Theodore Dalrymple has sparked a heated controversy with his new book Romancing Opiates: Pharmacological Lies and the Addiction Bureaucracy. His argument that the official doctrine concerning drug addiction is mistaken and self-serving has provoked much criticism from various quarters. Today we invite Dr. Dalrymple to face some of his critics and we also invite a supporter of his views. We are joined by:
Theodore Dalrymple, a contributing editor to City Journal and the author of his collection of essays Our Culture, What's Left of It: The Mandarins and the Masses. He is the author of the new book that serves as the topic for this discussion: Romancing Opiates: Pharmacological Lies and the Addiction Bureaucracy.
Chris Rutenfrans, a criminologist who formerly worked at the University of Nijmegen and the Department of Justice in the Netherlands. Since 1998 he was one of the two editors of the famous supplement Letter & Geest (Letter and Spirit) of the daily newspaper Trouw.
Ron Fisher is an active illicit opiate user since 1994. After several attempts at detox, meetings and rehabilitation, like so many other opiate abusers, he kept on relapsing. To find any type of stable life without the chase for the drugs and the depression caused by its withdrawal or abstinence, he found it through long-term methadone maintenance. He is currently on a 150 mg a day dose. Having been off illicit (non-prescribed) drugs for 5 years, he maintains he enjoys the maximum benefit of getting a month's worth of take home-medication at a time.
Percy Menzies, Director of Assisted Recovery Centers of America. He has a master's degree in pharmacy and worked for DuPont Pharmaceuticals that developed naltrexone for the treatment of heroin addiction. His special responsibility was training physicians and counselors on the rationale for the development of naltrexone.
Fontpage: Theodore Dalrymple, Chris Rutenfrans, Percy Menzies and Ron Fisher, welcome to Frontpage Symposium.
Theodore Dalrymple, let's begin with you. Illuminate for us your general thesis and argument.
Dalrymple: My general thesis is simple: that addiction is not an illness and treatment is therefore metaphorical rather than real. Mao Tse Tung threatened addicts with dire consequences if they did not stop, and they did stop. This suggests that there is a category difference between addiction and, say, cancer of the bowel.
Addiction is one answer to perennial existential problems - in my view not a very good answer, but I don't claim to have a perfect one - and so-called medical treatment is beside the point. It often does tangible harm, and in my view does harm in an intangible way as well by persuading addicts that they 'need' the help of professionals to stop. This, of course, is all to the advantage of a group of professionals.
Fontpage: Percy Menzies, Theodore Dalrymple appears to be just stating a basic given, so what exactly is the problem? Humans are all plagued by a spiritual human hunger that cannot be filled by the physical world, yet the obsessive attempt to do just that often leads to addiction. So addiction is not necessarily an "illness" that can necessarily be cured by professionals' medication for it. And the assumption that they do have a cure can obviously make things worse. Right?
Menzies: Heroin use may begin as a voluntary action, but over a period of time the use becomes involuntary primarily through negative reinforcement. The withdrawal symptoms are not life-threatening but they are so uncomfortable that few patients stop voluntarily. The addiction is further sustained through Pavlovian Conditioning. Patients who are off opiates for a period of time will experience all the symptoms of acute withdrawal (conditioned abstinence) when they are exposed to the sights, sounds, people, places etc. of past drug use. At my clinic detoxed patients are required to ingest naltrexone under supervision every other day and attend counseling sessions and the results are amazing. Naltrexone debunks the theory that opiate addicts need replacement medications for the rest of their lives. I am surprised that Theodore Dalrymple makes no mention of naltrexone in his book.
Rutenfrans: In favor of Dalrymple's thesis are the experiences in the US when the Harrison Act made the use of opiates illegal in 1914. Before 1914 opiates, often in the form of laudanum, were used mainly by women, especially to ease the discomfort of menstruation. As the Harrison Act made these practices illegal, most women who, even less than men, don't like to be regarded as criminals, stopped the use of opiates immediately, without any medical or psychiatric or psychological support. How could this happen, when opiates are indeed as addictive as much people think?
Fisher: I do believe addiction is a disease. I do not think it is comparable to a standard disease like bowl cancer or a brain tumor, but than again, not all illnesses are apples to apples comparison.
Having suffered first-hand from addiction, what I find similar to addiction and any other disease is that addiction is insidious, progressive, and fatal if ignored. I beg to differ with Dr. Dalrymple's statement: "Mao Tse Tung threatened addicts with dire consequences if they did not stop, and they did stop." Where are the statistics of how many addicts there were at the beginning? How many stopped as a result? How many were killed? How many suffered in silence? How many stopped for a period of time only later to relapse? If they did stop because of this threat, does that negate completely that addiction is a problem? Using Mao's example of how he addressed addicts is not valid since the communist regime of the time probably did not keep statistics of how many people were dealt with under the threat of dire consequences.
The same lack of statistics also applies to the reference Mr. Rutenfrans made of the Harrison 1914 Act making opiates illegal resulted in users quitting. Both examples with their inherent flaws and lack of statistics make part of the argument that addiction is not a disease, baseless.
Addiction is not an answer to perennial existential problems, it is in itself a perennial existential problem -- one that has endured throughout the ages. The two main methods of dealing with opiate addiction for long term clean time recently have been 12 Step meetings and methadone maintenance treatment. Many addicts are helped without the so called medical treatment at all. That is the basis of 12 step programs -- addicts helping addicts. However, there are many addicts that have repeatedly failed with 12 step programs as I have.
Not knowing of any other way to deal with addiction effectively, I felt I was really running out of options and was suggested methadone maintenance treatment. It was not much of a choice since it was either that or ending up in a jail, psychiatric ward, or even dead. Surprisingly methadone gave me the breathing room I needed to begin to think clearly. My obsession to use was removed. Methadone itself does not make one high but somehow blocks chemically the hunger one has for opiates. I began to be able to think clearly again. I was able to finally deal with the wreckage of my past and look forward to a future.
Dalrymple: I do not agree that conditioning makes people automata. If it were true that addicts really cannot help themselves, that they lose all volition in the matter, it would justify the most illiberal measures to help them, to prevent them from destroying themselves and so forth.
But the fact that millions of addicts, not just of opiates, have given up, merely by taking thought, suggests that conditioning is not very important.
As to various drug treatments, they all suffer from very similar drawbacks. Readers will be interested to know that in a recent edition of the Lancet, the 'epidemic' of fentanyl injection in the mid-west of America, which is claimed to have taken the lives of 'hundreds' was explained by the fact that fentanyl gives a stronger 'rush' of pleasure than other drugs - suggesting that the search for pleasure is at the root of the problem.
In a Lancet just two weeks previously, it was reported that buprenorphine has become the drug of abuse favoured by tens of thousands in the Republic of Georgia - all in the last 3 years, since addicts in France started selling their treatment to dealers to export it to Georgia (the drug was already the favourite opiate of abuse in Finland, thanks to the same source). At the very least, this suggests how deeply addicts value their treatment.
At the same time, in the New England Journal of Medicine, a trial was reported with a clever drug which combined buprenorphine with naloxone, so that, if injected, it precipitated withdrawal symptoms. A very clever drug combination, if I may say so.
Of 497 subjects (heroin addicts) recruited, 296 were excluded immediately because of their antisocial behaviour or use of other drugs, and 35 refused to take part. Of the rest, only 44 per cent completed the study (75 subjects) which lasted only 24 weeks, and whose criteria of success included not failing to obtain the prescription for longer than a week, and not missing more than 3 appointments. Given the fact that trials are more successful than treatment in 'natural' conditions, and the fact that addicts are well able and willing to fool doctors with urine samples and self-reports, this was hardly a therapeutic triumph, and is absolutely typical of the whole methodology of the treatment model, whichever pharmacological 'treatment' is used. It depends on the willingness of the so-called patients to take it, and according to the theory on which treatment is necessary, they have no will.
As to China, the figure I have taken is a commonly quoted one, though higher numbers are sometimes quoted. In any case, it doesn't matter for the sake of the argument whether the real figure is 1, 5, 10 or 100 million.
The methods used by the new regime are in many books on China.
As to personal experience, it is of very limited evidential value in a field in which the subjects are so given to deceit and self-deceit.
Menzies: I am surprised that Dr. Dalrymple dismisses conditioning as a contributing factor to addiction. All the drive states involved in the survival of the species, i.e. food, sex, shelter etc. are a function of conditioning. Schools are trying to reduce near epidemic levels of obesity by removing or limiting access to fatty and high-sugar food and thus extinguish the conditioning caused by the easy access to these foods.
Mao eliminated opium addiction through extreme coercion of both the users and the suppliers. Would Mao have succeeded if the flow of opium was unimpeded? Heroin addiction is back big time in China due to the heroin coming from Laos and Burma. Just yesterday, China announced that it is going to open 100 new methadone clinics to treat the addicts. I once again contend that price and access are the two biggest contributing factors to the spread of addiction. We can see this in countries like Georgia, Pakistan, Iran etc.
Addiction by its very nature will lead to neuroadaptation and tolerance. The addicts will make futile attempts to reach new 'highs' by increasing the dose, frequency and when that does not work -- poly drug use. Addicts learn very quickly to boost the effects by mixing other substances. 'Speedball' is a popular combination of heroin and cocaine that has killed tens of hundreds. The newest 'supercharger' is fentanyl and addicts will discover newer combinations to feed the narcissistic behavior.
Scientists learned many years ago that drugs that have even a mild addiction potential can cause havoc. This quest is on for drugs that have no addiction potential whatsoever. The best example is the treatment of alcoholism. The three drugs approved by the FDA -- Antabuse, naltrexone and acamprosate are all non-addicting. We learnt this from the disastrous results of the past of treating alcoholism with addictive drugs like Laudanum, beer and yes Valium (Mother's Little Helper).
The antithesis is the treatment of addiction to opiates. This is based on an unproven and phony theory that opioid addiction causes irreversible 'metabolic lesions' that can only be treated with replacement therapy. As a result, the three most widely used drugs -- methadone, LAMM and buprenorphine are addicting have kept tens of thousands of patients depended on these drugs for years and years.
This acceptance of replacement therapy is so well-entrenched and the use of methadone so widespread that I call this 'pharmacohegemony'. I am certain Mr. Fisher was not offered naltrexone as a viable treatment. Tens thousands of patients and even physicians are just as ignorant about naltrexone.
Naltrexone was introduced in 1984 to protect detoxed heroin addicts from relapsing to heroin use when they returned home to the familiar surrounding of past drug use. A single 50 mg tablet of naltrexone will prevent heroin from activating the brain. It can best be described as a 48-72 hour 'vaccine' against all opiates. Other physicians have described naltrexone as an 'insurance' against opiate use.
We have treated hundreds of opiate addicts with naltrexone and counseling with extraordinary results. Most patients take naltrexone for a six month period. If they slip they go back on it. To further enhance compliance, naltrexone is now available are a depot injection that lasts for a month. Indeed, when opiate addicts refuse naltrexone we know the reason -- they want to go back to using heroin. We treat patients at our clinic only if they are willing to take naltrexone.
The rejection of naltrexone and similar non-addicting medications has left opiate addicts in a perpetual cycle of ineffective treatments and relapse.
I would be very interested in comments on naltrexone from the panel members.
Rutenfrans: I am not a medical doctor, so I cannot comment on naltrexone or whatever medicine is used to cure opiate addiction. I am convinced that by far the most important factor to stop an addiction is the will of the addict to stop. Experiments with mice have shown that nicotin is the most addictive drug, opiates the second most addictive, alcohol the third and cannabis the least addictive. Let's suppose this is also true for human beings. How can it be explained that in the last ten years millions of men and women in the western world stopped smoking, simply by the exercise of their free will? This fact seems to me strongly supportive of the thesis of Mr. Dalrymple.
Fisher: I agree with Mr. Dalrymple's statement, "I do not agree that conditioning makes people automata." I also do not think conditioning has much to due with addiction. You are biochemically prone to addiction or you are not. Many people can use opiates for pain relief purposes and come off without ill effects at the end of their treatment. However, those that are biochemically prone most likely by genetics, as the studies have shown, suffer withdrawal and the desire to return to the drug.
The statement that millions have stopped using drugs with the mere desire and will power is overstated. I have yet to meet anyone in the depths of addiction to make it out without some type of support group or harm reduction program. It just does not happen. The sad fact is most die, are sent to jail, or put away to some asylum. There are no "millions that just quit on their own."
Why are people able to quit nicotine and if they are able to do so, why not other addictions? Simple: the reward of using nicotine is not great enough, it does not dement your state of reason, and it does not get you high. How many people get pulled over for driving while under the influence of nicotine?
As far as the various results of other treatments, such as Bupronorphine, Naltrexone, LAAM, and methadone, there is only one so far with enough studies and results to show some amount of effectiveness and that is Methadone. Bupronorphine is still rather new and its attraction is that it is given under a physician setting instead of a clinic setting. This opens a door to abuse that is much harder to achieve under the methadone clinic system.
LAAM as an effective treatment option has proved risky due to the potential cardiac problems it can cause and is being phased out completely. As far as Naltrexone, I had the experience of taking it at one point after one of my hospital detoxes. The problem with Naltrexone is it does not actually ease withdrawal effects, deal with the cravings, or curb the long lasting anhedonia that follows for years after heavy opiate abuse. The desire to stay with the Naltrexone treatment fades quickly. I was lucky I did not have Naltrexone implants which I was offered since the desire to use while on Naltrexone was so great I am sure I would have removed them under less than a sterile setting as many other have done.
The solution is to keep looking for an answer. To ignore the problem in itself is not a solution. I know it is frustrating to see those in harm reduction programs like methadone treatment that continue to use. The key is harm reduction, not elimination. By providing the methadone, it may reduce the amount of heroin or other opiates one uses and in many cases, eliminate illicit use completely. Dealing with the problem by being more realistic has proven to have better results than being idealistic.
Dalrymple: First, the question of genetics. I accept that, within a population, there may be some genetic predisposition to abuse drugs of various kinds (or, in the case of East Asians, not to take alcohol). But I do not think that you can explain the very large variation between populations by means of genetics. When I started work in the city in which I spent the last part of my career, heroin addiction was very rare. By the end of my career, it was very common. (I don't think my presence was causally related to the increase). This huge increase cannot be explained genetically: in the 1950s there were at most a few score addicts, and by 2000, between 150 and 300,000.
My belief is that the whole rationale of treatment is flawed. It is true that, if you take the case of methadone, you can show that a certain small percentage do well on it. That is true; but it would also be true that if you gave money to burglars - and there would be a dose-response curve - some, not all, would stop burgling. That does not make burglary a disease. In any case, treatment is not the answer to the social problem and never will be: in England, for example, stopping one person from taking heroin is not like interrupting the transmission of TB; it is just transferring the problem to someone else, as the drug-dealer finds another willing client/dupe. This fits what has happened, at least in Britain.
Finally, Mr Rutenfrans is right: millions of people, especially in the middle classes, have given up smoking because they have become convinced of the need to do so - among them my mother and my wife. Interestingly, criminals rarely give up.
The recurrence of opiate addiction in China could bear the interpretation given it, but it is also the case that the society is far less repressive and more individualistic now, and this bears out my fundamental point.
Menzies: The treatment of heroin addiction remains highly polarized. On one side are the passionate advocates of replacement treatment with methadone and on the other side are the equally passionate advocates of no intervention. The divisions along ideological lines has only contributed to the enduring stigma and left tens of thousands of patients with few treatment options.
In liberal societies, drug use is often seen as an expression of 'free speech' and those impacted by drug addiction; especially the disenfranchised are entitled to life-long 'pharmacological welfare'. This approached is based on an unproven theory that heroin addiction leads to irreversible 'metabolic lesions'. There is no doubt that a certain percentage of opioid addicts will do well on replacement therapy but it is preposterous to suggest that methadone is the only treatment. It is even more preposterous to suggest that since methadone has been used for forty plus years, it is the only effective treatment.
The near-epidemic levels of heroin and opioid use is directly related to availability and price. Wars and weak governments in the poppy growing regions and the smuggling routes has flooded European countries with heroin and caused even bigger problems for countries like Pakistan, Russia, Iran etc. Easy access to drugs, the sense of hopelessness particularly among the young and unemployed and societal views on drug use has created this situation. Therefore it is not surprising that our prisons are bursting with drug addicts. Twenty years ago, chronic pain was a relatively unknown disease. Now we are told that 65 million Americans suffer from chronic pain and most of them will need opioid pain medications. Small wonder, 36 million Americans have used opioid pain medications for non-medical purposes. We are now seeing more and more people addicted to pain pills.
Tens of millions of people have experimented with drugs but only relatively small percentage of people will have difficulty getting off the drug and we have to focus our efforts on this group. We have tried incarceration, sloganeering -- Just Say No, replacement therapy, needle exchange, safe injection sites and none of them have worked to make a major impact on the problem.
I am shocked at the misinformation and the hostility towards naltrexone. We have detoxed hundreds of opioid patients on an outpatient basis at our clinic and started them on naltrexone with excellent outcomes. The key is explaining to the patients the rationale for the development of medication and its pharmacology. Way too often heroin addicts appear to know all about the neurobiology of addiction and this is classical example of: Little knowledge is dangerous!
We will succeed only when we put aside ideology and learn to use every medication approved for the treatment of opioid addiction.
Rutenfrans: Mr. Dalrymple finds it interesting that so many people have given up their addiction to nicotine, which indeed is a drug, while criminals rarely give up that addiction.
The explanation of that fact is that criminal behavior, smoking tobacco, using drugs and alcohol, and poverty are different manifestations of one and the same underlying characteristic: a low level of self-control. A person with a low level of self-control finds it difficult not to respond immediately to his needs. He is short-term directed. A person with a high level of self-control is able to quit a habit when it appears to be bad for his health, which has occurred with the habit of smoking in the last decades.
A person with a low level of self-control, for example a criminal, finds it more difficult to quit the bad habit of smoking. This explanation bears the danger of being interpreted deterministically. Even human beings with a low level of self-control are able to recognise that they have a low level of self-control. His self-consciousness of this characteristic can be the first step to do something about it. He can improve his level of self-control by exercise. I am convinced that we can help individual human beings to improve their level of self-control when we as a culture succeed to value self-control as high as the Asian cultures do (for example China and Japan), and as western culture used to do in the not so distant past.
Since the Second World War western culture has had the tendency to ridicule self-control. When so-called ordinary people in a television-show are asked what they value the most in their friends, lovers or partners, the unchangeable answer is: 'spontaneity'. A culture with a high level of spontaneity has also high levels of criminality and drug addiction.
Fisher: After failing traditional 12-Step methods of treatment half a dozen times, I felt I really had no option left -- death or methadone. Such was the stigma of methadone. I thought if one was on it; it would be akin to a zombie-like existence. Even detoxification (with the help of Naltrexone) would not take away the obsession or compulsion to use. I really did not know what to expect on methadone, though once I started, the compulsion to use went away and I did not feel high or that I was exchanging one drug for another. I felt liberated almost instantly. Though it worked well for me, I think Methadone should only be used after one has failed many times at other methods. One should educate oneself about the benefits and the drawbacks of methadone before ever submitting to a possible life time of drug maintenance.
Dr. Dalrymple has discounted many studies up to now based on the excuse that they support the flawed treatment options that exist currently. But such studies proved long term opiate abuse causes damage to one's endorphin producing system. This blanket discount of studies also precludes one to seeing that each dollar spent in the U.S. towards methadone treatment has a payback on an average of $7.00 in saved government funded healthcare and costs of incarceration. It prevents one from seeing that methadone and other current treatment options have helped more than a small percentage suffering from addiction.
Traditional current treatment for addiction is through one of the various 12 step programs or harm reduction with use of Methadone, LAAM, or Bupronorphine. Though methadone originally was to be used to detoxify opiate addicted patients gradually, it has since transformed into a maintenance drug much like insulin for the diabetic.
There has been talk of hostility towards Naltrexone in harm reduction, however there really is none since Naltrexone has its place in opiate detoxification. Detoxification and long term abstinence from illicit use are two different things, and unfortunately Naltrexone's long-term potential is not comparable to that of methadone. Addicts in general understand the neurobiology of addiction after countless years of trial and error of trying to kick the habit on their own usually without success. This is knowledge gained through experience, much like the dog in Pavlov's experiment. But a little bit of knowledge and explanation of pharmacology has never kept anyone clean.
There are no perfect solutions for drug treatment but to deny any and all successes that have been made so far or say to that the whole rationale of treatment is flawed is irresponsible -- especially when no alternative is suggested. It takes no courage to criticize an imperfect approach. Those who have not suffered from addiction tend to suggest simplistic non-tolerant, holier than thou approaches of "threaten the addict with death and they'll quit." But they really lack true understanding of the diversity of the human soul. Additionally, the constant belittling of addicts and treating them as less than human makes many of the critics of current treatment options, just that -- critics -- but they fail to make any real contributions or humane suggestions of dealing with the problem.
Fontpage: Dr. Dalrymple, last word goes to you sir.
Dalrymple: I would say that the idea of treatment is the one that belittles addicts, since it suggests that, unlike other people, they cannot behave other than as they do. The same has been said of criminals. They are then less than fully human. I am not so pessimistic about them. It is, besides, empirically mistaken.
However, so long as addicts tell lies to themselves and doctors, and doctors tell lies to addicts (and the whole idea of 'treatment' is a lie), the absurd pas de deux will continue.
Fontpage: Theodore Dalrymple, Chris Rutenfrans, Percy Menzies and Ron Fisher, thank you for joining Frontpage Symposium.
Read the entire article on the Front Page Magazine website (new window will open). Reprinted with permission.