The War on Drugs Meets Science

Many are fond of trumpeting “Science!” as the basis for rational policy, but one look at the War on Drugs’ defenestration of science tells us that, in practice, such are the minority. This is nothing new or unique. There is a long and terrible history of science being subjugated to politics. Just ask a phrenologist about it, if you can still find one. Einstein had a great answer, when presented with the paper “1,000 physicists on why Einstein is wrong.” His retort? “Only one has to be right.” Let’s concern ourselves, now, with one compromise of scientific categorization and its catastrophic social consequence.

The Drug Enforcement Agency defines Category One drugs as “substances, or chemicals with no currently accepted medical use and a high potential for abuse.” There is no scientifically supportable justification for this category.

The phrase “currently accepted medical use” tautology is the issue. Medical science is highly evolutionary, with knowledge best thought of as a movie that unfolds over time. This stands in stark contrast with the DEA’s law of knowledge, which freezes drug classification at the moment of declaration. How can medicine comply with the law of acceptance of something if it’s illegal to use or even study? Medical logic would say that the best agent for accepted use is the one that best achieves the clinical goal. That agents and goals evolve in dizzying variation is reflected in the galaxy of options over the whole world’s pharmacopeia.

Take this in: America has the world’s highest incarceration rate, achieved mainly through our approach to drug abuse, and using a legal framework to enforce a medical concept that does not exist in medicine. And, without moving the needle of the problem of drug abuse one inch, while unleashing God-only-knows how many consequences of drug-related crime, while creating the most powerful organized crime entities the world has ever known. This link reveals that no such consequences have been unleashed all of the other times in our history opioid addiction manifested itself as an issue, because it was relegated to being a medical issue.

This illogic was also imposed on the world (but Portugal was able to wriggle free and show the way) with our power as its protector, by UN convention. We shut down freedom options-of-the-solution space not just here, but across the world.

Now we are caught in a crisis that kills more Americans than guns do. But contrast the (nigh daily) litany of proposed solutions to the gun death problem with the pinched and narrow range of proposals allowed in dealing with illegal drugs. In a half century of unsuccessful (hard) drug war we got Narcan liberalization, a besieged implementation of Medically Assisted Treatment, and a besieged concept of Safe Injection Sites. These, and the usual American Kabuki opera of decades-long lawsuits which only pay out the government and the lawyers.

And we never stopped to examine whether the mantle of expertise required to command such power (otherwise unprecedented in America) was a self-serving prophesy into which no information in the sciences of addiction medicine would thereafter be admitted. Who “accepts?” Those employed in enforcing the tautology (henceforth abbreviated as Tautology Enforcement Agency, TEA)! Infamously, marijuana is in the same risk/zero benefit classification as heroin (zero deaths vs over 60,000). No plain-as-nose-on-the-face evidence of wrongness can strip away that mantle of power. Into our worldwide legal/medical conceptual distortion we can add religious fallacy: “thou shall not study” was the position of the church against Galileo.

Heroin being Category One is also a denial of the length and breadth of the history of medicine. Opium is a therapy for the relief of suffering, a worthy goal of medicine and very much a “currently accepted medical use.” Severe pain can gnaw a person to death, or it can kill him outright. This ethic of pain mitigation predates by a few millennia the microorganism model all modern medicine is based on. For patients in more pain, more relief is not a concept that requires medical school to grasp.

Pain mitigation should be done with the best clinical agent available for that purpose without having to clear it with the TEA. I’ve administered morphine for pain mitigation many times, and the emergency community regards it as an utterly safe drug to use, since it’s the only one we have whose effects can just be “taken back” (with Narcan). Burn centers goes through huge amounts of morphine, then taper down the doses when clinically appropriate, and they discharge their patients with no greater incidents of addiction than the patients had when they went in.

It can be conceded that some doctors misuse opioids, and that some opium sellers were greedy (while trying to alleviate pain). They would do the same with heroin if it were re-categorized by the logic of treatment efficacy (same logic applies to any drug, any product really). A case could be made with libertarian ethics (any governing system’s ethics) that egregious misuse of pain medication, and addiction manipulation, could fairly warrant prison. But can the same concept be turned on the DEA: egregious misuse of their power should earn the same criminal sanction (jailing pot heads, while trying to alleviate crime)?

A revolution of information may yet overtake the deadly status quo, like information revolutions always do (and the DEA will continue to stand in its way, as top-down government power always does): a web search on heroin recovery will reveal thousands of heroin tapering plans for recovery. Recall, heroin is a potent refinement of opium, and common sense would hold that addicts like it over opium because of its potency. Addicts are in an arms race with the potency of their opioid, with the evolution towards greater potency, as they build tolerance. Another factor in this arms race is “the iron law of prohibition: the harder the laws the harder the drugs.” Since criminality is defined by drug weight, the dealers figure out that lighter and more potent is better, as if they were cargo engineers for a space shuttle mission, in another maladaptive miracle of unintended consequences. That same evolution to purity does not exist in, say, the liquor business, where spirits other than 151-proof rum are plentiful. Legal marijuana sellers will warn you if your weed will have you hunched in a closet gibbering for five hours.

Can we also consider the idea that the networked experiences of thousands of people, anonymously reported, “from their natural habitat,” with no incentive other than recovery from the problem, with their agreed-upon conclusions, should be considered “valid” as a “study?” Realize that there is an on-going crisis in scientific reproducibility, in another validation of this article’s premise of the elusive, highly evolutionary nature of knowledge (but a flawed scientific method of study in managing the opioid epidemic would be better than the Thou-shall-not-study approach of the TEA).

A physician might legally wean an addict from heroin with lesser opioids and opioid antagonists methadone, but it would be illegal for them to supervise a heroin taper, as is done in burn centers. Heroin to methadone is like falling off a cliff, not a taper. Interestingly, the online addicts claim staying “on the needle” after the heroin has been diluted to nothing is an important step, since they are “addicted to the pop of the needle too” (many will also warn that a heroin taper takes more discipline than most addicts have, but that’s, of course, without true medical support and supervision).

Addiction medicine specialists will equivocate even on whether opioid rehab is a safe, sustainable goal, if given their druthers, and here is why: it is an all-or-nothing thing, very different from other addictions. A single relapse will often be fatal if the opioid addict fails to adjust their dose for their lack of tolerance (whereas an alcoholic or coke-head will not die from one bender). For addicts, it’s like society’s war against terror: the defense has to get it right all day, every day, the attacker wins by getting it right only once. It may well be that some heroin addicts cannot be recovered (science needs to study to find out). The very notion of recovery might be the real issue: we pass no judgements on people who cannot recover from their hypertension. It is not regarded as a failure when a diabetic is not weaned off insulin (but in our interlocking thicket of laws, opioid addicts should not be able to sue for medical disability if they cannot be allowed to run a construction crane).

On a deeper level, it can be said that the art of medicine is issue-mitigation, in that it’s all that can be done, as we all die of something sometime. Medical ethics can address heroin and opioid addiction because medicine enforces nothing other than a clinical relationship between doctor and patient, based on a detailed symbiosis of desires and possibilities. Yes, the death rates for addiction are high (and that includes alcohol), but so are the death rates for cancer. In the last half generation, compare our rates of improvement in those diseases, with the TEA’s punitive and legalistic approach to technological improvement in the treatment of the opioid addict.

The first step in reforming this state of affairs is to take the mantle of power from the TEA and have true clinicians enshrine into policy the clinical concepts needed to solve medical problems. Any scientist will require all scientific concepts be subjected to a scientific standard of classification. First, create categories that actually exist. What scientist would welcome a lawyer’s mandate in this? A bureaucrat’s? Or (shudder) a politician’s?