Books By Addicts: A Collection

The Up and the Down.
 
(Click titles for full review)

Steve Earle and the Ghost of Hank Williams: I’ll Never Get Out of This World Alive

Musician Steve Earle made a solo name for himself with "Guitar Town" and "Copperhead Road" after playing in legendary country and bluegrass bands as a young prodigy. He was nominated for a Grammy, his reputations soared, he added rock and roll to his range—until 1991, when Earle put out the aptly named live album, Shut Up and Die Like An Aviator. Shortly thereafter, he was dropped by his record label for long-standing drug problems, and landed in prison with a heavy sentence for possession of heroin….






When Did I Become the Junkie Auntie Mame? Courtney Love tells her tangled tale in a new e-book.

Maer Roshan, author of Courtney Comes Clean: The High Life and Dark Depths of Music’s Most Controversial Icon, logged a dozen “exhilarating and exhausting” sessions with the widow of Nirvana’s Kurt Cobain over the course of a year, pulling together a definitive look at Love’s drug addictions and other demons. Roshan taped countless hours of interviews, and received additional written material from the “Tolstoy of texting,” as Love refers to herself. The book is highly readable, almost, one is tempted to say, addictively so. Sure, it’s tabloid stuff—let he or she who has never peeked at Gawker or Jezebel cast the first stone….





Mike Doughty Talks About The Book of Drugs: Former Soul Coughing front man on sobriety and life as a solo artist.

Over the phone, Mike Doughty doesn’t have much to say about his former band, Soul Coughing. When I mention it, he gives out a low growl as a warning. He said it all in The Book of Drugs, and it doesn’t sound like he had much fun. Although the avant-garde rock band created music that was spiky and sneaky and immensely popular, topped off by Doughty’s monotonic but strangely penetrating vocal delivery on such classics as “Super Bon Bon,” “True Dreams of Wichita,” and “Circles,” Doughty was drug-dependent and miserable….






Writers On The Edge: A compendium of tough prose and poetry about addiction

Here’s a book I’m delighted to promote unabashedly. I even wrote a jacket blurb for it. I called it an “honest, unflinching book about addiction from a tough group of talented writers. These hard-hitters know whereof they speak, and the language in which they speak can be shocking to the uninitiated—naked prose and poetry about potentially fatal cravings the flesh is heir to—drugs, booze, cutting, overeating, depression, suicide. Not everybody makes it through. Writers On The Edge is about dependency, and the toll it takes, on the guilty and the innocent alike.”






Book Review of Drunken Angel: A hipster gets his shit straight—sort of.

Addiction memoirs remain one of the most popular forms of autobiography on the shelves. But now, when considering a new addition to the genre, it’s impossible not to wonder whether the claims being made by the author are genuine. Since serious drunks often end up visiting the lower circles of hell during the course of their disease, hair-raising and improbable scenes are lamentably common—that is part of the genre’s charm, if that is the right word for it. But how are we to react now? The answer is, you can’t know, and you never really could, that bastard James Frey notwithstanding....






Addiction Fiction: Coming-of-Age Drug Novels

Call it “addiction fiction.” In the past few years we have seen a blossoming of this genre, where the private eye goes to 12-Step meetings, and one day your sponsor may just save your life by gunning down a rival in the street. Or, where the wise-beyond-their-years prep school drug addicts engage in Brett Easton Ellis-style sex and ennui….








Addiction Noir: The Next Right Thing

To date, I’ve only reviewed one novel here at Addiction Inbox—Steve Earle’s I’ll Never Get Out of This World Alive, featuring the ghost of Hank Williams standing in for the addictive pleasures that musicians are heir to. Now comes The Next Right Thing by Dan Barden, an exemplar of a new literary genre I am going to call addiction noir….








John Berryman and the Poetry of “Irresistible Descent”: The penal colony’s prime scribe

A year before he committed suicide by jumping off a Minneapolis bridge in 1972, Pulitzer Prize-winning poet John Berryman had been in alcohol rehab three times, and had published a rambling, curious, unfinished book about his treatment experiences. Recovery is a time capsule. If you think we have little to offer addicts by way of treatment these days, consider the picture in the 60s and 70s. In Recovery, treatment consists almost entirely of Freudian group analysis, and while there is regular talk of alcoholism as a disease, AA style, there is no evidence that it was actually dealt with in this way, after detoxification....

Weight Loss Redux

Why diet pills are problematic.

"Physicians who treat obesity hailed the Food and Drug Administration's recent approval of two new diet drugs—the first in 13 years—as a new era in weight-loss management."
--Wall Street Journal, July 30, 2012

 (The following post was originally published on September 20, 2011)

It took many years to bring depression and its treatment into the rational light of day. Addiction in the mid-1990s was in the process of undergoing a similar medical transformation. Even so, scientists were wary of pronouncing that overeating was in some cases a treatable chemical disorder.

Obesity, in any form other than pituitary cases, was not typically considered a medical disorder at all. In a 1998 interview with MIT’s student newspaper, The Tech, neurology professor Richard Wurtman recalled that ten years earlier, the major drug companies had shown little interest in a drug treatment for obesity: “They thought that if you were obese, it was your fault.” It was the same view that had prevailed concerning depression, alcoholism, and other drug addictions. Bulimia and carbohydrate craving were no different: a simple failure of will was once thought to explain them all. But everything changed when the serotonin-boosting diet pill called Redux (dexfenfluramine) won full FDA approval in 1996. Redux was the first drug ever approved in the U.S. for the long-term treatment of obesity.

In truth, Ely Lilly and Company did move forward with earlier efforts to win approval of high-dose Prozac for weight loss. That petition had been languishing in the FDA pipeline for years under the trade name Lovan. Back in the late 1980s, when Eli Lilly scientists were investigating rats that consumed fewer calories on fluoxetine, the company called upon Dr. Richard Wurtman, the MIT brain scientist who specialized in the connection between serotonin levels and carbohydrate intake. Scientists at Lilly had become increasingly concerned that the weight loss from Prozac was short-lived, and the mechanism of action remained maddeningly imprecise. For more than a decade, Eli Lilly had pursued Prozac along three separate but related lines of development: depression, weight control, and alcoholism. If you took it for depression, and it worked, you might also lose a few pounds, and drink less. If you took it for bulimia or weight loss, you might also feel better emotionally, and drink less. When the FDA made encouraging noises about Prozac as a new front-line treatment for bulimia in 1994, Eli Lilly followed that indication to market, and again chose not to follow up on weight loss or alcoholism.

Eli Lilly was no longer interested, but Richard and Judith Wurtman were undeterred. As it happened, the couple had already patented a serotonin-active drug of their own—dexfenfluramine—which French laboratories had been testing as a weight loss pill. The Wurtmans went public with a new company, Interneuron Pharmaceuticals, and filed with the FDA to market their weight-loss remedy. The Wurtmans became instant millionaires on paper.

“Diet pills” had always had a somewhat unsavory reputation. Typically, they were amphetamines, or the near-beer equivalent, ephedrine—and neither compound was anything like a healthy long-term answer to chronic overeating. The serotonin-active drugs were a new class of medications altogether. Dexfenfluramine wasn’t addictive, any more than Prozac was addictive. Moreover, fenfluramine was specifically intended for use by people suffering from carbohydrate-craving obesity. But would doctors be able to resist the demands of other patients who just wanted to trim off a few pounds?

Initially, the Wurtmans licensed the serotonin-active weight loss drug to several marketers in Europe, where it met with initial success. After a few small-scale studies, Rochester University in New York published a report showing that the weight loss effect was enhanced when fenfluramine was combined with a drug called phentermine. The resulting combination was widely known as “phen-fen.” As with Prozac, dexfenfluramine was tested as an anti-obesity medication at dosages several times higher than the amount typically prescribed for depression.

Early red flags were raised when Johns Hopkins researchers reported some cases of neurological toxicity in monkeys on dexfenfluramine, but MIT, which shared patent rights with the Wurtmans, was understandably enthusiastic when Redux, as dexfenfluramine became known, won full FDA approval in 1996.

And for many people, Redux worked. In the first six months after its approval, physicians wrote at least two million prescriptions for Redux. The phen-fen combination swept the weight loss industry. Estimates of total users of phen-fen ran as high as six million in the U.S. alone. Doctors and weight loss clinics sometimes prescribed Redux, sometimes the phen-fen combination. Initial earnings estimates were running as high as $600 million a year for the Redux portion of phen-fen, netting MIT between one and five per cent of the royalties.

The euphoria didn’t last long. By the time Redux made the cover of Time, researchers were already rumbling about continued reports of high toxicity and hypertension in rat studies. In addition, the serotonin surge associated with the use of dexfenfluramine caused concerns about pulmonary hypertension. In August of 1997, doctors at the Mayo Clinic in Minnesota reported serious heart valve abnormalities in 24 women taking the phen-fen combination.

A month later, at the FDA’s request, phen-fen and Redux were permanently pulled off the market.  In 2002, American Home Products settled a class action suit on behalf of almost 300,000 phen-fen users for $3.75 billion. As class action suits go, this put it right between the $2.4 billion Dalkon Shield settlement and the $4.5 billion breast implant accords.

What went wrong? Researchers now believe that the two drugs, which were never offered for sale as a single pill, should never have been combined in the first place. Somehow the fact that the phen part of the combination allegedly acted as an MAO inhibitor, and hence should not have been combined with yet another serotonin-enhancing medication, escaped notice. The combination of the two drugs apparently raised blood plasma levels of serotonin to abnormal levels. Too much serotonin in the bloodstream can damage blood vessels in the heart and lungs. Other suspected MAO inhibitors, like St. John’s Wort, or the Chinese herbal remedy ma huang, would not have combined well with Redux or phen-fen, either. Referring to the casual use of Ecstasy, Dr. Rick Doblin drew a parallel with phen-fen in the autumn 1995 issue of the Multidisciplinary Association for Psychedelic Studies (MAPS):

This use of MDMA, though not conducted in the context of a scientifically controlled experiment, does provide an opportunity for a very large epidemiological study. Similarly, over fifty million people have tried a prescription drug called fenfluramine, a diet aid prescribed for daily use for months or years at a time that causes the same kind of neurotoxicity in animals as does MDMA.

The phen-fen disaster highlighted the need to investigate drug synergies thoroughly before combining them as a pharmacotherapy. The phen-fen heart and lung damage may have been related to a potentially toxic condition known as “serotonin syndrome.”

And the Wurtmans? Ironically, Richard and Judith Wurtman had patented the use of Prozac for severe PMS years earlier, and ultimately sublicensed the rights back to Eli Lilly for several million dollars. Eli Lilly disguised the fact that their PMS drug was a case of old wine in new bottles. As Wellbutrin had become Zyban, so Prozac metamorphosed into Serafem, when prescribed for premenstrual syndrome.

Photo Credit: http://www.drugnet.net/

Status of Medical Marijuana to be Tested in U.S. Appeals Court

Ten-year old petition could change everything.

Medical marijuana advocates will finally have their day in federal court, after the United States Court of Appeals for D.C. ended ten years of rebuffs by agreeing to hear oral arguments on the government’s classification of marijuana as a dangerous drug.

A decision in the case could either finish off medical marijuana for good, or else upend the fed’s rationale for its stepped-up war against the medical marijuana industry. Americans for Safe Access v. Drug Enforcement Administration asks that the federal government review the scientific evidence regarding marijuana’s therapeutic value. The D.C. Circuit Court of Appeals has agreed to do so in October.

The original petition, filed by the Coalition for Rescheduling Cannabis (CRC) in 2002, has languished in obscurity, but recent moves to have marijuana rescheduled from its status as a Schedule 1 drug—a class that includes heroin—have increased in the wake of America’s Civil War over medical marijuana.  “This is a rare opportunity for patients to confront politically motivated decision-making with scientific evidence of marijuana’s med efficacy,” said Joe Elford, chief council for Americans for Safe Access, the group that successfully challenged the denial of the original CRC petition. “What’s at stake in this case is nothing less than our country’s scientific integrity and the imminent needs of millions of patients.”

The Controlled Substance Act reserves Schedule 1 for drugs that “have a high potential for abuse, have no currently accepted medical use in treatment in the United States, and there is lack of accepted safety for use of the drug or other substance under medical supervision.”

Recently, an article by Dr. Igor Grant in the Open Neurology Journal argued that marijuana’s Schedule 1 classification and surrounding political controversy were “obstacles to medical progress in this area.”

Seventeen states have now adopted some form of medical marijuana law, but the nascent field remains in limbo due to federal regulations about the illegality of marijuana use. Over the past year, the U.S. Justice Department has stepped up its pressure on medical marijuana purveyors, culminating in dozens of indictments, seizures, and shutdowns. Most recently, the Los Angeles City Council simply threw up its hands and banned most marijuana dispensaries in the city. But it’s not even clear if the ban on state-legal dispensaries is itself legal. A pot collective in Covina recently won its challenge to a blanket ban on pot sales in unincorporated areas of Los Angeles County in the state’s 2nd District Court of Appeal. As a Los Angeles Times editorial aptly put it, “we’re confused about how to legally restrict a quasi-legal business.”

According to Chris Roberts, writing in the SF Weekly, “the court hearing would be the first time the medical merits of cannabis would be examined in a federal courtroom since 1994.” At the core of the argument is the federal government’s contention that the marijuana plant has no redeeming medical value, as opposed to the mountain of scientific studies suggesting that marijuana may be applicable in the treatment of glaucoma, cancer, chronic pain, and possibly other conditions, such as multiple sclerosis.

Graphics Credit:   http://en.wikipedia.org/

Misdiagnosing Fetal Alcohol Spectrum Disorder

Facial abnormalities not present in most cases.

Back in 1967, when a French pediatrician tried to alert doctors to developmental problems he had recognized in the children of alcoholic mothers, he didn’t make much progress.  A few years later, pediatrician David Smith began seeing the same sorts of trouble as Paul Lemoine had seen in France. Hoping to draw more attention to the problem, Dr. Smith coined the term fetal alcohol syndrome, or FAS. It was a successful gambit. By now, almost everyone has heard of the disorder. And once NIAAA-funded studies had succeeded in proving that the problem did not only affect the children of poor alcoholic women, research on it has been a major theme at the National Institute on Alcohol Abuse and Alcoholism (NIAAA) ever since. Fetal alcohol disorders may in fact be the most common and preventable form of developmental disorder in the world.

Typically, physicians have used three basic features to diagnose full FAS:

--Characteristic facial abnormalities
--Growth deficits
--Nervous system dysfunctions

But there’s a problem: Fetal Alcohol Syndrome is considered a spectrum disorder, meaning that it includes variations on the full pattern of birth defects. Fetal Alcohol Spectrum Disorder (FASD) doesn’t always show all three of these diagnostic features. In the early going, therefore, clinicians missed a lot of children suffering from FASD, catching only full FAS in the diagnostic net. Kenneth Warren, acting director of the NIAAA, said in a press release that “if you didn’t have the distinctive facial features, you weren’t diagnosed with FAS. If you didn’t have a growth deficit, you weren’t diagnosed with FAS.”

All of this means that recognizing the effects of fetal alcohol exposure is trickier than first thought. For example, FASD is often mistaken for attention deficit hyperactivity disorder (ADHD). The distinction certainly matters, because stimulant medications, which work for some kids with ADHD, are of no use to children with fetal alcohol spectrum disorder. Now, a long-term study of heavy drinking during pregnancy by researchers at the University of Chile appears to nail down the fact that most children regularly exposed to alcohol in the womb do not show the distinct facial characteristics of fetal alcohol syndrome (FAS). Rather, said collaborators on the study at the U.S. National Institute of Child Health and Human Development (NICHD), abnormalities of the nervous system and behavioral problems like language delays, hyperactivity, and attention deficits are far more reliable diagnostic clues.

In the study, investigators interviewed a group of 9000 women in Santiago, Chile, and eventually matched 101 pregnant women who drank four or more drinks a day with a control group of pregnant non-drinkers. The study followed the children until the age of 8. The investigators found “functional neurologic impairment” in 44 % of children whose mothers consumed four or more drinks per day. In contrast, only 17 % of the alcohol-exposed children showed any abnormal facial features. 

“Our concern is that in the absence of the distinctive facial features,” said Devon Keuhn of the NICHD in a prepared statement, “health care providers evaluating children with any of these functional neurological impairments might miss their history of fetal alcohol exposure.”

The NICHD University of Chile Alcohol in Pregnancy Study is an ongoing project.

Photo Credit: http://en.wikipedia.org

Broken Treatment: How the Addiction Industry is Failing its Clients

It’s not medical. It's not psychiatric. What is it?

1. Most clinicians who treat addicted patients are counselors, not physicians; thus they cannot prescribe medication and they generally don’t “believe” in the use of medication for addictive disorders.

2. Most patients have medical insurance that excludes or severely limits treatment of addictive disorders, so payment for service is not good. This situation may change in the near future with the advent of healthcare reform in the United States.

So writes Dr. Charles O’Brien of the University of Pennyslvania Perelman School of Medicine, in a recent article for The Dana Foundation’s website.  In his article—“If Addictions Can Be Treated, Why Aren’t They?”—Dr. O’Brien asks a basic question: “Why are most patients not even given a trial of medication in most respected treatment programs?”

Even though pharmaceutical companies have throttled back on their interest in anti-craving drugs in recent years, there are, in fact, a few medications recognized by the FDA, primarily for use in the treatment of alcoholism. But they are not much in favor, and O’Brien believes he knows why:

The answer seems to be that there is a bias among treatment professionals, perhaps passed down from past generations when addictions were not understood to be a disease. Medically trained personnel are minimally involved in the addiction treatment system and most medical schools teach very little about addiction so most physicians are unaware of effective medications or how to use them.

What is on offer at most addiction treatment facilities is not actual rehabilitation, but rather short-term detoxification. And what we’ve learned from neuroscience is that taking away the drug is only stage one. The addiction remains, the reward and memory systems still operating erratically. We understand some of this circuitry better than at any time in history, but the concrete effects of these insights at the level of the community treatment clinic have been small to nonexistent. Money, of course, is part of it, since addiction has only recently, and sporadically, gotten the attention of funding agencies in the public health community. 

Health journalist Maia Szalavitz, writing at Time Healthland concurs: “Unlike most known diseases, the treatment of addiction is not based on scientific evidence nor is it required to be provided by people with any medical education—let alone actual physicians—according to a new report.” The report in question, from Columbia University’s National Center on Addiction and Substance Abuse (CASA), notes that most people are shoehorned into a standardized approach built around the 12 Step model of Alcoholics Anonymous. “The dominance of the 12-step approach,” writes Szalavitz, “also leads to a widespread opposition to change based on medical evidence, particularly the use of medications like methadone or buprenorphine to treat opioid addictions—maintenance treatments that data have show to be most effective.”

  Szalavitz also believes she knows why, and her thinking is similar to O’Brien’s. “Other medications that are known to treat alcohol and drug addiction, such as naltrexone, are also underutilized,” she writes, “while philosophical opposition to the medicalization of care slows uptake.”

There is a straightforward reason for considering the use of medication in the treatment of addiction: strong suggestions of recognizable genetic differences between those who respond to a given medication, and those who don’t. As O’Brien explains, a prospective study now in progress will be looking to see if alcoholics with a specific opioid receptor variant show a better outcome on naltrexone than those with the standard gene for that opioid receptor. And if they do, the FDA may allow a labeling change “stating that alcoholics with this genotype can be expected to have a superior response to naltrexone.”

But that won’t be happening tomorrow. In the meantime, we are stuck with the addiction treatment industry as it is. “The [CASA] report notes that only 10% of people with substance-use problems seek help for them,” Szalavitz concludes. “Given its findings about the shortcomings of the treatment system, that’s hardly surprising.”

Photo Credit: Creative Commons

John Berryman and the Poetry of “Irresistible Descent”

“The penal colony’s prime scribe.”

“Will power is nothing. Morals is nothing. Lord, this is illness.”
—John Berryman, 1971

A year before he committed suicide by jumping off a Minneapolis bridge in 1972, Pulitzer Prize-winning poet John Berryman had been in alcohol rehab three times, and had published a rambling, curious, unfinished book about his treatment experiences. Recovery is a time capsule. If you think we have little to offer addicts by way of treatment these days, consider the picture in the 60s and 70s. In Recovery, treatment consists almost entirely of Freudian group analysis, and while there is regular talk of alcoholism as a disease, AA style, there is no evidence that it was actually dealt with in this way, after detoxification.

Best known for “Dream Songs,” Berryman taught at the University of Minnesota, and was known as a dedicated if irascible professor. Scientist Alan Severence, Berryman’s stand-in persona in the book, comes into rehab hard and recalcitrant, despite his previous failures: “Screw all these humorless bastards sitting around congratulating themselves on being sober, what’s so wonderful about being sober? Great Christ, most of the world is sober, and look at it!” And he is suffering from “the even deeper delusion that my science and art depended on my drinking, or at least were connected with it, could not be attacked directly. Too far down.”

Berryman was a difficult man, and knew it. He quotes F. Scott Fitzgerald: “When drunk, I make them pay and pay and pay and pay.”

Alcoholics, writes Berryman, are “rigid, childish, intolerant, programmatic. They have to live furtive lives. Your only chance is to come out in the open.” Berryman catches the flavor of group interaction after too many hours, too much frustration, and too much craving. One inpatient lashes out: “You’re lying when you say you do not do anything about your anger. You get bombed. It is called medicating the feelings, pal. Every inappropriate drinker does it. Cause and effect. Visible to a child. Not visible to you.”

Berryman was a shrewd observer, a singular writer, and, after all, a poet. He is extraordinary on the subject of alcoholic dissociation: “I found myself wondering whether I would turn off right towards the University and the bus home or whether I would just continue right on to the Circle and up right one block to the main bar I use there, and have a few. Wondering. My whole fate depending on pure chance…. as if one were not even one’s own actor but only a spectator.”

Berryman puts it all together in a horrific capsule description of the “irresistible descent, for the person incomprehensibly determined.”

Relief drinking occasional then constant, increase in alcohol tolerance, first blackouts, surreptitious drinking, growing dependence, urgency of FIRST drinks, guilt spreading, unable to bear discussion of the problem, blackout crescendo, failure of ability to stop along with others (the evening really begins after you leave the party)… grandiose and aggressive behavior, remorse without respite, controls fail, resolutions fail, decline of other interests, avoidance of wife and friends and colleagues, work troubles, irrational resentments, inability to eat, erosion of the ordinary will, tremor and sweating… injuries, moral deterioration, impaired and delusional thinking, low bars and witless cronies….

Berryman had no illusions about his failed attempt to hide behind the mask of a social drinker: “It seems to be loss of control. Unpredictability. That’s all. A social drinker knows when he can stop. Also, in a general way, his life-style does not arrange itself around the chemical, as ours does. For instance, he does not go on the wagon…”

In the end, he was "pleading the universal case of hope for abnormal drinkers, for all despairing and deluded sufferers fighting for their sanity in a world not much less insane itself and similarly half-bent on self-destruction…”

As the head nurse in the facility tells the group: “You are all suffering from the lack of self-confidence… often so powerful that it leads to consideration of suicide, a plan which if adopted will leave you really invulnerable, quite safe at last.”

And as Saul Bellow wrote in the introduction to Recovery: “At last there was no more. Reinforcements failed to arrive. Forces were not joined. The cycle of resolution, reform and relapse had become a bad joke which could not continue.” Berryman agreed. Toward the end, he wrote: “I certainly don’t think I’ll last much longer.”

“There’s hope until you’re dead,” a woman tells him during his final stay in rehab. Sadly, that hope ended a few months later.


Photo posted by Tom Sutpen for the series: Poets are both clean and warm

The Summer Olympics and the “War on Doping”

 
Time for a change in strategy?

The Summer Olympics are fast approaching, and that can only mean one thing: drugs. After more than a decade, you might wonder, how goes the so-called “War on Doping?”

Not so good, but thanks for asking. The World Anti-Doping Agency, established in 1999 and backed by the UNESCO anti-doping convention, will be operating 24/7 during the games, protecting the “purity” of Sport, trying to ferret out everything from cannabis and cocaine to steroids and arcane metabolites unfamiliar to the world at large. Marijuana as a “performance enhancing” drug? Doesn’t sound likely, but cannabis derivatives are on the banned list anyway. As Bengt Kayser and Barbara Broers of the Institute of Movement Sciences and Sports Medicine at the University of Geneva write in the Harm Reduction Journal, marijuana seems to have been included “largely because of pressure from the ‘war on drugs’ movement, even though there are no known proven performance enhancing effects but rather evidence for the contrary.”

No matter. That’s just for starters. As in life, an athlete can be busted for a banned substance taken days earlier, in some other recreational context, and not intended as a sports enhancer, if the metabolites linger too long in the body. The current policy, Kayser and Broers write, “is still essentially based on repression and surveillance from a zero-tolerance viewpoint.”

Did they say “surveillance?” Top athletes are not like you and me. Jocks operate under a “strict liability” rule: It doesn’t matter how it got in your body, or why. If they find proscribed metabolites, you’re busted. It’s entirely possible to get banned from your sport for life. In 2003, British sprinter Dwain Chambers tested positive for a proscribed substance and was subsequently banned from competition for life by the British Olympic Association. (Chambers recently won an appeal, and continues to compete.)

And to make sure that the Olympic Committee can be diligent about the ever-growing list of banned substances, Olympic-level athletes are subject to something called the “whereabouts” rule, say the authors. Elite athletes must “inform the anti-doping authorities where they will be each day of the year, to allow unannounced out-of (and in)-competition testing…” This requirement is clearly impossible for almost anyone to honor, certainly including globetrotting athletes. But Sebastian Coe, chairman of the London Organizing Committee for the Olympic Games, didn’t let even a ray of ambiguity enter the picture, stating: “I don’t think there is room for drugs cheats in sport.”

However inartfully phrased, this sentiment reflects the Olympic Committee’s desire to increase testing, even though the Geneva sports scientists believe that the “probability for false positives rises with the number of tests performed, as well as with a drop in prevalence of actual doping. Furthermore, for some forms of doping practices, there exist no laboratory tests.” The result? “A greater number of tests would lead to a greater number of false positives, wrongly accusing innocent citizens.”

In fact, you can now be busted even though no trace of a banned drug was found in your blood or urine. Here’s how it works:

Longitudinal testing, looking for fluctuations in certain blood parameters compatible with doping, is now also being introduced. This practice, known as the "athlete biological passport" (ABP), has recently led to the first indictments of athletes, based on indirect indices of presumed doping rather than laboratory tests directly showing the presence of the forbidden substance or their metabolites.

This practice is even shakier, write Kayser and Broers, producing even more false positives “due to analytical variability and outlying individual patterns resulting from the effects of behavior (training, altitude exposure) and genetics.

But the purpose of anti-doping—to celebrate the “clean” and upright athlete as exemplar of everything good and fair—is unrealistic, say the authors. “Doping has always been a part of sports…. Performance enhancement is a logical and essential ingredient of competitive sport. Athletes look for ways to get better, by changing their training paradigm, by eating differently, by taking vitamins, by taking licit medication, by taking supplements.” In short: “The line between licit and illicit fluctuates and has dimensions that can be perceived as arbitrary.”

The essay asks us to consider whether anti-doping tests might one day be logically applied to coaches, trainers, and referees as well—not to mention students studying for a final exam.

So what do we do? Just throw the doors open to any and all drug taking at the Olympics? Since the paper was published in the Harm Reduction Journal, the authors have some thoughts on that. “The argument that it would change sports into an arena akin to Formula 1 where the best engineering team wins is only partly correct,” they write. Which is only partly reassuring. But the authors hasten to argue that “such a scenario is already in place anyway; today well-assisted athletes may engage in complex training regimes and strategic doping while remaining undetected.” They advocate shortening the list of forbidden substances, banning only those with “actually proven performance enhancing effects and major health hazards.” In amateur sports, the authors urge the establishment of so-called steroid clinics, where jocks could get syringes, anonymous service, and professional advice from medical staff.

It would require a major change of heart, and a whole different way of viewing competitive sports. Throttling back the anti-doping program would not sit well with many sports parents of young athletes. The authors are aware of this need, and note that “since athletic careers often start very early, the protection of young talents would be mandatory.”

As a former collegiate athlete, I don’t have an answer to this dilemma. Not even a clue, really. Testing is cumbersome and intrusive and puts the innocent under suspicion. On the other hand, performance-enhancing drugs are unfair and unevenly applied—but so are things like good coaching and state-of-the-art equipment. The answer, perhaps, is to begin viewing anti-doping efforts as wholly distinct from drug war efforts—different rationale, logistics, and deployment.

Kayser B, and Broers B (2012). The Olympics and harm reduction? Harm reduction journal, 9 (1) PMID: 22788912

Photo Credit: http://www1.skysports.com/