Unbroken Brain

[This is a very long post, but only the top 1/5th or so is "the post". The remaining ~4/5th is excerpts from Unbroken Brain. Feel free to consider the top 1/5th "the post" and the rest footnotes. How do I include enough detail to answer objections/issue qualifications without making the post so long that nobody will read it? This "the bottom bulk of this post is just a big footnote" is  my clumsy attempt.]

I strongly recommend the book Unbroken Brain by Maia Szalavitz. It is half autobiography and half a treatise on the science of addiction, with both halves merging together into a brilliant synthesis. Szalavitz describes in some detail her own addiction with heroin and eventual recovery. I have read some non-fiction books that attempt to interweave the scientific with the autobiographical and failed, but Unbroken Brain made it work.

Szalavitz pushes back hard against the "chemical hooks" theory of addiction. It certainly isn't true that the pharmacology of drugs compel people against their will to continue using. She points to the example of patients who spend weeks recovering from surgery on high doses of painkillers. They are gradually tapered off throughout their recovery and the vast majority of them never have addiction problems. Some of these people may not even connect their physical discomfort to the opioid withdrawal that's causing it. They may go home and experience a nasty "hospital flu," but it never occurs to them to go down to the corner and try to score some heroin to stave off the cravings. Indeed, the withdrawal doesn't even register as a craving. The drug-seeking addiction behavior is a learned behavior, not some once-and-you're-hooked effect of the drug. Likewise, babies who are born "addicted" don't grow up craving the drugs their pregnant mothers used. They go through incredibly unpleasant withdrawals and these newborns are very costly to treat, for sure. But they grow up with no memory of their "addiction." If they are more likely than the general population to become addicts as adults, that is far more likely a consequence of heritable causes of addiction. (Many personality traits are highly heritable, conscientiousness/impulsiveness included.) These babies born of addicted mothers did not have the self-awareness to connect their early suffering to the drug, and we don't retain memories from below age two anyway. Certainly not from the first few days and weeks after birth.

Szalavitz describes getting busted by the cops and being processed by the system. She goes through withdrawals and completes a treatment program. According to the biological/pharmacological/"chemical hooks" theory of addiction, this should have fixed her problem. It didn't. She describes being in custody, post withdrawal, and desperately wanting to get back to her apartment because she was quite sure the cops hadn't found her stash of Dilaudid pain pills. This story reminded me of a long passage in Chasing the Scream by Johann Hari in which the author describes his relationship with caffeine. Even after cutting out coffee cold turkey and going through those nasty withdrawals, Hari still felt the occasional craving for a hot cup of coffee with the resulting jolt of energy. Physical dependence is gone, but you're still sometimes left with a feeling of "Man, it sure would be nice..." or even "Today, I really need it." The point here is that addiction is not simply physical dependence. These are learned patterns of behavior that are deeply psychological; they persist long after the physical dependence has been beaten. Just as Szalavitz "learned" that an opioid high made her problems go away, Hari had "learned" that caffeine brings him superhuman creativity and productivity and lets him meet all his journalistic deadlines. Until these chemical fixes cease working. Tolerance sets in. A normal dose doesn't do anything for you. Withdrawals start hitting you when you're not taking your drug of choice, and you just feel shitty unless you're doing it all the time.

(I'm reminded of this post at Econlog by James Schneider. Apparently it's fairly common for heroin addicts to go through withdrawal while incarcerated, then to relapse when they get out. Relapsing when your tolerance has disappeared is quite dangerous. This is one of the most common causes of heroin overdose, at least it was until very recently.)

Szalavitz reminds her readers that the "drug-seeking addict-zombie" story is overplayed and defies common sense. Addicts don't shoot up in front of cops or judges. They often engage in deliberate, sometimes elaborate, planning to acquire their next high. Explanations of addiction in which the drug completely dominates the will are probably wrong, given these glimpses of self-restraint and deliberate planning. Salient alternatives seem to matter, too. Unbroken Brain reminds the reader repeatedly that people tend to outgrow their addictions. Most addicts develop their habits around their mid-20s but outgrow their addictions by their late-20s to mid-30s. Szalavitz describes this as undeveloped brains maturing and finally learning appropriate coping mechanisms. I think there's also a "salient alternatives" explanation lurking here. Perhaps early- to mid-30s is when you have to make a hard choice between a rewarding career and family, and a pathetic existence on the margins of society. A fully mature brain may be better at making decisions than an immature one, but incentives matter too.

(BTW, for more evidence of the "meaningful alternatives to drug use" thesis, read Carl Hart's book High Price. He describes a series of experiments in which drug users, heavily screened by the experimenters to ensure it was ethically done, are offered the choice of high-quality crack or money. Sometimes it is trivial amounts of money: a few dollars or a gift card. More often than not, the drug user turns down the crack. Yes, really.)

There is a long discussion of various drug treatment programs toward the later half of the book. There are "tough love" programs that emphasize responsibility, punishment, and withdrawal of privileges (and withdrawal of affection and even of contact with addicted loved ones). People in these programs are often committed against their will, confined to severely restricted living quarters, and punished or verbally abused for trivial infractions (or for no infractions, or for failing to adequately recite the programs catechisms). There have been many truly heart-breaking cases of abuse and even death resulting from these kinds of programs, and several multi-million dollar lawsuits have been won by the victims of the organizations that run them. And for all this misery, they just don't seem to work very well.

Twelve-step programs are another form of treatment that just don't seem to work very well. Szalavitz herself went through a 12-step program and had a pleasant experience with it. She describes it as working "for her," but she is extremely careful to caution the reader not to believe anecdotal evidence like the kind provided by her example. She goes so far as to say (paraphrasing): The next time someone tells you that some treatment "worked for them," ask them if they have an identical twin who did not receive the treatment. This is scientific journalism at its very best. It must be irresistible to sing the praises of a treatment that "worked for me," but Szalavitz nonetheless resists. She also discusses some of the hidden dangers of 12-stepping. She describes how some of the male members of 12-step groups use them to hook up with women, who they must assume are weak-willed or loose. In fact she describes barely escaping one such male who tried to rape her, and several friend who "weren't so lucky." If this is happening in 12-step programs, which I understand are meetings of equals, I can't imagine what must have been happening in some of the "tough love" programs which often have an authoritarian power structure with designated disciplinarians. (I once overheard a conversation at a coffee shop. Some old guy was saying that 12-step programs weren't much good for anything but picking up loose women. He said it in a tone that disparaged that kind of opportunistic behavior. Still, this is apparently a common perception. It's not something Szalavitz is making up or some weird idiosyncrasy of her group.)

There is one kind of treatment that works particularly well for opioid addiction: maintenance therapy. Give the addict a maintenance-level dose of a drug over an extended period of time. Taper them off when they are ready to quit. Given the discussion above about people eventually aging out of their addictions, maintenance therapy has the obvious advantage of keeping people alive until they are ready to quit. Because opioids don't cause the kind of cumulative organ damage that some other drugs cause, you can keep people on high doses for a very long time and they will come out of it unharmed. Alcohol damages your liver and kidneys and cocaine damages your heart, at least if you overuse these substances. No such problem for opioids. The biggest risk with heroin or prescription painkillers is an accidental overdose (and most so-called "overdoses" are actually mixtures of drugs that interact to slow your breathing, such as with benzodiazepines or alcohol). People have moralistic hang-ups about maintenance therapy. They think it's simply "trading one high for another." But for the most part maintenance therapy patients aren't getting high. Maintaining someone on a very high dose of opioids might actually make it hard or impossible for that person to get high. Maintenance therapy patients do relapse and overdose occasionally; it's not like this is a 100% cure or a magic bullet. But it seems to work better than any of the alternatives.

Unfortunately, drug addicts who are processed by "drug courts" or who are on probation may not legally have access to maintenance therapy. These people may have strict abstinence conditions applied to them. They may be forced into a twelve-step program. Their "treatment" may be overseen by someone with no psychiatric or clinical training. Szalavitz describes encountering one such clueless "counselor" during her treatment; the book The War on Drugs: An Old Wive's Tale by Christine Shuck describes similar frustration with poorly qualified individuals. In responding to the recent "opioid epidemic," some people are positively giddy about expanding drug treatment and drug courts. Unless these treatment programs are strictly voluntary, and unless drug courts are assigning people to maintenance therapy, I'm extremely skeptical that these policy levers will do any good.

Anyone who is interested in drug policy should read Unbroken Brain. I've read every book I could find on drug policy, and this one had some novel ideas and information I hadn't seen elsewhere.

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Below are some passages I highlighted.

On brain maturation:

Brain maturation stage is also important: Addiction is far less common in people who use drugs for the first time after age 25, and it often remits with or without treatment among people in their mid-20s, just as the brain becomes fully adult. In fact, 90% of all substance addictions start in adolescence, and most illegal drug addictions end by age 30. The implications of the developmental perspective are far-reaching. For one, if addiction is a learning disorder, fighting a “war on drugs” is useless. Surprisingly, only 10–20% of those who try even the most stigmatized drugs like heroin, crack, and methamphetamine become addicted. And that group, which tends to have a significant history of childhood trauma and/or preexisting mental illness, will usually find some way of compulsively self-medicating, no matter how much we crack down on one substance or another. In this context, trying to end addiction by attempting to eliminate particular drugs is like trying to cure compulsive hand washing by banning one soap after another. Although you might get people to use more or less harmful substances while in the grips of their compulsions, you aren’t addressing the real problem. Second, given that addiction is a learning disorder, it isn’t necessarily a lifelong problem that demands chronic treatment and the acceptance of a stigmatized identity: studies find that the majority of cocaine, alcohol, prescription drug, and cannabis addictions end before people are in their mid-30s and most do so without treatment. Similarly, between one third and one half of children diagnosed with ADHD no longer meet criteria for it as adults, and treatment doesn’t seem to affect whether they outgrow the disorder or not, although it certainly can affect their ability to thrive.

 On the rareness of addiction, even for "dangerous" drugs:

Though drug education programs tend to avoid publicizing these statistics, the expert consensus is that serious addiction only affects a minority of those who try even the most highly addictive drugs, and even among this group, recovery without treatment is the rule rather than the exception.

On the bizarre double-standard for alcohol:

These ideas about the failure of Prohibition to arrest addiction are now widely accepted—at least in the case of alcohol. However, they aren’t nearly as well established in relation to illegal drugs, even though addiction rates for users of heroin, methamphetamine, and cocaine are comparable to those seen with alcohol, and addiction rates for marijuana are lower.

 On how people "learn" addiction through repetitive behavior:

But in OCD and Asperger’s, as in addiction, over time the behavior stops serving its intended purpose. Rather than making things better, it starts to make them worse. Unfortunately, by this time, habitual responses are already deeply engrained and well learned; and even if you know the ritual you perform to try to make you less anxious will actually make you more so, you don’t believe it. You feel compelled to repeat it, even when you are utterly sure that it will not help. This is the heart of why addictions—and, not incidentally, OCD—are learning disorders. It also has critical implications for drug policy. OCD is not driven by the wonderful anxiety-reducing properties of, say, hand washing. There is not something hidden in soap or water that makes people want to wash and wash again. People don’t “catch” OCD by simply washing their hands—and, by the same token, they don’t develop drug addictions by just taking drugs. Preexisting differences in temperament and in negative experiences are what drives the learning of addiction.

 On the futility of punishment as a "cure" for deeply ingrained behaviors:

A child with autism may seem more typical if he stops flapping his hands—but this by itself doesn’t alter the underlying reason for the activity or change his autism. As a result, the behavior will either be hidden or replaced by a substitute action if the real driver of the behavior isn’t addressed. Indeed, many autistic adults describe being traumatized by therapies aimed at suppressing their self-soothing and self-stimulating behavior because this left them exhausted, upset, and without alternative means of coping.

 On the difference between dependence and addiction:

Addiction is, first and foremost, a relationship between a person and a substance, not an inevitable pharmacological reaction. A striking example of this can be seen in people who are treated for pain with opioid drugs like morphine or Vicodin for several weeks in the hospital following surgery or accidents. That is enough time for some people to develop physical dependence, although even something as seemingly biologically standard as the amount of time it takes to become tolerant and dependent is actually quite variable. People who do become dependent will experience symptoms like nausea, vomiting, cramps, sleeplessness, and diarrhea when released to go home without medication. However, many of them never realize that this “hospital flu” is actually opioid withdrawal. They don’t suddenly, out of nowhere, get an urge to “cure” the problem by buying painkillers or heroin on the street, because they haven’t learned that lack of drugs is the source of their symptoms. Because they haven’t identified drugs as the source of their comfort or as the best way to cope, they don’t have the severe anxiety levels seen in people with addictions during withdrawal. If you haven’t learned that a drug “fixes” you, you cannot be addicted to it, even if your body is dependent on it. Past ideas about “physical” and “psychological” dependence, which still shape public opinion on drugs today, led us down the wrong road. The idea that physical dependence was “real” addiction but psychological dependence was a mere trifle led people to ignore the role of learning.

... 

 The failure to distinguish between physical dependence and the learning that creates addiction is also why, contrary to claims you may see made in the media, babies can’t actually be “born addicted.” Infants can be born with physical dependence on a drug like heroin or Vicodin, but since they do not learn the vital relationship between choosing to take the drug and feeling better, they can’t crave it.

 Addiction may have some genetic causes:

And genetics interacts with learning in many ways to create addiction. Consider the fact that about one in seven people seriously dislikes opioids—the drugs themselves make them feel nauseous, dizzy, and uncomfortably, rather than comfortably, numb. While many people think that heroin or Oxycontin are heavenly for everyone, that’s only true for a minority of users. Longtime CBS News anchor Dan Rather, for example, once took a shot of heroin for a news program. He said that he’d never want to repeat the experience and that it gave him a “hell of a headache.” Two normal volunteers who injected heroin for several days (in a 1969 experiment that would now be considered unethical) also found it primarily unpleasant. “My personal view at present is just one made grey and utterly grim by heroin. The extraordinary thing is that it brings no joy, no pleasure.… At most, some hours of disinterest … how can people want to take this stuff? To escape to all this—life must be hell if they want to escape to all this.” A more recent study, which gave 228 healthy adult twins an intravenous infusion of alfentanil—an opioid around five times stronger than heroin—found that only 29% emphatically liked it. Most had mixed (58%) or neutral (6%) experiences—and 14% found it outright unpleasant.

This rings true to me, incidentally. I was prescribed hydrocodone after oral surgery several years ago. It made me feel sleepy and uncomfortable without actually helping my pain or allowing me to fall asleep. I must be one of those people who has an unpleasant reaction to opioids.

Some interesting data on people with very well controlled heroin habits, which is quite contrary to the popular wisdom:

The way cultural pressures, individual expectations, and other aspects of people’s state of mind affect the amount of control people have over their drug use was first explored in Norman Zinberg’s classic, Drug, Set, and Setting. The book examined controlled use of marijuana, heroin, and psychedelics in the absence of addiction and was among the first research to show that nonaddictive drug use was even possible. Zinberg found people who took heroin only on weekends for decades without negative consequences; he also did the first study showing that although nearly half of American soldiers in Vietnam took drugs like opium and heroin, 88% of those who had been addicted while overseas did not become readdicted upon returning home. Other researchers later confirmed that even among those who used heroin a few times after coming back, when they were out of the war zone, the overwhelming majority did not return to addiction, to the great surprise and relief of the military leadership. Indeed, those who relapsed—around 1%—were mainly those who had had drug problems before the war.

 The amazing effect of maintenance therapy on mortality:

Maintenance treatments are the only therapies that can lower mortality by 75%—something that would be considered a miraculous success in any other type of treatment but addiction care.

 Maintenance might even block the ability of addicts to get high by building up their tolerance to very high levels:

The end result is that on a dose that could kill a user with no tolerance, stable maintenance patients can work, drive, and be otherwise unimpaired, simply because their dose is not varied and is taken regularly and consistently. Tolerance also means that maintenance does not block emotional growth or automatically make people distant in relationships. In order to use opioids to escape emotion, you need to get “high,” and stable maintenance patients are too tolerant to do so. Unfortunately, because people don’t understand these basic facts about the role of timing and dosing in addiction, maintenance patients are stigmatized as being constantly “high” and “not really in recovery,” even though tolerance means that this is inaccurate.

 This is something weird that I remember reading in a high school psychology textbook. This passage brought it back to me:

In these cases, the unconscious cues that normally activate tolerance don’t do so—and without tolerance, the normal dose becomes an overdose. It seems that sometimes, context alone can change a safe dose to a lethal dose. And this effect can even be seen in rats: if they are made tolerant to a high dose in one place and then given the same dose in a new environment, 50% will actually die of overdose.

I remember reading about some sick, dying old man who got his morphine in his study rather than the living room where he usually got it, and promptly died from respiratory suppression. I guess it's a real effect after all.

The double-standard for alcohol might be warranted if only it worked against alcohol:

Alcohol, incidentally, also does not work for maintenance. Unlike opioid tolerance, alcohol tolerance doesn’t completely eliminate impairment, even if the drug is given in steady, regular doses. That means that even with high levels of tolerance, heavy alcohol users on a consistent dose are still significantly impaired. Contrary to the claims of those who criticize opioid maintenance as “just replacing vodka with gin,” the difference is that opioids produce complete tolerance in steady-state dosing, while alcohol does not.

 On salient alternatives:

People with decent jobs, strong relationships, and good mental health rarely give that all up for intoxicating drugs; instead, drugs are powerful primarily when the rest of your life is broken.

 On Rat Park:

Although a few early experiments failed to replicate the Rat Park effect, most did so.

I think these experiments on Rat Park are a little beside the point. These were experiments in which rats were given enriched environments: larger cages, more toys, more rats to socialize with. They were found to consume less cocaine (or sometimes not!) than rats kept in very small, desolate cages. I don't particularly care if the replications are real or not. The lessons of Rat Park may or may not apply to rats, but they certainly apply to humans.

On the decision-making of adolescents and young adults:

CORNELL’S VALERIE REYNA studies how young people’s risk decisions can go awry—and her conclusions are counterintuitive. Her research suggests that the major reason that teens and young adults are unreasonable about risk is not that they are too emotional when they consider it—but rather, that they are too rational. Although my own behavior during my late teens and early 20s now seems completely irrational to me, her work helps make sense of it. As noted earlier, studies find that adolescents often significantly overestimate their odds of bad outcomes from activities like sex and drug use. For instance, when asked to estimate the odds that a teenage girl who is sexually active will become infected with HIV (in a study conducted in the ’90s, when AIDS was not as treatable as it is now), the average guess was 60%. The actual risk was less than 1% for an American teen in most parts of the country. But even absurd overestimations like this don’t deter youth. And that’s not because they don’t consider them. Instead, there are two important factors. First, young people do tend to weigh immediate benefits more heavily: the visible prospect of pleasure literally looms larger in their minds than anything else that might happen later. Second, adolescents get lost in deliberation when they do consider negative consequences—and being out in the weeds doesn’t tend to spur good judgment.

...

In contrast, teens and young adults haven’t developed this rapid gut-level calculus. Instead, they “rationally” and deliberately think through the odds of success in things like playing Russian roulette, drinking Drano, or setting their hair on fire.

I found it interesting that young people overestimate the risks of drug use but do it anyway. That suggests that any government program that tries to accurately communicate the risks to young people will be counterproductive.

On the rationality of addicts:

People with addictions typically don’t shoot up when the police are watching; we often work quite hard to hide our behavior. We also specifically plan things like drug deals by taking steps to avoid detection.

 Szalavitz describes her harassment at the hands of police:

Immediately after they arrived, two of the officers took me into the hallway outside my apartment. I was now high, still feverish and completely dazed; I was also terrified. Their guns were prominent and visible to me in their holsters. They promised that if I signed the form that they shoved in my face, they wouldn’t arrest me. Stupidly, I complied. To this day, I still don’t understand exactly why: it must have been some combination of fear, fever, intoxication, and perhaps my ongoing Aspie tendency to take what other people say at face value. Aside from selling drugs, it’s probably the single most idiotic thing I ever did. Of course, the police were lying to me; if I had been thinking at all clearly, this should have been obvious. The document turned out to be permission to search. They had no warrant. If I hadn’t signed, there might never have been an attempt to prosecute me.

I just want to say, I have zero respect for cops who do this shit. Using a drug offense as a pretext for incarcerating someone who's "really" guilty of something else, okay, sure. But deliberately talking drug "offenders" out of their legal rights in order to make a pointless drug bust? This is pure social harm with no corresponding benefit. These cops are doing enormous harm to society because "the law" tells them it's okay. I find this just unbelievably irresponsible. Even granting that police officers have to follow the law, they have quite a lot of discretion regarding who to target and what crimes to prioritize. They have a responsibility to de-prioritize bad mandates that harm the communities they serve. Drug policing is a prime example of something that should be given extremely low priority.

 On the downfall of Synanon, a "tough love" treatment program, run by Charles Dederich:

Ultimately, Synanon’s downfall began when Dederich ordered his henchmen to place a derattled rattlesnake in the mailbox of Paul Morantz, a courageous attorney who’d won cases against the group. The snake bit Morantz, who, fortunately, survived. (Dederich eventually did time for conspiracy to commit murder in the case; when arrested, the “ex-alcoholic” who had found a “cure” for addiction was drunk.)

 Once again, these programs were never tested for effectiveness:

Many Tough Love members became prominent within Al-Anon and treatment organizations. They advocated publicly for tougher laws and for harsh, Synanon-based treatment programs like Straight, Incorporated, which actually traumatized thousands of families. As with AA, however, Tough Love was never tested before it was widely accepted and implemented. While there are clear indications that it can sometimes do harm, no one knows how widespread the problem is because there is virtually no research on what happens to people whose parents or spouses decide to practice it.

 Another "tough love" horror story:

In 1986, though, I was in the grip of the system. That year, I read an article in the New York Times Magazine that terrified me. It was a positive profile of a New Jersey program called KIDS, an unapologetically harsh youth rehab. Treatment at KIDS consisted primarily of sitting rigidly in one particular position on hard chairs for 12-hour days and being subjected to constant emotional attacks. I would later write a book that exposed just how torturous and harmful that particular program was. I learned, for instance, that one thirteen-year-old girl, who didn’t even have a real addiction, was held in it for thirteen years, eventually winning a $6.5 million settlement in a stunning civil case that exposed emotional, physical, and sexual abuse.

Szalavitz describes her encounter with an unqualified addiction counselor:

 Nationally, this lack of genuine qualifications is more the rule than the exception among addiction counselors, even now.

 Here is the part where she tells the reader to not trust her own anecdotal evidence in favor of 12-step programs:

It’s impossible for me personally to know whether 12-step groups were essential for my recovery—or whether another method would have been just as effective. In fact, when someone says to me that the 12 steps or any other treatment were the “only thing that could have helped,” I sometimes ask whether the person has an addicted identical twin who failed all other approaches to provide a counterfactual control. The lack of this type of evidence—obviously, with far larger numbers, not just one case—is the problem.

...

 Anecdotes, in contrast, can make quack treatments seem effective and thereby deter progress for years, even centuries. A critical part of why addiction treatment fares so poorly in contrast to general medicine is that it has not been held to a standard that requires scientific proof. It isn’t even held to the Hippocratic oath of ensuring first and foremost that no harm is done.

 Bravo. Her relief at the end of her legal troubles:

The official end to my encounter with the Rockefeller laws was so bureaucratic and anticlimactic, thankfully, that I can barely remember it. According to records that are now sealed, it occurred on July 17, 1992, nearly six years after my arrest. That day, Judge Snyder granted a motion by my lawyer to dismiss the case “in the interest of justice.”

 Harm reduction as universally accepted in another context:

In alcohol policy, harm reduction (though not labeled as such) has long been both successful and relatively uncontroversial. The “designated driver” is a harm reduction approach: it accepts that people will drink to excess and works to cut drunk driving, not drinking. Media campaigns against driving while intoxicated also fall under this rubric. Just as needle exchange is neutral on needle use per se, campaigns that criminalize or stigmatize stigmatize taking the wheel while drunk do not argue that drinking itself is wrong. Their target is impaired drivers.

It would be nice to see this context-dependence applied more broadly to other substances.  It's like I've said before, drinking per se is not the cause of drunk driving. Likewise heroin use per se is not the cause of property crime.

Interesting bit about how opioids may be useful for treating depression:

Historically, in fact, opiates were among the first antidepressants—and there is now research suggesting that the opioid maintenance drug Suboxone can help with depression that is resistant to other treatments.

 On her response to antidepressants:

Of course, for a person who is undersensitive, reducing emotionality could truly be awful and perhaps even produce suicidal thoughts or pathological ennui. For a sociopath, it might reduce empathy even further, which could be catastrophic. In other people, it might be neutral. However, for me, it was positive. The action of a drug depends not just on its pharmacology but on the person’s baseline. If you are starting out way too high on a dimension—even a seemingly good one like sensitivity—going lower may be helpful. The wide range of responses to antidepressants probably has to do with the huge variety of natural human wiring, which can make the same drug into a poison, a panacea, or a placebo, depending on the dose, the timing, and the patient.

Once again, drugs don't simply have one effect on all humans. There is heterogeneity in human responses to drugs. It makes sense that this will be particularly true of psychiatric drugs, given that the symptoms are incredibly subjective experiences (and certainly no less real for that).

On the total hypocrisy of American drug policy:

No sane policy maker, for example, could justify allowing commercial sales of a drug like tobacco, which cuts life expectancy by ten years on average, while using incarceration to punish those who take marijuana, which is not associated with increased mortality at all. Our policies are not based on rationality, risk assessment, or logic—just history.

I have never heard a serious response to this point. I have heard plenty of unserious responses.

 An amusing story of a bureaucrat in New Zealand testing a popular synthetic drug and concluding that there's nothing to worry about:

Given that it was his job to investigate BZP, Sellman decided to try it himself, as an added data point for his research. “I went down to Cosmic Corner,” he says. “They gave me this little packet. I went home on a Friday night and took it and sat in front of the television, waiting.” Nothing happened at first. “But the extraordinary thing was that I was still sitting in front of the television at four o’clock in the morning and I just didn’t need to sleep,” he says. The next day he had what he describes as the world’s worst hangover. “I went back to the [committee] and said, ‘You don’t have to worry, really, about this drug,’” he says, citing the lack of euphoria and the aftereffects.

There is a long and interesting section about New Zealand's attempt to legalize and regulate its synthetic drug market. Of course, governments who attempt to ban new synthetic after new synthetic are missing the point:

AS MANY OTHER countries have since discovered, outlawing one legal high doesn’t solve much. The Kiwi BZP ban set off an early version of a pattern now familiar globally: the legal highs arms race. One substance would be banned, only to be replaced by another, sometimes more harmful than the last. “I’ve banned 33 separate substances, 51 or 52 different products, and they keep being reformulated and reappearing,” New Zealand Associate Minister of Health Peter Dunne told a local paper, looking back at the worst period, in 2013. By then over 4,000 New Zealand stores were selling legal highs.

Keep pushing that boulder up the hill. Maybe one day you'll get there!
There are legal complications, too:

The inability of experts to agree on what an analog really is makes prosecuting these cases complicated—and the U.S. Supreme Court recently ruled that prosecutors must prove that sellers know the drug is an analog if they are to be convicted.

This isn't a problem that you can just "legislate away." Fundamentally, the law has to be predictable and pre-defined. Otherwise police and prosecutors are just making up the law as they go. Err...more so.

Pleasure counts:

But these issues are where values shape science and where the rubber hits the road in recreational drug regulation. Typically, pleasure and transcendent experience have not even been seen as worth consideration in discussions of recreational drug laws; only harms are counted, with benefits seen as being products of user delusions or simply ignored.

 Bravo. It makes no sense that any drug that's fun is automatically banned, no matter how insignificant the risk. There are broad classes of drugs that have almost no overdose risk, do no cumulative organ damage, and that aren't addictive. Psychedelics and dissociative anesthetics, for example, are mostly harmless. The knee-jerk urge to ban them is literally puritanical.

On cops and prosecutors playing doctor:

In essence, the drug court system allows judges to practice medicine without a license—deciding what medications and treatments are acceptable in a way that they never do for other illnesses. No judge, faced with a mentally ill defendant, says that he can take only Haldol but not Risperdal, or that talk therapy must be psychoanalytic, not cognitive. However, drug court judges frequently require that patients be denied or tapered from medications that are the standard of care, and often, they only allow them to attend certain programs.

Law enforcement folks are fundamentally unqualified to make these kinds of decisions, but they give it a go anyway. It doesn't have to be this way:

 Police enforce laws—unless these laws are changed to make drug possession for personal use legal, people with addiction will face prosecution for what they do every day in order to cope.

 On the shining example of Portugal:

Since the law was changed nearly 15 years ago, Portugal’s results have been astonishing—at least to those who predicted that such a move would produce a chaotic, drug-crazed country. HIV infection rates in drug users have fallen, the number of people in treatment rose 41%, and drug use rates by teenagers declined.

BTW, the Portugal example is also something to which I've never heard a coherent response but have heard many flippant ones.

On the self-limiting nature of drugs that are "too good":

Healthy users, who make up 80%–90% of those who try drugs, often become scared when a drug is too euphoric, rather than purely delighted. They frequently say things like, “It was so good; I knew I couldn’t risk taking it again” in response to the same experience that people who go on to develop addictions respond to by using more as soon as possible.

In other words, people anticipate addiction risk and (mostly) adjust their behavior for it. People don't just keep doing "good feeling thing" over and over again until they collapse. They anticipate the bad consequences and the onset of tolerance (or mere habituation for non-drug thrills). They avoid behaviors that are "too tempting", or relegate them to strict scheduling.

Drug prohibition is "reverse-optimized" to target the people we don't need to worry about and miss the people we should worry about:

However, because there is always a demand for mood-altering substances and the most vulnerable people are the most likely to get addicted, absolute prohibition tends to deter those who aren’t at risk and harm those who are, by criminalizing them.

I've also noticed this.

Reiterating that drug addicts retain their free will:

Although the traditional disease model suggests that people in the grip of addiction have no free will, this has never fit the facts. As noted earlier, addicted people don’t get high in front of the police; they plan specifically to ensure their supply and to avoid being detected. They frequently end addictions when circumstances change, such as when they fall in love, get a new job, or graduate college. On the other hand, addicts certainly also behave compulsively and apparently irrationally.

Advocating decriminalization:

 One policy change that is completely supported by existing data is decriminalizing low-level possession and personal use of all drugs. Arresting and jailing users makes no more sense and is no more effective for heroin and cocaine users than it is for marijuana users. There may be some drugs for which prohibitions of sales remain sensible—but this shouldn’t be the unquestioned default because our policies were not originally made rationally.

I loved this short bit (emphasis mine):

 People who use drugs also need access to accurate harm reduction information—and this includes high school and college kids, who are at the age when use is most common. They need to know, for example, that mixing depressant drugs like alcohol with pain relievers can be deadly, but that there is no way to overdose on marijuana. Telling kids that all drug use is bad is not effective: teens are exquisitely sensitive to hypocrisy and this makes them dismiss fear tactics that don’t jibe with their own experience.

The "just say no" and the hyperbolic scare tactics are likely to backfire, in other words. And, yes, it's perfectly fair for junior to point to your scotch and cigar and even your coffee when you scold him for his marijuana use.

On stigmatizing drug use:

  It is impossible to simultaneously criminalize and destigmatize a behavior: one of the key points of criminalization is, in fact, to deliberately create stigma in order to deter lawbreaking. How can you destigmatize a condition as you argue that your patients only respond to the brute force of the law?

I had an interesting conversation recently in which someone claimed that the social stigma against drugs is a "free lunch." It's a punishment that deters conscientious people, but that low-conscientiousness/high-impulse individuals, the kind who are especially prone to drug addiction, don't feel it. It was an interesting attempt to push back against the arguments I presented in my recent post Against Drug Prohibition, but I think it fails. People who persist in their drug use are definitely harmed by the social stigma. They feel the censure, if not viscerally, in denied job opportunities or the dismissal of their real problems by uncaring third parties.

I loved this excerpt in which Szalavitz describes being given naloxone. It speeds up withdrawal, but it also intensifies the very unpleasant withdrawal symptoms:

I lay on a gurney, shaking and crying, holding my mother’s hand. At some point, I was given a shot that seemed to have no effect. The nurse wouldn’t say what it was. I later learned that I’d been injected with naloxone, an opioid antagonist that is merciful when used to revive overdose victims but slightly sadistic for someone already in withdrawal, as it can intensify the symptoms. It works as an antidote, removing any remaining opioid drugs from their receptors. (It is the same drug now being made available to addicts, their loved ones, and police officers to reverse overdose, and this way of using it undoubtedly saves lives.) 

I guess the “therapeutic” rationale for administering naloxone in detox was the theory that this would more rapidly remove the drugs from my system; the punitive one is that it increases your distress. Naloxone worsens withdrawal symptoms and it was given without my consent—another sign of the paradoxical way addiction is viewed as both a sin and a disease. The idea that addicted people should have the right to informed consent like any other patient wasn’t even considered. Though treatment and punishment were supposed to be opposite approaches, in fact, harsh moralistic tactics were the rule, not the exception, when I sought help, and they are still part of the treatment experience for most people with addictions.

Emphasis mine. What a crazy idea, that an addict be treated like a human patient?  That their preferences should be acknowledged and their consent acquired?