Alcoholism

Most People Use Substances Positively

Are they telling us something useful?

Posted Feb 05, 2020

America has long been against alcohol — and drug — use.

Sort of.

In early Colonial America, Puritan minister Cotton Mather considered alcohol both as “a good creature of God” as well as also believing that “the abuse of drink is from Satan.” 

The full-out demonization of alcohol in our country came later, introduced by the 19th-century Temperance Movement, which still lives with us. Temperance invented the idea that a substance can control your behavior, fate, and identity in regards to alcohol; only at the turn of the last century was this belief applied to heroin and other drugs.

Yet, throughout history, most people have enjoyed using substances, including alcohol, hallucinogens, cannabis, cocaine, and opium — all of which have been known of and used since antiquity. Any mature, societally useful consideration of substances must reflect that there are no demon drugs and no elixirs. All drugs have benefits and harms depending on how they are used.

Could we reduce the latter by expanding the former? After all, these substances won’t disappear. All of us use them or other drugs and always will. Should we try to optimize their use, perhaps even turning them into personal and social assets? 

America’s Jekyll-and-Hyde ambivalence about alcohol readily spread to drugs in the last century. From the 1914 Harrison Act to the present the United States has undergone repetitive cycles of drug scares. As Jacob Sullum describes this social process, “The history of drug control in America is a series of panic-propelled policies.” As one example of this transference, Carl Hart traces the meth scare of the last decade back to the crack panic of the 1980s and ‘90s. 

Joe Biden is one of the politicians still apologizing for the special penalties for crack introduced in that period, with severe and racially disproportionate outcomes. Rest assured, he and others will have plenty more to apologize for in decades to come. Fentanyl, the demon drug du jour, is one focus of current pressures to increase penalties.

The Cost of Demonization

The argument against modern American fear and scapegoating of drugs is readily observed through the U.S.’s world-leading drug harms.

In the mid-2010s we witnessed opioid deaths rise rapidly while public alarm around opioid use was reaching the flashing-red-light stage, leading to a radical decline in painkiller prescriptions.

At the same time, we can note that substance use disorders/addiction and drug-related deaths are rare among patients who are prescribed opioids. These harms are instead overwhelmingly associated with chaotic drug use and mixing of drugs by people who obtain opioids illicitly.

Our increasingly stringent approach to opioids has thus paradoxically made the beneficial use of opioids less likely while increasing harmful use (often mixed with other drugs), primarily among disadvantaged people.

Somehow, these trends continue despite “PR-savvy law enforcement messaging about a public health response to mitigate the toll.” 

Must there always be at least one evil drug on the American horizon for law enforcement and politicians to rail against, with many public health advocates joining the chorus? Of course, few in these groups would dare be seen as insufficiently damning of drug use, what with people dying. And deaths are occurring, including, as recently headlined around the media, with alcohol. But why is that? 

A bifurcated response by different segments of society has led to seemingly paradoxical outcomes: Kids and Americans at large are drinking less; yet more people are dying from alcohol-related causes. As the New York Times noted in January:

The death rate tied to alcohol rose 51 percent overall [from 1999 through 2017], taking into account population growth. . . .

Like much research of its kind, the findings do not alone offer the reasons behind the increase in alcohol deaths. In fact, the data is confounding in some respects, notably because teenage drinking overall has been dropping for years, a shift that researchers have heralded as a sign that alcohol has been successfully demonized as a serious health risk.  (My emphases)

The Stratification of Substance Users

How is this split between level of use and experienced harm possible? 

First, consider that different groups—religious, social, ethnic and economic—display different drinking behaviors and attitudes. For example, Mediterranean (and Catholic) cultures are more likely both to drink and to drink moderately, with Protestants occupying the opposite positions. 

High-income, highly educated Americans are also more likely to drink than their less privileged counterparts. However, research finds “the latter group seems to bear a disproportionate burden of negative alcohol-related consequences.” 

Marginalized populations are more likely to internalize the negative images of drugs thrust upon them by government and media. The African-American community in particular has suffered from this phenomenon—with internal and external alarms reverberating from similar levels of drug use as observed in prosperous suburbs. And rather than protecting these populations, this hysteria exacerbates the inequalities they suffer as expressed through disproportionate harms relating to alcohol, nicotine, and other drugs.

Meanwhile, as Americans in general drink less, they are more likely to binge drink. This phenomenon is similarly noted across Europe. Northern European cultures create more negative images of drinking, drink less, but then drink in binges. This contrasts with Southern European cultures. In the words of Italian researcher Allaman Allamani;

“In the Northern countries, alcohol is described as a psychotropic agent ... It has to do with the issue of control and with its opposite–‘discontrol’ or transgression. In the Southern countries, alcoholic beverages–mainly wine–are drunk for their taste and smell, and are perceived as intimately related to food, thus as an integral part of meals and family life. . .[so that drinking] is not connected to the topic of control.”

In Southern European cultures, alcohol is typically consumed with meals, in multi-generation, gender-mixed groups, and with explicit norms that emphasize, per Allamani, that alcohol is not to be used as an excuse for misbehavior. 

Rather, positive drinking involves regular, moderate consumption that complements social interactions, enjoyable activities, and life purpose. The Allamani/Mediterranean model (practiced as well by other groups of positive drinkers) confers benefits at psychological, social, and national health levels.

This model of normalization would, and in certain instances does, apply to the positive use of every substance that humans choose to use—albeit the safety picture for illegal drugs is clouded by the supply-side dangers due to demonization and prohibition.

What are the chances that American public health will encourage healthy drinking practices (let alone utilizing such practices for currently illegal drugs)? 

Right now, I would say nil, as U.S. epidemiologists have joined with those from other Temperance cultures in classifying any drinking as putting people at risk. That’s right: WHO epidemiologists have declared zero to be the ideal level of alcohol consumption. This recommendation flies in the face of research which consistently shows that, by far, the most common reason people give for consuming alcohol is that drinking is pleasurable. And pleasure is a priceless human benefit, despite its blacklisting by drug researchers.   

Enjoying Drugs

The U.S. has never learned that the demonization of substances is a bad public health message. It encourages abstinence by the obedient and the vulnerable. But the latter, with higher psychosocial stressors, are especially prone to fall off the wagon (or never get on it), leading to the very worst outcomes, up to and including death. 

The alternative would be a happy societal embrace of appropriate, medically desirable or personally enjoyable substance use, without oppression or stigma. 

Impossible to guarantee such balance, you say? Fine, but then don’t claim to trouble yourself about the death rates and harms that devastate our most vulnerable socioeconomic groups. 

Nicholas Kristof and Sheryl WuDunn, in their new bestseller Tightrope: Americans Reaching for Hope, graphically describe the decimation of “working-class men and women of every shade [who] increasingly are dying ‘deaths of despair’—from drugs, alcohol, and suicide.”

These authors rightly decry the lack of economic investment in such populations. At the same time, they vilify the “explosion of drugs—oxycodone, meth, heroin, crack cocaine and fentanyl—aggravated by the reckless marketing of prescription painkillers by pharmaceutical companies.” 

What Kristof and WuDunn fail to realize is that the focus on drugs is itself the cause of the drug war, which they also decry for its disproportionate impact on deprived populations. Moreover, money has over decades explicitly been diverted from social programs and used instead for drug control, prevention, and treatment. 

Our resources could best be used in support of people’s lives through education, housing, and healthcare. This is exactly what Kristof and WuDunn call for to reverse the downward life spirals of the people they so movingly document. But their demonization of drugs works in exactly the opposite direction of their stated goal.

One European college student attending an American university wrote me (as quoted in my book Addiction-Proof Your Child) about what moderate, pleasurable drug users have to teach us:

I know quite a few parents who smoke marijuana or do an occasional line of coke, keeping such use secret from their children. But is it better that, given their own moderate use, they proffer their own drug-related behaviors as models, in case their children ever do drugs? This is of course a controversial suggestion. Still, having lived in a country where some drug use was decriminalized [this was in 2007], I believe that seeing adults use marijuana or ecstasy occasionally while maintaining their jobs, families, and hobbies was a decisive factor in my own liberation from the idea that drugs are inevitably addictive and my own faith in moderation.

And, while psychedelics are used to treat everything from mood disorders to traumas to addiction and end-of-life issues, Michael Pollan recommends them for personal enjoyment and consciousness expansion in How to Change Your Mind.

This would mean replacing “harm reduction” with “pleasure enhancement”—which could be the most effective harm reduction measure of all.