no capacity to intimidate the government or to corrupt the eradication teams — or they take opposition — rival politicians and their networks and their power base — and eradicate some elements of their poppy.

Afghan farmer beheaded with a PENKNIFE after refusing to let drug lords take his daughter and sell her as a sex slave, Daily Mail (UK)

Opium gangs are taking the sons and daughters of Afghan farmers as collateral for unpaid debts.
A documentary exposes the fate of those who borrow from drug lords to set up cultivation of the heroin plant but are left destitute when NATO-backed forces destroy their crops.
The drug lords then take their children, including girls as young as ten, to Pakistan and Iran to sell them into the sex trade or use them as drug mules.

Solution: Blame the Users

I have reproduced two comments posted in response to the Daily Mail article. Like many sites, comments can be voted either up or down, The rating reflects how many positive and negative responses the comment received, positive numbers reflect more "likes" and negative numbers "dislikes."

"To anyone who does illegal drugs: I know you won't care, but this is what your money is buying. You are paying for all this murder, suffering and misery to be done in you[r] name. It's just as well for you that you have no soul, otherwise you wouldn't be able to live with yourself."
- Steve, Gateshead, 29/1/2013 11:30
Rating: +566 

"This is why heroin MUST be legalized. Heroin has a large profitability because it is illegal, if you legalize it and tax it then the price will crash and these ruthless assassins won't gain anything from the stuff. WHEN WILL YOU LEARN????????"
- Getreal, Corby, 29/1/2013 11:03
Rating: -75

Clearly among the Daily Mail readers there is a lot of support for blaming heroin users for the mess in Afghanistan, and very little support for legalizing heroin. Also, illegal drug users apparently have no soul.

On the surface there is very little reason why using heroin should be considered morally wrong. Heroin is produced from opium, itself dead plant matter. Therefore using heroin is the moral equivalent of eating lettuce. The belief that using mind altering chemicals is morally wrong is a religious belief, no one who uses legal drugs (tobacco, alcohol, caffeinated beverages) ought feel morally superior to illicit drug users. Even those who completely abstain (Mormans, "Straight Edgers") from mind altering chemicals[1] should not consider themselves morally superior. Jesus was a drug user.

There may indeed be a moral argument for abstaining from heroin use, given the situation around its production. If purchasing heroin does contribute to terrorists' funding and the slavery of fellow human beings, especially children, a case against heroin consumption can be made even if heroin use is morally neutral. 

Are there other products out there, for which there is a demand that fuels human rights violations and civil unrest. I can think of an obvious analogy: oil (keeping in mind the word analogy means a comparison of similar features, there are obvious differences too). The developed world's "addiction" to oil certainly funds many regimes which then use the money to oppress their people. Oil money funded the Libyan dictator Col. Muammar el-Qaddafi. 

Libya's Oil Money Buys Allies for Qaddafi NY Times

From Liberia to South Africa to the island of Madagascar, Libya’s holdings are like a giant venture capital fund, geared to make friends and win influence in the poorest region in the world. This may help explain how Colonel Qaddafi has been able to summon sub-Saharan African soldiers to fight for him in his time of need — Libyans have spoken of “African mercenaries” killing protesters and helping him rout rebel fighters — and why so many African leaders have been so slow to criticize him, even as his forces slaughter his own people. 

So lets insert gasoline in place for drugs in that Daily Mail comment:

"To anyone who buys gasoline: I know you won't care, but this is what your money is buying. You are paying for all this murder, suffering and misery to be done in you[r] name. It's just as well for you that you have no soul, otherwise you wouldn't be able to live with yourself."

The parallels now become obvious. People need oil to live their lives, our entire economy is based on oil, without it our economy would grind to a halt. We will, and have, gone to war over oil (does anyone believe Iraq was all about WMDs anymore?). Nobody wants their gas money to fund dictators who use it to commit human rights violations, but they don't have a lot of choices. Similarly heroin users would prefer to buy "free trade" heroin, but have to take what they can get. Much like oil, consumers do not need heroin (that is they will not die without heroin), but there is a large demand because heroin makes life better. As to why heroin users use heroin, that will be a subject for another day, but suffice to say many users need heroin in their lives  in the same way many citizens need gasoline and petroleum products.

I have no sensible suggestions on how to solve the world's oil "addiction". Unlike the "addiction" to oil, the world's "addiction" to opiates is eminently solvable. The answer is to legalize and regulate the trade in opium. Allowing the heroin users in the destination countries to purchase opium and opium products (morphine, heroin, ect) directly from the farmers in the producer countries would completely end the drug-related corruption in Afghanistan. Opium legalization will not solve all of Afghanistan's problems, but we are currently funding both sides of the conflict. Drug users fund the crops and traffickers while governments fund (completely corrupt and counter-productive) eradication efforts. After years of this, and unbelievable "collateral damage" (eg "Opium Brides") caused by our war on opium, there is no end in sight. It is well past time for a new approach.


[1] What exactly is a mind altering chemical, or drug, will be the focus of a future post. The distinction between food and drug is mostly cultural/sociological, we call some substances people consume drugs and others food.

Further Reading:
 The Opium Brides of Afghanistan, Newsweek
What You Should Know About Women's Rights in Afghanistan, Huffington Post

Some Thomas Szasz Quotes

The Second Sin (1973)
The wise treat self-respect as non-negotiable, and will not trade it for health or wealth or anything else.
p. 56

Marx said that religion was the opiate of the people. In the United States today, opiates are the religion of the people.
p. 63

The Nazis spoke of having a Jewish problem. We now speak of having a drug-abuse problem. Actually, “Jewish problem” was the name the Germans gave to their persecution of the Jews; “drug-abuse problem” is the name we give to the persecution of people who use certain drugs.
p. 64

Since this is the age of science, not religion, psychiatrists are our rabbis, heroin is our pork, and the addict is the unclean person.
p. 64

We speak of a person being “under the influence” of alcohol, or heroin, or amphetamine, and believe that these substances affect him so profoundly as to render him utterly helpless in their grip. We thus consider it scientifically justified to take the most stringent precautions against these things and often prohibit their nonmedical, or even their medical, use. But a person may be under the influence not only of material substances but also of spiritual ideas and sentiments, such as patriotism, Catholicism, or Communism. But we are not afraid of these influences, and believe that each person is, or ought to be, capable of fending for himself.
pp. 65-66

Although both the natural and moral sciences seek to understand the objects of their observation, in natural science the purpose of this is to be able to control them better, whereas in moral science it is, or ought to be, to be better able to leave them alone. The morally proper aim of psychology, then, is self-control.
p. 115

Formerly, when religion was strong and science weak, men mistook magic for medicine; now, when science is strong and religion weak, men mistake medicine for magic.
p. 115

The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (1974)
I became interested in writing this book approximately ten years ago when, having become established as a psychiatrist, I became increasingly impressed by the vague, capricious and generally unsatisfactory character of the widely used concept of mental illness and its corollaries, diagnosis, prognosis and treatment.
Although (mental illness) might have been a useful concept in the nineteenth century, today it is scientifically worthless and socially harmful.
In non-psychiatric circles mental illness all too often is considered to be whatever psychiatrists say it is. The answer to the question, Who is mentally ill? thus becomes: Those who are confined in mental hospitals or who consult psychiatrists in their private offices.
-Preface to the First Edition

Ceremonial Chemistry (1974)
If, nevertheless, textbooks of pharmacology legitimately contain a chapter on drug abuse and drug addiction, then, by the same token, textbooks of gynecology and urology should contain a chapter on prostitution; textbooks of physiology, a chapter on perversion; textbooks of genetics, a chapter on the racial inferiority of Jews and Negroes.
p. 11

Why is self-control, autonomy, such a threat to authority? Because the person who controls himself, who is his own master, has no need for an authority to be his master. This, then, renders authority unemployed. What is he to do if he cannot control others? To be sure, he could mind his own business. But this is a fatuous answer, for those who are satisfied to mind their own business do not aspire to become authorities.
Revised edition, 1985. p. 175.

Our Right to Drugs (1992)
As Justice Olive Wendell Holmes, Jr. put it, censorship rests on the idea that “every idea is an incitement.” Perhaps he should have specified “every interesting idea,” for a dull idea is not. By the same token, every interesting drug is an incitement. And so is everything else that people find interesting.
p. 35

The Manufacture of Madness: A Comparative Study of the Inquisition and the Mental Health Movement (1997)
The disease concept of homosexuality—as with the disease concept of all so-called mental illnesses, such as alcoholism, drug addiction, or suicide—conceals the fact that homosexuals are a group of medically stigmatized and socially persecuted individuals. ... Their anguished cries of protest are drowned out by the rhetoric of therapy—just as the rhetoric of salvation drowned out the [cries] of heretics.
p. 168

The homosexual is a scapegoat who evokes no sympathy. Hence, he can only be a victim, never a martyr.
p. 169

So long as men denounce each other as mentally sick (homosexual, addicted, insane, and so forth)—so that the madman can always be considered the Other, never the Self—mental illness will remain an easily exploitable concept, and Coercive Psychiatry a flourishing institution.
p. 170

There is a fundamental similarity between the persecution of individuals who engage in consenting homosexual activity in private, or who ingest, inject, or smoke various substances that alter their feelings and thoughts—and the traditional persecution of men for their religion. ... What all of these persecutions have in common is that the victims are harassed by the majority not because they engage in overtly aggressive or destructive acts, ... but because their conduct or appearance offends a group intolerant to and threatened by human differences.
pp. 208-209

Thomas Szasz died on September 8, 2012
Read an obituary by Jeffrey Schaler here.

Dr. Charles E. Terry on the Aftermath of the Harrison Narcotic Act

"At this stage the truth of my opening sentence is apparent, for while I recognized the medical and public health angles of the problem, I still felt that rigid laws offered great promise. I felt with others that national law which would control interstate traffic in these drugs would solve the greatest part of the difficulties confronting us. It must be home in mind that at this period only a few states had restrictive laws that were not openly broken on every side and for the most part the formality of a physician's prescription was rarely observed by druggists in dispensing any of the addiction or habit forming drugs'. Effectual restrictive legislation had never been tried and it was perhaps not unnatural to suppose that with the well-known sources of supply curbed, the use of these drugs would be very materially if not entirely prevented. It is obvious, however, that we had counted without the peddler. We had not realized that the moment restrictive legislation made these drugs difficult to secure legitimately the drugs would also be made profitable to illicit traffickers.

"I had had practically no experience with this fraternity for a reason which I now understand well, namely because we furnished in the health office free prescriptions for those unable to pay for them, nor did we try to dictate to them the quantities they should take or for that Matter humiliate or persecute them in any other way. As a consequence the peddler could not make a living in our town, though he had begun to flourish in Massachusetts and New York.


"Feeling as I did about the need for further restrictive legislation, I looked forward to the Passage of the Harrison Act, and during the months immediately preceding its beginning operation in May 1915 we tried to prepare our indigent cases for the drug deprivation which we believed was in store for them. They were urged to reduce their daily amount to the lowest possible limit, and they earnestly cooperated, and looked forward as did we to the time when they would be cured. Meanwhile, a fund was raised by private subscription and hospital and nursing facilities provided for about 20 beds. These beds were filled and refilled until between 65 and 75 patients had been treated. This is one of the experiences in my attempts to work out this problem which I do not like to recall. A local physician kindly volunteered to treat these cases. Although not practicing I visited them daily, and the nursing attention they received was of the highest order. The method of treatment employed was that known as the Towns treatment [rapid withdrawal plus administration of a belladonna mixture]. We felt, as do most when contemplating drug addiction treatment, that a certain amount of suffering was necessary, but I was not prepared for the extreme suffering which I witnessed in these cases, nor was I prepared for one death which occurred in an apparently healthy woman. With the exception of 2 or 3, all of these cases relapsed within a very short time after their discharge as cured, and I realized more than ever that here was indeed a medical problem and I began to harbor my first doubts as to the wisdom of blind restrictive legislation. And by this I mean legislation based upon habit and vice theories of drug addiction and upon the assumption that satisfactory methods of treatment are generally available.

"That my experience was not unique was determined by the committee on habit forming drugs of the American Public Health Association, through a questionnaire submitted to the medical schools of the country.
It would seem unnecessary to state that the narcotic drug addict must be supplied with his drug in doses physically necessary until such time as he may receive treatment which will leave him in at least as good condition as that in which it found him. That to supply this drug is not only necessary, but is vital, that to deny it is to cause a physical and possibly a moral wreck, while to heap contumely upon narcotic drug addicts as a whole is to drive them to the underworld for their supply, It never must be lost sight of that among the sufferers from this disease are numbered many of the highest intellectual types of men and women in the business and professional worlds, and that individuals of this type May not contemplate the indignities which many administrators seek to heap upon them, through their ignorance of the true nature of this condition and their apparent misconception of the character of its victims."

-Dr. Charles E. Terry, who had been working with addicts in Jacksonville, Florida, from 1911 until the Harrison Act went into effect in 1915

Quoted from "the Addict and the Law" by Alfred Lindesmith [Bold added -Ed]

Afterword:
I am compiling a list of fatalities resulting from opiate detoxification for a future post. This is one of the earliest records I have been able to uncover that refutes the notion that nobody dies from opiate withdrawal. While the evidence in this particular case isn't overwhelming, as the patient may have died as a result of the belladonna mixture, there are other cases in which people have died from going "cold turkey" (usually while incarcerated). If anyone has evidence of other cases of people dying from an opiate (opioid) withdrawal please send me an email or leave a link in the comments.