A prescription of drug abuse -- Addiction: From Biology to Drug Policy by Avram Goldstein

Issues in Science and Technology, Spring 1994 by Bloom, Floyd

Less than a month after Surgeon General Joycelyn Elders made headlines by suggesting that the government "actively examine" the legalization of illegal drugs, the Clinton administration announced a new anti-drug policy that emphatically rejected her suggestion. The new policy is intended to shift funds away from interdiction of narcotic supplies and toward drug prevention, education, and treatment programs. This shift, however, is modest: Out of a total budget of $13.3 billion--the largest such budget request ever--the administration would add $355 million for the treatment of "chronic hard-core users" (enough to cover only about 140,000 of the estimated 1.1 million heroin and cocaine addicts). Another $191 million would be spent for drug education programs in the schools. Nearly 60 percent of the budget will still go toward stopping drug suppliers or prosecuting them.

After decades of inconsistent public policies, drug abuse remains a persistent social and medical problem. According to a recent report from The Robert Wood Johnson Foundation, substance abuse is the nation's number one health problem. In fact, the report notes, when one considers not only the direct costs of drug-induced health problems but the added deaths due to accidents, HIV, or drug-related acts of violent crime, there are "more deaths, illnesses and disabilities from substance abuse than from any other preventable health condition."

In his new book, Addiction: From Biology to Drug Policy, Avram Goldstein, professor emeritus of pharmacology at Stanford University, sets out to close the gap between the growing scientific knowledge about drug addiction and national drug policy. Goldstein is a distinguished physician-scientist, renowned for his work on naturally occurring brain peptides with morphinelike actions (the endorphins) and for his efforts to devise rational and scientifically convincing ways to treat opiate addicts. Goldstein was also the founding editor of Molecular Pharmacology, a journal devoted to understanding drug actions in molecular terms.

Goldstein directs this readable, small volume toward "intelligent non-experts." He begins with the assertion that substance abuse goes well beyond the use of heroin and cocaine, the two classes of drugs targeted by the Clinton administration. Instead, he argues that we should eliminate the artificial distinctions commonly made among the seven classes of addictive drugs, three of which--caffeine, tobacco, and alcohol--are not only legal but form the basis of rather important industries. The other four classes of addictive drugs include the opiates (heroin, morphine and codeine), the psychostimulants (mainly amphetamine, cocaine, and crack), cannabis (marijuana), and the hallucinogens (LSD, PCP, peyote, and Ecstasy). His methodical presentations provide a very lucid summary of some of the most exciting developments in our understanding of the fundamental brain chemistry underlying the specific actions of each of these classes of addictive drugs.

Goldstein describes the general principles of addiction in simple terms. He explains that the use of all addictive drugs follows a common progression. As initially aversive side effects diminish, so does the pleasure of the experience. The brain has automatically taken steps to diminish the ability of the drug to alter arousal and attention--a phenomenon scientists call tolerance. The choices for the user at this point are to overcome the tolerance, at least temporarily, by using more of the drug, or to stop. However, when the user stops, these silent adaptive processes in the brain continue. In the absence of the drug, these processes lead to the physical and psychological symptoms of withdrawal, motivating users to return to the drug.

Goldstein goes to great lengths to show how each class of drugs produces its own form of addiction and why humans will go to such great effort to take them. He explains in detail the techniques scientists use to determine how each of these drug classes acts to reinforce addiction.

Crossing the boundaries of his own discipline, Goldstein explores the specific problems posed by such drugs for individuals and society. He draws on epidemiological evidence to show that drug-use patterns are highly predictable. This research indicates that tobacco and alcohol are gateway drugs for at least some adolescents on the way to cocaine and heroin. The end results depend largely on the social circumstances of young abusers. Youths who come from impoverished environments and whose peers are engaged in illegal or hazardous activities are most likely to move on to abusing illicit drugs.

REDUCING DEMAND

Goldstein has definite opinions on what should be done about the use of each class of addictive drugs, and presents his recommendations in the book's final chapter. His suggestions include the creation of a presidential advisory committee on drug abuse, a move that would reflect the importance of drug abuse as an element of national domestic policy. He differs strongly with the emphasis that current and previous administrations have placed on sup ply reduction--the interdiction of drug shipments and prosecution of the suppliers. Instead, he firmly advocates spending the lion's share of the anti-drug budget on "demand reduction"--specifically, educating potential users about the health risks of drug addiction. In addition, he makes specific drug-by-drug recommendations focused on "harm reduction"--reducing the amount of drugs taken and their attendant problems rather than insisting on complete abstinence as the only goal.