Fearing Medicine

By Dirk Hanson

Have Americans become afraid of their doctors?

Once upon a time, Americans went to their doctors to get pills. Doctors complained that patients believed competent medical care consisted of being handed a prescription. In the absence of that piece of paper with the unintelligible signature, a patient was apt to claim that the doctor’s visit had been a waste of time. What was the point of seeing a doctor if the doctor didn’t give you anything that would cure what ailed you?

That was then. Patients now demand that doctors and pill makers come clean about the safety of the products they offer (long overdue), and that the pills themselves be absolutely benign in their effects (utterly impossible). In ever-greater numbers, Americans are coming to fear prescription drugs. This condition, in extremis, is a phobia with a recognized set of diagnostic criteria: pharmacophobia—an abnormal fear of medicine.

Today, Americans go to their doctors to be healthy and “drug-free.” If they are taking prescription medications, their goal is to get off them. Yesterday, patients demanded pills for conditions they didn’t have, or for which pills were ineffective. Today, patients are routinely filing lawsuits, demanding to know why their doctor gave them pills. Ironically, one of the major hindrances to health care, from a doctor’s point of view, is “patient non-compliance”—sick people often don’t take their pills properly. (This may be a good place to note that I do not work for, or with, or against Big Pharma, as the drug companies are now called. I don’t work for anybody.)

The drug industry, one of the most tightly regulated industries in America, is the kind of corporate villain Americans understand. What particularly rankles many critics is that the drug companies advertise.

“Presumably,” Joseph Davis concedes in his jeremiad against drug advertising in the journal Hedgehog Review, “some percentage of those who identify their face and their feelings with those signified in the ads actually suffer from a debilitating condition. So much to the good.”

But of little significance, it seems. The central issue for Davis is: What if people who don’t need those pills are exposed to those ads? Normal people might think they need those pills—and they don’t! And very soon, as you can easily see, you’ve got trouble in River City. In the same issue of Hedgehog Review, biomedical ethics professor Leigh Turner professes similar shock, recounting with indignation “a world where a host of marketing strategies are used to package tidy, authoritative, and often profoundly misleading claims” about the safety and effectiveness of products. You can imagine how I felt when I learned that commercial advertisers were capable of doing that.

For lack of a better term, we will have to settle for calling it the real world, where soap, life insurance, housing, cars, psychiatric care, and legal advice are all marketed in misleading ways, to people who don’t always need them. And so it is with pills. However, where once patients desired this, they now resent the offer. Writing in the May 2007 issue of Harper’s, Gary Greenberg declares that “Under the agreement we’ve made—that they are doctors, that I am sick, that I must turn myself over to them so they can cure me—the medicine must be treated with the reverence due a communion wafer.”

Previously, patients wanted their communion wafers, and doctors were often accused of withholding them. Now, as Greenberg makes clear, patients fear doctors will drag them to the altar and force the holy wafers down their throats. One cannot help wondering what manner of pact Greenberg would like to arrive at with his treating physicians. His approach does not seem like a particularly promising step forward in doctor-patient relations.

Interestingly, Americans have shown little interest in a thorough examination of the adverse side effects of non-pharmaceutical approaches to health. Talk therapists and holistic practitioners of every stripe operate in a virtually regulation-free environment. Where, for example, can one find a list of common side effects associated with the practice of various forms of psychotherapy, from post-Freudian talk therapy to, say, the increasingly popular varieties of cognitive therapy? Where, I would like to know, is the list of unwanted side effects that can occur as the result of an on-air encounter with that manipulative bruiser, Dr. Phil?

Science writer Sharon Begley, in a June 18 Time column entitled “Get Shrunk at Your Own Risk,” declares: “What few patients seeking psychotherapy know is that talking can be dangerous, too—and therapists have not exactly rushed to tell them so.”

Among many other examples, Begley reminds us of the “recovered memory” therapies that tore families apart and sent innocent people to prison for the alleged sexual abuse of children. And “stress debriefing,” a method of re-experiencing traumatic events in an effort to eliminate Post Traumatic Stress Disorder, sometimes leads to increased stress and higher levels of anxiety, compared to PTSD victims who do not undergo such therapy. I’ll privilege an upset stomach and occasional loose stools from pills over that kind of deep-seated trauma any day.

Begley also cites a 2000 study of professional grief counseling which concluded that four out of ten people grieving for the death of a loved one through formal therapy would have been better off with no therapy at all. Compared to a control group, 40 per cent of mourners in professional therapy experienced increased depression and grief. (In some cases, the most benign contraindication is when the treatment doesn’t do anything at all.)

The side effects associated with talk therapies remain shrouded in mystery. “The number of people undergoing potentially risky therapies reaches into the tens of thousands,” Begley concludes. “Vioxx was yanked from the market for less.”

New World Nicotine: A Brief History

“Drinking the Smoke”

The prototypically North American contribution to the world drug trade has always been tobacco. Tobacco pipes have been found among the earliest known Aztec and Mayan ruins. Early North Americans apparently picked up the habit from their South American counterparts. Native American pipes subjected to gas chromatography show nicotine residue going back as far as 1715 B.C. “Drinking” the smoke of tobacco leaves was an established New World practice long before European contact. An early technique was to place tobacco on hot coals and inhale the smoke with a hollow bone inserted in the nose.

The addicting nature of tobacco alarmed the early missionary priests from Europe, who quickly became addicted themselves. Indeed, so enslaved to tobacco were the early priests that laws were passed to prevent smoking and the taking of snuff during Mass.

New World tobacco quickly came to the attention of Dutch and Spanish merchants, who passed the drug along to European royalty in the 17th Century. In England, American tobacco was worth its weight in silver, and American colonists fiercely resisted British efforts to interfere with its cultivation and use. Sir Francis Bacon noted that “The use of tobacco is growing greatly and conquers men with a certain secret pleasure, so that those who have once become accustomed thereto can later hardly be restrained therefrom.” (As a former smoker, I am hard pressed to imagine a better way of putting it.)

Early sea routes and trading posts were determined in part by a desired proximity to overseas tobacco plantations. The expedition routes of the great 17th and 18th Century European explorers were marked by the strewing of tobacco seeds along the way. Historians estimate that the Dutch port of Amsterdam had processed more than 12 million pounds of tobacco by the end of the 17th Century, with brisk exports to Scandinavia, Russia, Prussia, and Turkey. (Historian Simon Schama has speculated that a few enterprising merchants in the Dutch tobacco industry might have “sauced” their product with cannabis sativa from India and the Orient.)

Troubled by the rising tide of nicotine dependence among the common folk, Bavaria, Saxony, Zurich, and other European states outlawed tobacco at various times during the 17th Century. The Sultan Murad IV decreed the death penalty for smoking tobacco in Constantinople, and the first of the Romanoff czars decreed that the punishment for smoking was the slitting of the offender’s nostrils. Still, there is no evidence to suggest that any culture that has ever taken up the smoking of tobacco has ever wholly relinquished the practice voluntarily.

A century later, the demand for American tobacco was growing steadily, and the market was worldwide. Prices soared, with no discernible effect on demand. “This demand for tobacco formed the economic basis for the establishment of the first colonies in Virginia and Maryland,” according to drug researcher Ronald Siegel. Furthermore, writes Siegel, in his book “Intoxication”:

"The colonists continued to resist controls on tobacco. The tobacco industry became as American as Yankee Doodle and the Spirit of Independence…. British armies, trampling across the South, went out of their way to destroy large inventories of cured tobacco leaf, including those stored on Thomas Jefferson’s plantation. But tobacco survived to pay for the war and sustain morale."

In many ways, tobacco was the perfect American drug, distinctly suited to the robust American lifestyle of the 18th and 19th Centuries. Tobacco did not lead to debilitating visions or rapturous hallucinations—no nodding out, no sitting around wrestling with the angels. Unlike alcohol, it did not render them stuporous or generally unfit for labor. Tobacco acted, most of the time, as a mild stimulant. People could work and smoke at the same time. It picked people up; it lent itself well to the hard work of the day and the relaxation of the evening. It did not act like a psychoactive drug at all.

As with plant drugs in other times and cultures, women generally weren’t allowed to use it. Smoking tobacco was a man’s habit, a robust form of relaxation deemed inappropriate for the weaker sex. (Women in history did take snuff, and cocaine, and laudanum, and alcohol, but mostly they learned to be discreet about it, or to pass it off as doctor-prescribed medication for a host of vague ailments, which, in most cases, it was.)

Excerpted from The Chemical Carousel: What Science Tells Us About Beating Addiction © Dirk Hanson 2008, 2009.
By Dirk Hanson

Does AA Work?

Bill W., co-founder of AA








Adapted from The Chemical Carousel: What Science Tells Us About Beating Addiction © Dirk Hanson 2008, 2009.


Despite recent progress in the medical understanding of addictive disease, the amateur self-help group known as Alcoholics Anonymous, and its affiliate, Narcotics Anonymous, are still regarded by many as the most effective mode of treatment for the ex-addict who is serious about keeping his or her disease in remission. A.A. and N.A. now accept anyone who is chemically dependent on any addictive drug—those battles are history. In today’s A.A. and N.A., an addict is an addict. A pragmatic recognition of pan-addiction makes a hash of strict categories, anyway.

Nonetheless, under the biochemical paradigm of addiction, we have to ask whether the common A.A.-style of group rehabilitation, and its broader expression in the institutionalized form of the Minnesota Model, are nothing more than brainwashing combined with a covert pitch for some of that old-time religion. As Dr. Arnold Ludwig has phrased it, “Why should alcoholism, unlike any other ‘disease,’ be regarded as relatively immune to medical or psychiatric intervention and require, as AA principles insist, a personal relationship with a Higher Power as an essential element for recovery?”

The notion is reminiscent of earlier moralistic approaches to the problem, often couched in strictly religious terms. It conjures up the approach sometimes taken by fundamentalist Christians, in which a conversion experience in the name of Jesus is considered the only possible route to rehabilitation. But if all this is so, why do so many of the hardest of hard scientists in the field continue to recommend A.A. meetings as part of treatment? Desperation? Even researchers and therapists who don’t particularly like anything about the A.A. program often reluctantly recommend it, in the absence of any cheap alternatives.

In 1939, Bill Wilson and the fellowship of non-drinkers that had coalesced around him published the basic textbook of the movement, Alcoholics Anonymous. The book retailed for $3.50, a bit steep for the times, so Bill W. compensated by having it printed on the thickest paper available—hence its nickname, the “Big Book.” The foreword to the first printing stated: “We are not an organization in the conventional sense of the word. There are no fees or dues whatsoever. The only requirement for membership is an honest desire to stop drinking. We are not allied with any particular faith, sect or denomination, nor do we oppose anyone. We simply wish to be helpful to those who are afflicted.”

In short, it sounded like a recipe for complete disaster: naive, hopeful, objective, beyond politics, burdened with an anarchical structure, no official record
keeping, and a membership composed of anonymous, first-name-only alcoholics.
......................
Amid dozens of case histories of alcoholics, the Big Book contained the original Twelve Steps toward physical and spiritual recovery. There are also Twelve Traditions, the fourth one being, “Each group should be autonomous except in matters affecting other groups or A.A. as a whole.” As elaborated upon in Twelve Steps and Twelve Traditions, “There would be real danger should we commence to call some groups ‘wet’ or ‘dry,’ still others ‘Republican’ or ‘Communist’…. Sobriety had to be its sole objective. In all other respects there was perfect freedom of will and action. Every group had the right to be wrong. The unofficial Rule #62 was: “Don’t take yourself too damn seriously!”

As a well-known celebrity in A.A. put it: “In Bill W.’s last talk, he was asked what the most important aspect of the program was, and he said it was the principle of anonymity. It’s the spiritual foundation.” Co-founder Dr. Bob, for his part, believed the essence of the Twelve Steps could be distilled into two words—“love” and “service.” This clearly links the central thrust of A.A. to religious and mystical practices, although it is easily viewed in strictly secular terms, too.

Alcoholics Anonymous recounts a conversation “our friend” had with Dr. C.G. Jung. Once in a while, Jung wrote, “…alcoholics have had what are called vital spiritual experiences…. They appear to be in the nature of huge emotional displacements and rearrangements.” As stated in Twelve Steps and Twelve Traditions, “Nearly every serious emotional problem can be seen as a case of misdirected instinct. When that happens, our great natural assets, the instincts, have turned into physical and mental liabilities.”

Alcoholics Anonymous asserts that there are times when the addict “has no effective mental defense” against that first drink.

Bill Wilson wrote:
"Some strongly object to the A.A. position that alcoholism is an illness. This concept, they feel, removes moral responsibility from alcoholics. As any A.A. knows, this is far from true. We do not use the concept of sickness to absolve our members from responsibility. On the contrary, we use the fact of fatal illness to clamp the heaviest kind of moral obligation onto the sufferer, the obligation to use A.A.’s Twelve Steps to get well."

This excruciating state of moral and physical sickness—this “incomprehensible demoralization”—is known in A.A. as hitting bottom. “Why is it,” asks Dr. Arnold Ludwig, “that reasonably intelligent men and women remain relatively immune to reason and good advice and only choose to quit drinking when they absolutely must, after so much damage has been wrought? What is there about alcoholism, unlike any other ‘disease’ in medicine except certain drug addictions, that makes being in extremis represent a potentially favorable sign for cure?”

Hitting bottom may come in the form of a wrecked car, a wrecked marriage, a jail term, or simple the inexorable buildup of the solo burden of drug-seeking behavior. While the intrinsically spiritual component of the A.A. program would seem to be inconsistent with the emerging biochemical models of addiction, recall that A.A.’s basic premise has always been that alcoholism and drug addiction are diseases of the body and obsessions of the mind.

When the shocking moment arrives, and the addict hits bottom, he or she enters a “sweetly reasonable” and “softened up” state of mind, as A.A. founder Bill Wilson expressed it. Arnold Ludwig calls this the state of “therapeutic surrender.” It is crucial to everything that follows. It is the stage in their lives when addicts are prepared to consider, if only as a highly disturbing hypothesis, that they have become powerless over their use of addictive drugs. In that sense, their lives have become unmanageable. They have lost control.

A.A.’s contention that there is a power greater than the self can be seen in cybernetic terms—that is to stay, in strictly secular terms. The higher power referred to in A.A. may simply turn out to be the complex dynamics of directed group interaction, i.e., the group as a whole. It is a recognition of holistic processes beyond a single individual—the power of the many over and against the power of one.

“The unit of survival—either in ethics or in evolution—is not the organism or the species,” wrote anthropologist Gregory Bateson, “but the largest system or ‘power’ within which the creature lives.” In behavioral terms, A.A. enshrines this sophisticated understanding as a first principle.

alcoholics anonymous

Drug Rehab in China

After two years of a nationwide “people’s war” against drug addiction in China, government authorities are claiming major accomplishments—but treatment, which is mostly compulsory, remains limited and largely ineffective, Chinese doctors say.

The Chinese surge against drugs was credited with numerous successes almost before it had begun. Zhou Yongkang, Minister of Public Security, told the official news agency Xinhua that officials had seized more than two tons of methamphetamine, and three million “head-shaking pills”--otherwise known as Ecstasy tablets.

Two years later, in June of 2007, Minister Yongang, claimed that the number of drug abusers in China had been cut from 1.16 million to 720,400 due to compulsory rehabilitation measures. “The effort has yielded remarkable results,” Yongang told the China Daily. (Other drug experts estimate the number of Chinese drug addicts to be 3 million or more.)

However, a recent paper co-authored by several Chinese physicians, published in the Journal of Substance Abuse Treatment, suggests that things are not so rosy. The report, titled, “Attitudes, Knowledge, and Perceptions of Chinese Doctors Towards Drug Abuse,” paints a dismal picture: Less than half the Chinese doctors working in drug abuse had any formal training in the treatment of drug addicts, the report found. Moreover, less than half of the treatment physicians believed that addiction was a disorder of the brain. (One cannot help wondering whether the percentage for American doctors would be any higher.)

The study could find no coherent doctrine or set of principles for drug rehabilitation being employed in China, beyond mandatory detox facilities. In the Chinese government’s White Paper on “Narcotics Control in China,” the practice of “reeducation-through-labor” is considered to be the most effective form of treatment. Another name for this form of treatment would be: prison.

There are perhaps as many as 200 voluntary drug treatment centers as well. These centers emphasize treating withdrawal symptoms, and feature more American-style group interaction and education, but observers say such centers are often used by people evading police or running from their parents.

In addition, the lack of formal support from the Chinese government has led to the closing of several such facilities after only a few months. The American origins of such treatment modalities have not helped sell such programs to government officials. Pharmaceutical treatments for craving remain unavailable in China.

SOURCES:

--Fan, Maureen. “U.S.-Style Rehabs Take Root in China as Addiction Grows.” Washington Post Foreign Service, A14, January 19, 2007.

--Yi-Lang Tang, et. al. “Attitudes, Knowledge, and Perceptions of Chinese Doctors Towards Drug Abuse.” Journal of Substance Abuse Treatment. vol. 29 no. 3. 215-220.

--“Anti-Drug Campaign Yields Result.” China Daily. June 16, 2007. http://www.china.org.cn.

--“With Prohibition Failing, China Calls for ‘People’s War’ on Drugs.” Drug War Chronicle. vol. 381. 4/8/05 http://stopthedrugwar.org