Addiction Rehab: Everything is Broken

Down the rabbit hole in search of effective treatment.

When I first began researching drugs and addiction years ago, a Seattle doctor told me something memorable. “It’s as if you had cancer,” she said, “and your doctor’s sole method of treatment consisted of putting you in a weekly self-help group.”

I’ve got nothing against weekly self-help groups, to be sure. But as Ivan Oransky, executive editor of Reuters Health and a blogger at Retraction Watch, told me as recently as least year, addiction treatment appeared to be “all selling and self-diagnosis. They’re selling you on the fact that you need to be treated.”

In his introduction to Inside Rehab by Anne M. Fletcher (pictured), treatment specialist and former deputy drug czar A. Thomas McLellan writes that the book is “filled with disturbing accounts of seriously addicted people getting very limited care at exhaustive costs and with uncertain results...”

A common notion about addiction treatment facilities, or rehabs, is they are commonly called, is that they are staffed by professional social workers, certified counselors, and family psychologists, as well as addiction specialists. However: “Of the twenty-one states that specify minimum educational requirements for program or clinical directors of rehabs, only eight require a master’s degree and just six require credentialing as an addiction counselor,” writes Fletcher. Neuroscience journalist Maia Szalavitz, who writes for Time Healthland and specializes in addiction and rehab, told Fletcher that “the addiction field has been about as effectively regulated as banking before the economic crisis in many states.” According to Tom McLellan, counselor and director turnover in addiction treatment programs is “higher than in fast-food restaurants.”

In the United States, where for-profit treatment is prevalent, money does not buy access to superior treatment. Fletcher, author of several self-help books on weight loss and alcoholism, doggedly documents what she learns from visiting treatment facilities and interviewing current and former staff and clients. One difficulty with a book of this kind, based primarily on first-hand accounts, is that the same treatment program can offer vastly contrasting experiences from one client to another. And Fletcher, no fan of the 12 Steps, wants AA and NA to account for themselves in a way those volunteer institutions were never designed to accomplish.

But let’s just say it: Addiction treatment in America is a disaster. Addicts get better despite the treatment industry as often as they get better because of it. How did it all go wrong? Part of the answer is that addiction, like depression, tuberculosis, and other chronic conditions, is a segregated illness, as McLellan explains in his introduction. Traditionally, chronic conditions like alcoholism “were not recognized as medical illnesses, and have only recently been taught in most medical schools and treated by physicians. They were seen as ‘lifestyle problems’ and care was typically provided by concerned, committed individuals or institutions not well connected to mainstream health care.”

For treatment of alcoholism and drug addiction, the work has historically fallen to addicts themselves, due to discrimination, segregation, and stigmatization. This prevailing condition is still seen today in many group treatment programs, which are often administered in large part by former addicts with little or no formal training, rather than medical or psychological professionals. Addiction, as the author’s husband wryly remarked, “is the only disease for which having it makes you an expert.”

Which brings up a central point: Where are all the M.D.s? Doctors aren’t helping, either, when they fail to screen for risky drinking or drug use, or when they automatically refer addicts rather than treating them.

If Christopher Kennedy Lawford’s new book, Recover to Live, is the pretty picture, then Fletcher’s Inside Rehab is the gritty picture, in which most addicts who recover don’t go to treatment, 28 days is not long enough to accomplish anything but detox, group counseling is not always the best way to treat addiction, the 12 Steps are not always essential to recovery, specialty drugs are often needed to treat drug addiction, and, perhaps the most troubling of all, most addiction programs do not offer state-of-the-art approaches to treatment that have been shown to be effective in scientific studies.

What clients get, for the most part, is “group, group, and more group,” Fletcher writes. And in many cases of residential or outpatient rehab, “the clients did most of the therapy.” The scientific evidence suggests that some addicts do better with an emphasis on individual counseling, rather than the constant reliance on group work that traditional rehabs have to offer. As one counselor put it: “If I made an appointment to see a therapist because I was depressed, would I be told I have to do a program with everyone else?”

Monthly residential treatment can easily cost $25,000 or more. But public, government funded rehab centers, which presumably have less incentive to treat clients like money, are frequently full. And since these programs run the bulk of prison-related treatment in this country, addicts often stand a better chance of getting into these less expensive programs if they commit a crime.

Even if you manage to get in, rehab rules all too often seem arbitrary and punitive: Recreational reading materials, musical instruments, cell phones, and computers are frequently not permitted. And there is a strong tendency to insist that use equals abuse in every circumstance. Rehab management—the business of what happens after formal treatment ends—is largely neglected in the treatment sphere.

Fletcher rails against the disease model, but mostly in response to how she believes this concept is presented by AA/NA. Like other critics, she dwells on the idea that the disease tag serves as a crutch and an excuse, rather than as an extremely empowering notion for many addicts. In fact, the disease model, as addiction scientists understand it, is seriously underrepresented in the treatment field. Too many mental health professionals continue to insist that “all you need to do is get to the bottom of the problem and the need to use substances to cope, will dissipate,” said an M.D. specializing in addiction. “However, there is absolutely no evidence that this approach works for people who are addicted to alcohol or drugs… The primary-secondary issue is moot and an artifact of the bifurcation of the treatment delivery system.”

A significant number of rehabs still oppose medication-assisted treatment, Fletcher makes clear. Hazelden made news recently for dropping its long-standing opposition to buprenorphrine as a maintenance drug for opiate addicts during treatment. Richard Saitz of Boston University’s School of Medicine says in the book that if addiction were viewed like other health problems, “patients addicted to opioids who are not offered the opportunity to be on maintenance medications would sue their providers and win.”

According to Dr. Mark Willenbring, former director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA): “No one wants to say, ‘Treatment as we’ve been doing it probably isn’t as effective as we thought, and we need more basic research to really come up with new tools. In the meantime let’s do what we can to help suffering people in the most cost effective way and strive to not harm them.’”

How to Kick Everything

Christopher Kennedy Lawford on recovery.

Christopher Kennedy Lawford’s ambitious, one-size-fits-all undertaking is titled Recover to Live: Kick Any Habit, Manage Any Addiction: Your Self-Treatment Guide to Alcohol, Drugs, Eating Disorders, Gambling, Hoarding, Smoking, Sex, and Porn. That pretty much covers the waterfront, and represents both the strengths and the weaknesses of the book.

There’s no doubting Lawford’s sincerity, or his experiential understanding of addiction, or the fact that the raw ingredients were present in his case: bad genes and a traumatic early environment. He is related to Ted Kennedy, two of his uncles were publically murdered, and he started using drugs at age 12. But this book doesn’t dwell on his personal narrative. Lawford is a tireless supporter of the addiction recovery community, and Recover to Live is meant to be a one-stop consumer handbook for dealing with, as the title makes clear, any addiction.

To his credit, Lawford starts out by accurately pegging the addiction basics: A chronic brain disorder with strong neurological underpinnings. He cites a lot of relevant studies, and some questionable ones as well, but ultimately lands on an appropriate spot: “You can’t control which genes you inherited or the circumstances of your life that contributed to your disease. But once you know that you have the disease of addiction, you are responsible for doing something about it. And if you don’t address your problem, you can’t blame society or anyone in your life for the consequences. Sorry. That’s the way it works.”

Once you know, you have to treat it. “It can turn the most loving and nurturing home into a prison of anger and fear,” Lawford writes, “because there is no easy fix for the problem, and that infuriates many people.”

 Lawford includes good interviews with the right people—Nora Volkow, Herb Kleber, and Charles O’Brien among them. And he makes a distinction frequently lost in drug debates: “Nondependent drug use is a preventable behavior, whereas addiction is a treatable disease of the brain.” Due to our penchant for jailing co-morbid addicts, “our prisons and jails are the largest mental health institution in the world.” He also knows that hidden alcoholism and multiple addictions mean “rates of remission from single substances may not accurately reflect remission when viewed broadly in terms of all substances used.”

One nice thing about Lawford’s approach is that he highlights comorbidity, the elephant in the room when it comes to addiction treatment. Addiction is so often intertwined with mental health issues of various kinds, and so frequently left out of the treatment equation. The author is correct to focus on “co-occurring disorders,” even though he prefers the term “toxic compulsions,” meaning the overlapping addictions that can often be found in the same person: the alcoholic, chain-smoking, compulsive gambler being the most obvious example.

The curious inclusion of hoarding in Lawford’s list of 7 toxic compulsions (the 7 Deadly Sins?) is best explained by viewing it as the flipside of compulsive shoplifting, a disorder which is likely to follow gambling into the list of behavioral dependencies similar to substance addictions. In sum, writes Lawford, “If we are smoking, overeating, gambling problematically, or spending inordinate amounts of time on porn, we will have a shallower recovery from our primary toxic compulsion.” Lawford sees the exorcising of childhood trauma as the essential element of recovery—a theory that has regained popularity in the wake of findings in the burgeoning field of epigenetics, where scientists have documented changes in genetic expression beyond the womb.

But in order to cover everything, using the widest possible net, Lawford is forced to conflate an overload of information about substance and behavioral dependencies, and sometimes it doesn’t work. He quotes approvingly from a doctor who tells him, “If you’re having five or more drinks—you have a problem with alcohol.” A good deal of evidence suggests that this may be true. But then the doctor continues: “If you use illicit drugs at all, you have a problem with drugs.” Well, no, not necessarily, unless by “problem” the doctor means legal troubles. There are recreational users of every addictive substance that exists—users with the right genes and developmental background to control their use of various drugs. And patients who avail themselves of medical marijuana for chronic illnesses might also beg to differ with the doctor’s opinion.

Lawford attempts to rank every addiction treatment under the sun in terms of effectiveness (“Let a thousand flowers bloom”), an operation fraught with pitfalls since no two people experience addictive drugs in exactly the same way. Is motivational enhancement better than Acamprosate for treatment of alcoholism, worse than cognitive therapy, or about as good as exercise? Lawford makes his picks, but it’s a horse race, so outcomes are uncertain. Moderation management, web-based personalized feedback, mindfulness meditation, acupuncture—it’s all here, the evidence-based and the not-so-evidence based. Whatever it is, Lawford seems to think, it can’t hurt to give it a try, and even the flimsiest treatment modalities might have a calming effect or elicit some sort of placebo response. So what could it hurt.

Lawford’s “Seven Self-Care Tools” with which to combat the Seven Toxic Compulsions vary widely in usefulness. The evidence is controversial for Tool 1, Cognitive Behavioral Therapy. Tool 2, 12-Step Programs, is controversial and not to everybody’s taste, but used as a free tool by many. Tool 3 is Mindfulness, which is basically another form of cognitive therapy, and Tool 4 is Meditation, which invokes a relaxation response and is generally recognized as safe. Tool 5, Nutrition and Exercise, is solid, but Tool 6, Body Work, is not. Treatments like acupuncture, Reichian therapy, and other forms of “body work” are not proven aids to addicts. Tool 7, Journaling, is up to you.

One of the more useful lists is NIDA director Nora Volkow’s “four biggest addiction myths."

First: “The notion that addiction is the result of a personal choice, a sign of a character flaw, or moral weakness.”

Second: “In order for treatment to be effective, a person must hit ‘rock bottom.’”

Third: “The fact that addicted individuals often and repeatedly fail in their efforts to remain abstinent for a significant period of time demonstrates that addiction treatment doesn’t work.”

Fourth: “The brain is a static, fully formed entity, at least in adults.”

Finally, Lawford puts a strong emphasis on an important but rarely emphasized treatment modality: brief intervention. Why? Because traditional, confrontational interventions don’t work. The associate director of a UCLA substance abuse program tells Lawford: “I haven’t had a drink now in 25 years, and this doctor did it without beating me over the head with a big book, without chastising me, or doing an intervention. What he did was a brief intervention. Health professionals who give clear information and feedback about risks and about possible benefits can make a huge difference. A brief intervention might not work the first time. It might take a couple of visits. But we need more doctors who know what the symptoms of alcohol dependence are and know what questions to ask.”

If your knowledge of addiction is limited, this is a reasonable, middle-of-the-road starting point for a general audience.

Khat: A Psychologist's Field Trip

Looking for a chew in London.
 
I ran across a great story by Vaughan Bell at Mind Hacks, about his stroll around London, looking for khat, the East African stimulant plant that is chewed much like coca leaves.

 Research psychologist Vaughan Bell is not your average armchair academician. Currently a Senior Research Fellow at the Institute of Psychiatry, King’s College, London, Bell is well known online for his contributions to the Mind Hacks blog, which covers unusual and intriguing findings in neuroscience and psychology. He recently taught clinical psychiatry at Hospital Universitario San Vicente de Paúl and the Universidad de Antioquia in Medellín, Colombia, where he remains an honorary professor. He has also worked for Médecins sans Frontières (Doctors Without Borders) as a mental health coordinator for Colombia. (See my interview with Bell last year).

Reprinted with permission:


Finding myself at a loose end yesterday I decided I’d try and track down one of London’s mafrishes – a type of cafe where people from the capital’s Ethiopian, Somali and Yemeni community chew the psychoactive plant khat.

I’d heard about a Somali cafe on Lewisham Way and thought that was as good a place as any to try. The cafe owner first looked a bit baffled when I walked in and asked about khat but he sat me down, gave me tea, and went out back to ask his associates.

“Sorry, there’s no khat in Lewishman. We have internet?” he suggested while gesturing towards the empty computers at the back. I kindly declined but in reply he suggested I go to Streatham. “There are lots of restaurants there,” he assured me.

Streatham is huge, so I arrived at one of the rail stations and just decided to walk south. Slowly I became aware that there were more Somali-looking faces around but there were no cafes to be seen.
Just through chance I noticed some Somali cafes off a side street and walked into the first one I saw. “There’s none here, but next door”, I was told. The people in the next cafe said the same, as did the next, and the next, until I came to an unmarked door.

“Just go in,” a cafe owner called to me from across the street, so I walked in.

The place was little dark but quite spacious. My fantasies of an East African cafe translocated to London quickly faded as my eyes adjusted to the trucker’s cafe decor. Inside, there were four guys watching the news on a wall-mounted TV.

The cafe owner greeted me as I entered. I asked my usual question about khat and he looked at me, a little puzzled.

“You know, khat, to chew?” I ventured. A furrowed brow. Thinking. “Oh, chat. Yes, we have bundles for three pounds and bundles for seven. Which do you want?”

“Give me one for seven” I said. “No problem” he replied cheerily. “Have a seat”.

This wasn’t the first time I had tried khat. Many years ago, when I was an undergraduate in the Midlands, I discovered khat in an alternative shop. It was sold as a natural curative soul lifting wonder plant from the fields of Africa.

I bought some, didn’t really know what to do with it, and just began to ‘gently chew’, as the leaflet advised, while walking through the streets of Nottingham.

So when my bundle of khat arrived, I just picked out some stems and began chomping on one end. “Wait, wait, stop!” they shouted in unison. “We’ll help you” said one and I was joined by the cafe owner and a friend. “Anyway, he said”, “you’re not allowed chew alone, it’s a social thing.”
I was given a bin to put beside my table, was shown how to strip off the stems and pick out the soft parts, and how to chew slowly. I was provided tea and water on the house and told to keep drinking fluids. Apparently, it can be a little strong on the stomach and the plant makes you go to the toilet a lot as, I was told, ‘it speeds up the body’.

I had the company of the cafe owner, a Somali Muslim, and his friend, an Ethiopian Christian.
Over the next two hours we chewed and talked. Ethiopian politics, football, living in another country, khat in Somalia, Haile Selassie, religion, languages, Mo Farah, stereotypes of Africa and family life in London.

People strolled in an out of the cafe. Some in jeans and t-shirt, others looking like they’d just walked in from the Somali desert. Everyone shook my hand. Some bought khat and left, others joined us, all the while chewing gently and drinking sweet tea. At one point I asked the Christian guy why he wore an Islamic cap. He whipped off his hat. “I’m bald” he said “and it’s the only cap you can wear inside” which sent me into fits of laughter.

Khat itself has a very tannin taste and it is exactly like you’d imagine how chewing on an indigestible bush would be. It’s bitty and it fills your mouth with green gunk. The sweet tea is there for a reason.
The effect of the khat came on gently but slowly intensified. It’s stimulating like coffee but is slightly more pleasurable. There’s no jitteriness.

It reminded me of the coca plant from South America both in its ‘mouth full of tree’ chewing experience and its persistent background stimulation. But while coca gave me caffeine-like focus that always turned into a feeling of anxiety, khat was gently euphoric.

My companions told me that it lifts the spirits and makes you talkative. They had a word, which for the life of me I can’t remember, which describes the point at which it ‘opens your mind’ to new ideas and debate.

The active ingredient in khat is cathinone which has become infamous as the basis of ‘bath salts’ legal highs which chemists have learnt to create synthetically and modify. But like coca, from which cocaine is made, the plant is not mental nitroglycerine. It has noticeable effects but they don’t dominate the psyche. It’s a lift rather than a launch.

The guys in the cafe were not unaware of its downsides though. “Don’t chew too often” they told me “it can become a habit for some”. I was also told it can have idiosyncratic effects on sexual performance. Some find it helps, others not so much.

Not everyone was there for khat. Some guys chewed regularly, some not at all, some had given up, some only on special occasions. Some just came to hang out, drink tea and watch the box.

Towards the end when I felt we had got to know each other a bit better I asked why the cafe was unmarked. The owner told me that while khat is legal they were aware of the scare stories and were worried about the backlash from less enlightened members of the community. ‘Immigrants sell foreign drug’ shifts more papers, it seems, than ‘guys chew leaves and watch football’.

Eventually, I said my goodbyes and decided I could use my buzz to go for a walk. I made London Bridge in a couple of hours. But I think my newfound energy came as much from the welcome as it did from the khat.


Bath Salts Mixed With Spice: Two Drugs In One

Researchers document latest recreational Frankenmolecule.

Researchers in Japan have run across what is believed to be the first example of a hybrid synthetic drug that is a combination of a methamphetamine-related cathinone (bath salts) and an entirely new synthetic cannabinoid.

In a paper now in press for Forensic Science International, investigators from the National Institute of Health Sciences in Tokyo conducted a new round of drug buying on the Internet, also netting and identifying 12 more synthetic cannabinoids, heretofore unseen in the market for non-THC marijuana substitutes. Japan, like the U.S. and Europe, has been attempting to outlaw these problem compounds. In the paper by Nahoko Uchiyama and others, a “completely new type of designer drug, URB-754,” was identified. It is a new synthetic cannabis compound, and the researchers found it packaged together with a cathinone derivative called 4-Me-MABP.

That, in itself, was odd enough. But mass spectrometry and a little mixing of their own revealed to the scientists that the two chemicals had also blended to create a third thing, a freak admixture, half fake marijuana, half designer amphetamine, and 100% new under the sun. This combination drug is so new it doesn’t have a short name yet. It’s called (N,5-dimethyl-N-(1-oxo-1-(p-tolyl)butan-2-yl)-2-(N′-(p-tolyl)ureido)benzamide). Check out additional coverage by Vaughan Bell at Mind Hacks, where the journal report was discussed earlier.

And that, at present, is all we know about the matter. It’s not even clear how this combination substance would be ingested for maximum effect. The authors of the paper express concern about the “reactive nature of both compounds” that comprise the new hybrid, but refrain from making any predictions about its effects. “There is little information about most of the newly detected compounds,” the authors write. “Furthermore, the recent trend seems to be to mix different types of designer drugs such as cathinones (stimulants) or tryptamines (hallucinogens) with synthetic cannabinoids in illegal products. Therefore, there is the potential for serious health risks associated with their use.”

Yes, that’s right, one additional product the Japanese researchers analyzed was found to contain a synthetic cannabinoid in combination with a tryptamine, a category of compounds that includes psychedelics such as LSD, DMT, psilocybin, and others. Swell. It’s now completely clear that without a sophisticated lab analysis of bath salt and spice products, there are no guarantees whatsoever about what is being smoked, snorted, or based.

Quite a haul: A new type of designer drug, 12 new cannabis-like drugs, and a crazy reaction product made up of synthetic cannabis and cathinone. The DEA charts above clearly show that something is causing an increase in drug-related toxic reactions lately.

Overall, the trend of scientific research on bath salts and spice drugs continues to be troubling. Whether any of this will resonate with people in their prime drug-using years, after all the years of “This is Your Brain on Drugs” disinformation campaigns, remains to be seen. It looks more and more like the best harm reduction advice available is to stick with marijuana and meth, if that’s what you’re using or abusing. Nothing coming down the pike as bath salts or spice cannabinoids is an obvious improvement, and the ability to know what you are actually taking has fallen to virtually zero in this category. Early identification and constant monitoring of new substances is now a vital task, however Sisyphean.


Uchiyama N., Kawamura M., Kikura-Hanajiri R. & Goda Y. (2012). URB-754: A new class of designer drug and 12 synthetic cannabinoids detected in illegal products, Forensic Science International,    DOI: 10.1016/j.forsciint.2012.08.047

Photo: Illinois Poison Control Center Blog

The Media and Drug Policy: Where’s the Science?

Groping blindly toward a new framework.

As states and the federal government clash at the legal, social, and political levels over legalizing marijuana, the science of drugs and addiction has taken a back seat. The dismal state of the addiction treatment business has recently been documented by Anne M. Fletcher in Inside Rehab, while over the past few years, drug policy officials in the U.S. have had to cope with three major developments: the medicalization and legalization of marijuana, the emergence of new synthetic drugs, and the abuse of potent prescription painkillers.

Major media outlets have largely failed to highlight the relevant scientific issues in each case. What we see instead is that journalists and others who are covering drugs and addiction issues are not making connections with solid scientific sources in the neurochemical research community. All too often, media reports of adverse drug events are sourced solely by police officers, or spokespersons on behalf of for-profit rehab centers, who are no more ready to make science-based pronouncements on these matters than anyone else.

States are now in the process of relaxing strictures on the possession and use of cannabis—and they are doing it well before they have put in place a set of evidence-based policies for the implementation of this new state of affairs. Who is in charge of directing policy decisions in Washington and Colorado? What will be the regulatory structure at the level of county and municipal government? Whose voices will actually be heard? Should the feds leave it to the states, and the states leave it to the counties, who then leave it to the cities? To what degree are the two states taking the medical and health aspects of this sweeping change into account? Can evidence be substituted for opinion in such cases? If so, how?

Even if the Department of Justice decides to shut down all efforts at relaxing marijuana statutes, it will need to rely upon a sound collection of scientific evidence to make its argument. The media play a compelling role in drug discussions, but coverage traditionally has been limited to articles about the legal, political, and sociocultural ramifications of the changes. These are all critical parts of the story, but science journalists need to step forward and direct more coverage toward emerging medical issues and the findings of science. Ordinary citizens will want to have at least a partial grasp of the medical and science-based decisions that state and federal governments will be making about personal health and habits as they legislate and adjudicate these concerns.

The federal government will have to begin working with states rather than against them, if public opinion continues to change on legalization issues. At the same time, the feds will be called upon to provide guidance for the states that is consistent with international drug treaties. Congressional committees will have to grapple with the realities of setting forth the limits and logistics of the market for marijuana in coherent and consistent ways. Incredibly, very little of this is pinned down, firmly understood, or even grasped as imminent problems by either legalizers or their opponents. Many of the issues that took years to wrestle down with cigarettes, such as warning labels on cigarette packages, will present themselves with equal and immediate force in the case of states with legalization plans.

In addition, marijuana policy makers in Colorado and Washington will have to render decisions concerning sales to minors, cannabis in the workplace, DUI marijuana laws, addiction issues, sales outlets, tax issues, and the results of ongoing medical research on marijuana. Some states allow private dispensaries, some have banned them. Some allow private cultivation of cannabis, and some do not. 

As for the newer synthetic drugs—the cannabis-like products known as Spice, and designer stimulant drugs known collectively as “bath salts”— these chemicals exist in a twilight zone of ignorance, with very little sound medical information passing to the public. Few people understand with any degree of certainty just what is inside those shiny foil packages. This glaring disconnect between clinical research and media reports leads to unsupported tales of face-eating zombies and dead teenagers on bath salts, well in advance of the drug testing that might factually answer questions about drug-related behavior. Meanwhile, scientists fear that the continuing effort to ban every substance illegally marketed in this category will close off certain valuable avenues of research, including new drug discovery.

Finally, the ongoing battle to lower the soaring use and abuse of oxycontin, Vicodin, and other opiate drugs has caused problems for legitimate pain patients across the country. Yet this medical aspect of the painkiller panic is rarely remarked upon. Some addiction researchers believe that as prescription painkillers are removed from the market or made more difficult to abuse, those with opiate addictions will migrate to heroin in greater numbers. Scientific research on addiction suggests that this may well be the case. 

What is missing specifically from most drug policy debates is the recognition of the vast metabolic variation among individuals. Different drugs affect different people differently, and for the first time, neuroscientists are building a solid body of information that could help policy makers better forecast the results of their actions. Lethality, side effects, tolerance, and susceptibility to addiction all vary widely due to metabolic differences among people.

But some shared reactions, and basic withdrawal parameters, do exist. Congress, the FDA, NIDA, as well as state health agencies and other regulatory bodies, need information about drugs and drug use that scientists have been busily compiling. The public needs this information, too. We need to search for ways media can more effectively inject science-based drug information into current policy debates. 

Science journalists are perfectly situated to serve as potential communicators between warring parties. What can the media do to markedly enhance intelligent, science-based coverage of drug issues?

Photo: Telstar Logistics

The House That Drugs Built

Eugene Jarecki’s documentary.

The following quotes have been excerpted from "The House I Live In," the recent documentary about drug addiction and law enforcement written and directed by Eugene Jarecki.


“We like to look at the war on drugs as black hats and white hats, and good guys and bad guys, and victims and offenders. And on the ground, it’s a lot more mixed up than that.”
—Criminal justice professor

“There’s no question that there was a passion with which the early narcotics enforcement culture pursued black America, even though the addict population was always distinctly biracial.”
—TV producer

“Because they’re addicts, they find themselves committing the same crime that just put them in jail, say, a week or so prior.”
—Police officer

“We’re locking up everybody just because we’re mad at them. We need to lock up people that we’re afraid of.”
—Drug offender in prison

“There are more African Americans under correctional control today than were enslaved in 1850, a decade before the civil war."
—Writer, historian

“Sometimes I think you can trace any crime you want to drugs.”
—Police officer

“Everybody involved hates what’s going on.”
—Attorney

“Today the average person I sentence in a drug case is a non-violent blue collar worker who lost their job and then turned to manufacturing methamphetamine to support their habit. And we treat them like they’re kingpins.”
—Federal court judge

“People want to lock people up and then when their sentence is over, they expect them to be reformed, or a different person. If you haven’t given them skills or trained them, how can they be?”
—Corrections officer

“Nobody respects good police work more than me. The drug war created an environment in which none of that was rewarded.”
—TV writer

“I don’t think people fully understand, in the inner city, these kids are making rational choices.”
—Journalist

“Historically, anti-drug laws have always been associated with race.”
—Historian

“Prisons are almost a self-fulfilling prophecy. You build a bed, they fill the bed. It starts sucking in money at an astronomical rate. And it just grows and grows of its own accord.”
—Corrections officer

“Whenever you have a new drug introduced in society, you can say incredible things about that drug, and people will believe you.”
—Psychology professor

“I’d like to see empirical evidence be used in our shaping of public policy.”
—Ex-addict

How I Quit Gambling

Projectile vomiting can be your friend.

I never should have found myself inside casinos in the first place. As a former alcoholic, cigarette smoker, and drug abuser, taking up gambling does not, in retrospect, sound like a solid life plan. But in my addictive heyday, gambling was definitely a part of my life. I would go the casino, stand inside the entrance, gaze out across the dark, jangling world of the slot machine floor, populated by solitary figures seated on stools, busily drinking and smoking cigarettes, and mutter: “My kinda people.”

And they were. Lurking out there were a significant number of fellow addicts, as I now understand. They weren’t there to have fun, to play games, to be entertained, or to quit while they were ahead. They were there to experience the act of risking more money than they intended to—more money than they wanted to lose. They were self-medicating with machines, as I had learned to do. The money bought you time on the machine, and the time on the machine was the medicine. The money had less to do with it than you might think. The money was only the means.

My spell as a compulsive gambler was nasty, brutish, and short. The extent of my losses is classified. It’s not a well-known fact, but addicted individuals who compulsively gamble tend to prefer the machines to the tables these days. Table gambling—blackjack, roulette, poker—requires a level of social interaction that is the opposite of what the pathological gambler is seeking: total immersion in a null state marked by regularity and the absence of human interactions. Give a cursory glance around any major casino’s slot room, and you will quickly notice that slot and machine poker players don’t talk to each other. They don’t even sit next to each other, if they can help it. Like an alcoholic on a secret binge, they DO NOT WISH TO BE DISTURBED. Even the periodic interchange with a cocktail server can feel like an unwarranted intrusion into the gambler’s zone.

I used to say, only partly in jest, that there is nothing quite like the sick thrill of wagering money you can’t afford to lose. The traditional trajectory has the gambler setting a limit on what she’s willing to lose, then going past that limit and resetting it, repeatedly, until her money is gone. Slot machine players know they are going to lose. They aren’t brain-damaged. (Well, in a way, they are, but that’s another story). They know perfectly well what the house percentage is. Sure, they hope to hit a jackpot against all odds—but they are also playing for time. One of the sacred casino industry metrics is “time on device,” and addicts put up some impressive numbers, since they are known to do things like pee their pants or ignore a medical emergency, rather than give up their machine.

In the old days, a roulette wheel was more likely to lead to the same result. In the words of the stricken protagonist in Dostoevsky’s The Gambler:

I had lost everything then, everything. I was going out of the Casino, I looked, there was still one gulden in my waistcoat pocket: ‘Then I shall have something for dinner,’ I thought. But after I had gone a hundred paces I changed my mind and went back… there really is something peculiar in the feeling when, alone in a strange land, far from home and from friends, not knowing whether you will have anything to eat that day—you stake your last gulden, your very last! I won, and twenty minutes later I went out of the Casino, having a hundred and seventy guldens in my pocket. That’s a fact! That’s what the last gulden can sometimes do! And what if I had lost heart then? What if I had not dared to risk it?...

I once won a $900 jackpot, and remember being irritated that it took the attendants so long to show up and pay out. Or maybe “pay” is not really the right word. What was that money, exactly? First, it wasn’t $900, it was really $500, since I was down $400 for the evening when I hit. The night before, I was down $250 when I quit. Not big numbers by any means, for a weekend in Vegas, but illustrative of how the numbers work. My $900 payday added up to a net of $250, drinks and room not included. This is an example of the “false jackpot,” a cousin to the “near miss.” A false jackpot occurs when the winnings are less than the wager. A near miss is a design technique where the reels frequently stop so that high-paying symbols appear just above or below the pay line—meaningless from a statistical point of view, but oh-so-close from the gambler’s perspective. 

I have serious tinnitus, the intrusive ringing-in-the-ear condition that can be brought on by a variety of causes, both environmental and neurobiological. Years ago I came down with a version of the condition, called cochlear hydrops, which often evolves into a set of additional symptoms including dizziness, nausea, complete loss of balance, vertigo, and vomiting. Remember that ears are essential for balance and navigation through space, so when things go wrong, it can be very debilitating indeed. But other than hearing loss and that constant roaring in one ear, I had none of the vestibular symptoms.

One weekend at Bally’s, after several hours planted in front of a single slot machine, the old kind, with three reels and cherries and 7s, I uncharacteristically felt like I’d had enough. In fact, I didn’t feel very good at all. And when I finally looked up from the machine, the curving lines of other machines and the swirling pattern of the casino carpet weren’t helping me feel any better. I decided to go to my room and rest for a while. On the way to the elevators, I lurched into a cocktail waitress, spilling drinks off her tray. In my room, I flung myself on the bed just in time to watch the walls beginning to spin. An interesting experience, when you haven’t had any alcohol to drink in years. This was nothing like seasickness, or a hangover. This was an express ride to hell without moving a muscle. Full-on vertigo. Faster and faster went the walls. And when I finally got up and staggered to the bathroom for a glass of water, I made it just inside the bathroom door before an episode of projectile vomiting (my first) convinced me that my gambling days were over.

I have no idea what happened, exactly, or how I have managed so far to have only one major vertigo event due to ear problems. I’m pretty sure that the spinning reels on the hit-the-button-and-go slots set me up for it. I haven’t been back to repeat the experiment. If there’s any better aversive training than vertigo and projectile vomiting, I don’t want to hear about it. Call it serendipity, a not-so-gentle push in the direction of recognizing that casinos were not a healthy place for me to be. Impulse control, risk/reward, anticipation, long-term thinking: these systems are all malfunctioning during active addiction. For recovering addicts, all those buzzes and whistles on the slot machines are like Pavlov’s bells, recalling the old mindset, and priming you for a fall that costs more than money. They now have digital slot machines with 100 pay lines. So I’ve heard. I don’t go there any more.

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