A Drug is a Drug is a Drug

The modern understanding of what drugs do in psychiatry, the basis of psychopharmacology, is fatally flawed.” (Joanna Moncrieff)

In The Myth of the Chemical Cure, British psychiatrist Joanna Moncrieff persuasively argued that believing modern drug treatments are specific cures for specific illnesses “is just as mistaken as the belief that insulin coma treatment was an effective and specific treatment for schizophrenia.” This misperception has resulted in “the misdirection of research, the misinterpretation of available evidence and the obstruction of a fuller and more accurate understanding of what psychiatric drugs do.”

Essentially all of the drugs currently used in psychiatry have been developed since the 1950s. While drugs were widely used before that time, they were seen as having crude effects, “usually acting as chemical forms of restraint.” Since that time, drug treatment has been seen as making psychiatry “truly scientific.” Part of this transformation was a radical change in theories of what drugs actually do. “Instead of being seen as substances that induced effects that were crude but useful, they came to be seen as specific treatments for specific illnesses. They became ‘cures.’”

As a consequence, Moncrieff called the current view of psychotropic drug action the “disease-centered model.”  It exists in two related forms. One suggests that drugs act on the underlying causes of a disease or condition. The other suggests that drugs act on the specific pathology responsible for producing the psychiatric symptoms.

This disease-centered model is assumed and rarely articulated. But its existence can be inferred from the way that psychiatric drugs are described and investigated. The names of drug classes themselves reflect this disease centered-model: antipsychotics; antidepressants; anti-anxiety medications. It begs the question of exactly what the biological state is that these drugs are supposed to correct. “The predominant psychiatric theory about this is colloquially referred to as the ‘chemical imbalance’ theory of psychiatric disorder.”

Moncrieff proposed an alternative model, that she called the “drug-centered model.” It suggests that the therapeutic value of a drug is derived from the particular quality of the abnormal brain state it produces. “Psychiatric drugs are psychoactive drugs which, by their neurophysiological effects alter ‘mental and emotional life and behaviour for the duration of the treatment.’” Here is a reproduction of a table Moncrieff used in The Myth of the Chemical Cure to show the differences between the two models:

Disease-centered model

Drug-centered model

Drugs help correct an abnormal brain state

Drugs create an abnormal brain state

Therapeutic effects of drugs derive from their effects on presumed disease pathology

Therapeutic effect derive from the impact of the drugs-induced state on behavioral and emotional problems

Drug effects may differ between patients and volunteers

Effects do not differ

Outcomes of drug research consist of effects of drugs on measures of the ‘disease’ and its manifestations or symptoms

Outcomes are the global state produced by drug ingestion and how this interacts with behaviors and experiences

Paradigm: insulin for diabetes

Paradigm: alcohol for social phobia/social anxiety

Along with their immediate effects, when psychiatric drugs are taken over a long period of time on a regular and frequent basis, they “induce physical adaptations to the presence of the drug.” These adaptations can be understood as the body’s defense against the effects of a foreign substance and have several consequences. First, they counteract the immediate effects of the drugs, so that larger doses are needed to achieve the same effects. In other words, tolerance to the drug occurs. A second adaptation occurs:

When the drug is stopped or reduced, especially if this is done suddenly, the bodily adaptations are suddenly unopposed by the presence of the drug. It is these unopposed adaptations that cause withdrawal symptoms and they may cause other problems such as precipitating an episode of psychiatric disorder.

If this is interpreted through the disease-centered model, the bodily reaction is interpreted as evidence of the supposed reactivation of an underlying psychiatric condition, rather than a withdrawal syndrome resulting from the decreased presence of the drug in the individual’s body. In opposition to this understanding, the drug-centered model of drug action suggests the effects of drugs used in psychiatry work essentially the same way that recreational drugs do.

In the case of recreational use of drugs, it is effects such as euphoria, stimulation, indifference, disinhibition, psychedelic experiences and some types of sedation that are sought after. These effects are valued as pleasant in themselves, and also as ways of blocking out and anasesthetising people against painful memories and current difficulties. Drugs used in psychiatry have a similar range of effects, and several psychiatric drugs are also drugs of misuse.

I have to confess that while I’ve spent my professional counseling career working with individuals struggling with drugs of abuse, the disease-centered model of drug action encompassed my worldview of the so-called mental disorders for too long. This was despite knowing on some level that what Joanna Moncrieff said was true.

There is a saying in Narcotics Anonymous (N.A.) that applies to the drug-centered model for psychiatric medications introduced here: “A drug is a drug is a drug.” We have lived too long with the disease-centered model of psychotropic drug action. A drug is a drug, regardless of whether it is alcohol, cocaine, Prozac or Seroquel. Psychotropic drugs do not correct abnormal brain states; they create them. You can watch YouTube videos of Joanna Moncrieff here (The Myth of the Chemical Cure: The Politics of Psychiatric Treatment) and here (De-mystifying psychiatric drugs). You can also go to her website for more information. She’s even made some of her published papers available.


Strange Bedfellows: Terrorists and Drugs

© Hurricanehank | Dreamstime.com - Terrorist In Mask With A Gun Photo

© Hurricanehank | Dreamstime.com – Terrorist In Mask With A Gun Photo

This past May, the DEA raided a Birmingham Alabama warehouse as a part of Project Synergy. Inside, agents found hundreds of thousands of “Scooby Snax” baggies containing spice (synthetic marijuana). Sales of the product were also linked to $40 million in wire transfers to Yemen. Yemen is the home base for Al-Qa‘ida in the Arabian Peninsula (AQAP). While not able to directly link the money to a particular group or organization, DEA spokesperson Rusty Payne said: “It doesn’t take a rocket scientist to figure out that people aren’t sending $40 million to their struggling relatives overseas.”

Derek Maltz, the director of the Special Operations Division of the DEA said: “There’s a significant, long history between drug trafficking and terror organizations.” More than 50 percent of the State Department’s designated foreign terrorist organizations (FTOs) are involved with the drug trade. While the Obama administration has been successful in cutting off state-sponsored funding for terrorist organizations, they have looked for other sources of revenue. The $400 billion annual international drug trade is the most lucrative illicit business in the world and a tempting “investment opportunity” for terrorists.

Maltz went on to say that the synthetic drug market is a “two-for-one deal” for terrorists—they undermine Western countries with the drugs and make millions in the process. We’ve put a bull’s-eye on our back, he said. “When you see a designer synthetic drug industry as lucrative as this in the U.S., it would only be natural that it would be a huge target for those trying to finance their terrorists.”

The world of narcoterrorism has some diversity in its investers. The Taliban in Afghanistan distribute heroin; FARC in Columbia deals in cocaine; and al Shabab in West Africa is alleged to sell khat. While the association of al Shabab and khat may be questionable (here and here), the links between the Taliban and heroin as well as FARC and cocaine are well documented.

While Afghanistan and growing opium have been linked for thousands of years, it has only been in the last three decades that it has become the center for worldwide opium cultivation. Since 2001, opium production in Afghanistan has increased from 70 percent of the overall global opium production to 92 percent. To give you a sense of the size of this, the 2013 World Drug Report indicated that in 2011, Afghanistan produced 5,800 tons of opium, down from 7,400 tons in 2007. The next largest opium producer in 2011 was Myanmar with 610 tons of opium.

The World Bank estimated that the opium GDP of Afghanistan is between $2.6 and $2.7 billion. This amounts to 27 percent of the country’s total GDP, both licit and illicit. And yet, only 3 percent of the natural agricultural land in Afghanistan is used for its production. Poverty is widespread in Afghanistan and many of farmers are compelled by economics and force to grow opium. “Opium is valued at over $4,500 per hectare, as opposed to only $266 for wheat.” Because of this potential profit, many farmers are pressured to cultivate opium by various organizations, warlords and landowners.

The provinces of Helmand and Kandahar, which were regularly in the news during the war in Afghanistan, are also the primary opium producing provinces in the country. As former Afghan president Hamid Karzia said: “The question of drugs . . . is one that will determine Afghanistan’s future. . . . [I]f we fail, we will fail as a state eventually, and we will fall back in the hands of terrorism.”

According to sources in Spanish intelligence, the Islamic State and other jihadist groups are using their connections in the illegal drug market to finance their operations in Iraq and Syria. Jihadists use their knowledge of drug smuggling routes to export arms, contraband and new recruits from Europe to Iraq and Syria. Ironically, the pressure to dry up legal fundraising for terrorist organizations has contributed to their increased trade with illegal arms and drugs.

According to reports from Spain’s recently established government intelligence and counter-terrorism unit CITCO, 20% percent of those detained in Spain under suspicion of working with Islamic State and other jihadist groups have previously served prison sentences for offences such as drug trafficking or document counterfeiting.

FARC rebels control over 60 percent of Columbia’s drug trade, including overseas trafficking. The Revolutionary Armed Forces of Columbia (FARC) earns about $1 billion annually from the production and sale of cocaine in Columbia. According to General Jose Roberto Leon, the head of the Columbian national police force, “We have information found on computers after operations that have captured or killed FARC leaders, and it’s involvement in drug trafficking is evident.” The Columbian anti-narcotics police chief, General Ricardo Restrepo, said that officials fear that if a peace deal with FARC is successfully negotiated, thus cutting into cocaine production, that new gangs producing synthetic drugs will emerge. “It will be our next battle.”

The connection between terrorism and drug trafficking does not currently get much attention in the news media, in part, because the connections are difficult to make. But it does exist and seems to be a growing trend. Spanish intelligence sources have reported that European jihadist groups are using drug smuggling routes to export drug contraband and new recruits from Europe to Iraq and Syria. And most of the cocaine entering Europe is reportedly going through territories controlled by the Islamic State.

The Birmingham bust discussed above is particularly disturbing to me as it connects the making and distribution of the newest addictive danger, new psychoactive substances (NPS), with terrorism. This combination truly is a two-for-one threat. But we can have a two-for-one response to that threat. Both the war on drugs and the war on terrorism can be fought by social policies as well as drug treatment and education that aim for the reduction of drug use.  Who would have thought that the slogan in the war on drugs would someday be: Fight Terrorism by Becoming Drug Free.