Customer Reviews

Romancing Opiates: Pharmacological Lies and the Addiction Bureaucracy

5 star:		(10)
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3 star:		(5)
2 star:		(1)
1 star:		(7)

 

 

Theodore Dalrymple has made an inestimable contribution toward productive discourse on western social ills by insisting first on clarity of language beginning with the critical distinction between `the poor' and `the underclass', a distinction that will ultimately improve our efforts to help both groups. Thus, I recommend reading his prior books `Life at the Bottom' and `Our Culture' first, unless you have a special interest in the subject of opiate addiction, which I do. Like Dalrymple, I am a physician. My experience is also with an almost exclusively white, Anglo-Saxon population; his reference group being British, and mine being a decade spent working in a rural section of the southern Appalachian mountains. The similar ethnic factor we share in patient demographics is helpful in demonstrating how substance abuse, like other underclass behaviors, is a cultural rather than a racial issue - important in that race issue mischaracterization has been a smokescreen often blown over reality by both white and minority activists for reasons other than a desire to help the needy. Here again I thank Dalrymple for bringing the core issue into focus, as we are unlikely to solve any problem we do not correctly understand.
In rural Appalachia intravenous heroin use is relatively rare. But the past decade has seen an explosion in the abuse of what is sometimes termed `hillbilly heroin', which is prescription diversion of oral synthetic opiates such as hydrocodone, oxycodone, and morphine. Of seven national hotspots of per capita hydrocodone use, four are in eastern Kentucky, and between 1998 and 2001 annual grams of hydrocodone consumed per capita increased in some Appalachian counties more than five fold. These drugs get to the streets and hollows and into the high schools not by way of international crime cartels, but straight from the signatures on physician's prescription pads.
I was there, as a primary care doctor to the poor and underclass, and I can say that every conceptual and practical mistake made in American and British attempts to address heroin abuse in the urban environment are mirrored in drug saturated rural communities in the USA. I can also attest that the big city drug seeker's country cousins are every bit as flagrantly dishonest, manipulative, self-centered, and lazy at any enterprise other than acquiring their drugs as are their urban counterparts.
It is intentional that I use the words 'abuser' and 'seeker', rather than 'addict' in regards to the misuse epidemic of synthetic opiates in rural America. The term 'addict' incorrectly conjures up images of someone with a hellish physiological dependancy upon opiates who could not possibly face more than a few hours without their drugs before decending into horrific and life threatening withdrawl. This is pure nonsense. What one typically sees instead is the sporadic though habitual turning back to opiates as life's preferred alternative, involvment in the underground pill trade as supplemental income, or both.
One important factor overlooked in Dalrymple's analysis is that of the vulnerabilities often inherent to the physician personality, vulnerabilities heightened by the commission of the medical enterprise to be empathetic and to help, and the training process to listen and to believe what the patient tells you - all good things, to be sure. Yes, I'm now jaded, but these factors, positive as they are, set us up as suckers for the historical myths about opiates, the drug seeker's mastery of the victim role and of manipulation, and the more recent general myths about contemporary underclass American. This book should be required reading for all fourth year medical students. Read it if you interface with opiate abuse in any way. Read Dalrymple's other books as well if you want the full picture.

This is my third Dalrymple book, so needless to say I like his work. I'm giving it four stars because I like his writing style and I think he makes an interesting point, but this is a weaker effort than "Life at the Bottom" and "Our Culture". That said, here's a synopsis of the plot, and what I found to be strengths and weaknesses.

To start with the bad- it's a bit repetitive. It relies for its major premise, that we have romanticized opiate addiction, on a couple of books written a hundred years ago by obscure authors. I think his point is still true, but other than "Trainspotting" and one or two other examples, he built a rather elaborate structure on a rather slender foundation. I also had a lot of problem with his treatment of the addiction itself. A major point, which I thought he demonstrated admirably, was that opiates are not physically addicting and more than that, the physical withdrawal even from heroin is trivial. This is a salient point, and one that if true (and he makes a strong case for it) should be far more widely disseminated. On the other hand I don't think giving up much of any drug is like swearing off broccoli, and a kind word or two of praise to those endeavoring to beat their addiction would've make the book better for me.

His writing style is dry and witty and persuasive. His research is thorough, and his personal opinions are usually not left to stand on their own, but are buttressed with facts. As I said in the title, if you haven't read one of his other books- read one of them first. If you have and you like his style, you'll probably like this as well- just maybe not quite as much.

I agree with almost all of the major points that "Dr Dalrymple" presents about opiates: it is not a horrid experience to withdraw from them, it takes some effort to become addicted, a very large many have stopped using them with no professional health care help, and most tellingly that the industry of aid and comfort to addicts (at least in the UK and western Europe) is a self-sustaining one.

Yet there is something lacking in this book, and it is that it does not try to delve further into the sense of craving that many addicts feel, except by recourse to the explanation that it is natural, when returning to one's prior life before (perhaps) forced withdrawal (i.e. prison), to return to that lifestyle. This seems shallow and incomplete to me.

It is true that one can become "addicted" to many things that do not now seem to have a neuro-psychological basis (chocolate, gambling, pedophilia, to go from the moderately innocent through the dangerous to the horrific), Dalrymple condemns from a moral perspective a phenomenon (addiction) that he does not try to understand.

I don't think that Dalrymple has ever been addicted, and has little sympathy for the sensation. As a reformed nicotine addict (among other addictions), I can only cite Mark Twain: "It's easy to stop smoking--I've done it hundreds of times." There are other addictions even more powerful, and I would wish that Dalrymple would turn his mind to these, in a constructive way.

This is not so much a book about opiate addiction as it is a mirror to the nanny society. Romancing Opiates is a continuation of Dr. Dalrymple's long, well-documented, incisive illumination of the decline of our culture. His decades' long observation of society and its ills has produced another gem. His books, this one included, notice what many other commentators have missed, i.e., the nihilism of our society has much to do with the lack of something to live for. This absence of meaning has as much to do with a loss of classical education as it does with the increasing "freedom" sans responsibility wrought by the 60's cultural revolution.
As with much of his work, he sees links in literature and follows those leads through generations. One reads Dalrymple with a quiet shake of the head as he points out what most of us know but refuse to see. As Cicero once observed, "One falsehood easily leads to another", Dr. Dalrymple has been in a position to observe the results of the Beat Generation's promise that happiness is possible in a pill. Wishing the good life does not make it happen. And perhaps as important, trying to legitimize, support, and sustain personal failings as society's responsibility only makes them worse. Thanks again, Dr. Dalrymple.

I've been a fan of Dalrymple's writing for years, and looked forward to his latest book. It doesn't disappoint. Dalrymple demonstrates, both with examples from his practice and citations to medical literature, that withdrawal symptoms from opiates such as heroin are comparable to the flu, and are actually far less medically serious than the DTs experienced by alcoholics (which can actually be life-threatening). Our society is nevertheless far more sympathetic to heroin addicts than alcoholics, seeing them as tragic figures in need of medical treatment who have little if any responsibility for becoming addicted in the first place. Dalrymple traces the tendency to romanticize opiate addiction from the Romantic poets up through the recent "heroin chic." Required reading for anyone interested in addiction.

Dalrymple does a service by pointing out the illogicality of the notion that addiction, and its attendant criminality, are caused by aversion to withdrawal. If the unpleasantness of the Oakland Flu were such a driving factor, why are the less pleasant effects of opiate use (e.g. nausea and constipation) not a deterrent? For that matter, why would anyone drink alcohol in quantities sufficient to cause a real hangover after their first experience?

Simply put, addicts are driven by the compulsion to use, not by fear of withdrawal. After all, no addict has such a perfect supply line that they do not face withdrawal pretty regularly. Many withdraw, at least partially, several times a year. The problem, as the book Alcoholics Anonymous put it 67 years ago, `lies in the mind.' The addict, like the drunk, will use again, no matter how nasty the consequences.

Thus, as Dalrymple notes, most persons who have used opiates long enough to experience withdrawal--Vietnam veterans and hospital patients for example--will not rush to repeat the experience. Neither will the majority of teenagers eagerly repeat the misery of the day after a drunken prom night. But a significant number will. Almost all cigarette smokers become seriously addicted, but only one in ten or twenty drinkers will blossom into alcoholism. Opiates lie in between, but certainly closer to the tobacco end of the spectrum.

From here on Dalrymple's thinking is harder to follow. If, as he insists, addiction is a moral issue, why are Vietnam veterans and the victims of Maoist tyranny more `moral' than the junky jailbirds of Dalrymple's experience? And how many of those veterans only managed to `abandon the habit ... by means of a substitute drug' probably alcohol? If opiate addiction is a problem of morality, is Dalrymple willing to hold alcohol or tobacco to the same standard? If criminality `causes' addiction why don't smokers and drunks commit more crimes? Or is Dalrymple really just imposing another romantic myth onto opiates, endowing them with `special' qualities to explain away the trouble they cause?

Public opinion about drugs and booze, including `expert' opinion, is usually molded by a priori concepts far removed from reality. Opiates have been romanticized into Satan's own, while cocaine was held to be a `harmless recreational chemical' well into the 1980s. Religion, psychotherapy, and death threats have been touted as solutions, with little or no evidence of success.

Bluntly then, the solution to addiction is for addicts to stop using. More important still is that they refrain from starting again. No social engineering scheme has any chance of success unless this condition is met. Thus far the most effective approach is the association of like-minded, non-using, addicts. Unfortunately, no plan yet devised can manufacture the willingness for change in the individual.

Dalrymple is right to deplore the 'special' status of opiates as the Biggest Baddest Drugs, but his anarcho-libertarian world view blunts his perception.

Everything you know about addiction is wrong. Heroin is not addictive--it takes a lot of hard work to become addicted to it--and withdrawal is, at most, mildly uncomfortable. Addicts do not commit crimes to buy drugs to avoid withdrawal; raher, those already criminal tend to become addicts. Why? Because of their bad ideas about how to live, ideas which percolated from middle-class intellectuals to lower-class petty criminals. In particular, Mill's view that all authority (including teachers' and cops') is against libery and self-expression led to the glamorizing of the criminal anti-hero, whose crimes are really virtues--an expression of his "authentic" "rebellion" against opressive "society". Criminals take drugs as another sign they are "rebels".

Dalrymple's criticism of the liberal drug dogma is quite insightful. The problem is, his own view is its exact mirror image--and the mirror image of an absurd position is itself absurd. For example, he is correct to say the "instant addiction/horrible witdrawal" liberal dogma is incosnsistent with demand to legalize drugs: if drugs really *were* that addictive and harmful, they surely should be kept illegal. However, if addicts' crimes are a free choice which has nothing to do with their alleged craving for drugs, why would legalizing drugs make it more likely for them to commit crimes--which he gives as an argument against legalization?

Similarly, he blames middle-class intellectual for making the lower class their playthings, sacrifising millions to the all-against-all culture of the slums in order to promote their unrealistic Millian view of "freedom" and "rebellion". But he suggests to stop offering addicts clean needles, hoping fear of HIV and hepatitis woud be an incentive to addicts to take less drugs. Isn't this sacrifising thousands of lower-class addicts to preventable diseases in order to support an unrealistic view of "moral responsiblity" held by middle class intellectuals--specifically, Dalrymple himself?

Dalyrmple's diagnosis of what ails liberal drug-addiction dogma is excellent; but his suggested cure is worse than the disease.

I found this to be an very interesting account of the possible falacies surrounding addiction to drugs, in particular to heroin. I am not medically trained, and only have the lay person's knowledge of drugs, but I found the tough attitude taken by Dr Dalrymple to be convincing.

I did feel a little uneasy that he presented no opposing thinking to be examined and rejected, and I felt the medical evidence supplied was rather dated. I did like his premise that drug addiction is a positive life choice to start out with, even though perhaps he could have given more attention to why some people make that choice and others, with equally disandvantaged, reject drugs out of hand and live worthwhile meaningful lives.

He seems to have much more sympathy with alcoholics, who in my view create much more harm in society than drug addicts do. Perhaps this is because alcohol is his admitted drug of choice. I felt a little more human warmth would have made his case more convincing, and the latter part of his book drifted back to 19th century literature, which seemed at times to be a conceit too far, but nonetheless, a very interesting book and I look forward now to reading his other works.

As a long time recovering alcholic and an observer of the decline in the culture of the USA, and also as a Conservative (politically and personally), I am happy to add my name to the list of folks that recommend Dalrymple's books!

I tend to agree with Dr. Dalrymple...

From the jacket blurb:
"Almost everything you know about heroin addiction is wrong. Not only is it wrong, but it is obviously wrong. Heroin is not highly addictive; withdrawal from it is not medically serious; addicts do not become criminals to feed their habit; addicts do not need any medical assistance to stop taking heroin; and contrary to received wisdom, heroin addiction most certainly IS a moral or spiritual problem."

By "moral" or "spiritual", he doesn't mean what US Americans would take it to be. He's a British psychiatrist. He means it's a personal problem or what we might call a psychological problem. "values" or "God" has nothing to do with his analysis.

Here's from the introduction:
"Romancing Opiates draws the appropriate conclusion from this: that addiction to opiates is a pretend rather than a real illness, treament of which is pretend rather than real treatment. How and why addicts came to lie to doctors, how and why doctors came to return the compliment, and how and why society in general swallowed the lies wholesale, is explored in this book."

Make you want to read it yet? Here's more.

"Romantic claptrap invests intoxication by opiates with a philosophical significance beyond mere self-indulgence. The idea is that an addled brain is capable of insights into the nature of existence deeper than those produced by the clearest mind. It also encourages people to suppose that rebellion against society, in the form of such intoxication, is a good in itself, and is self-justifying, no matter what is being rebelled against or what the consequences might be, personal or social. It elevates feeling and intuition above knowledge and thought in the pantheon of human desiderata. It invests the personal pettiness of addiction with the aura of titanic and tormenting struggles against mighty forces, while at the same time implying that there is a connection between opiates, talent, creativity and genius. It encourages histrionic self-dramatization, to the detriment of real character...

I suppose the self-deception could be defined as untruth that one easily recognizes as such when uttered by another, but unrecognized (though of course not unrecognizable) when uttered by onself."

That latter has a general application that is very powerful. No one is immune.

"Why is there such wide acceptance of it? For many of the reasons that non-addicted writers accept it. In addition, there is very little opposition to it: it has become an almost unassailable dogma. Moreover, the public likes victim groups on which it can expend compassion vicariously, at no real cost to itself. But in order for victim groups to be worthy of compassion, they must be entirely free of blame or responsibility for their misfortunes. It is the blamelessness of victims that confers their high moral standing. That is why the imagery of addiction as enslavement is so popular."

So in conclusion:
"It should be clear by now that the causes of opiate addiction, and the reasons why it is maintained, have nothing to do with medicine as a discipline. The addict has a problem, but it is not a medical one: he does not know how to live. And on this subject the doctor has nothing, qua doctor, to offer. What he ought not do, however, is to mislead the addict, or allow the addict to mislead him, into thinking that the problem is medical and requires, or is susceptible to, a medical solution.

Contrary to our current pieties, therefore, which give those who subscribe to them a comfortable warm glow of generosity of spirit, but which are actually dehumanizing because they reduce addicts to the status of mere physiological specimens or preparations in a laboratory, addiction is a moral weakness par excellence. Moreover, addicts tend to be bad people (if bad people are those who consistently behave badly). They usually impose costs, often very severe costs, on other people without giving anything in return. Their lives are usually selfish and self-centred. Susceptibility arising from their pre-addiction circumstances is at best a mitigation, not a complete excuse. This is not to say that they are necessarily the worst people who exist, or that they are irredeemably bad (it is one of the theses of this book, after all, that they can, and often do, redeem themselves): but bad they are so long as they maintain themselves in their addiction. Addicts should therefore be stigmatized far more than they are. It is perfectly just that they should be and it could be beneficial as well, in the absence of medical 'treatment'."