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Showing posts with label addiction. Show all posts
Showing posts with label addiction. Show all posts

Thursday 8 November 2018

The making of an opioid epidemic

When high doses of painkillers led to widespread addiction, it was called one of the biggest mistakes in modern medicine. But this was no accident. By Chris McGreal in The Guardian 

Jane Ballantyne was, at one time, a true believer. The British-born doctor, who trained as an anaesthetist on the NHS before her appointment to head the pain department at Harvard and its associated hospital, drank up the promise of opioid painkillers – drugs such as morphine and methadone – in the late 1990s. Ballantyne listened to the evangelists among her colleagues who painted the drugs as magic bullets against the scourge of chronic pain blighting millions of American lives. Doctors such as Russell Portenoy at the Memorial Sloan Kettering Cancer Center in New York saw how effective morphine was in easing the pain of dying cancer patients thanks to the hospice movement that came out of the UK in the 1970s.

Why, the new thinking went, could the same opioids not be made to work for people grappling with the physical and mental toll of debilitating pain from arthritis, wrecked knees and bodies worn out by physically demanding jobs? As Portenoy saw it, opiates were effective painkillers through most of recorded history and it was only outdated fears about addiction that prevented the drugs still playing that role.

Opioids were languishing from the legacy of an earlier epidemic that prompted President Theodore Roosevelt to appoint the US’s first opium commissioner, Dr Hamilton Wright, in 1908. Portenoy wanted to liberate them from this taint. Wright described Americans as “the greatest drug fiends in the world”, and opium and morphine as a “national curse”. After that the medical profession treated opioid pain relief with what Portenoy and his colleagues regarded as unwarranted fear, stigmatising a valuable medicine.

These new evangelists painted a picture of a nation awash in chronic pain that could be relieved if only the medical profession would overcome its prejudices. They constructed a web of claims they said were rooted in science to back their case, including an assertion that the risk of addiction from narcotic painkillers was “less than 1%” and that dosages could be increased without limit until the pain was overcome. But the evidence was, at best, thin and in time would not stand up to detailed scrutiny. One theory, promoted by Dr David Haddox, was that patients genuinely experiencing pain could not become addicted to opioids because the pain neutralised the euphoria caused by the narcotic. He said that what looked to prescribing doctors like a patient hooked on the drug was “pseudo-addiction”.
Portenoy toured the country, describing opioids as a gift from nature and promoting access to narcotics as a moral argument. Being pain-free was a human right, he said. In 1993, he told the New York Times of a “growing literature showing that these drugs can be used for a long time, with few side-effects, and that addiction and abuse are not a problem”.

Long after the epidemic took hold, and the death toll rose into the hundreds of thousands in the US, Portenoy admitted that there was little basis for this claim and that he had been more interested in changing attitudes to opioids among doctors than in scientific rigour.

“In essence, this was education to destigmatise and because the primary goal was to destigmatise, we often left evidence behind,” he admitted years later as the scale of the epidemic unfolded.

Likewise, Haddox’s theory of pseudo-addiction was based on the study of a single cancer patient. At the time, though, the new thinking was a liberation for primary care doctors frustrated at the limited help they could offer patients begging to get a few hours’ sleep. Ballantyne was as enthusiastic as anyone and began teaching the gospel of pain relief at Harvard, and embracing opioids to treat her patients.

“Our message was a message of hope,” she said. “We were teaching that we shouldn’t withhold opiates from people suffering from chronic pain and that the risks of addiction were pretty low because that was the teaching we’d received.”

But then Ballantyne began to see signs in her patients that experience wasn’t matching theory. Doctors were told they could repeatedly ratchet up the dosage of narcotics and switch to a new and powerful drug, OxyContin, without endangering the patient, because the pain, in effect, cancelled out the risk of addiction. To her dismay, Ballantyne saw that many of her patients were not better off when taking the drugs and were showing signs of dependence.

Among those patients on high doses over months and years, Ballantyne heard from one after another that the more drugs they took, the worse their pain became. But if they tried to stop or cut back on the pills, their pain also worsened. They were trapped.

“You had never seen people in such agony as these people on high doses of opiates,” she told me. “And we thought it’s not just because of the underlying pain; it’s to do with the medication.”

As Ballantyne listened to relatives of her patients talk about how much the drugs had changed their loved ones, her misgivings grew. Husbands spoke of wives as if a part of them were lost. Mothers complained that children had become sullen and distant, their judgment gone, their personality warped, their character altered. None of this should have been happening. Pain relief was supposed to free the patients, not imprison them. It was all very far from the promise of a magic bullet.

As the evidence that opioids were not delivering as promised piled up, the Harvard specialist began to record her findings. By then, though, there were other powerful forces with a big financial stake in the wider prescribing of painkilling drugs. Pharmaceutical companies are not slow to spot an opportunity and the push for wider prescribing of opioids had not gone unnoticed by the drug-makers, including the manufacturer of OxyContin, Purdue Pharma, which rapidly came to play a central role in the epidemic.

As the influence of the opioid evangelists grew, and restraints on prescribing loosened, the pharmaceutical industry moved to the fore with a push to make opioids the default treatment for pain, and to take advantage of the huge profits to be made from mass prescribing of a drug that was cheap to produce.

 
Bottles of painkiller OxyContin, made by Purdue Pharma. Photograph: Reuters

The American Pain Society, a body partially funded by pharmaceutical companies, was pushing the concept of pain as the “fifth vital sign”, alongside other measures of health such as heart rate and blood pressure. “Vital signs are taken seriously,” said its president, James Campbell, in a 1996 speech to the society. “If pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly. We need to train doctors and nurses to treat pain as a vital sign.”

The APS wanted the practice of checking pain as a vital sign as a matter of routine adopted in American hospitals. The key was to win over the Joint Commission for Accreditation of Healthcare Organizations, which certifies about 20,000 hospitals and clinics in the US. Its stamp of approval is the gateway for medical facilities to tap into the huge pot of federal money paying for healthcare for older, disabled and poor people. Hospitals are careful not to get on the wrong side of the joint commission’s “best practices” or to fail its regular performance reviews.

In response to what it called “the national outcry about the widespread problem of under-treatment” – an outcry in good part generated by drug manufacturers – the commission issued new standards for pain care in 2001. Hospital administrators picked over the document to ensure they understood exactly what was required.

Every patient was to be asked about their pain levels, no matter what the reason they were seeing a doctor. Hospitals adopted a system of colour-coded smiley faces, to represent a rising scale of pain from 0-10. The commission ruled that anybody identifying as a five – a yellow neutral face described as “very distressing” – or above was to be was to be referred for a pain consultation.

The commission told hospitals they would be expected to meet the new standards for pain management at their next accreditation survey. Purdue Pharma was ready. The company offered to distribute materials to educate doctors in pain management for free. This amounted to exclusive rights to indoctrinate medical staff. A training video asserted that there is “no evidence that addiction is a significant issue when persons are given opioids for pain control”, and claimed that some clinicians had “inaccurate and exaggerated concerns about addiction, tolerance and risk of death”. Neither claim was true.

Some doctors questioned the value of patient self-assessment, but the commission’s regulations soon came to be viewed as a rigid standard. In time, pain as the fifth vital sign worked its way into hospital culture. New generations of nurses, steeped in the opioid orthodoxy, sometimes came to see pain as more important than other health indicators.

Dr Roger Chou, a pain specialist at Oregon Health and Science University who has made long-term studies of the effectiveness of opioid painkillers and helped shape the Centers for Disease Control and Prevention’s policy on the epidemic, said the focus on pain caused patients to give it greater weight than made sense.

“When you start asking people: ‘How much pain are you having?’ every time they come into the hospital, then people start thinking: ‘Well, maybe I shouldn’t be having this little ache I’ve been having. Maybe there’s something wrong.’ You’re medicalising what’s a normal part of life,” he said.

One consequence was that people with relatively minor pain were increasingly directed toward medicinal treatment while consideration of safer or more effective alternatives, such as physiotherapy, were marginalised. Another, said Chou, was the increased expectation that pain can be eliminated. Chasing the lowest score on the pain chart often came at the expense of quality of life as opioid doses increased. “It’s better to have a little bit of pain and be functional than to have no pain and be completely unfunctional,” said Chou.

Health insurance companies piled yet more pressure on doctors to follow the path of least resistance. This meant cutting consultation times and payments for more costly forms of pain treatment in favour of the direct approach: drugs.

The joint commission needed a way to judge whether its 2001 edict on pain was being adhered to and latched on to patient satisfaction surveys. It took a determined doctor to resist the pressure to prescribe. Physicians could spend half an hour pressing a person to take more responsibility for their own health – eat better, exercise more, drink less, find ways to deal with stress – only to watch an unhappy patient make their views known on the satisfaction survey and face a dressing down from hospital management. Or they could quickly do what the patient came in for: give them a pill and get full marks.

In Detroit, Dr Charles Lucas’s three decades of experience as a surgeon told him it was possible to what was easy and sign the prescription, or to do what was hard. Lucas grew up in the city and had been instrumental in establishing Detroit’s publicly owned hospital as the highest-level trauma centre in Michigan and one of the first top-tier centres in the country.

 
Activists in New York, during a protest denouncing the city’s ‘inadequate and wrongheaded response’ to the opioid overdose crisis. Photograph: Getty
Emergency departments became beacons for the opioid dependent, who quickly learned to game the system to get drugs on top of their prescriptions. They turned up feigning pain, knowing harassed medical staff under pressure of time and the commission’s standards were likely to prescribe narcotics and move on without too many questions.

“Some of the old-time nurses, they have that jaundiced look in their eye and say ‘So-and-so’s complaining of pain’. You can tell by the look in their eye that they don’t think it’s justified that they get any more medicine,” said Lucas. “The younger nurses, they say we have to treat this pain – because they’ve been indoctrinated – they’ve got to get rid of the pain. God forbid you don’t get rid of the pain. That would be like a mortal sin.”

But there was a price for resisting the pressure to prescribe ever higher doses of pain relief.

Lucas was knocked back in surprise, and then infuriated, to be summoned to appear before his hospital’s ethics committee after a nurse reported him for failing to provide adequate pain treatment.

The surgeon’s longstanding patients included Gail Purton, the wife of a well-known Michigan radio personality. Lucas operated on Purton a few times, and she was back for surgery after her ovarian cancer spread. “It was a big operation. Cut off all sorts of cancer.” The next day, a nurse asked Purton if she was in pain. Purton said she was. The nurse reported Lucas for failing to properly address a patient’s pain. “I got reported because I wasn’t giving her enough pain medicine. She had a big cut from here to here,” Lucas said, running his finger across the front of his shirt and scoffing at the idea that she could be pain-free after an operation like that.

The surgeon responded with a five-page letter to the ethics committee chairman, whom he happened to have trained, challenging the questioning of his professional judgment. Purton wrote her own letter, praising Lucas’s care and saying that she never expected not to have pain after a major operation.

The case was dropped, but it was not an isolated incident. Lucas has worked closely with another surgeon, Anna Ledgerwood, since 1972. She too was hauled before the ethics committee on more than one occasion, on the same charge. It cleared Ledgerwood, but Lucas said more junior surgeons buckled to the pressure to administer opioids just to stay out of trouble.

Lucas regarded the new pain orthodoxy as a growing tyranny. He also thought it was killing patients. He began to collect his own data.

As the joint commission was pushing out its new standards for pain treatment in the early 2000s, the industry was driving a parallel effort to influence the prescribing habits of doctors in small clinics and private practices across the country. Many were still hesitant to prescribe narcotics, in part because of fear of legal liability for overdose or addiction.

The American Pain Society and Haddox, who was by then working for Purdue Pharma, were instrumental in writing a policy document reassuring doctors they would not face disciplinary action for prescribing narcotics, even in large quantities. The industry latched on to the Federation of State Medical Boards because of its influence over health policy individual US states which regulate how doctors practise medicine.

In 2001, Purdue Pharma funded the distribution of new pain treatment guidelines drawn up by the FSMB that sounded many of the same themes as the standards written by the joint commission.

The document picked up on Haddox’s pseudo-addiction theory. “Physicians should recognise that tolerance and physical dependence are normal consequences of sustained use of opioid analgesics and are not synonymous with addiction,” it said.

The FSMB pressed state medical boards to adopt the guidelines and to reassure doctors that adhering to them would diminish the likelihood of disciplinary action.

Over the following decade, the FSMB took close to $2m (£1.52m) from the drug industry, which mostly went to promote the guidelines and to finance a book, Responsible Opioid Prescribing, written with the oversight and advice of a clutch of doctors who were strong advocates of wider use of prescription narcotics. The book was sold to state medical boards and health departments for distribution to physicians, clinics and hospitals. The drug industry paid for the publication but the FSMB kept the $270,000 profits from sales.

Within a few years, the model guidelines were adopted in full or in part by 35 states, and the floodgates were open to mass prescribing of what Drug Enforcement Administration agents came to call “heroin in a pill”. Opioids were soon the default treatment even for relatively minor pain. Dentists gave them to teenagers after pulling their wisdom teeth. Not just one or two days’ worth of pills, but a fortnight or a month’s worth, which, if they did not draw the intended recipient in, frequently sat in the medicine cabinet waiting to be discovered by someone else in the family. The lack of caution in prescribing left an impression among the users that the drugs were harmless, and some people shared them with others as easily as they might an aspirin. Prescribing escalated year on year. So did profits. OxyContin sales passed $1bn a year in 2000. Three years later they were twice that. Other opioid makers were pulling in huge profits too.

By the time the FSMB guidelines were landing in doctors’ inboxes in the early 2000s, Ballantyne had reached her own conclusions about the impact of escalating opioid prescribing. In 2003, she co-authored an article in the New England Journal of Medicine highlighting the dearth of comprehensive trials and saying that two important questions remained unanswered even as mass prescribing of opioids took off. Do they work long term? Are higher doses safe to take year after year? The drug industry and opioid evangelists said yes, but where was the evidence for it?

Ballantyne wrote that there was evidence that putting some patients on serial prescriptions of strong opioids has the opposite of the intended effect. High doses not only build up a tolerance to the drug, but cause increased sensitivity to pain. The drugs were defeating themselves.

Her assessment seemed to warn that if there was an epidemic of pain, it was partly driven by the cure. On top of that, there was evidence that the drugs were toxic. Then came the conclusion that stuck a dagger into the heart of the campaign for wider opioid prescribing. “Whereas it was previously thought that unlimited dose escalation was at least safe, evidence now suggests that prolonged, high-dose opioid therapy may be neither safe nor effective,” she wrote.

Ballantyne was also increasingly aware that the claim that pain neutralised the risk of addiction was false. Quantifying addiction, and who may be vulnerable, is notoriously difficult. Ballantyne, like a lot of doctors, estimated that between 10 and 15% of the population is vulnerable, but that it depends on the substance and circumstances. What she was certain of was that Purdue’s high-strength pill, OxyContin, had been a game changer. “The long-acting opiates suddenly put much higher doses into people’s hands and much more of it, and taking it around the clock made them dependent on it.”

From her research, Ballantyne concluded that OxyContin supercharged what was already widespread dependence on weaker opioid pills by drawing a new group of people into the category at risk of addiction and death. The danger was compounded by OxyContin’s failure to live up to its promise of holding pain at bay for 12 hours. For some patients, it wore off after eight, causing them to take three pills a day instead of two, greatly increasing their overall dose of narcotic and with it the risk of addiction.

Ballantyne thought the article would at least cause her profession and the drug industry to take stock of the impact of mass prescribing. By the time the article appeared, the documented death toll from prescription opioids was running at around 8,000 a year.

“When the 2003 New England journal article came out, I thought it was going to make the medical community sit up and say: ‘Wow. These drugs that we’ve been thinking are helping people are not. We have a real problem.’ But the medical community didn’t at all say: ‘Wow,’” Ballantyne said with half a laugh, 15 years later.

“People in my field who had been, like me, taught we have to do this – people who’d been lobbying to try and increase opiate use, like the palliative care physicians – said: ‘What are you doing? We worked so hard to get to this point, and now you’re going to turn it all around. They become so rattled when you suggest you shouldn’t give the opiates – it’s partly people in the pain field and especially people in pharma – because it’s big business.”

Lucas and Ledgerwood had their own study on the impact of opioids in the works. They came to believe the tyranny of the colour-coded smiley faces was costing lives. Years of surgery have given Lucas a healthy respect for pain as a tool for recovery. To suppress it was dangerous. But as large doses of opioids became the norm, the surgeon noted an increasing number of incidents of patients struggling to breathe after routine operations and being moved to intensive care.

Lucas and Ledgerwood visited trauma centres to collect data on deaths before and after the joint commission standards on pain treatment. In 2007, the two doctors published their findings. Before the commission’s dictum, 0.7% of trauma centre patients died from “excess administration of pain medicines”. The death toll rose to 3.6% after the commission’s policies kicked in.

“In each case, administration of sedation led to a change in vital signs or a deterioration in the respiratory status requiring some type of intervention which, in turn, led to a cascade of events resulting in death,” the paper said. Those were only the deaths in which there was little doubt opioids were responsible, and the real toll was almost certainly higher. “Overmedication with sedatives/narcotics … clearly contributed to deaths,” the study concluded.

A memorial in Washington DC, consisting of 22,000 engraved white pills representing the face of someone lost to a prescription opioid overdose in 2015. Photograph: Mark Wilson/Getty

“I’m convinced that because of the pressures brought to bear by the joint commission, we are killing people,” Lucas told me. The study said the medical staff lived in fear of the joint commission standards which created “great psychological pressure on caregivers” to use narcotics.

In a damning critique, the paper said that the commission’s reliance on pain scales to guide treatment had created an “excessive emphasis on undermedication at the same time ignoring overmedication”. The obsession with ensuring people were not in pain came at the expense of ignoring the dangers of giving large amounts of opioids to people recovering from surgery or serious injury. The drugs may kill the pain but they also risked killing the patient.

The two doctors made no secret of who they blamed for “this preventable cause of death and disability”. “It’s about money. Money has influence, and it influenced the joint commission,” said Lucas.

The surgeon presented the paper to a meeting of the Central Surgical Association and saw it published by the Journal of the American College of Surgeons under the headline “Kindness Kills: The Negative Impact of Pain as the Fifth Vital Sign.”

Afterwards, Lucas got a stream of letters and emails from doctors who recognised the problem. But, unlike Ballantyne, he wasn’t surprised when the policy remained the same. “Did I expect a change? No. It is too ingrained into the medical profession. It’s become financial just like the drug industry is financial. It’s nothing to do with right or wrong. It’s about how the money flows,” he said. “When you write a paper you want there to be unemotional data out there. You want that unemotional data to be analysed and interpreted in one way or the other, but you don’t expect the Renaissance.”

In 2012, nine years after Ballantyne’s cautioning against the mass prescribing of opioids as a quick fix for pain was published in the New England Journal of Medicine, a renowned British pain specialist, Cathy Stannard, called the doctor’s paper “a distant warning bell”, challenging the opening of the floodgates to strong opioids.

Ballantyne continued to collect data and publish ever more detailed insights into the impact of painkillers. A less rapacious drug industry might have paused in its headlong charge to sell opioids, and less blinkered and compliant regulators might have determined that this was the moment to weigh the claims made in favour of permitting such widespread prescribing.

Instead the pharmaceutical companies took the warnings as a challenge to their business interests. Through the 2000s, industry poured money into a political strategy to keep the drugs flowing. It funded front groups and studies to claim that there was indeed an epidemic – but it was of untreated pain. The millions coping with chronic pain were the real victims, the industry said, not the “abusers” hooked on opioids they often bought on the black market or obtained from crooked doctors. That one frequently became the other was conveniently overlooked.

Pharma’s lobbyists worked to persuade Congress and the regulators that to curb opioid prescribing would be to punish the real victims because of the sins of the “abusers”, and it worked. As a result, the devastation ran unchecked for another decade and more. By 2010, doctors in the US were writing more than 200m opioid prescriptions a year. As the prescribing rose, so did the death toll. Last year, more than 72,000 Americans died of drug overdoses, the vast majority from opioids, nearly 10 times the number at the time Ballantyne published her warning.

The head of the FDA at the time OxyContin was approved for distribution two decades ago, Dr David Kessler, later described the opioid crisis as an “epidemic we failed to foresee”. “It has proved to be one of the biggest mistakes in modern medicine,” he said.

Kessler was wrong. It wasn’t a mistake. It was a betrayal.

Saturday 3 January 2015

Johann Hari: ‘I failed badly. When you harm people, you should shut up, go away and reflect on what happened'

When I heard that Johann Hari had written a book about the war on drugs, two immediate concerns sprang to mind. The first was whether anyone would trust a word he wrote.
The author used to be the Independent’s star columnist, a prolific polemicist and darling of the left, until his career imploded in disgrace when it emerged in 2011 that many of his articles contained quotes apparently said to him but in fact lifted from his interviewees’ books, or from previous interviews by other journalists. Worse, he was exposed as a “sockpuppet”, or someone who anonymously furthers his own interests online. Using a false identity, Hari had maliciously amended the Wikipedia pages of journalists he disliked – among them the Telegraph columnist Cristina Odone and the Observer’s Nick Cohen – accusing them of antisemitism, homophobia and other toxic falsehoods. Under the same pseudonym, he had also edited his own Wikipedia page, lavishly flattering his profile to, as he puts it, “big myself up”. The Independent suspended him, four months later he resigned, and no British newspaper has published his journalism since. He has never spoken publicly about the scandal, until now.
My other worry was whether anyone would want to read yet another polemic about drugs. I wouldn’t, and I’m quite interested in the subject. The prohibition-versus-legalisation debate tends to be interminably dreary, chiefly because neither side ever seems to change anybody’s mind.
“I think that’s totally right,” Hari agrees. “I did not want to write a 400-page polemic about the drug war. I didn’t want to have an argument about it, I wanted to understand it.” For that matter, he admits, “It’s struck me that, actually, polemic very rarely changes people’s minds about anything.” He says so as a former columnist? “A recovering former columnist, yes.” He laughs. “It’s not just that polemic doesn’t change people’s minds. It says nothing about the texture of lived experience. People are complex and nuanced, they don’t live polemically.”
Hari’s book turns out to be a page-turner, full of astonishing revelations. I had no idea that the war on drugs was single-handedly invented by a racist ex-prohibition agent, who needed to find a new problem big enough to protect his departmental budget. One of the first victims of his ambition was Billie Holiday, whose heroin addiction enraged him to the point where he hounded her to death. After he’d had the singer jailed for drugs, she was stripped of her performing licence, and as she unravelled into destitution and despair, his agents continued to harass her, even summoning a grand jury to indict her as she lay dying under police guard in a hospital bed.
Hari travelled all over the world meeting other casualties of the drug war: a transsexual former crack dealer in Brooklyn; a homeless junkie in Vancouver who mobilised the local heroin addicts into activists and rewrote the city’s drug laws; a housewife from Ciudad Juárez who marched across Mexico to shame the politicians and cartels protecting her daughter’s murderer.
Woven between the human dramas are Malcolm Gladwell-ish examinations of the surprising science and statistics of drug use, and of the varying success of drug policies. Hari goes to Portugal, where all drug possession was decriminalised 13 years ago, and where even the police chief of the Lisbon drug squad now admits, “The things we were afraid of didn’t happen.” He also visits Tent City, a prison in the Arizona desert where the inmates live in tents in temperatures of 44C, wear T-shirts proclaiming I AM BREAKING THE NEED FOR WEED or I WAS A DRUG ADDICT, and are shackled into a chain gang every day and marched in public while reciting chants of repentance.
I’ve got to know Hari a bit over the past two years, and it’s quite hard to picture him in the badlands of the drug war. He doesn’t look much like an underworld adventurer. He could pass for almost a decade younger than his 35 years, is slightly knock-kneed and prone to giggly yelps, and readily admits he can’t be trusted to make it to the corner shop and back without getting lost. His north London flat, where we meet, is full of books and almost nothing else, its sole concession to domesticity a massive flatscreen TV. Hari puts his general air of unworldly distraction down to his dyspraxia, but it comes across as donnish.
There was nothing academic about his background, growing up in suburban north London in the 80s. His Glaswegian mother worked in a refuge, his Swiss father was a bus driver, and they were pleased but rather puzzled by their son’s obsession with books. “My mum and my dad and my brother all left school when they were 16. I was the first person in my family to go to a fancy university.” After graduating with a double first in social and political sciences from Cambridge, he joined the New Statesman and quickly established his name as a columnist. He was hired by the Independent, where he won Young Journalist of the Year in 2003 and became the youngest ever recipient of the George Orwell prize in recognition of his political reporting.
Johann Hari
Pinterest
 Johann Hari: “I want to make it clear that I’m not in any way attributing anything I did to that drug use. They are totally separate things.” Photograph: Richard Saker
As a journalist, Hari wrote a lot about the war on drugs, and was always a passionate opponent. His book is presented as an objective investigation, but did it really change his mind about anything? “Oh yes. I think the thing that shocked me the most was the stuff about addiction. I thought I knew about addiction. But addiction is not what we’ve been told it is at all.”
When Hari began the book three years ago, he was familiar with the two prevailing theories: people become dependent on drugs either because they lack self-control, or because the chemicals are so inherently addictive that they hijack the brain. Addiction is a moral weakness, or it is a disease, but implicit in either analysis is the theoretical possibility that if we could get rid of the drugs, we would solve the problem.
One of Hari’s earliest memories is of trying to rouse a relative from a drug-induced stupor, and his ex-boyfriend is a crack and heroin addict. “So I’d seen addiction in people I loved, and I could see it wasn’t that they were just selfish, morally flawed people. I never believed that. So I erred towards thinking, well, obviously it must be a disease.” Seminal experiments conducted on rats in the 70s appeared to have proved this. Offered a choice between pure water and water laced with heroin, the rats quickly became addicted to the opiate and kept taking the drug until it killed them.
But something didn’t add up. “Every day, all over the world, hospital patients are given medical heroin, diamorphine, very often for long periods. And virtually none of them afterwards goes out and tries to score on the street. Which made me think, the issue here can’t just be the drug.”
Hari went to Vancouver to meet a psychology professor, Bruce Alexander, who had been similarly puzzled, so had replicated the original experiments. This time, instead of experimenting on solitary rats locked in empty cages, he offered the choice of clean or drugged water to rats kept in what he called Rat Park, a kind of rat heaven full of wheels and coloured balls and delicious food, and other rats to play and mate with. When these rats tried heroin, they weren’t very interested.
“They just didn’t like it. None of them overdosed. Even more strikingly, he then took rats that had become addicted in the isolated cages, and put them into Rat Park. And they almost immediately stopped using. What Alexander had found is that we’ve fundamentally misunderstood what addiction is. It isn’t a moral failing. It isn’t a disease. Addiction is an adaptation to your environment. It’s not you; it’s the cage you live in.”
The book is populated by a compelling cast of meth users, junkies and crack addicts. Other than addiction, what they have in common is heartbreaking early trauma and abuse. Childhood violence and prostitution, abandonment and homelessness, all led their victims to the same remedy: a narcotic anaesthetic for pain and loneliness. “Human beings have an innate need to bond. Healthy, happy people bond with other humans. But if you can’t do that because you’re so traumatised by your childhood that you can’t trust people, you may well bond with a drug instead.” The scientific evidence of the correlation is so overwhelming, Hari writes, that “child abuse is as likely to cause drug addiction as obesity is to cause heart disease”.
“What I learned is that the opposite of addiction is not sobriety,” Hari says. “The opposite of addiction is human connection. And I think that has massive implications for the war on drugs. The treatment of drug addicts almost everywhere in the world is much closer to Tent City than it is to anything in Portugal. Our laws are built around the belief that drug addicts need to be punished to stop them. But if pain and trauma and isolation cause addiction, then inflicting more pain and trauma and isolation is not going to solve that addiction. It’s actually going to deepen it.”
He breaks off, looking anxious. “But I didn’t tell their stories, because I thought they were a better way of persuading people of an argument. It’s a book of stories about people, because I think stories are a fundamentally better way of thinking about the world.”
Nevertheless, these stories build a compelling case for the legalisation and regulation of drugs. If, as the book suggests, 90% of us can take drugs safely without harming ourselves or others, and criminalising the 10% who can’t only turns them into desperate thieves and prostitutes, then the war on drugs is not merely unwinnable, but inherently counterproductive. But one of the stories Hari tells is mentioned so fleetingly that a reader could blink and miss it. In just a few sentences, Hari writes that he himself had been addicted to a drug for several years.
Provigil is an anti-narcolepsy prescription drug, popular among Ivy League students for its reputed power to turbo-charge the brain. When Hari discovered it in 2009, “I thought: great, I’ve maxed out the amount of antidepressants you can use – here’s something that will speed things up even more.” He’d been prescribed the antidepressant Seroxat at 17 and, barring one or two brief breaks, had been taking it ever since. Now, with Provigil, Hari was thrilled to discover, “you can do even more work, and be constantly processing information, and sleep only four hours a night”. He began buying the drug on the internet – and for a while it worked. But when he tried to stop taking it, he failed. “When you’re prone to depression, there can be a strong temptation, or there was for me anyway, to try to accelerate through it – to speed up, to kind of outrun the feelings of depression and I did that for years.
“But this is totally unrelated to the things I did wrong journalistically,” he says quickly. “This is really important. I did those things before and during the use of this drug. So I want to make it clear that I’m not in any way attributing anything I did to that drug use. They are totally separate things.”
This is the last time he says anything quickly. The moment we come to his scandal, all the animation drains from him; he turns still and pale, and speaks in halting sentences prefaced by painful silences. He stopped taking both Provigil and Seroxat one week after leaving the Independent, but can’t be sure what withdrawal was like because, “It’s hard to separate the challenge of stopping those drugs from the wider challenge of what was happening at that time.” I ask if he would place himself in the 10% vulnerable to addiction, and he says, “Probably at that point, yes. Not now, because I’ve changed the way I live so much that I wouldn’t put myself in that category any more.” But when I ask how his susceptibility relates to his childhood, he falls silent.
“Look,” he says eventually, “I can talk to you about why what happened in my life happened. But I just think that’s a way of trying to invite sympathy, and that would be weaselly. If you tell a detailed personal story about yourself, you’re inherently asking people to sympathise with you, and actually I don’t think people should be sympathetic to me. I’m ashamed of what I did. I did some things that were really nasty and cruel.”
Suspicions began circulating online in 2011, when bloggers noticed uncanny similarities between quotes in Hari’s work and previously published interviews and books. The New Statesman began to dig further, and soon the internet was awash with incriminating examples. At the same time, several journalists who’d clashed with Hari in the past, including Nick Cohen and Cristina Odone, began to wonder in public about the identity of a mysteriously vengeful Wikipedia contributor who’d been editing their pages. He called himself “David Rose” and began issuing inventively elaborate online denials of the accusation that he was really Johann Hari. After his IP address was traced back to the Independent’s offices, the deception crumbled. The humiliation must have been toe-curling, but when I ask how he dealt with it, he says, “I just think that would be asking people to see it from my point of view.” Sympathy should be for the people he smeared online, for the Independent and its readers: “Not for me.”
Hari had sounded considerably less remorseful when the plagiarism allegations first surfaced. He found them “bemusing”, he wrote on his website, and justified using quotes interviewees had not said to him because his interviews were “intellectual portraits”. The defence sounded rather grandiosely self-serving – so why should anyone trust his new-found contrition? “I think, when you’re in the middle of being attacked, obviously your defence mechanisms go up and you can’t think clearly. It’s the moment when you most need your good judgment and are the least able to bring it.”
The mystery is why someone so clever could have behaved so stupidly. I ask Hari to explain what he’d been thinking, and he literally winces.
“I’m very reluctant to go into a personal narrative and give the why. Most people restrain their self-aggrandising and cruel impulses, and I failed to. I failed badly. I think when you do that, when you harm people, you should shut up, go away and reflect on what happened. Going on about myself would just be arrogant and actually repeating being nasty, and that’s what I’m trying not to be. When you fuck up, you should privately reckon with the harm you have caused and you should pay a big price.”
When the scandal broke, the George Orwell prize board ordered Hari to return his award. The Independent published a personal apology and sent him off to journalism school in New York on unpaid leave, but in January 2012 he resigned from the paper. Was the price he paid disproportionately high? Hari shakes his head. “It was incredibly humiliating, yes. It was absolutely devastating, and I fell apart. But I would not want to live in a culture where people could be horrible about other people under a pseudonym online, or act as if something someone had written had been said directly to you, and not pay a big price for it.”
For his new book, Hari has posted audio files online of every interview, so he is obviously worried about his credibility. Does he think this elaborate transparency will restore it? “Well, I fucked up and it’s perfectly right for people to be sceptical. I know I’ve got work to do in regaining trust.”
I ask how he thinks his disgrace changed him. “In two really big ways. One was just slowing down; writing much more slowly, living much more slowly, being less work-obsessed.” He is single, and shares his flat with a primary schoolteacher, one of his oldest friends. Most of his friends stood by him through the scandal, and a new one has been Russell Brand, for whom Hari has worked off and on since helping him prepare his 2013 standup tour, Messiah Complex. “We have long political conversations, and sometimes that sparks something useful for him, and then I send him links or books about what we’ve discussed.” He helps produce Brand’s podcast, the Trews, but when I ask about the rumours that he ghost-wrote Revolution, he laughs. “No. I didn’t write a word of it. As I suspect anyone who reads it can tell, those are all Russell’s words.”
It’s a relief, he says, not to be “in a state of mania any more, ripped up into a frenzy of constant opinionating and polemicising in my room”. I’m amazed more columnists don’t lose it, unhinged by the insatiable outrage of the Twittersphere, but when I ask if he thinks the register of public debate is becoming dangerous, he smiles. “Funnily enough, one of the good things about not being a columnist is that I don’t have to have an opinion on things like this. You’re probably right, and it sounds very persuasive to me, but I don’t want to join an angry argument against angry arguments.”
The other big change, he says, is that “I lost my taste for rendering judgment on people. I think now I’m more interested in understanding why people are the way they are.” What does he miss about his former life as a columnist? This time the silence lasts so long that I wonder if he heard the question. “It was the only job I ever wanted to do,” he says finally, and looks ashen. But he is already working on his next book, and says his new life makes him happier and healthier than his old one ever could.
If disgrace turned out to be a release, it still doesn’t feel that way to Hari. “No.” He shakes his head. “I’m not going to present it like a redemptive fable. It was awful, and I wish I hadn’t done it, and I wish I could go back and undo it.”

Tuesday 10 January 2012

The cost of our habits


By Ardeshir Ommani

 

Altria Group is the leading cigarette maker in the United States. The stock of the company rose 20% in 2011's depressed markets and it's up 50% over the past two years, nearly four times the market's average gain. About two weeks ago, the stock of the company, which is the parent of Philip Morris USA and that of the Marlboro brand hit a 52-week high of $36.40.

The rise in its stock price is influenced by the company's stable cash flow and a dividend yield of 5.5%. At the time when money market rates are less than 0.5%, and the 10-year Treasury is 
yielding less than 2%, the stocks of Altria Group attracts all the attention of the investors who do not ask how many smokers would die this year because of addiction and succumbing to lung cancer. It is worth noting that on December 23, 2011, from Richmond, Virginia, Altria's operating companies launched "Citizens for Tobacco Rights", a nation-wide website to assist the tobacco companies in promoting lowering taxes on cigarette sales.

Although US cigarette sales have been in a severe long-term decline, to be exact, its shipments dropped by a third over the past 10 years, the industry has been able to offset the volume decline with increases in wholesale prices. Naturally after addicting a large segment of the youth around the world, the owners of Altria Corporation are led to raise the cost of their habits and suffering.

The companies have raised cigarette prices by nearly 35% over the past 10 years, even as smokers shouldered huge jumps in federal and state cigarette taxes. Altogether retail prices and additional taxes hiked the cost of a pack to $5.95. This was more than double the rise in overall consumer prices.

This shows that the high rates of profitability in addictive substances is the ideal method of exploiting not only the workers, but also the consumers. The change in the demographics of cigarette addicts has forced the industry to intensify the rate of exploitation of those who can least afford the habit in a long period of economic stress and high rates of unemployment.

The captains of the stock market seem unshaken. The stocks look rich based on their double-digit price per earning ratios. The high rates of profitability in the industry have led the management to implement the strategy of stock buybacks and huge stock awards for management compensation.

Altria is by far the biggest US cigarette maker in both market weight ($61 billion ) and revenue-wise (over $16 billion a year). A substantial share of the company profits are generated outside the US. Philip Morris International, a subsidiary of Altria, sells Philip Morris brand lineups in about 180 countries around the world.

In other words, the men, women and more frequently, elementary-aged children - often at the cost of their lives - are providing these gentlemen in New York and Chicago with lavish life-styles. (Looking at just a few of the advertisements in major corporate newspapers as the Financial Times, New York Times, The Telegraph, etc. directed at this wealthy 1%, we see a woman's handbag selling for $4,000).

In 2009, Altria purchased the smokeless-tobacco producer UST, which makes Copenhagen and Skoal brands at the cost of $11.7 billion. The reason Altria shouldered such a high cost price is that smokeless tobacco is a much-less regulated part of the worldwide cigarette market. Lack of regulations leaves the smokers at the mercy of the tobacco industry. Altria generates in an average $3.5 billion a year in cash flow, most of which ends in the investor's bank accounts in the form of dividends and interests and conspicuous consumption.

As a group, cigarette smokers have lower household incomes than non-smokers and are nearly twice as likely to be unemployed, says a financial officer of Morgan Stanley, a banking corporation. Studies have shown that in communities with higher economic status, its members send their children to better-financed public schools and private universities where environmental sciences and healthier life-styles are emphasized in the educational curriculum from early grade school through university level.

Anti-smoking campaigns partially financed by higher city and state budgets are more predominant on expensive billboards in these higher income communities.

On average a member of this lower economic class spends more than $2,000 annually, smoking a pack a day, the amount that could be allocated towards the present and future sustenance. Smokers, in their attempts to halt casting a large amount of money to the rich, many have traded down to either cheaper cigarettes or bulk tobacco for rolling their own cigarettes.

For this reason, shipments of roll-your-own and pipe tobacco jumped 30% in the first half of 2011. In the brave new world, particularly the Facebook generation age 21 through 29 is no longer fascinated with that rugged cowboy who was for many decades the symbol of Marlboro.

Alongside Altria in the tobacco market stand such giants as Reynolds American, maker of Camel and Pall Mall as well as Natural Spirit brands selling the ugly and more hazardous chewing tobacco brands. To entice new smokers or keep the old ones in the loop, the cigarette companies constantly hatch out new names with new packets. Recently, Philip Morris USA came up with what it calls the "Marlboro Leadership Program" which puts a price cap on what the retailers can charge for a pack of Marlboro in return for promotional incentives, such as a free pack for every carton sold.

While in the US, after years of public pressure, the federal and state governments have imposed some restrictions on advertising and marketing tobacco products, the same companies in the markets of the developing countries promote and glamorize smoking among school children, going so far as to distribute free packs of cigarettes along the pathways leading to schools, the way they did just a few decades ago in the run-down parts of the big cities and the depressed small towns across the US.

Also, the ruling classes of the countries whose economies are dependent on the US and its partners benefit from such relations through providing lucrative markets for the tobacco products of the major international cigarette producers.

It is telling that the gains posted by these tobacco companies in 2011 was skyrocketing when few other stocks were thriving last year. A group of mutual fund managers who tried to avoid negative performance by the end of the year resorted to placing the shares of several tobacco firms among their top holdings.

Gains of more than 20% among the addiction enablers helped these funds outperform their rivals and attracted the moderate savings and the retirement funds of the employed and retired working class. Such is the political economy of the habit-forming industry, addiction of the oppressed and higher rates of profitability.

Ardeshir Ommani is a writer on issues of war, peace, US foreign policy and economic issues. He has two Masters Degrees in the fields of Political Economy and Mathematics Education.