Kerlikowske: Is Heading the Director of Drug Control Policy Position Appropriate?

While Gil's not without his faults, I have to say that overall I've come to rather like Kerlikowske, the more I read about him. We'll start with some of the bad, to get it out of the way, then we'll get into the good. But ultimately, I have to conclude that Drug Czar isn't the right position for him.

In 2001 Kerlikowske made some errors in judgment that led to one death and several injuries, some critical during a Mardi Gras celebration. He did not take decisive action and allowed his second to order officers to pull back when the celebration started getting violent. However, Kerlikowske also accepted full responsibility for what happened and admitted that mistakes were made. Small comfort for those injured and the family of the young man who died, but at the same time decisions made in the heat of the moment are not always the right ones.

Kerlikowske also has a record for supporting fairly extreme gun control measures, something that I tend to have mixed feelings about. While I certainly see some gun control laws as critically important to public safety, I also believe very strongly in the right to own and in many cases carry firearms. Some of the discussion surrounding Kerlikowske's position on gun control has made me a bit uncomfortable. This is especially ironic, given that in 2004 he left his own weapon under the seat of his car while shopping with his wife - which ended up being stolen from the car.

There are a lot of other tidbits that do paint Gil in an unfavorable light, but ultimately I don't think you're going to find an effective chief of police anywhere that doesn't create a fair amount of controversy. And to counter the negatives, Kerlikowske has some very positive marks.

Gil Kerlikowske has a solid record for effectively supporting harm reducing public health measures. He changed the policy of having police officers watching needle exchange sites, a practice that previous to his administration was a matter of policy. He also instituted a policy of making misdemeanor cannabis arrests a low priority, even before I-75 passed in Seattle, a ballot measure reflecting the voting public's support for that policy. Seattle journalist Dominic Holden lays it out clearly (link above):

The bigger issue—and safer issue, politically—is replacing enforcement with public services. On that issue Kerlkowske has incubated a revolution. Seattle implemented two programs that get drug users off the street before they get arrested. Most notably, the Get Off The Streets (GOTS) program hatched in the Central District when Lieutenant John Hayes (now a captain) set up a table as an arrest-free area that people with criminal warrants could visit for health and human services.

“That was, at that time, a very edgy approach, and the chief was willing to let one of his people staff the program,” says City Council Member Nick Licata, who soon seized on the idea, passing legislation to fund the project permanently. “It was a stage where Gil could have stopped it from [getting funding], but he allowed it go forward,” he says.

I also really like Kerlikoswke because I am a very strong advocate for community policing, which he is as well. Under the Clinton administration he was director of the Office of Community Oriented Policing Services of the DOJ. During this time he developed a strong working relationship with then Deputy AG Eric Holder, now Obama's AG. He has fostered solid, positive community policing strategies in every police department he's worked in.

That pretty well defines my support for Kerlikowske. While he certainly doesn't support legalization, no one who does is going to get this slot. But Kerlikowske is a strong advocate for harm reductionist drug policies and seems to have a record for listening to the science and basing his decisions on evidence. But there are two very good reasons why I think Gil's the wrong choice for Director of Drug Control Policy.

First, he's a cop, not a public health expert. While I think his respect from law enforcement leadership across the U.S. is a major advantage, I still believe that having a public health expert in the field of illicit drugs would be a much better direction to go. Doing so would show a firm commitment on Obama's part that his desire to shift the focus of drug policy to public health is absolute. Appointing a police officer to the position, even one with a solid record on public health sends a very mixed message.

But most importantly, I think that Kerlikowske would be far more valuable in a law enforcement position that is in desperate need of new leadership. The DEA is in dire need of leadership that will reflect the priorities of the Obama administration. And there are several reasons why Kerlikowske would be a excellent choice for the role, not the least being - he has an interest in the position.

The respect he commands from the law enforcement community would be just as useful in the head slot at DEA, as it would as DDCP. This is an agency that often works in cooperation with local law enforcement, having a leader who is well respected by cops across the country would go a long way towards smoothing the often rocky relationships between federal and local law enforcement officers.

Kerlikoswke has a solid relationship with AG Holder. I have no doubt that he would also develop a fine relationship with the public health expert who should get the DDCP position, which in turn would help develop reasonable priorities for the DEA. But most importantly, Gil Kerlikowske has a solid record as a law enforcement leader. While he has listened closely to the communities he's worked in and public health experts, he is not a policy maker. He's a policy enforcer and top notch leader.

I suspect that Kerlikowske will make a fine DDCP. I definitely think his appointment signals a serious commitment on Obama's part to the shift of focus in drug policy. But I feel very strongly that Kerlikowske's skills would be far more valuable, focused on enforcement instead of policy.

Addiction: A New Paradigm

This is my first addiction paper. Unfortunately I got too distracted in the middle of writing it and had a rather awkward change of focus. While it will work for the assignment, I am less than pleased with the results. I will try to amend it when time and opportunity allow. Here is a link to the annotated bibliography.

I should mention that any comments and criticisms are quite welcome, especially those that are constructive in nature. I know that some of the folks who come by are quite well versed in psychology and addiction. Please don't hesitate to point out errors, either factual or implied. And of course I welcome criticism of the writing itself.

Substance abuse and addictions cost American taxpayers more than $500 billion a year (NIDA). And more than sixty-five percent of Americans are affected by substance abuse issues, either directly as an addict, or because they are close to someone with substance abuse issues (Riskind). Yet twelve step programs, the dominant method for treating addictions in the U.S. has proven itself woefully inadequate at reducing the harms associated with addictions. Only a very small percentage of addicts and substance abusers who utilize twelve step therapies manage to get control over their addictions, and the percentages associated with cognitive-behavioral approaches are equally dismal. Society is in desperate need for a new addiction paradigm, a paradigm that addresses not only treatment, but our very perception of addiction and successful addiction management.

According to the American Psychology Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), addiction is defined as "impaired control over drug use” (APA). The NIH's MedlinePlus medical dictionary defines addiction as "...compulsive physiological need for and use of a habit-forming substance..."(Merriam-Webster), while the MedlinePlus encyclopedia claims that "A physical dependence on a substance (needing the drug to function) is not always part of the definition of addiction”(NIH & USNLM) Stedman's Medical Dictionary defines addiction thus; "Habitual psychological and physiological dependence on a substance or practice beyond one's voluntary control”(Houghton Mifflin).

While the aforementioned definitions may seem to be quite similar, there are important differences. The distinction between overt chemical dependence and the underlying psychological dependence is particularly critical. It's also a major point of contention for those involved in addiction science. Another critical point of contention is whether or not non-substance addictions are addictions at all. Language largely defines reality and in regards to addiction it fails us in the most fundamental context: addiction science. It's no wonder that many of the people who work with addicts and substance abusers tend to eschew the word “addiction.” Lacking a coherent, cohesive clinical definition, addiction has become a very loaded term, even in the realm of hard science.

In Over the Influence Dr. Denning et al. express concern that “addiction” is often used too loosely “and does not speak to the user's relationship with a drug” (Denning 141). Instead the authors prefer to restrict “addiction” to the very top of a definitive spectrum that describes specific characteristics of the different relationships that people have with drugs. Moreover, the authors prefer to use the word “chaos” to define that point on the spectrum (Denning 28-30). While their desire to eschew the using the word addiction and it's related connotations is understandable, doing so ignores the broader social perception of what “addiction” means. And there is nothing to prevent describing the important distinctions between the different sorts of relationships people have with drugs, within a broader contextual framework of “addiction.”

The generalized social perception of what “addiction” means is in parts more simplistic and more complex than the confusion surrounding it in the clinically-oriented definitions presented above. Outside the hard science and clinical frameworks, context becomes even more important when discussing “addiction.” From the myriad pop songs that describe a romantic relationship as “addiction” to describing a homeless drunk who exists in a perpetual stupor, the connotations of “addiction” range from something warm and loving to something very dark and ugly. While on it's face it might appear that the use of “addiction” in the context of a romantic relationship or other ambivalent/benevolent contexts is irrelevant to the discussion at hand, it cannot be ignored. Again, language largely defines reality. More clearly our use of language largely defines reality. So like it or not, in the broader social context, ambivalent/benevolent behaviors are an important aspect of the discussion of “addiction.”

When Denning et al. shy away from the negative implications of “addiction,” they are also shying away from the positive connotations. While those connotations aren't part of any clinical framework of “addiction,” they are an important part of the broader social connotations. There is no reason not to take advantage of these implications in a clinical setting and many ways it could be used to effectively help people who are significantly hampered by substance abuse or other negative “addictive” behaviors. Words, with their implications, hidden meanings and quiet connotations are incredibly powerful tools. We should never be afraid to explore the possibilities that these tools have to offer. Especially when we are working with the intricacies of the human mind. There is no reason, when discussing addictions in a clinical setting, to ignore the less negative connotations of addiction. When someone comes forward with concerns about their substance use issues or other negative addictive behaviors, “addiction” is in the room, whether the therapist wants it to be or not. Instead of trying to change their language, it would be much easier to work on the association they have with the language they're thinking in.

In The Heart of Addiction, Lance Dodes, MD doesn't shy away from it. He takes a very broad approach that strikes to the core:

Addictions have been segregated as though they are different from other human problems, as though they required a unique approach (as in Alcoholics Anonymous), and as though they could not be understood as emotional issues by either the people treating them or the people suffering with them. But if addictions and compulsions are basically the same, psychologically, there can be no reason to think of or treat them differently. Like compulsions, addictions are...in the mainstream of the human condition (Dodes 185).

And this is why it is so very important to embrace the use of the term “addiction.” Not so addicts can cower in fear, in the hopelessness of their ability to ever manage their addictions, as the dominant approach to addiction treatment would have them do. Nor so they can exist apart from society, as some are wont to do. We should embrace the term “addiction” because we are human and addictions are very much a part of the human condition. Not just the negatives either, by embracing the language of “addiction” we are embracing it in all of it's glory, the good, the bad and everything in between. By embracing the language of “addiction” we are embracing the humanity of the addict and facing head on the problems of the addict's addictions. By embracing the language of addiction, addiction becomes less scary – less insurmountable, because we come to understand that addictions, like every other aspect of the human condition, aren't inherently good or bad, it's the expression that defines its positives/negatives.

Unfortunately, many of the expressions of addiction are quite negative and destructive. Substance abuse alone really is a mainstream human condition, all in itself. As NIDA tells us, it costs more than five-hundred billion dollars a year (NIDA). And as the survey posted by Faces and Voices for Recovery points out, addictions affect more than sixty-three percent of Americans (Riskind). Addressing the definitions of addiction only gets us so far, while definition is important, we also need to address the approaches of addiction treatment. There are three basic approaches to addiction treatment, which I will discuss in the order of their prevalence in practice. But it is important to understand that when dealing with addictions, there is no “one size fits all” approach. While I am going to be rather critical of the most prevalent, twelve step programs, it's important to keep in mind that for some addicts, the twelve steps not only work, but are critical – in many cases a lifesaving approach. The problem is not with the twelve step programs, it's with the broad assumptions that go with them.

The twelve steps to recovery are based on the disease model of addiction. The disease model of addiction is rather controversial, with notables in the field, such as Dr. Stanton Peele and the authors of Over the Influence, Denning et al., disputing its validity altogether. But a lot of research suggests a fairly definite link between alcoholism and genetics and there is a growing body if evidence to suggest a link between dopamine deficits and substance abuse. At the same time it's pretty clear that not all addictions are founded in that disease model and even those that are, don't necessarily fit into a single treatment approach. The Narcotics Anonymous: Basic Text typifies the basic assumptions that dominate the social and political addiction paradigm.

We realize that we are never cured, and that we carry the disease within us for the rest of our lives. We have a disease, but we do recover. Each day we are given another chance. We are convinced that there is only one way for us to live, and that is the NA way.(NA International 8)

Over time some addicts lost contact with other recovering addicts and eventually returned to active addiction. They forgot that it is really the first drug that starts the deadly cycle all over again. They tried to control it, to use in moderation, or to use just certain drugs. None of these

control methods work for addicts. (NA Inernational 78)

The problem with this, is that it presupposes that any addict who doesn't follow the NA or some other twelve step program, is doomed to a life of addictions. It also presupposes that it doesn't matter if someone alters their drug use to be less harmful. Any use is considered failure and any other method of treatment for addictions cannot possibly succeed. This is patently false and the repercussions of this position resonate throughout our society to the detriment of the vast majority of addicts.

This position has a huge influence on public policy in the U.S., including the sentencing guidelines for a variety of civil and criminal offenses. From drunk driving, to simple possession of an illicit drug, hundreds of people are sentenced to twelve step drug treatment programs every day in the U.S. Many of these people aren't addicts at all. Others are simply not going to successfully respond to twelve step treatment plans. In spite of several studies, including studies in which AA and NA were involved with (AA 12), showing that coercion into twelve step programs is ineffective and possibly counterintuitive, the principle that only the twelve steps can successfully treat addictions provides the momentum to keep such policies alive.

This position also has a detrimental effect on the perception of society as a whole. First off, it provides many addicts with an excuse not to try anything. They believe that because the twelve steps failed them, they should just give up – or that because they know they can't quit everything they won't bother trying to quit using the substances that are causing them the most harm. Second, it creates a perception in our society, that more people have addiction problems than really do. It convinces parents and friends, that because an individual has had substance abuse issues in the past, that any use on their part is a “relapse,” which can lead to alienation. And finally, this view segregates addicts from the rest of society. It says that addicts are somehow different from everyone else, that we're somehow damaged, weak or otherwise unfit.

With those criticisms in mind, it is also important to remember that AA, NA and other twelve step programs do seem to work for some people. Just because they don't work for everyone, there is no reason to assume they don't work at all. There are a great many people alive today, who attribute their survival to the twelve step approach to addiction recovery. And for some addicts total abstinence from all psychoactive substances is an absolute necessity. While the assumption made by many proponents of the twelve step philosophy, that the only treatment for addictions are the twelve steps is absolutely wrong, it is equally erroneous to assume that this makes the twelve steps a categorical failure. Indeed, quite often the twelve step approach is combined with the second most prevalent approach to addiction treatment, cognitive-behavioral therapy.

The most common cognitive-behavioral (C-B) approach is really quite simple. The premise is to change the way that an addict thinks of their addictions. The goal is to empower the addict, help them think in terms of strength and success. To move them away from hopeless, defeatist thought processes (Kadden et al). It is rarely, if ever a stand-alone therapy. It is a part of almost all in-patient addiction treatment programs. Indeed, it is rarely engaged outside the context of in-patient or aggressive out-patient treatment programs. While engaged in C-B therapy, the addict will usually meet with their therapist several times a week, sometimes daily for the initial few weeks of treatment. As treatment progresses, the patient will meet with the therapist less often. Usually they will be down to one session a week with their therapist after ten to fifteen weeks. Sometimes they will stop meeting with their therapist altogether at this point (Barry ch4).

A less common form of C-B is meeting with a therapist in a more traditional psychotherapy setting. Dr. Dodes. author of The Heart of Addiction, engages is therapy in a similar manner. The idea is to redirect the thinking and actions of the addict (Dodes). Really, this form of therapy has existed for as long as we've had psychotherapy, though the individual tactics have changed considerably over the years. One of the advantages to this method is that therapy is tailored to the addict and the addict has the advantage of a trained therapist who can help him or her make decisions about treatment beyond the C-B therapy sessions. Quite often, this form of therapy forms the core of harm reduction approaches to treating addictions.

The harm reduction approach to addiction treatment is firmly entrenched in the idea that there is no and never will be a “one size fits all” approach. As Patt Denning, Phd puts it in Over the Influence, “The harm reduction way of understanding drug use and abuse takes into account the complexity of each person's relationship with drugs” (Denning 8). That's right, everyone who uses drugs has a “relationship” with the drug or drugs they use. Moreover, people who engage in any addictive behavior have a specific relationship with that behavior that is central to their addiction. This recognition that there is a relationship involved and that said relationship is unique to the person experiencing it, is the key advantage that harm reduction therapy has over other, singular methods of addiction treatment.

By understanding that everyone has their own relationship with drugs, harm reduction can help addicts find approaches that will work for them. The harm reduction approach recognizes that not everyone will be abstinent from all psychoactive substances or even the substance that is the object of their addiction. Harm reduction doesn't gauge success by arbitrary standards. Success is gaged by reducing the harm of the addictive behaviors. The harm reduction approach recognizes that success may be an ongoing process of gradual reduction of harm. But most importantly, the harm reduction approach recognizes that success is entirely relative to the addicts relationship to their drugs or other addictive behavior.

Another powerful advantage to recognizing that people have relationships with drugs and their addictive behaviors, is possibly the most powerful. “Relationships change” (Denning 28). Our relationships are always changing, always evolving – no matter the relationship being discussed. As they grow and change, my relationship with my children changes. I'm confident that it will continue to do so well into their adulthood, because my relationship with my own parents has been ever changing. Change is very much the nature of relationships.

But while the harm reduction approach sounds and ultimately is pretty remarkable, many practitioners of the harm reduction approach have a very singular view just the same. As was shown in our exploration of the definitions of addiction, many harm reduction practitioners are uncomfortable using the word addiction. In part, because they are uncomfortable with the disease model of addictions as a whole. And this is ultimately to the detriment of the addicts who come along, who would be best served by a twelve step program. Just like the dominating twelve step approach that claims that nothing else can work, many harm reduction practitioners would exclude ideas outside their purview. And even Dr. Dodes, who seems very open to many different approaches isn't immune to the language of exclusion. While he really does have a rather revolutionary approach to viewing addiction and avoids couching his terms in outright absolutes, it's clear that he has a very strong preference for his analytical approach.

It is time for us to chart a new course for dealing with addictions in our society and at the very top of the list is a driving need to get over our petty turf wars. You saw the figures in the introduction to this paper. We aren't running out of addicts any time soon, there are more than enough to go around. Unfortunately all too few of them are getting any help at all. While this is largely due to the exclusivity of the dominant paradigm, it is also due to the claims by various elements that they have the method to help the addict with their addictions. What the message to addicts should be, is that one way or another, there is a way to help them reduce the harm caused by and ultimately overcome their addiction. That if one approach doesn't work, there are other options available.

Beyond that, we need to fundamentally change our perception of addictions. Addiction is a mainstream, even a fundamental aspect of the human condition. Humans are creatures of habits and compulsions. When taken out of the context of negative, harmful behaviors, “addiction” takes on a great many connotations that range from benign to outright positive. While searching for a coherent clinical definition for addiction, it was hard not to notice that there are probably hundreds of pop songs with addiction in the title or as the title. People talk about their addictions to books, walks in the park, hiking, spending time with their kids, community service – the list is endless. And there isn't a single thing in that list that couldn't be taken to a unhealthy, negative extreme. There are few, if any humans who can truly claim to have never manifested some sort of addictive behavior that was taken to an unhealthy extreme.

Yet as a society, we feel justified in segregating the “addicts” into a special group. And “addicts” are just as guilty of anyone else in perpetuating this tendency. Because people want to believe that there are addicts and there are “addicts.” It's easier that way. Segregative labeling is also, quite unfortunately in the mainstream of the human condition.

There are a great many things that would make a major difference in helping people reduce the harm of their addictions. Policy changes, such as legalizing, regulating and taxing currently illicit drugs, for example, would make it much easier for people with serious addictions to get help, while removing a lot of people who don't have addiction issues with those drugs out of the treatment system. Making sure that people who commit crimes such as driving under the influence of intoxicating substances both pay for their crime and get treatment that will help them get control of their addictions, instead of just pawning them off on AA or NA. Providing kids with a realistic view of drugs and drug use, that doesn't make claims they're going to know are false but ensures that they understand the very real dangers involved with drug use and other risky behaviors.

But most important, is fundamentally altering our view of addictions as a society. Language largely defines reality. Before humans developed language, we were little different than any other omnivore out there. It could be and in fact has been argued that language is what makes humans human. We need to be using our language to move us forward with regards to addictions. Because right now we are failing and failing badly. Considerably more than half of the people in our society are dealing with the effects of harmful substance addictions. We are spending more than $500 billion every year in the U.S. alone, just dealing with substance addictions. And according to the median of several statistics I saw, from sources at the NA website, to the harm reduction sites and substance abuse help clearinghouse sites, we are failing more than seventy percent of the people who actually go looking for help. No way of knowing what percentage of actual addicts we fail, because most of them never look for help.

Why I am pursuing a education for a career dealing with addiction

I am now busy as all hell. I have a lot of writing to do in the next week and posting may get sparse, though I may throw some more up as I get into the nuts and bolts of my paper. For now, I just wanted to mention the abysmally poor record of the dominant substance abuse paradigm.

There is very little information available about recidivism, but what there is is chilling. I suspect that the figures we have, strongly contribute to why we don't have more. This is a link to Comments On AA's Triennial Survey, from 1989. This is analysis of survey compilations performed by AA. Of particular interest, is the graph on page twelve, showing that of those who start attending AA, only five percent are there after a year. Other studies (scroll up a couple pages) have shown a slightly better picture, but there is little question that twelve step programs are not for everyone.

Meanwhile, American taxpayers are pumping out two hundred billion a year for substance abuse issues. Add to that the loss of production and other factors, substance abuse costs us more than five hundred billion every damned year.

Harm Reduction Part 2: How do we Define Success?

The dominant addiction paradigm makes some very strong assumptions about the nature of addiction. It assumes a one size fits all approach, stating categorically that the only measure of successful treatment is complete abstinence from psychoactive drugs. And it assumes that the best method for achieving abstinence is a confrontational model that forces the addict to accept that they are powerless to deal with their addiction. That only through dependence on a higher power, can their addiction be brought under control. This is the basis for the twelve step program for treatment of addictions.

What is truly remarkable about this paradigm, is that it encompasses over ninety percent of addiction treatment in the United States today. It is a multi-billion dollar industry and firmly entrenched in our educational system. Go to med school and you're quite likely to be taught that this is pretty much the end all of addiction treatment. Public policy is based firmly on these ideas. This is remarkable to me, because not only is there no evidence to support this confront/depend on higher power paradigm, there is a lot of evidence that it simply doesn't work for the vast majority of people. Because of the lack of reporting on the part of most twelve step programs, it's hard to come up with very definitive figures, but the estimates range anywheres from a five to thirty percent success rate. Most science based research tends to assume the low end of the spectrum.

This is absolutely insane. At the high end estimates, this means we are failing seventy percent of the addicts who seek treatment. And yet this is the treatment paradigm that we allow to dominate our society and public policy. Don't get me wrong, I don't believe there's some vast conspiracy out there, propping up a failed system for profit. There's very little profit to be had in all this. At it's heart, I think it has to do with the Us/Them dichotomy that makes non-addicts, and especially addicts who haven't accepted what they are, feel better at night. This dichotomy is also very conducive to reinforcing addicts who are sober, because they've beat tremendous odds and manage to stay clean. This makes it really easy to just say; "Screw the other seventy to ninety-five percent."

"They're weak." "They just don't really want it." "They just haven't hit bottom yet." And underlying it all; "I'm better than them." Which isn't to say there isn't a lot of "we failed them," intermixed in all that. But which is more likely to keep this failed system propped up, "I'm better than them," or "we're failing them?"

At the core of this are some important questions to be asked. The same sort of stark, realistic assessments, very much like the self assessments that are an integral part of any addicts quest for control over their own lives. For this post, I am going to focus on one of them; How should we define success in one's battle with addiction? To try to answer this, I am going to ask you to try for a moment to ignore that nagging voice in the back of your mind that insists that success can only be defined as abstinence. Please, just try to pretend you've never heard of AA and other twelve step programs. Open your mind to the understanding that black and white is a flawed, simplistic dichotomy - that life exists in the shades of gray.

Meet Steve. Steve is an alcoholic who drinks from the time he gets out of bed, until he passes out, later in the day. Catch Steve in a rare moment of lucidity and you'll discover that the man is absolutely brilliant, rife with penetrating insight into human nature and it's interplay with the people around him. Steve first got high when he was eight years old. His drinking was out of control by the time he was thirteen years old. Not surprisingly, he never graduated high school, though he did manage a GED. He managed to stay sober in the Marines, at least when he was on duty. Steve spent several years in LA as a gangster, existing in a very ugly frame of reference. When I met him, he had left LA to get away from it all - but the memories of what he had seen, the things that he's done, drove him into the absolute depths of alcohol abuse.

Now meet Allen. Allen is an alcoholic who drinks in the evenings. Allen has, over the years, built a great business. He's also raised one of the very least dysfunctional families I've ever met. He has four fantastic kids, who absolutely adore their parents and who all have the foundation for great success in life. Allen has wonderful friends and is a very well respected, highly regarded member of his community. Not that he or his business are perfect, but his failings are the human failings that everyone can fall victim to, rather than being the result of his drinking. And make no mistake, Allen can drink. He proves that nearly every day of his life. As often as not, he proves it by getting fairly drunk. And it is quite likely that ultimately, Allen's drinking is going to foreshorten his life, though probably by very little.

So lets explore these two people, both men addicted to alcohol, but with very different lives, very different relationships to their drug of choice. According to the dominant paradigm, the only measure by which either of them can be successful, is for them both to abstain from the use of alcohol and other psychoactive drugs. But I would argue that success is in the eye of the beholder, that rather than searching for absolutes, success is very much a relative concept.

If Allen stopped drinking altogether, stayed absolutely clean and sober, what benefit would he gain? Certainly, his health would be positively impacted, though I should be clear that his health is very reasonable for a man his age. As such, this can really be counted as a minor benefit. It won't improve his family life, which is already quite rich and fulfilling. It isn't going to do anything for business, which while less than perfect, is that way because of the economy, not because of Allen's substance abuse. It certainly wouldn't improve his social life, which is largely focused around his brewing of great beers and appreciation for the. To be sure, he does have more to his social life than these, but a lot of his social activities are centered on his appreciation of fine drink.

Ultimately, we need to take into account Allen's relationship with alcoholic beverages. Why he drinks, what he drinks and the circumstances in which he drinks. Allen is a beer hobbyist. He belongs to beer a couple of beer clubs and has even taken classes for judging beer. He and his wife both take part in these activities together. He's taught his son to brew beer, along with a number of friends. He doesn't drink alcoholic beverages that aren't pretty much top of the line. And he never seems to drink alone. For Allen to quit drinking altogether, would require a major shift in how he lives and how he interacts with his friends and family. Since his drinking causes minimal harm to himself and no harm to others, I would argue that there is simply no reason for him to change.

Now lets look more closely at Steve. At first glance, Steve seems to be the typical, at the bottom alcoholic. It would be easy to make the assumption that Steve simply must either quit drinking altogether, or die an alcoholic. Honestly, that may well be the reality of things. The question becomes; Is abstinence from any psychoactive drugs the only measure of success we can use on Steve? What if Steve quit the destructive drinking, but took up smoking pot in the evenings and on weekends? How about if Steve was able to get help from a therapist and get a handle on the problems that have pushed him to drink to such destructive excess and started drinking only in the evenings? Could it not be said that some level of success has been achieved, if Steve is able to functionally work and take care of his family - even if he isn't completely abstinent from alcohol?

While I think it is safe to assume that in Steve's case, abstinence is the underlying ideal, helping him reduce his drinking and become more functional can be considered a success. This is not to say that when he's reduced his drinking and become more functional, that the work is done. Steve has goals that will ultimately require he quit drinking altogether at some point. Taking the step of reducing the drinking would be huge for him and more importantly, his family. Being able to hold down a job and support his family would also make a major difference. But ultimately, Steve wants to be in a position to ensure that he never gets this bad again.

Steve runs into a few problems with our dominant paradigm. One, it requires that he get sober now, instead of letting him take steps to get there. With the exception of his stint in the Marines, Steve hasn't managed to get to sleep without alcohol in almost twenty seven years, since he was thirteen years old. And even in the Marines, it was tough for him to sleep without it. After busting ass all day in training and maneuvers, he was still having trouble with sleeping. And the haunting memories of being a gang banger are still there, even if he gets the drinking to settle into a more functional pattern. But if he can manage to reduce his drinking and work with his therapist to deal with the underlying issues that push the hard drinking, it is likely that he will get there in the end. The other problem that Steve faces in the current paradigm, is that he simply cannot contend with the notion of a higher power. He believes that either god doesn't exist, of if he does, hes "one evil motherfucker," as he put it to me.

It is really easy to stick with the status quo. It doesn't take any work to assume that people who use drugs are out of control and simply cannot get through it on there own. To paint addicts as powerless to deal with their addictions. It's also very easy to create an us/them dichotomy. To assume that "us" are somehow better people, even as we recognize that addiction is a disease and not necessarily the fault of the addict. We all have a mix of feelings about addiction and addicts that just make it really easy to denigrate substance abusers. From equating the worse of substance abuse behaviors, such as driving while intoxicated, or destroying one's family, with everyone who has substance use issues.

Harm reduction, on the other hand, is a good way to get past the black and white and embrace the gray areas. Because most addicts and people with substance use issues live in the gray. Simplistic dichotomies rarely apply. But even harm reduction isn't the end all that some would assume, or at least hope it would be. There is balance that must be struck and there needs to be a tacit understanding that while it fails most people, the current paradigm has it's place as well. In the next post, I will be exploring this, as well as the shortcomings that I see in the harm reduction approach to substance use and abuse. I will be trying to get back into this and posting links to various sources of information, but I am mostly using these posts to try to lay down the information I want to put into my paper. That way I will have all the information in front of me and ready to organize.

I am also thinking on discussing some of my other friends with substance abuse issues, from time to time. Having been a very voracious abuser of substances, I spent a lot of time around abusers of substances and there are several I want to write about. In every case, I am renaming the people involved and trying to change as many details as possible to protect their identities. I am more than happy to post stories with the actual name of the person and more pertinent details about their situations, but will only be doing so with their permission. The thing about harm reduction, as I mentioned in my last post on this topic, is that it is very natural for some people to engage in it. The problem is that the current paradigm assumes that if they don't abstain, they are just deluding themselves. More to go in; Harm Reduction Part 3: Where I Digress or Harm Reduction Falls Short

DrugMonkey Asks; Decriminalization: What would happen? Part 2

Or Why I am studying to become an Addiction Researcher......

So now I am going to talk about the drug users, both current and potential. But I am probably not going to get to the decriminalization/legalization aspect of the discussion until we get a ways into this. First I would like to discuss addiction, overt dependence and what I see as the failure of our current addiction paradigm.

I think it is important to make the distinction between addiction and overt dependence. I think a very good way of expressing this is to identify two different types of heroin junkies. You have most heroin junkies, who even after they detox from opiates, still have a driving need to use more heroin. Then you have a much rarer type of heroin junkie, the junkie who after detox, will have absolutely no desire to even look at heroin again, much less still want to use it.

Overt dependence (OD) is the specific chemical mechanism that is very different from substance to substance. It is what makes heroin detox very different from detoxing from crack, or meth from alcohol. Using a particular drug will cause specific changes in one's neurochemistry. While some of these mechanisms might be somewhat similar, they each have their own unique patterns, that are nonetheless going to be common to other people who have OD on the same substance.

Addiction on the other hand, has some common characteristics, no matter what the addiction in question. These are characteristics that you will find with heroin addiction, alcohol addiction and shopping addiction or sex addiction. It would be way oversimplifying and completely inaccurate to claim that this is the whole story, but there are factors that are common to all addictions, something you just won't find with OD.

The known neurological common denominator in addiction is one that I am personally very familiar with, dopamine. This is why substance abuse is so very common with people who have ADHD. We are always on the lookout for better ways of getting our dopamine fix, as one aspect of ADHD is a dopamine deficit. At the same time, I suspect that this very trait is what provides most people with ADHD, some immunity to OD.

I suspect that there are more common neurological threads, that wind their way through addiction, which is why I am going in the educational direction I am. Not to say that I am limiting myself to neuropsych. I am going to work my way through clinical psychology on the road to my goal, because I think that there is a great deal of value to be had by approaching this from multiple directions. But ultimately, I want to study the common elements of addiction and the human brain. At the same time, I also want to find some of the uncommon neurological elements. Because I suspect that in the quest for both, lies a better answer, or a better paradigm for treating addiction.

So what do I mean by uncommon elements? Let me use my own addiction to tobacco as an example. Nicotine dependency is but a tiny aspect of my addiction to cigarettes. As is my dopamine fix (though that is by no means negligible, as I suspect that the OD on nicotine really is). What is far more important to my driving need to smoke cigarettes, is what smoking means to me.

When I was fairly young, I left home and then left the state to wander the U.S. and even some outside the U.S. I hitchhiked nearly every state. During those years, I slept outside far more often than I slept in. I lost absolutely everything I had on multiple occasions, starting completely over - mind you all I had at any given point was what I could carry on my back. The only consistency I had in my life, was cigarettes and coffee. The only things that were absolutes in my life. Next to that, I almost always had marijuana and a copy of Huxley's Brave New World.

Of the things I've listed, the only elements that are still critical components of my life are cigarettes and trying to hang onto a copy of Brave New World. I usually drink the coffee, but at times I feel the need to detox. And I have for a few reasons, found it necessary to quit smoking or otherwise use marijuana. So smoking is a huge issue for me, because it is one of the very last threads that tie in important aspects of my life.

On top of that, I have made smoking more than just a fix. I really enjoy smoking. I enjoy trying new tobaccos and blends. I like how it tastes and because of the quality of tobacco I smoke, I actually like the way that it smells. So defeating my addiction to cigarettes, is going to take a lot of effort on my part.

I did warn you that it would take us a minute to get to my hypotheses to answer DM's question, didn't I? If you're still with me, take heart, because we're there baby! Kind of, sort of....

Here's the problem. I honestly doubt that with our current addiction paradigm, as addiction pertains to drug users, our society would look much different than it does now. This is accepting that many of the changes I detailed in part 1 would make some rather significant changes to society. But as far as drug users go, things don't really look a whole lot different.

The exception to that, is that I do believe that we would see a temporary spike in drug use and with it, a spike in addiction rates - also temporary. This is not to say that the addictions accrued during this time would be any more temporary than addictions are now, just that as use dropped back down, so would the rates of new addicts.

I suspect though, that in the long term, overall use of most drugs would ultimately drop below the levels we have now. Because I believe rather strongly that legalization would foster an environment that encourages us to explore new addiction paradigms and that it would also foster new approaches to prevention/education.

I am honestly not that sure about what a new addiction paradigm should encompass. But I certainly have some ideas. First and foremost, I would love to see our society gain a much better picture of what addiction really is and accept that while addiction can be and all too often is a very ugly existence, addiction can not only be benign, but can even be an unmitigated positive. That it is ok to tell a drug addict that they are always likely to be an addict, with the caveat that they need not always manifest their addiction in the use of harmful substances or destructive behaviors.

I have mentioned that I have ADHD. Not only do I have ADHD, I have very severe ADHD. I have also been diagnosed with bipolar disorder and have been an insomniac since birth (seriously, I slept less than ten of my first twenty-four hours outside the womb - it was downhill from there). I know about dopamine deficiencies and have spent a rather large percentage of my life trying to compensate. When I was younger, that led me to using a lot of different substances for such compensation, but it also led me in other, unexpected directions.

I love to write and perform music. Performance in itself isn't the key though, what really gets the dopamine squirting, is when I am effectively influencing the emotions of my audience, making them feel what I feel or want them to feel. The stronger the effect I have on someones emotional state, the more intense the experience is for me. Given my Christian upbringing, this made the next step in my musical addiction a natural; writing worship music and leading worship. Because this brought the emotional intensity to a whole new level, making the effect could garner so much more intense.

I am not going to go into the interchange that brought me to that place right now, though I may address it another time. Suffice to say that in this process, I managed to do what a lot of addicts do. I lied to myself to make me believe this was ok, and by extension lied to others. That in itself isn't the worse, my addiction led me to stick with it after I had realized the lies I had told myself. To be sure, I was encouraged by some folks in the church who knew where I was at, for a variety of reasons, but when it came down to it, I stuck with it because of what it did for me. Because of my addiction.

The thing is, it could have been and has become an honest, benign addiction again. I stick to writing music that I believe in and while I'm not performing now, I know that when I am able to share my music with others, it will affect them. No lying and no harming anyone - least of all myself. Yet addiction it most certainly remains. The act of creating beauty with one of my favorite mediums, words, gets the dopamine moving. Even sitting here right now, putting these words on this page is making it happen. It's an addiction, but quite arguably a very positive one. After all, I believe what I am saying. I believe it strongly enough, that I want to direct my education so that I can either prove it, or discover that I am wrong - either of which is fine with me, because either result will still be a step in the right direction. That direction being furthering our understanding of the world, specifically addiction.

And if I can convince others that I might well be right, that may encourage them in a positive way. Or this may encourage people to challenge me and maybe even make a cohesive argument that encourages me to change my position. Or their challenge may encourage me to think more and develop a more cohesive position of my own. Hell, their challenge may be so ridiculous that it fills me with righteous indignation. Any and all of these possible results, will produce yet more dopamine spikes and feed my addiction even more. All without me resorting to the use of destructive chemicals or other destructive behaviors.

There is a lot more I could say and maybe I will. But I think I have provided about as much a overview as I can for now. I realize that much of this seems quite tangential to the issue of what decriminalization or legalization might look like, but it's all interconnected - or should be. I think that it is quite reasonable to say that both the prohibition and war on drugs have been abysmal failures. But that is not the only failure. Our entire drug paradigm is an absolute, categorical failure. Our entire addiction paradigm is an absolute, categorical failure.

Therefore, I think it is rather unreasonable to attempt to discuss any of these in a vacuum.

DrugMonkey asks; Decriminalization: What would happen?

I am happy to answer. Accepting of course, that I have no special knowledge of the future and what it will actually look like. But I can make some pretty reasonable hypotheses.

First, I will note that I think decriminalization would be about the stupidest thing we could do. It ignores too many of the reasons we have made it illicit in the first place and creates an environment in which regulation is far more of a challenge.

Legalization is a great way to solve a lot more problems and create a much greater tax base. And I believe that from a harm reduction standpoint, it is a win, even when dealing with addiction. But I would like to step back from that, onto a point that applies to both legalization and decriminalization. Please bear with me, as to fully extend my hypothesis requires throwing prostitution and even gambling into the mix - though it's not absolutely necessary.

I would argue that just as important as the discussion of drug users and potential new drug users, is the cost of the illegal nature of drugs to society as a whole. We'll split it up into it's different aspects, though there is some overlap.

First factor is the direct financial cost. We are spending untold billions every year, both in fighting the war on drugs and imprisoning offenders. Several states are spending significant percentages of their budgets on maintaining our massive prison and jail populations. In a lot of states, drug offenses account for better than half the incarcerations at any given time. The state of MI for example, spends better than sixty percent of it's budget on incarcerations. This does not include what we spend on addiction treatment and research. On top of that, we spend billions every year, just on prosecuting the war on drugs.

By ending the war on drugs, we could save a lot of that money and move some of it into the realms of treatment and research. By ending the overarching war on vice, we could reduce the incarcerated population even more and save even more money.

Second, doing so would help foment stability in some notoriously unstable regions of the world. While I have no illusions that legalization would put cocaine lords in Columbia out of business, it would legitimize their business and remove much of the impetus to maintain the volatile status quo. And in the poppy fields of the mid east it would do wonders for farmers, while possibly making it easier to dislodge some of the local warlords who are in turn, supporting or directly engaged in terrorism. Which brings us headlong into my next point.

Third, we would be decimating a major source of funding for terrorists of all stripes. It's not just Jihadis who fund their activities through the illicit drug trade. The IRA did it, the PLO has and probably still does it. Hamas has had it's hands in it and probably still does. German national socialist groups do it. White supremacist groups in the U.S. do it, in the hopes of committing attacks on U.S. soil. Anyone who wants to have a hidden source of ready cash, can and often does turn to illicit drug dealing. And terrorists top the list of folks who need ready cash they don't have to account for (maybe behind our own intelligence organizations).

Finally, we get to crime. Not the specific crime of using/dealing illicit drugs - we're ignoring that in this point. I'm talking about related crime and this is where prostitution and gambling come into play. Because the vast majority of violent crime in the U.S. is related to one of those three trades.

I won't try to pretend that decrim or legalization is going to eliminate it. I won't even claim that everyone who engages in vice related violent crime will stop using violence. But the fact of the matter is, that there will be an inevitable and significant reduction in violent crime, when the war on vice is ended and vice is legal and safe. The majority of people who get into the illicit trades and by default end up involved in violent crime, would not go there is there wasn't a significant profit to be had from it.

You don't see the guy who owns the convenience store up the street, shooting it out with his dairy supplier, because he got a load of rotten milk. Why not? I mean if the crack dealer at the other end of the block gets a bunk supply, he's likely to go out ready to kick some serious ass, if he doesn't go out with a loaded gun. Well, the convenience store owner has the law on his side. He has legitimate venues in which to seek redress. The crack dealer simply doesn't and violent crime happens.

I realize that I'm ignoring the factor of how this affects the drug users themselves. I will try to get to it, but anyone who's read my blog knows to take that with a grain of salt. Ultimately, I don't believe that the affect on users and abusers is as important as the affect on the rest of society. As it stands, we all are paying a massive price for a proven abysmal failure and the users and abusers are suffering for it too. Bottom line, we're at a point where it can only get better from here.