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Monday, May 13, 2013

Addiction

I remember the event clearly.  All of the 5th and 6th graders in my school filed into the auditorium.  The mood was somber and quiet.  The look on everybody's face was perfectly serious, not a smile or even a smirk could be found.  There was a display on the stage which showed what various illegal drugs (marijuana, amphetamines, narcotics, etc.) looked like.  A policeman began the lecture.  He went through each of the drugs with stern face and furrowed brow, describing the terrible things that would happen to you if you were foolish enough to take them.  He ended with heroin.  He explained that taking it even a single time was guaranteed to leave you permanently and hopelessly addicted and that the craving would cause you to take ever larger amounts until you died from overdose or other factors.

While that lecture was a bit extreme, that pretty much was and still is the narrative of drugs: drugs are extremely addictive and damaging, should be avoided at all costs, and justify the huge costs of the so-called "War on Drugs" which is, of course, really a war on people.

I'm going to explain why I'm extremely skeptical of this narrative.  Let's start with heroin, the bogeyman of drugs.  Heroin is not quite as debilitating as you might think.  It has adverse effects, for sure, but "like most opioids, unadulterated heroin does not cause many long-term complications other than dependence and constipation."  The constipation can be overcome by increasing consumption of leafy greens and other fruits and vegetables.  Addiction (dependence) is an actual problem because it's illegal and expensive, but a perceived problem primarily because it makes us uncomfortable to think that someone might be addicted to something.  If heroin were legal and reasonably inexpensive, then a user who took heroin nightly in moderate doses, even if addicted, would be little different than a drinker who has a couple of glasses of wine nightly, addicted or not.

It's impossible to really know what addiction rates are, especially for a drug that's illegal since that makes studying it somewhat difficult.  However, there are some statistics available.  For example, from the Substance Abuse and Mental Health Services Administration (whose charter is to reduce substance abuse), as of 2010 (latest available year) an estimated 4.1 million people in the United States have used heroin sometime in their life, yet only 618,000 used heroin in the last year and only 240,000 used heroin in the last month.  Even if every last one of the 240,000 users last month is addicted, that's only a 5.8% addiction rate when compared to lifetime use.  Compare this to marijuana (a drug considered to be much less addictive) where over 16% of those who have ever used it also used it in the last month.  While these numbers don't tell us anything terribly concrete, it's hard to reconcile them with the narrative of immediate and permanent addiction.

As Nobel Prize winning economist Gary Becker points out:
The likelihood of becoming and remaining addicted to drugs or other goods is not determined only by personal biological and psychological propensities to become addicted. For example, many individuals end their addictions to smoking and drinking alcohol when they get married, find good jobs, or mature.
This is also difficult to reconcile with immediate and permanent addiction.

At least some experts believe that "Alcohol More Harmful Than Crack or Heroin", with an overall harm index of 72 for alcohol, 55 for heroin, 20 for marijuana, and at the bottom end, a mere 5 for mushrooms.

The lead researcher for this study was David Nutt.  Unfortunately for Dr. Nutt, who was the chairman of the British Advisory Council on the Misuse of Drugs (ACMD) at the time of publication, the need for the evil drug narrative is so strong that he was summarily sacked for presenting this information.  His dismissal lead to several resignations from other researchers in protest.  As a society, we're clearly not ready to face the facts and strive to cling to The Narrative.

I've seen addiction up close because my father was a severe alcoholic who turned his back on his job, friends, and family and lived for years as a homeless drunk. He wasn't alone:  "In the United States and Western Europe, 10 to 20 percent of men and 5 to 10 percent of women at some point in their lives will meet criteria for alcoholism."  Note those are percentages of ALL adults, not just those who drink.

While the addiction rates for narcotics are probably somewhat higher than those for alcohol users, alcohol is a good representative for addictive drugs, especially since we all have experience with ingesting it and observing others who drink.  The spectrum for all drugs ranges from using the drug with no significant negative effects to having a devastating impact on quality and quantity of life with a distribution of these effects being similar to that for alcohol.  Alcohol is bad enough, but the others are no worse (per Nutt's research).  If fact, alcohol is the only drug (other than things like blood pressure medication) for which, when severely addicted, withdrawal can kill you.

To summarize so far, there is no drug that is immediately and universally addictive.  With the possible exception of alcohol, all non-medicinal dependencies can be beat, and indeed, most people do manage and eventually escape addictions to illegal drugs.

On the other hand, the majority of people are addicted to something.  Even ignoring food addiction (when it causes obesity, sometimes severe and even life-threatening), there are all kinds of medicines that keep users alive (for blood pressure, asthma, angina, etc.), there's caffeine (coffee, tea, and don't forget chocolate), there's alcohol and tobacco; and all sorts of other obsessions (video games, porn, sports, etc.) to which people are addicted.  Many of these addictions are beneficial or even life-sustaining.  Others may be detrimental, but it's not the addiction, it's the activity itself that's detrimental.

Even for potentially detrimental things, it's very hard to measure.  For example, smoking an occasional cigar statistically reduces life expectancy which is generally considered detrimental, but if it brings enough pleasure and enjoyment to the smoker, is it really detrimental overall?

The bottom line is that fear of addictive substances is terribly overwrought and has lead to bad policies that have damaged tens of millions of lives and prevented the use of substances that may enhance quality of life overall.

9 comments:

Bret said...

I wrote this post in response to some discussion on the ADHD post.

Hey Skipper said...

First, perhaps, a quibble:

In the United States and Western Europe, 10 to 20 percent of men and 5 to 10 percent of women at some point in their lives will meet criteria for alcoholism." Note those are percentages of ALL adults, not just those who drink.

That can't possibly be true, both in principal and magnitude. It has to be percentages of drinkers, simply because non drinkers can't meet the criteria. I'll bet the rate of alcoholism among Mormons is lower than in the general population, simply because abstention is a cultural norm. It is impossible to discover your inner alcoholic if you never take the first drink.

Also, I suspect the "criteria" are sufficiently encompassing to cast a wider net than is really justified. Most every evening I have a couple martinis, and maybe a scotch before bed. Do I fulfill the criteria for alcoholism? If so, and I wouldn't be surprised if I did, the criteria is suspect, because I never get even within shouting distance of inebriation.

Thinking back to all the people I've known, those that I could identify as having an unmanageable problem with alcohol (with the ever present possibility, my wife would say certainty, of a certain obliviousness introducing some bias) is much less than 10%.

On the other hand, the majority of people are addicted to something.

Interesting. I don't think that is right, but I can't say why it is wrong.

Part of the problem is perhaps, casting the net too widely. Clearly most people have things they very much enjoy -- martinis, in my case -- but the question is whether that enjoyment impinges upon other areas of life, and how easily one can forego that enjoyment. Not at all, and quite, in my case.

I think the war on drugs is predicated on two entering arguments: first, that everybody can get addicted to something; and, second, that raising the deterrence to consumption in the first place means that the population of addicts is smaller than it otherwise would be.

I don't agree with the first premise. I think a smallish number (5%) of people are born addicts, regardless of the substance, and that everyone else can exercise at least adequate self-control.

But that's just a guess.

Bret said...

Skipper wrote: "It has to be percentages of drinkers..."

Well, that's why I provide links - so we can all do our own interpretation. I interpret that to say, for example, that if only 1/2 the people ever drink, then 20-40% of those men and 10-20% of those women will at some point meet the criteria for alcoholism, which when diluted by the total population would be the 10-20% and 5-10% quoted.

Skipper wrote: "Part of the problem is perhaps, casting the net too widely."

And that's partly what I'm saying. "Addiction" is too much like the bogeyman. I think you've said you don't use caffeine. Consider: "Global consumption of caffeine has been estimated at 120,000 tonnes per year, making it the world's most popular psychoactive substance. This amounts to one serving of a caffeinated beverage for every person every day." Also, "In North America, 90% of adults consume caffeine daily." Most regular users become addicted in that when they stop they get a headache and are irritable for a few days.

So caffeine alone nearly gets us to a majority of people (at least in North America) addicted to something. Add in tobacco and alcohol and we're easily there.

But who cares about caffeine addiction? Pretty much nobody anywhere in the world. The addiction doesn't matter. It doesn't matter because caffeine is inexpensive and readily available. If, suddenly, it became unavailable, there would be a lot of unhappy people with headaches, but they'd get over it in a week or so.

Hey Skipper wrote: " I think a smallish number (5%) of people are born addicts, regardless of the substance, and that everyone else can exercise at least adequate self-control."

I almost agree except would add that there are situational factors and maturity that come into play (for example, see the Becker quote) so perhaps more are "born" "addicts" but once fully mature, 5% or so seems to be the right number from the statistics I've seen.

Annoying Old Guy said...

"alcohol is a good representative for addictive drugs, especially since we all have experience with ingesting it and observing others who drink"

Well, some of us are teetotalers so we don't have a visceral grasp of the first point (which may partly explain my party aversion).

"The [caffeine] addiction [...] doesn't matter because caffeine is inexpensive and readily available"

I think you also mean "and has minimal negative health impact", given the other points you raised.

Hey Skipper said...

Well, that's why I provide links - so we can all do our own interpretation. I interpret that to say, for example, that if only 1/2 the people ever drink, then 20-40% of those men and 10-20% of those women will at some point meet the criteria for alcoholism, which when diluted by the total population would be the 10-20% and 5-10% quoted.

It's almost impossible to say, because the various sources interchangeably use "alcohol dependence" and "alcoholism". I looked at the epidemiology study which was the basis for those numbers. It was a bit of a plow, and I wasn't able to figure out how it defined dependence. However, it did have this to say about previous studies:

In surveys using DSM-IV criteria, prevalence of current alcohol abuse and dependence was 1.9% to 4.3% and 3.6% to 4.4%, lifetime prevalence was 4.5% to 13.2% and 3.8% to 13.3%, and lifetime prevalence of any alcohol use disorder was 8.3% to 18.2%.

It is interesting that the spread in results is so wide for lifetime prevalence, but quite narrow for current (as in last 12 months).

Anyway, that mostly squares with my guesstimate of about 5% of the entire population.

And that's partly what I'm saying. "Addiction" is too much like the bogeyman. I think you've said you don't use caffeine.

Actually, I do. When I'm at home, I typically have four cups distributed throughout the day. But consumption and addiction aren't the same thing. I can, without any problem go without. In Asia, lots of hotels don't have coffee, or at least anything more drinkable than Nescafé in the rooms, and I rarely, despite their prevalence, step into a Starbucks. If the Captain I'm flying with isn't a coffee drinker, than I won't fire up a whole pot just to have a cup or two. So that means while I prefer to take it, I can leave it, too.

On the other hand, the other SWIPIAW must have a diet Coke in the morning in order to avoid painful caffeine withdrawal headaches.

I think that is where the distinction lies -- we both consume, but she is addicted.

And as far as terminology goes, calling caffeine psychoactive also seems like casting far too wide a net. Heck, if that is true, then chocolate (at least for women) is psychoactive too.

The addiction doesn't matter. It doesn't matter because caffeine is inexpensive and readily available.

But let's say it is all coffee consumption is, in fact, addiction. The most important, and probably sole reason coffee addiction doesn't matter is because it has no sequelae worth talking about.

In contrast, true drug addictions leave all manner of destruction in their wake, and that destruction would be there no matter how inexpensive and readily available meaningfully psychoactive drugs might be.

Bret said...

aog wrote: "Well, some of us are teetotalers..."

No wonder you didn't like college parties. I absolutely agree that hanging out with a bunch of drunk people when you're not drinking is definitely NOT entertaining.

aog wrote: "I think you also mean "and has minimal negative health impact", given the other points you raised."

No. I mean that while using caffeine is fine because it has minimal negative health impacts, the addiction has minimal impact because it's cheap and readily available.

Clearly, few others look at it the same way, but in my mind the damage (or not) of using the drug is completely separate from the damage (or not) caused by addiction with the latter being more related to cost and ease of getting a good supply of the drug.

And the reason it seems completely separate to me is that some people become addicted and some (most) people don't even given identical usage patterns. Also, whether or not one might become addicted should probably be given fairly low weight in choosing whether or not to use a drug that's widely and legally available. For example, there's really no reason not to use caffeine even though it's addictive and withdrawal for some people is pretty painful.

Bret said...

Hey Skipper: "In contrast, true drug addictions leave all manner of destruction in their wake, and that destruction would be there no matter how inexpensive and readily available meaningfully psychoactive drugs might be."

Well, I'm now convinced that you and others see it that way, but I just don't see it that way.

The effects of drug use and abuse are to me separate than the effects of that bogeyman called "addiction" which has no direct effect at all.

But now I better understand why drug policy is the way it is. I might be happier with the war on drugs if I believed that addiction was an integral component of the problem.

Hey Skipper said...

Bogeyman? Addiction seems definable enough: an inability to limit consumption. For example, I think that, at one time, I was addicted to blogging, because I frequently spent more time doing it than I intended to. My addiction wasn't so extreme that it cost me my job, health, nor (except for some more or less pointed wifely ribbing) affected my personal relationships.

There is no doubt that the "war on drugs" creates consequences that would not exist otherwise. However, those consequences don't define addiction.

That is, making, say, heroin legal, would not in any way reduce the number of heroin addicts, i.e., those people who are unable to control their consumption. Indeed, legalization would increase the number of addicts, because there must be at least some people who currently won't even try heroin simply due to its illegality.

I have no idea whether the cost to society due to some increase in the number of addicts consequent to legalization outweighs the costs of prohibiting heroin, but the possibility can't be denied a priori.

If I was the head dude what's in charge, I would legalize marijuana, and prohibit public consumption. Given the prevalence of anti-smoking laws, the latter is already a done deal.

Cocaine, heroin, meth? Not so sure about those.

(Full disclosure: with one exception, I have never tried any illicit drug. The one exception was hospital heroin for several days following surgery a half dozen years ago. I hated it damn near as much as the post-op pain. Baffles heck out of me why anybody would use that stuff the second time.)

Bret said...

To interject a little humor...

I know a guy who's addicted to brake fluid, but he says he can stop any time.