By Wells Shoemaker M.D.
-Mortuary Billboard in Bakersfield, Calif.
-U.S. Office of Substance Abuse Prevention
-Karl Marx
-Nancy Reagan
Drug! This four-letter word has recently joined our country's growing lexicon of guttural expletives for wartime enemies: Rebs, Japs, Krauts, Reds, Gooks.
Drug stores have disappeared from America's Chambers of Commerce. We now have pharmacies.
Drugs have been used by cultures of the world since before the dawn of recorded history. The use of mind altering drugs and the criminal culture associated with the sale of illegal drugs has turned the very word into a one-syllable emotional dagger, a rallying cry for Americans. We now have a Drug War.
What is a "drug" that earns such reflexive loathing? In cold pharmacological terms, a drug is a substance--a molecule--which has an effect upon the human body's function.
Are drugs inherently good or bad?
There are both medical and social answers, which hinge upon the questions:
-- What does it do?
-- How much does one use?
-- Why does one use it?
-- Who decides?
Let's look at what each of these things can mean.
What is does. Some drugs have such one-sided properties that good versus bad seems obvious. The poisonous alkaloid from Amanita phalloides mushrooms kills a man in gruesome fashion, while the bitter extract from Cinchona bark (quinine) cures malaria.
How much. Many drugs can be either helpful or harmful depending upon dosage. The extract from foxglove leaves, digitalis, can be lifesaving in proper dosage but lethal in overdose. Conversely, botulinus toxin is a ferocious poison in the amounts found in poorly preserved canned goods, yet quite useful therapeutically when diluted and used to relieve muscle tremors.
Why one uses it. Hallucinogenic mescaline from peyote cactus has served as part of a traditional, centuries old, religious ritual in Native American cultures. However, when sold to students on the streets of a modern city, the same substance becomes a criminal commodity. Cocaine was the first medically effective local anesthetic, and it remains a valuable drug for ear, nose and throat surgery. Yet, obviously, it is a dangerous and addictive drug when used to get high. Human intention, rather than biochemical properties, define good versus bad in these examples.
Who decides. Society's values clearly may dictate whether a drug is good or bad. Wine, for example, is an integral part of religious rituals in both the Jewish and the Catholic faiths. Is the alcohol in wine a "drug" when used in communion, or a sacred symbol? Sociologists might debate, but there would be no debate from an Islamic fundamentalist, for whom the very same glass of wine would be a despicable evil, a sinful indulgence.
Most drugs in the world occur naturally and just happen to affect people. The drug effects upon humans, whether good or bad, generally have little to do with the natural functions of the molecules in the living organisms that made them.
The sticky resin from the damaged seed pod of a red poppy relieves pain, induces sleep, and causes constipation in humans. Resveratrol, a natural phenolic compound found in grape skins, protects against fungal attack on the grapes, but coincidentally lowers cholesterol in people.
Taxol from the bark of the Pacific yew combats cancer of the ovary and breast. Quercetin, found in several vegetables as well as grape wine, has anti-cancer properties in mammals.
People who eat bread made from spoiled grain may suffer excruciating pain, delirium, and death from ergot poisoning. Pharmaceutical amounts of ergot alkaloids can relieve migraine headaches and stanch hemorrhage after childbirth. Aflatoxin, produced by a different fungus in moldy grain, causes cirrhosis of the liver. Ethanol, produced by yeast as bread rises or as grapes ferment, dilates blood vessels. Presumably, these effects are not prime concerns of the fungi that made the drugs.
The purification, concentration, or synthetic alteration of natural drugs tends to increase the potency and specificity of the drugs. For example, plain penicillin, a drug produced by a greenish mold, kills the strep bacteria that cause scarlet fever. Chemical modification of penicillin has created antibiotics that kill a much broader variety of disease-causing germs.
Morphine is a more potent analgesic than the crude opium from which it is extracted. Synthetic heroin is more powerful still, both in its pain-relieving effects and its toxic side effects in overdosage. Coca leaves have long been chewed safely by native Andeans, but purified cocaine powder can cause fatal cardiac standstill, seizures, and strokes in healthy young adults.
Distillation of wine or beer to produce more concentrated ethanol solutions led Thomas Jefferson to coin the term "ardent spirits." He also identified them as more harmful to both the individual and society than wine.
In general, the use of purified or synthetic drugs in abusive fashion leads to more dramatic--and more dangerous--effects than the "natural" ones.
Drugs of abuse are biologically active substances taken intentionally and voluntarily by individuals contrary to the prevalent values of society. Recalling that these values may differ radically between cultures of the world and epochs of history, we must still ask: "Why would someone abuse drugs and risk both society's disapproval and physical dangers?"
Stated bluntly, drugs of abuse do something that the user likes. Usually this effect involves alteration of state of mind, often a retreat from the reality of grim circumstances. "Recreational" users take drugs just to have fun or to heighten sexual experiences.
One of the best advertised consequences of drug abuse is addiction. Like "allergy", "addiction" tends to be a widely misused word. A strict medical definition includes several elements:
-- Tolerance. An addicted individual can use progressively more of a substance before achieving the desired drug effect.
-- Physical dependence. Withdrawal of the substance causes adverse symptoms that can be avoided by continued use of the drug.
-- Psychological attachment. An individual develops a craving for the substance, often compulsively searching out and using the substance despite overtly negative physical, emotional, and social consequences. Denial of this dependence characterizes nearly every addicted individual.
If society, or one of its respected agents (a doctor), offers a patient a release from painful or desperate straits, society defines the action as humane, compassionate, or therapeutic. In Aldous Huxley's Brave New World, the government of a fictional futuristic society dosed its citizens with "soma" to keep them submissively content.
However, if an individual chooses to dose himself on his own, without permission from society, then the drug use becomes "bad" and usually illegal. Users become outlaws, but the damage doesn't stop there.
The lack of product integrity of illegal drugs poses a lethal threat: unreliable potency, adulterated drugs, and toxic contaminants; all can kill or disable even casual drug users. Deprived of technological advances in packaging and sterility, abusers of injected drugs face mortal health threats from infection.
While the isolation, alienation, lost productivity, and poor health of drug abusers causes predictable personal and family stress, there is a far more socially corrosive consequence of drug abuse. The criminal behavior attached to the sale and distribution of illegal drugs adds a destructive dimension that touches every corner of American life. Drug users steal relentlessly to pay the inflated prices for their drugs. Dealers kill other dealers to secure the franchise of selling.
Children, policemen, health institutions, schools, and maybe our national conscience, are caught in a merciless crossfire of economic privation, social decay, and lead bullets.
In the Prohibition era of the 1920s, alcohol was the focus of this fusillade. Now the production and sale of alcohol is legal. It's also possibly the most meticulously regulated, crime-free activity in the U.S.A. The firing continues on the front of the "other drugs."
Is alcohol a "drug"? Sure, yes, without a doubt. Alcohol is a natural, organic substance that has an effect upon the human body. But...is it a "good" drug or a "bad" drug? The answer depends upon the response to the four questions defined earlier.
1. What does it do?
Alcohol affects mental functions, coordination, blood vessel tone, and urinary concentration, to name a few. It also raises HDL cholesterol and decreases the tendency for clots to form in arteries.
2. How much do you use?
Clearly, excessive use of alcohol can cause clumsiness, poor judgment, and poor impulse control. Prolonged heavy use can cause liver disease and heart muscle disorders and may contribute to throat cancer.
Moderate use, on the other hand, causes no measurable increase in chronic disease. In fact, moderate use affords its users a 20 to 40 percent reduction in the risk of heart attacks and a reduction in mortality from all causes, when compared to the extremes of both abstention and abuse.
3. Why do you use it?
If alcohol is used to blot out an unhappy experience or cope with a sense of failure or despair, then this is a "bad" drug. It doesn't work. If served to a naive teen-ager far from the safety and guidance of home, or if served to a drunken man about to drive a car, then this is a "bad" drug. It's dangerous. If consumed in large quantities by a pregnant woman, then this is a "bad" drug. It causes birth defects in heavy dosage.
If wine is served in moderation with a family meal, admired for its color and aroma, valued for its flavor, and esteemed for the years of skill required to make it, wine is more aptly considered a food than a drug. If served to brighten the pleasure of a meal for a person on a low salt diet, wine is a food. If wheedled to call it a drug because it contains alcohol, and then obliged to label it "good" or "bad," I would say, "Good," with conviction.
4. Who Decides?
Alcohol in the form of wine on the dinner table in Italy is an honored national custom. In Bagdad, it's a felony. On the altar, it's a communion with God. In high school, it's a felony.
Alcohol, like many substances we use or consume daily, is a drug -- one capable of both beneficial and detrimental effects, one with complex interactions with an individual, family, and society.
One-issue alcohol antagonists depict alcohol in any form as a "drug" in its most toxic and vile connotation. Intelligent, community-minded people who enjoy wine - or make it -- are denigrated with the same tarry brush as crazed, ruthless, drug- dealing gangs. This is an incorrect and simplistic tactic.
The question, "Who Decides?" reverberates as anti-alcohol groups talk about "Alcohol and Other Drugs." These people ignore such fundamentally crucial issues as dosage and lumping moderate use and abuse as extensions of the same dangerous habit. They ignore centuries of cultural experience and millennia of religious precedent.
The anti-alcohol groups deprecate and suppress medical facts that have clear relevance to a nation that loses half a million citizens a year to heart disease while exaggerating the value of studies supporting their viewpoint. They tell lies in public about issues of great sensitivity, such as the threat to the fetus from a mother's light drinking, as though Americans cannot be trusted to handle balanced information.
People can be trusted with both the truth and the humble uncertainties of science. No sane person disputes the potential of alcohol, when abused, to cause harm.
Rather than seeking bumper-sticker solutions, our country needs to develop a culture of responsible decision-making by both our youth and our mature citizens.
Americans need to support medical research to understand the causes and medical therapy to relieve the burdens caused by the abuse of alcohol, while preserving the ability of moderate people to use this "drug" in a pleasurable, healthful, and legal fashion.