Medication Nation

A scholar charges that drugs don't affect us the way we think they do.

(Vincent Penot / Getty Images)

THE CULT OF PHARMACOLOGY

How America Became the World's Most Troubled Drug Culture

By Richard DeGrandpre

Duke Univ. 294 pp. $24.95

Why isn't Nicorette gum a street drug? The Food and Drug Administration considers nicotine highly addictive. Tobacco companies seem to share this view when they manipulate the level of nicotine in cigarettes. But the gum, which packs a goodly dose of nicotine, appeals to almost no one. While we're at it, if nicotine dependence is what stands in the way of quitting, why do patched smokers -- their brains well-supplied with the substance -- still crave the next drag?

If these questions have an answer, it is that addiction is not a simple matter of chemical and receptor. Habit, ritual, social context and the means of delivery all affect how the brain processes a drug and how we experience it. As a result, drug research is replete with paradox. Charles Schuster, a behavioral pharmacologist, demonstrated that if you pair a stimulus (such as a colored light) with the administration of morphine, a test animal may later respond to the stimulus alone as if it were getting the drug. Conversely, Schuster found that presenting methadone in an unexpected flavor of Kool-Aid causes some addicts to act as if they have been deprived of the drug. Just as context makes a drug seem to be present, context can make it seem to be absent.

In The Cult of Pharmacology, Richard DeGrandpre uses findings of this sort -- the experiments he cites are more complicated ones -- to make the case that, when it comes to drugs, symbol outweighs substance. Psychoactive compounds, he writes, function "as mere stimuli, with more or less the same, potentially great, powers as other stimuli one experiences and gives meaning to." DeGrandpre derides a set of beliefs that he groups under the infelicitous name "pharmacologicalism." This false ideology, he writes, holds that "drugs contain potentialities that lie within the drug's chemical structure . . . and when taken into the body, these potentialities take hold of and transform both brain and behavior." According to DeGrandpre, drugs do not work in any consistent, predictable way -- and we've been brainwashed if we think that they do.

The prevailing ideology, DeGrandpre argues, has another, equally insidious side. It causes us to attribute different powers to substances that are effectively identical. We demonize cocaine, a natural stimulant, but sanctify its synthetic counterpart, Ritalin. This benefits the "medicopharmaceutical industrial complex," which favors what can be patented and profited from. Ultimately, our confused beliefs lead to forms of social control, causing us to drug our children with stimulants while imprisoning consenting adults for taking nearly identical substances such as crystal meth.

DeGrandpre is dead serious when he calls pharmacologicalism a cult. In a scholarly article he wrote, "No more impressive ideological system emerged in the 20th century with such a penetration of state power and private institutional force, than pharmacologicalism." In the current book, he likens the cult to Nazism. In this "limited metaphor," prescribed pharmaceuticals play the role of the Aryan and street drugs that of the Jew. (Alcohol, like the British, is acceptable but suspect.) The attributions, Aryan versus Jew, extend from substance to person: medicated patient versus dope fiend. This disturbing trope may cause readers to wonder whether DeGrandpre is fighting an ideology or advancing one.

The problem with DeGrandpre's argument is that he, more than his imagined opponents, ignores context. The findings of behavioral pharmacology are not unique; in medicine, environment often modifies physiology. Interferon, a medication used to treat certain cancers, causes depression, but it does so less in people who have social supports and more in patients who have had past depressive episodes. To show that the response is multifactorial hardly invalidates the claim that the drug triggers mood disorders.

Expectancy is powerful. Acupuncture is effective in pain relief. But so is sham acupuncture -- using shallow needles inserted at random points. Pain responds to placebos. It does not follow that pain lacks anatomical roots or that the use of aspirin for pain management amounts to a conspiracy.

Our drug policies, arising from puritanical moralizing as much as from the needs of corporations, are often irrational. Still, not every choice is without foundation. Like cocaine, Ritalin modulates dopamine transport in the brain. But schoolchildren who take Ritalin by mouth generally experience no high and develop no craving, while snorting cocaine famously does cause a rush. And crystal meth's minor chemical distinction -- it is water soluble and therefore easy to inject -- makes a major practical, and addictive, difference. That we allow Ritalin to be prescribed suggests that, as a nation, we pay attention both to drugs' chemical properties and to their customary usage -- hardly a sign of ideological rigidity.

As for "mere stimuli," DeGrandpre himself cites a study demonstrating that you can get addicts to crave some psychoactive substances but not others. No surprise there. Medications are not mere symbols. Different substances have different effects. Meanwhile, when DeGrandpre critiques prescription drugs, he refers to reports that antidepressants can foment suicides. Accepting this evidence resembles the stance that DeGrandpre otherwise attacks, the belief that drugs take hold of people in forceful ways.

Because its foundations include science, medicine, as a profession, tends to be ecumenical. Data that indict Prozac inform the literature; so do data that suggest Prozac prevents many more deaths than it causes. The major journals repeatedly contend that drug companies wield too much power. And behavioral pharmacology is mainstream medicine. Charles Schuster, a psychologist DeGrandpre praises as a pioneer, championed methadone-maintenance programs, hardly the stance of a man who doubts the power of physiological addiction.

We need to develop a humane approach to street-drug use. We need more independent testing of prescription drugs. But to hold these views does not require the belief that America has been hijacked by a cabal of doctors, politicians and entrepreneurs. DeGrandpre's attack comes from a libertarian posture, anti-business but even more anti-government. There's an element of the personal hobby-horse here as well: Pharmacologicalism conveys state power more effectively than communism or national socialism? Isn't it likelier that -- the undeniable flaws of capitalism and democracy notwithstanding -- we're muddling along, trying to make what sense we can of medications, licit and banned, that are ever better attuned to the workings of those admittedly complex organs, our brains? ·

Peter D. Kramer's most recent book is "Freud: Inventor of the Modern Mind."