Pubdate: May 1999
Source: Harper's Magazine (US)
Copyright: 1999 Harper's Magazine Foundation
Contact:  666 Broadway, New York, New York, 10012
Fax: : (212) 228-5889
Website: http://www.harpers.org/
Contact:  Joshua Wolf Shenk
Note:  Joshua Wolf Shenk is a former editor of The Washington Monthly who
writes frequently on drug policy, pharmacology, and mental illness. He lives
in New York City.

AMERICA'S ALTERED STATES

Part II

In 1912, Merck Pharmaceuticals in Germany synthesized a type of amphetamine,
methyllenedioxymethamphetamine, or MDMA.  It remained largely unused until
1976, when a biochemist at the University of California named Alexander
Shulgin, curious about reports from his students, produced and swallowed 120
milligrams of the compound.  The result, he wrote soon afterward, was "an
easily controlled altered state of consciousness with emotional and sensual
overtones."

Shulgin's immediate thought was that the drug might be useful in
psychotherapy the way LSD had been.  In the two decades after its
mind-altering properties were discovered in 1943 by a chemist for Sandoz
Laboratories, LSD was widely used as an experimental treatment for
alcoholism, depression, and various clinical neuroses.  More than a thousand
clinical papers discussed the use of LSD among an estimated 40,000 people,
and research studies of the drug led to some extraordinary advances
including the discovery of the serotonin system.  When LSD experiments were
restricted in 1962 and again in 1965, Senator Robert Kennedy held a
congressional hearing.  "If they were worthwhile six months ago, why aren't
they worthwhile now?" he asked officials of the Food and Drug Administration
and the National Institute of Mental Health.  "Perhaps to some extent we
have lost sight of the fact that [LSD] can be very, very helpful in our
society if used properly."

The answer to Kennedy's question was that LSD had leaked out of the
universities and clinics and into the hands of "recreational users." It had
crossed the line that separates good drugs from bad.  LSD was outlawed three
years later.  In 1970, when a new law devised five categories, or
"schedules," of controlled substances, LSD was placed in Schedule I, along
with heroin and marijuana.  This is the designation for drugs with no
accepted medical use and a "high potential for abuse." In 1986, MDMA would
be added to that list of demon drugs.  The question is: How does a substance
get assigned to that category? What separates the good drugs from the bad?

In the nineteenth century, now-illegal substances were commonly used in
medicine, tonics, and consumer products. (The Illinois asylum that housed
Mary Todd Lincoln in the 1870s offered its patients morphine, cannabis,
whiskey, beer, and ale. Sigmund Freud treated himself with cocaine-and, for
a time at least, praised it effusively-as did William McKinley and Thomas
Edison.) A new era began with the federal Pure Food and Drug Act of 1906,
which required the listing of ingredients in medical products.  Then, the
1914 Harrison Narcotic Act, ostensibly a tax measure, asserted legal control
over distributors and users of opium and cocaine.

On the surface, this might seem progressive, the story of a still-young
nation establishing commercial and medical standards.  And there was genuine
uneasiness about drugs that were intoxicating or that produced dependence;
with the disclosure required by the 1906 act, sales of patent medicines
containing opium dropped by a third. But the movement for prohibition drew
much of its power from a far less savory motive.  "Cocaine," warned Theodore
Roosevelt's drug adviser, "is often a direct incentive to the crime of rape
by the Negroes." (6) As David Musto reports in The American Disease, the
prohibitions of the early part of the century were all, in part, a reaction
to inflamed fears of foreigners or minority groups.

Opium was associated with the Chinese.  In 1937, the Marihuana Tax Act
targeted Mexican immigrants.  "I wish I could show you what a small
marijuana cigarette can do to one of our degenerate Spanish-speaking
residents, a Colorado newspaper editor wrote to federal officials in 1936.
Even the prohibition of alcohol was underlined by fears of immigrants and
exaggerations of the effects of drinking.  On the eve of its ban in 1919, a
radio preacher told his audience, "The reign of tears is over.  The slums
will soon be a memory.  We will turn our prisons into factories, our jails
into storehouses and corncribs.  Men will walk upright now, women will smile
and the children will laugh. Hell will be forever for rent."

But the federal authorities, temperance advocates, and bigots had reached
too far.  Whereas alcohol (like coffee and tobacco) has been a demon drug in
other cultures, in Western societies its use in medicine, recreation, and
religious ceremonies stretches back thousands of years.  Most Americans had
personal experience with drink and could measure the benefits of Prohibition
against the violence (by gangsters and by Prohibition agents, who, according
to one estimate, killed 1,000 Americans between 1920 and 1930) and the
deaths by "overdose." (7) After Franklin Roosevelt lifted Prohibition,
subsequent generations knew that the drug, though often abused and often
implicated in crimes, violence, and accidents, differs in its effects
depending on the person using it.  With outlawed drugs, no such reality
check is available.  People who use illegal drugs without great harm
generally stay quiet.

Alcohol also can be legally used in medicines, such as Nyquil, or used
medicinally in a casual way-say, to calm shattered nerves.  Demon drugs, on
the other hand, are prohibited or seriously limited even in cases of
exceptional need.  Forty percent of pain specialists admit that they
undermedicate patients to avoid the suspicion of the Drug Enforcement
Administration.  Their fear is justified: every year about 100 doctors who
prescribe narcotics lose their licenses, including, in 1996, Dr. William
Hurwitz, a Virginia internist whose more than 200 patients were left with no
one to treat them.  One of these patients committed suicide, saying in a
videotaped message, "Dr.  Hurwitz isn't the only doctor that can help.  He's
the only doctor that will help." Chronic pain, mind you, doesn't mean dull
throbbing.  "I can't shower," one patient explained to U.S. News & World
Report, "because the water feels like molten lava.  Every time someone turns
on a ceiling fan, it feels like razor blades are cutting through my legs."
To ease such pain can require massive doses of narcotics.  This is what
Hurwitz prescribed.  This is why he lost his license.

But at least narcotics are acknowledged as a legitimate medical tool.
Marijuana is not, despite overwhelming evidence that smoking the cannabis
plant is a powerful treatment for glaucoma and seizures, mollifies the
effects of AIDS or cancer chemotherapy, and eases anxiety.  The editors of
The New England Journal of Medicine, the American Bar Association, the
Institute of Medicine of the National Academy of Sciences, and the majority
of voters in California and six other states (plus the District of Columbia)
are among those who believe that these uses of marijuana are legitimate.  So
does the eminent geologist Stephen Jay Gould.  He developed abdominal cancer
in the 1980s and suffered such intense nausea from intravenous chemotherapy
that he came to dread it with an "almost perverse intensity." "The
treatment," he remembers, "seem[ed] worse than the disease itself." Gould
was reluctant to smoke marijuana, which, as thousands of cancer patients
have found, is a powerful antiemetic. When he did, he found it "the greatest
boost I received in all my years of treatment." "It is beyond my
comprehension," Gould concluded, "and I fancy myself able to comprehend a
lot, including much nonsense-that any humane person would withhold such a
beneficial substance from people in such great need simply because others
use it for different purposes."

This distinction between "people in great need" and those with "different
purposes" is crucial to the argument for the medical use of marijuana. (8)
Like Gould, many who use marijuana for medical reasons dislike the "high."
Many others don't even feel it.  But it is a mistake to think that the
reason these people can't legally use marijuana is simply that other people
use it for purposes other than traditional medical need.  Because the very
idea of "medical need" is constantly shifting beneath our feet.

I do not have cancer or epilepsy, or a disabling mental disorder such as
schizophrenia.  The "other purposes" Gould refers to are, in many ways,
mine.  The qualities of my suffering are (to simplify) anxiety, numbness,
and anhedonia.  If these were relieved by a legal drug-in other words, if a
pharmaceutical helped me relax, feel more alive, have fun-I would be firmly
in the mainstream of American medicine. This is my strong preference.  But
when I returned to see Donald Klein this past summer, hoping that new
medications might have emerged in the last five years, he told me that
"there are lots of things to try but there's only marginal evidence that any
of them would do any good." He also made it clear that I shouldn't get my
hopes up.  "What you have," he said, "is not a common condition, and it's
almost impossible [for pharmaceutical companies] to do a systematic study,
let alone make money, on a condition that's not common." And so, yes, I turn
sometimes to marijuana and other illicit substances for the (limited) relief
they offer.  I don't merely feel justified in doing so; I feel entitled,
particularly since, every year, the pharmaceutical industry rolls out new
products for pleasure, vanity, convenience.

When Viagra emerged, it was not frowned upon by the authorities that lead
the drug wars.  Instead, President Clinton ordered Medicaid to cover the
drug, and the Pentagon budgeted $50 million for fiscal 1999 to supply it to
soldiers, veterans, and civilian employees.  Pfizer hired Bob Dole to
instruct the nation that "it may take a little courage" to use Viagra.  This
is a medicine whose sole purpose is to allow for sexual pleasure; it was
embraced by the black market and is easily available from doctors, including
some who perform liexaminations" via a three-question form on the Internet.
But Viagra's legitimacy was never questioned, because it treats a
disease-erectile dysfunction.  Before Viagra, when the only treatment
options were less-effective pills and awkward injection-based therapies,
this condition was referred to as impotence.  The change in language is
interesting.  The "dys" sits on the front of dysfunction like a streak of
dirt on a pane of glass.  At a level more primal than cognitive, we want it
removed.  This is what we do with dysfunctions: we fix them.  Impotence, on
the other hand, meaning "weakness" or "helplessness," is something we all
experience at one time or another. Applied to men "incapable of sexual
intercourse, often because of an inability to achieve or sustain an
erection," the word carries a sense of something unfortunate but part of
living, and particularly of growing older.

Thus the advent of Viagra does not simply treat a disease.  It changes our
conception of disease.  This paradigm shift is a common occurrence but is
below our radar.  Hair loss becomes a disease, not a fact of life.  Acid
indigestion becomes a disease, not a matter of eating poorly.  If these
examples seem to make light of the broadening of disease, the ascent of
psychopharmaceuticals makes the issue urgent. Outside the realm of the
tangibly physical, the power of drugs and drugmakers is far greater.  What
we now know as "anxiety disorder," for example, existed only in theory from
Freud's time through World War II.  In the early 1950s, a drug company
polled doctors and found that most had no interest in a medication that
treated anxiety.  But by 1970, one woman in five and one man in thirteen
were using a tranquilizer or sedative, and anxiety was a mainstay of
psychiatry. The change could be directly attributed to two drugs, Miltown
and Valium, which were released in 1955 and 1963, respectively.  The
successor to these drugs, Xanax, introduced in 1981, virtually created a
disease itself.  Donald Klein had already proposed the existence of
something called "panic disorder," as opposed to generalized anxiety, some
twenty years before.  But his theory was widely refuted, and in practice
panic anxiety was treated only in the context of a larger problem.  Xanax
changed that.  "With a convenient, effective drug available," writes Peter
Kramer, "doctors saw panic anxiety everywhere." Xanax has also become the
litmus test for generalized anxiety disorder.  "If Xanax doesn't work,
instructs The Essential Guide to Psychiatric Drugs, "usually the original
diagnosis was wrong." (9)

This is not to say that all specific disorders are arbitrary, just that
there is a delicate line to be drawn.  "The term 'disease'-and the border
between health and disease-is a social construct," says Steven Hyman,
director of the National Institute of Mental Health. "There are some things
we would never argue about, like cancer.  But do we call it a disease if you
have a few foci of abnormal cells in your body, something that you could
live with without any problem? There is a gray zone.  With behavior and the
brain, the gray zone is much larger."

To Hyman's observation, it must be added that, whereas vague
dissatisfactions make money for psychic hot lines and interior decorators,
diseases make money for pharmaceutical companies.  What Peter Kramer calls
psychiatric diagnostic creep is not an accident of history but a movement
engineered for profit.

We have only begun to grapple with the consequences.  The example of Prozac
has been chewed over, but it's worth chewing still more because it is so
typical of a new generation of drugs, which are being used to treat
debilitating conditions and also by people with far less serious problems.
With Lauren Slater, author of the fine memoir Prozac Diary, we have a case
anyone would regard as serious.  Suffering from obsessivecompulsive
disorder, severe depression, and anorexia, she had been hospitalized five
times, attempted suicide twice, and cut herself with razors.  Prescribed
Prozac in 1988, she found the drug a reprieve from a lifetime sentence of
serious illness-"a blessing, pure and simple," she writes.  The patients
described in Peter Kramer's Listening to Prozac are quite unlike Lauren
Slater.  They share, he writes, "something very much like 'neurosis,'
psychoanalysis's umbrella term for the mildly disturbed, the near-normal,
and those with very little wrong at all." The use of Prozac for these
patients is not incidental; they make up a large portion, probably a wide
majority, of people on the drug. (One good indication is that only 31
percent of antidepressant prescriptions are written by psychiatrists.)

Throughout his book, Kramer flirts with "unsettling" comparisons between
Prozac and illegal drugs.  Since Prozac can "lend social ease, command, even
brilliance," for example, he wonders how its use for this purpose can "be
distinguished from, say, the street use of amphetamine as a way of
overcoming inhibitions and inspiring zest." The better comparison, I
suggested in a conversation with Kramer, is between Prozac and MDMA.  Both
drugs work by increasing the presence of serotonin in the brain. (Whereas
Prozac inhibits serotonin's reuptake, MDMA stimulates its release.) Both can
be helpful to the seriously ill as well as to people with more common
problems.  Most of the objections to MDMA-that it distorts "real"
personality, that it rids people of anxiety that may be personally or
socially useful, that it induces more pleasure than is natural have also
been marshaled against Prozac.  Both these drugs challenge our definitions
of normalcy and of the legitimate uses of a mind-altering substance.  Yet
Kramer rejects the comparison.  "The distinction we make," he told me, "is
between drugs that give pleasure directly and the drugs that give people the
ability to function in society, which can indirectly lead to pleasure.  If
the medication can make you work well or parent well, and then through your
work or parenting you get pleasure, that's fine. But if the drug gives you
pleasure by taking it directly, that's not a legitimate use." (Viagra,
because it allows men to experience sexual pleasure, falls on the side of
legitimacy.  But, Kramer said, a drug that directly induced an orgasm would
not.)

The line between therapeutic and hedonistic pleasure, however, is awfully
hard To draw.  I think of a friend of mine who uses MDMA a few times a
month.  His is a textbook case of "recreational" use.  He takes MDMA on
weekends, in clubs, for fun.  He is not ill and is not in psychotherapy. But
he will live for the rest of his life in the shadow of a traumatic
experience, which is that for more than two decades he hid his
homosexuality.  Some might say the drug is an unhealthy escape from "the
real world, that the relaxation and intimacy he experiences are illusory.
But these experiences give him a point of reference he can use in a "sober"
state.  His pleasure from the drug is entirely social-being and sharing and
loving with other people.  Is this hedonistic? "I found it astonishing,"
Kramer writes of Prozac, "that a pill could do in a matter of days what
psychiatrists hope, and often fail, to accomplish by other means over a
course of years: to restore to a person robbed of it in childhood the
capacity to play."

Perhaps I would find restrictions on MDMA more reasonable if they at least
carved out an exception for therapeutic use.  Keep in mind, that's where
this drug started.  After Shulgin's experiment word spread, and thousands of
doses were taken in a clinical setting.  As with LSD, MDMA was seen not as a
medicine but as a catalyst to be taken just a few times-or perhaps only
once-in the presence of a therapist or "guide." The effects were impressive.
Many users found their artifice and defenses stripped away and long-buried
emotions rising to the surface.  The drug also had the unusual effect of
increasing empathy, which helped users trust their therapists crucial
characteristic of effective healing-and also made it useful in couples
therapy.  In a collection of first-person accounts of therapeutic MDMA use,
Through the Gateway of the Heart, published in 1985, a rape victim described
working through her fears.  Another woman described revelations about her
son, her weight problems, and "why angry men are attracted to me."

I can hear the skeptics shuffling their feet, wanting data from double-blind
controlled trials.  But MDMA research never reached that stage.  Mindful of
what had happened with LSD, the therapists, scientists, and other adults
experimenting with MDMA tried to keep it quiet.  Inevitably, though, word
spread, and a new mode of use sprang up at raves, in dance clubs, in dorm
rooms.  An astute distributor of the drug renamed it Ecstasy to emphasize
its pleasurable effects. ("'Empathy' would be more appropriate," he said
later.  "But how many people know what that means?") ? (10)

As the DEA moved to restrict MDMA, advocates of its medical use flooded the
agency with testimony, pleading for a chance to subject the drug to
methodical study.  The agency's administrative-law judge, Francis Young, saw
merit in this argument.  In a ninety-page decision handed down in 1986, he
recommended that the drug be placed in Schedule III, which would allow for
it to be prescribed by doctors and tested further.  Young cited its history
of "currently accepted medical use in treatment in the United States" and
argued that "the evidence of record does not establish that ... MDMA has a
'high potential' for abuse."

DEA officials overruled Young and placed MDMA in Schedule I, with the
assurance that its decision would be self-fulfilling.  A Schedule I
substance cannot be used clinically and can be studied only with great
difficulty.  So medical use is essentially forever impossible.  That leaves
illicit use, which, by one common definition, is the abuse for which
Schedule I drugs have a "high potential." Since then, government-funded
researchers have sought to document MDMA's dangers. Here we come to the
truth about the line and how it is maintained.

With rare exceptions, everything we know about legal drugs comes from
research sponsored by the pharmaceutical industry.  Naturally, this work
emphasizes the benefits and downplays the accompanying risks.  On the other
hand, the National Institute on Drug Abuse, which funds more than 85 percent
of the world's health research on illegal drugs, emphasizes the dangers and
all but ignores potential benefits.

One recent NIDA-funded study on MDMA was widely reported last fall. Dr.
George Ricaurte found, in fourteen men and women who had used MDMA 70 to 400
times in the previous six years, "long-lasting nerve cell damage in the
brain." Specifically, Ricaurte found decreases in the number of
serotonin-reuptake sites.  The study begs three major questions.  First, do
its conclusions really reflect the experience of heavy MDMA users? British
physician Karl Jansen reports that he referred MDMA users who had taken more
than 1,000 doses and that "they were told by Ricaurte that they had a clean
bill of health" but were excluded from his study.  Second, should the brain
changes Ricaurte found be called "damage," given that a number of
psychiatric medications, Prozac and Zoloft among them, decrease the number
of serotonin receptors by blockading them? As psychopharmacologist Julie
Holland writes, "This could be interpreted as an adaptive response as
opposed to a toxic or 'damaged' response." Third, do Ricaurte's findings
have any bearing on the use of MDMA in therapy, which calls for a handful of
doses over many months?

In this climate, it's hard to know.  Charles Grob, a psychiatrist at
Harbor-UCLA Medical Center in Los Angeles, has been trying to restart MDMA
research for eight years.  He received FDA approval to conduct Phase I
trials on human volunteers, to see if MDMA is safe enough to be used as a
medicine.  But even with his impeccable credentials, the backing of a
prestigious research hospital, and an extremely conservative
protocot-involving terminal patient, Grob has faced a seemingly interminable
wait for permission to begin Phase II, in which he would study efficacy.
Grob's struggle explains why he has little company in the research
community.  "When you have a drug that's popular among young people," Grob
says, "that's the kiss of death when it comes to exploring its potential
utility in a medical context."

There is another "kiss of death": lack of interest from industry.  I asked
Lester Grinspoon, a professor of psychiatry at Harvard Medical School, who
led the legal challenge to the DEA's scheduling decision, whether he had
approached drug companies about supporting the effort. "We didn't even
consider it," he said.  "No drug company is going to be interested in a drug
that's therapeutically useful only once or twice a year.  That's a
no-brainer for them." When you see the feelgood ads from the Pharmaceutical
Research and Manufacturer's Association with the tag line "Leading the way
in the search for cures," keep in mind that cures-conditions in which
medication is no longer required-are not particularly high on the
pharmaceutical companies' priority list.

Market potential isn't the only factor explaining the status of drugs, but
its power shouldn't be underestimated.  The principal psychoactive
ingredient of marijuana, THC, is available in pill form and can be legally
prescribed as Marinol.  A "new" creation, it was patented by Unimed
Pharmaceutical and is sold for about $15 per 10-mg pill. Marinol is
considered by patients to be a poor substitute for marijuana, because doses
cannot be titrated as precisely and because THC is only one of 460 known
compounds in cannabis smoke, among other reasons.  But Marinol's profit
potential-necessary to justify the up-front research and testing, which can
cost upward of $500 million per medication-brought it to market.  Opponents
of medical marijuana claim that they simply want all medicines to be
approved by the FDA, but they know that drug companies have little incentive
to overcome the regulatory and financial obstacles for a plant that can't be
patented. The FDA is the tail, not the dog.

The market must be taken seriously as an explanation of drugs' status. The
reason is that the explanations usually given fall so far short. Take the
idea "Bad drugs induce violence." First, violence is demonstrably not a
pharmacological effect of marijuana, heroin, and the psychedelics.  Of
cocaine, in some cases. (Of alcohol, in many.) But if it was violence we
feared, then wouldn't we punish that act with the greatest severity? Drug
sellers, even people marginally involved in a "conspiracy to distribute,"
consistently receive longer sentences than rapists and murderers.

Nor can the explanation be the danger of illegal drugs.  Marijuana, though
not harmless, has never been shown to have caused a single death.  Heroin,
in long-term "maintenance" use, is safer than habitual heavy drinking.  Of
course, illegal drugs can do the body great harm. All drugs have some risk,
including many legal ones.  Because of Viagra's novelty, the 130 deaths it
has caused (as of last November) have received a fair amount of attention.
But each year, anti-inflammatory agents such as Advil, Tylenol, and aspirin
cause an estimated 7,000 deaths and 70,000 hospitalizations.  Legal
medications are the principal cause of between 45,000 and 200,000 American
deaths each year, between I and 5.5 million hospitalizations.  It is telling
that we have only estimates.  As Thomas J. Moore notes in Prescription for
Disaster, the government calculates the annual deaths due to railway
accidents and falls of less than one story, among hundreds of categories.
But no federal agency collects information on deaths related to legal drugs.
(The $30 million spent investigating the crash of TWA Flight 800, in which
230 people died, is six times larger than the FDA's budget for monitoring
the safety of approved drugs.) Psychoactive drugs can be particularly toxic.
In 1992, according to Moore, nearly 100,000 persons were diagnosed with
"poisoning" by psychologically active drugs, 90 percent of the cases due to
benzodiazepine tranquilizers and antidepressants.  It is simply a myth that
legal drugs have been proven "safe." According to one government estimate,
15 percent of children are on Ritalin.  But the long-term effects of
Ritalin-or antidepressants, which are also commonly prescribed-on young kids
isn't known.  "I feel in between a rock and a hard place," says NIMH
director Hyman.  "I know that untreated depression is bad and that we better
not just let kids be depressed. But by the same token we don't know what the
effects of antidepressants are on the developing brain.... We should have
humility and be a bit frightened."

These risks are striking, given that protecting children is the cornerstone
of the drug wars.  We forbid the use of medical marijuana worrying that it
will send a bad message.  What message is sent by the long row of pills laid
out by the school nurse-or by "educational" visits to high schools by
drugmakers? But, you might object, these are medicines-and illegal drug use
is purely hedonistic.  What, then, about illegal drug use that clearly falls
under the category of self-medication? One physician I know who treats women
heroin users tells me that each of them suffered sexual abuse as children.
According to University of Texas pharmacologist Kathryn Cunningham, 40 to 70
percent of cocaine users have preexisting depressive conditions.

This is not to suggest that depressed people should use cocaine.  The risks
of dependence and compulsive use, and the roller-coaster experience of
cocaine highs and lows, make for a toxic combination with intense suffering.
Given these risks, not to mention the risk of arrest, why wouldn't a
depressed person opt for legal treatment? The most obvious answers are
economic (many cocaine users lack access to health care) and chemical.
Cocaine is a formidable mood elevator and acts immediately, as opposed to
the two to four weeks of most prescription antidepressants.  Perhaps the
most important factor, though, is cultural.  Using a "pleasure drug" like
cocaine does not signal weakness or vulnerability.  Self-medication can be a
way of avoiding the stigma of admitting to oneself and others that there is
a problem to be treated.

Calling illegal drug use a disease is popular these days, and it is done, I
believe, with a compassionate purpose: pushing treatment over incarceration.
It also seems clear that drug abuse can be a distinct pathology.  But isn't
the "disease" whatever the drug users are trying to find relief from (or
flee)? According to the Pharmaceutical Research and Manufacturer's
Association, nineteen medications are in development for "substance use
disorders." This includes six products for "smoking cessation" that contain
nicotine.  Are these treatments for a disease or competitors in the market
for longterm nicotine maintenance?

Perhaps the most damning charge against illegal drugs is that they're
addictive.  Again, the real story is considerably more complicated. Many
illegal drugs, like marijuana and cocaine, do not produce physical
dependence.  Some, like heroin, do. In any case, the most important factor
in destructive use is the craving people experience craving that leads them
to continue a behavior despite serious adverse effects.  Legal drugs
preclude certain behaviors we associate with addictionlike stealing for dope
money-but that doesn't mean people don't become addicted to them.  By their
own admissions, Betty Ford was addicted to Valium and William Rehnquist to
the sleeping pill Placidyl, for nine years.  Ritalin shares the addictive
qualities of all the amphetamines.  "For many people," says NIMH director
Hyman, explaining why many psychiatrists will not prescribe one class of
drugs, "stopping short-acting high-potency benzodiazepines, such as Xanax,
is sheer hell.  As they try to stop they develop rebound anxiety symptoms
(or insomnia) that seem worse than the original symptoms they were
treating." Even antidepressants, although they certainly don't produce the
intense craving of classic addiction, can be habit forming.  Lauren Slater
was first made well by one pill per day, then required more to feel the same
effect, then found that even three would not return her to the miraculous
health that she had at first experienced.  This is called tolerance.  She
has also been unable to stop taking the drug without "breaking up." This is
called dependence.  "'There are plenty of addicts who lead perfectly
respectable lives, Slater's boyfriend tells her.  To which she replies, "'An
addict .... You think so?"'

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MAP posted-by: Don Beck