Leaving Psychiatry Chap 8; Responsibility.

Addiction and the Myth of the Hijacked Brain

"For the good that I would do, I do not; but the evil which I would not, that I do."

St Paul

"But to manipulate men, to propel them towards goals which you-the social reformers-see, but they may not, is to deny their human essence, to treat them as objects without wills of their own, and therefore to degrade them."

Isaiah Berlin

On Addiction; written mid 2019

Scarcely a day goes by when I am not confronted with some desperate family member demanding I lock up their drug using loved one force upon them a state of abstinence. It’s obvious these family members are well intentioned and tortured by seeing their significant other destroy their lives at the end of a needle, pipe, or bottle. The current chapter is not to trivialize their suffering. Nor is it to argue the case I should not lock them up on account of its utilitarian futility. Were I to grant the wish and psychiatrically incarcerate the consumer of drugs, abstinence would endure for only as long as the incarceration persists, along with perhaps an additional few hours or days until they source their drug of choice again. No, the question is why drug use, even repeated drug use, is a matter for psychiatry specifically or medicine in general? Separated from the physical sequalae, why is use per se seen as a “health” problem? We can hardly say there is place for the doctor if use impairs social and occupational function sparing the body. Or can we? It makes for an appealing holistic view of health to include everything good in a patient’s life. But good intentions lead to unintended consequences. Holistic models of health can easily be exploited by those who convert ecological or new age holism to political totalitarianism. It makes of the doctor a state agent of social engineering.  

Back to the family member. Hopefully we might begin to worry about all the cultural/political/legal/psychological assumptions creating the situation where they scream down the phone at me. They say their loved one has a disease and cannot control of their own behaviour. Criminality was very rarely mentioned, though throughout my career criminality has frequently been objectively the case and family members new it. Over my years of practice most of the substances of addiction are on the books as illegal to possess and use. Even cannabis for the most part has always been notionally subject to some legal sanction, as has public drunkenness. This is to say nothing of methamphetamine and other allegedly “harder” substances. How have we arrived at a point where the legally real is ignored (often even by the police themselves), whilst the philosophically debatable (drug abuse is disease) is reflexively assumed.

Not surprisingly, I place the blame at the feet of psychiatry. Long before Leshner wrote in the journal Science in October 1997 the nonsense non sequitur “that addiction is tied to changes in brain structure and function is what makes it, fundamentally, a brain disease,” psychiatry viewed it in the same way. To this day one will be hard pressed to find an article by the psychiatric intelligentsia that does not refer to drug use as a public health problem, repeated use as “addiction”, a “chronic relapsing disorder”, a “brain disease” or many other medicalized and materialistic permutations of the same.

The Reward Pathway

Almost every review article of addiction will mention the so called ‘reward pathway” and “neuro-circuitry” of addiction. The whole reward and addiction pathway story philosophically revolves around something which is not always presented as a circuit. A circuit is (by definition) a closed loop where one end fuses with and becomes continuous with the other. Every single model of any possible event involving brain, behaviour and environment can be represented as a circuit. And so, the model in its universality packs less of a punch than we think. What talk of neurocircuitry does best is a psycholinguistic trick of making it easier we see ourselves as a computer.   

Nor is it a pathway, where pathway is a metaphor invoking an image of something material by which a person with agency may move from point A to point B. Instead, the “reward pathway” is, at its most basic, nothing more than the physical extension of nerves fibres from an area deep in the brain (the ventral tegmental area, or VTA), to another area deep in the brain (the nucleus accumbens, or NA). This single extension also constitutes part of the greater “mesolimbic pathway”, a pathway which psychiatric trainees and medical students will also invoke if they are asked what pathway in its excess is involved with some of the more dramatic signs and symptoms of psychosis. That is to say, its role in the brain is not one which can be correlated with a single domain of conscious mind. The chemical substance released from the former (VTA) onto the latter (NA) is called dopamine, and many a lay reader will have heard of it and “dopamine hits”. A hedonic mental experience correlates with pleasure seeking behaviour externally and correlates also biologically with an activation of the mesolimbic pathway and dopamine release. From this basic splay of neurons we can elaborate many other inputs and outputs, from which circular feedback loops can be said to explain the phenomena. There are bidirectional connections between the mesolimbic pathway and the frontal cortex, the amygdala, the hippocampus and other centres. Like fractals within fractals each of these areas contains sub-centres and sub-circuits also. Let us not do an injustice to the complexity of the brain, which is gargantuan. In fact, given that the whole array of “circuits” include sensory perception apparatus (of cues) and the motor outputs (towards behaviour), anyone with an ounce of imagination and an undergraduate knowledge of neuroscience can construct a model of addiction and circuitry involving the whole brain without exception of any part. And why stop at the brain when the “circuit” can conceptually extend out into the entire world inclusive of non-biological points of flow and entry (including history itself).

It does reveal something of the silliness and arbitrary nature of the neuroscientist who, when examining a complex social behaviour, points to a part of the brain and says “there it is”, “there begins and ends the circuit”. By the same token it is absurd to say that something giving you pleasure is that little squirt of dopamine you get from it. Whatever other brain centres are required, and however the consciousness is thought to be an emergent distributed property, the materialists ultimately think that little spurt of dopamine is you. As was made clear in chapter 3, does it really add anything to the metaphysics of the mind brain/body problem to say that the mesolimbic pathway is further connected to area X of the brain which correlates or thought to be involved with impulsive inhibition, or area Y thought to be involved in anticipation and expectation, or area Z with anxiety as a driving force to use? As was also made clear in chapter 3, between mind and matter is a metaphysical divide that I assert can never be bridged. And a knowledge of biological connectedness does not advance us one jot or tittle towards the answer of phenomenological binding in consciousness. It’s not a knowledge problem.

Apart from the mind brain problem and the impossibility there are natural limits to constructed models of circuits, many more facts besides make the brain disease story problematic. Firstly, the same mesolimbic reward pathway is involved in any hedonic experience. It is not pathognomonic of addiction and does not make of it a different category to habitual pleasure seeking in work, love and play. Nor do elaborations outwards from the basic mesolimbic core constitute the coming into being of addiction, for they too are common. Take for example the cues to nostalgia and romance from a sight not seen for years. Or an anxiety provoking day at work associated with the want to get to the car and listen to favourite relaxing music for the drive home, or simply to “get pissed”. All pleasures and pains and hedonic seeking involve more than the mesolimbic pathway, without a categorical divide within the brain. And plasticity of these pathways is a response to use, not the cause of use, even repeated use, which is choice. It cannot be assumed that we can draw the line between good reward pathway and bad reward pathway without dragging in moral categories. These categories lay outside of neuroscience altogether.  

Secondly, this biological reduction is predicated on what the brain is seen as being, either something we are or a tool we use. People use pathways vs people are pathways is the basic philosophical point of division, also as partially addressed in chapter 3.

Thirdly there is the non sequitur of a change in structure and function in the balance of power between pathways somehow being the argument that the change in the brain is disease or pathology. A change in structure and function is often a consequent of use, lack of use or misuse. Once again these are not just biological considerations. Learn a musical instrument or a martial art. Change in structure and function of the brain. Become a cabbie and learn the knowledge of the London streets. Change in structure and function of the brain. Decide to languish in a haze of non-medicinal cannabis smoke or boil your brain on meth. Change in structure and function of the brain. Switching lifestyles will involve a change in structure and function of the brain. Even a materialist must admit this is the case. Their whole metaphysics is dependent on this basic fact, that mind and behaviour will have some representation of some kind in the brain. Now true some changes in behaviour and consequent structural and functional changes in the brain are harder won (or lost) than others. This is a microcosm for life writ large where the good, the beautiful and the true takes effort and sacrifice. It does not follow that the one who tries and succeeds has a healthy brain and the one who does not try and so fails has a disease. Neither does it follow that the changed brain of the user vs nonuser is disease. The different brains of the two are the result of choices made. Granted there are horizons of potentiality beyond which no human can pass. Anyone involved in recovery from stroke or anyone wishing to add to any skill base knows all too well the reality of physical limitations. But in the absence of a stronger argument of why brain change is necessarily disease, I will continue to insist that the behaviour and what one does with the will is a moral category. That drug use is often maladaptive and repeated compulsive use to the exclusion of more fruitful behaviour is harmful to the user and society alike is a common sense truism. We can grant that certain connections (so called impulsiveness inhibition pathways for example) become weaker in the addict. We can grant so called maladaptive behaviour promoting pathways become stronger.  So what? Used muscles become larger. Unused muscle may atrophy. But a pathway and its weakening/strengthening is a correlate to the self, not a determinant of the self, and not a definition of what the self in its being is. No one has found the self in the brain. The brain is the canvas upon which the addict paints their will. No one can paint too far outside the lines, though everyone can choose where they apply colour and shade and when they paint over what has been done before. Some start painting with certain appetites and these appetites might be neurologically informed (indirectly). Again so what?

But the Addict is Robbed of Free Will. They Are Special.

Nonsense. Beyond the desk where I write this chapter is a door. And beyond the door are hospital patients. And I read from the patient presentation list that one is a child with an allergic rash, one is a pregnant woman with problematic vomiting, another is an elderly gent with hip pain and possible fracture, another child has asthma, another is “post ictal” (i.e. has had an epileptic seizure). There are several “chest pains”. It likely one of these will be written off as anxiety or “costochondritis> Its also likely at least one of these is having a heart attack, soon to vanish downstairs to the cardiac lab. The list continues as I scroll down. Now I ask the reader to engage in a simple exercise of calibrating their common sense intuitions with the reality of the world.

I invite the reader to imagine something brutal to be sure, an experiment I’m not ever suggesting to be done in fact. Yet here is our gedanken experiment.

Imagine yourself holding a gun to the head of the pregnant woman. You inform her that if she vomits you pull the trigger. Or toward the elderly man with the busted hip you point the gun. As Christ told the cripple to up and walk, you say the same. Or the asthmatic turning blue you tell them they get the bullet if they do not under sheer force of will dilate and re-oxygenate their bronchiolar tree. Or the patient infected with the virus they must by force of will kill off a virus. Or the epileptic will face the firing squad if they don’t hold themselves back from the seizure. Or tell the skin not to rash at point of a gun. Or the cancer not to grow and spread. On and on the list goes. These are disease over which the person has limited to no control. Now we might say that the heart attack is informed by poor diet and such or the hyperemesis is informed by the choice to do what one necessaries in order to become pregnant. After all it wasn’t the immaculate conception. This is not the point. Nor is it the point that the mind can do amazing things all on its own to modulate pain and to soldier on in the face of injury and disability. With some Herculean effort people can even hold back an insistent diarrhoea for a little while or hold back a cough until they can hold back no longer. Psyche and the soma are linked for sure. Yet common sense often defines the limits of mind over matter, and we need not call upon the doctor to instruct us on its limits. Even those yogis who are said to be able levitate (though no one ever seems to film them) seem ironically unable alter the shape of their lens. Even gurus put on their eyeglasses in the morning. Returning to our diabolical little experiment, the odds all would be shot would be high indeed. Their disease will have its way with them and there is little they can directly do against it.

Now let’s imagine the same experiment, only this time replacing the above subjects with the alleged disease of addiction. Now the trigger is pulled if they reach for the bottle or the pipe, the bong or the needle. And our subjects know we are serious as they have seen us execute the previous cohort. Try not to allow our common sense intuition be contaminated with what we think may happen as per our indoctrination by psychiatry. This is not a psychiatric guild exam. This is reality we are appealing to now. What say the reader? Will they reach for the drug? Will the trigger be pulled or not?

I have not the slightest doubt that if such an experiment were performed that the survival rate would be enormously high, proof positive and beyond dispute that drug use is neither seizure nor rash, nor stroke nor vomiting nor cancer. It is pure and simple choice. Will power, as terribly unfashionable and politically incorrect as it is, exists!

As it so happens, the experiment has been run by a real monster. Mao Tse-Tung and the Communist party of China took power in the 1949 revolution and set about reforming the country. Part of the problem that Mao faced were anywhere dozens of millions were addicted to opiates (mostly opium itself). That they were addicted, I will argue, was a matter of choice though it didn’t help that the British had forced the opium trade upon them and even fought two wars to this end in 1839 and 1856 respectively. You see in those day we did not fight the war on drugs so much as fought a war for drugs or the war with drugs. Mao wasn’t about to waste tens of millions of bullets, and people means productivity for a new power on the march. Later with the great leap forward these tens of millions would kill off literally billions of rats, insects, and small birds in order to fix several other real public health crises of the times (but that’s another story). And so, Mao staged some very real yet very symbolic brutal public executions of drug barons and simply told the addicted masses to give up the poppy for the good of the people or die as an enemy of the state. And give up they did. Now I’ll grant the story is not as simple as that. Mao was not driven by principle as from political pragmatics. An earlier Mao himself traded opium out of Yanan to finance the revolutionary effort. A later Mao killed many more tens of millions than he sought to save. And for the teeming masses he saved to then kill, ceasing opium took effort and a mobilizing enormous social pressures also, a drive to a new state of belonging part of the people by seeing opiates as the enemy, not in toto a bad thing. And whilst he decimated opium use, granted he did not eliminate it completely. Forever and always, there will be an underground drug trade and organized crime. Still, no one can deny that Mao ran the world’s largest and by far most successful drug rehab facility, putting to shame the best rehab clinic you will ever find in the contemporary western world. If the incentives are perceived as being high enough, people can and do exercise choice.

The next political figure to do even a remotely similar thing was Richard Nixon and his “Operation Golden Flow”. In the closing days of the Vietnam war many thousands of American servicemen were “addicted” to heroin, which I’d speculate was readily available in the golden triangle after Mao pushed the centre of production south. American serviceman also used copious amounts of military sanctioned stimulants, cannabis and psychedelics, though this too is another story and the balance shifted more towards heroin by 1971. Nixon was concerned that returning serviceman would remain addicts and join the ranks of the urban black underclass. His solution was a simple one. A seat on the plane stateside was contingent on them being clean from heroin. Those who did not take him seriously were turned away at the tarmac until they proved themselves clean. Lo and behold these soldiers terribly afflicted with the disease of addiction, with supposedly reorganized and “hijacked” reward pathways stopped use and got on the plane. Even more surprising to disease mongers, only a minority continued a life of heroin state side, and only a minority of addicts even sought replacement of heroin with cannabis and alcohol, the latter of which has always been a problem. Back in the land of the free and the home of the brave they no longer faced intermittent cycles of monsoon and mosquitoes, of boredom and bullets and blood or any of the usual sights and smells of Vietnam. They had different connections and different meanings. All of this was the connective tissue upon which a change in choices was made. But it would be as much a nonsense to say that a Saigon Monsoon bio-mechanistically caused them to use heroin as it would be to say the sight of the statue of liberty bio-mechanistically caused them to stop. Indeed, it cannot even be easily argued that drug use was fuelled by psychological trauma of war. Just as much use was had by those who never approached the front line. It was part of the counterculture of the 60’s and 70’s to use drugs. People used drugs because they wanted to and enjoyed the altered mental state more than they disliked the consequences. It has always been thus.

Incidentally, punishment has a flip side, that being reward. There is abundant evidence that addicts given cash incentives can modify behaviour. Scale it up and imagine our patient with atopy who will get a luxury holiday if their skin does not rash, vs the addict who will get the same if they refrain from substances. Do we seriously think both are diseases equally beyond personal control? Would we seriously place our bets symmetrically across both groups?

Why do we see some people as powerless to addiction?

Part of the problem is the overreach of medicalized thought, of genetic determination, of brain pathways etcetera (vide supra). Part of the problem is also phenomenological and philosophical, something I’ll call the “cannot” vs “do not” fallacy. The addict might be described as someone who desires not to use and might be painfully aware of the negative consequence to use, both in their lives and that of loved ones. But they use anyway. (Or they might be described as someone who denies the obvious fact of their misuse being maladaptive. But how we know they don’t know their use is harmful and not wish to admit it). Back to the ordinary case. Despite the desire not to use they find themselves compulsively using, where compulsivity is a technical term of art to mean they have a powerful internal drive within them that results in the behaviour (the compulsion), a drive which is discharged for a time after use only then for it to gather force again. Consequently, the addict might pass through their entire life saying they are doing something they do not wish to do yet do anyway. This is true. But this is a description of observed facts, not an explanation of the why they never stopped. Surely, they are moulded into an automaton with their conscious awareness of the events only going along for the ride? Surely the disease forces them to use? This is the point where we ought not to lose our phenomenological, or logical, nerve. It does not logically follow that from what one does do, that one cannot do differently.

To begin, people have mixed motives. By exercising choice, the user may be advised to start their road to abstinence by forcing their will into not giving up but in pure self-knowledge. They might seek clarity in admitting just how much they lie to themselves as to their potential and motives. Sometimes there is a part of the addict who derives satisfaction from use, even harmful use. They see value in it. Psychiatry often helps in creating that value. One hears all the time from psychiatry ever greater procrustean excuses why the addict might want use, almost always at some point allowing the user absolve themselves of responsibility. Absolution from responsibility is the zeitgeist. I can and have lived literally years without ever hearing from a psychiatric colleague the simple insight that being drunk or high simply feels good. Desiring what feels good is as human as being human can get. This part of the addict dislikes the discomfort of the come down, withdrawal or the boredom of returning to a world of abstinence. This part of the addict would rather we stop badgering them and allow them to have their high. And this part of the addict will pay lip service to the impact of their use, to garner sympathy or simply have the complainant shut up for a time. We cannot discount the place of subtle agency in choosing this part of ourselves and wanting to be an addict even when other parts of ourselves wish we were not. It is not fashionable to press this fact upon the user. Psychiatry is full of soft caring minds in socialist health care. That or practitioners who are small business people do not wish to irritate a paying consumer out of using their services. Nor would psychiatrists like to admit that to declare the patient bereft of free will is in proportion with elevating the intensity of the problem and themselves as the intelligentsia with the expertise to stop something beyond the patient’s control. Narcissism depends on the patient’s power being reduced and the practitioners being elevated, to save them from themselves. Viewing addiction as a brain disease is also an excellent strategy to gather funding for the research industry. When the reality of an alleged medical illness is brought under question, follow the chain of whose egos benefit from the medicalization. And follow the money to the thought leaders in the field, and to the regulatory and research agencies for profit from it. And remember the psychiatric ethos as per previous chapters. The epistemology is pragmatic. The truth is what is useful. Nothing is more useful than money, power and praise.

All that having been said, I’m not making the claim addiction is necessarily a bad thing on moral terms. Some people have lives that are halfway between a train wreck and a horror show. I am more inclined each day to think much of the world is not worth the sobriety. So who am I to blame. We need walk a mile in the others shoes before letting loose on blame, and even then maybe not. Yet this is not to imply they lack choice in facing the horror show. And it is difficult to leave or rewrite a horror show when the mind is intoxicated. Nor is this to imply the appropriateness of the term “self-medicate”. We medicate against illness, not problems which ought to be considered non-medical. To place everything into the category of medicine from which we will medicate is to become the therapeutic state, the worst horror show of all.

Secondly, we must not medicalise moral weakness in the will of the drug addict as if drug use is a unique and reified category. Take the following examples. Someone wants dearly to apologize for that offence made years earlier. They think about this often (thought and temptation to change). But they never pick up the phone (they habitually fail to change behaviour). Or they want to learn that foreign language and never pick up the book. Or they want to correct their diet and never give the dessert spoon a rest. Or they always say they will take out the garbage without ever taking out the garbage. Sure, they feel guilty if they don’t, yet never take it out anyway. Or they want to exercise more yet never buy the running shoes. Or they wish to overcome their fear of flight. Or they find themselves each week writing a list to write to old friends and the list carries over weekly in the diary for years (something I’m guilty of). Or they fly off the handle and become irritable, regretting their anger later and vowing to change. The list is endless. “I do what I do not want to do” they say, and from it they say “I am what I do not wish to be”. Yet would we say they too are addicts of a kind? Would we say they are automatons to their faulty brain circuits? Not at all. We would say they are human. Most humans, nay all humans on some level, never gain a victory over themselves. They are akrasia versus enkrateia, score 1:0. The addict simply sits upon a spectrum upon which we all, without exception, stand. We might all say we love to gaze on the beauty of nature. We all say we care about the environment. But the smart phone and automobile has brought to the fore just how “addicted” we all are. In fact, rather than my banal examples arguing against the medicalization of addiction, in our age the banal has been swept into it. Think of the aggressive and adulterous celebrity who sheds crocodile tears as they speak of their “sex addiction” and their “anger disorder”. Some psychologists seriously lobbied to include compulsive shopping disorder in DSM 5. People want to lie to themselves and turn everything they do not want to be into a disease so they can become the thing itself (stated preferences are not revealed preferences, and revealed preferences arguably tell us more about ourselves).  In psychiatry they have a secular priest only too willing to give them the demon addiction they are possessed with, absolve them of responsibility and then enter an exorcism not likely to end.

This is where we come closer to approaching the cannot / do not fallacy. Imagine any one of these individuals manage to escape the gravity of habit and inner conflict, the drug user included. One day they did give up. This will surely be a proof not just of the exercise of free will in general as it also be a proof this individual possessed it. We might say (though this would be silly), that they have the lucky gene of free will or their frontal lobes luckily managed to seize the balance of power that fateful day the tide against addiction turned. Materialists will always be able concoct stories. We might conclude that there is a subclass of addicts where abstinence is possible.

Yet what of those who pass through life and draw their final breath always dipping their toe into the pool of a life better lived (i.e. abstinence), yet never to take the plunge. That is to ask, what of those who never give up? It will falsely be concluded as an empirical fact that they lacked the constitutional strength to make that change. Why? Because they never did change. It’s a nonsense conclusion but anyway. This will be inductively taken to be proof that there are a subclass of people who truly are compulsive automatons, who cannot change and so need either saving or excuse mongering. From this will come ever greater elaborations towards hijacked brains and overpowered and reorganized brain circuits, of fMRI results and all manner of nonsense and psychiatric industry. But pray tell how can anyone conclude from an unrealised outcome that the person lacked the potential? How are they seers of souls to reach this conclusion? It is to say that if I die having never purchased that item on the shelf that I never had the funds in my wallet? How do they know that? How can they know that?

Besides, saying that some people cannot ever control themselves irresistibly attracts many others who wish to be included in the leagues of the powerless to excuse themselves of their misbehaviour. Absolution of large responsibilities is the gateway drug to absolution from all responsibility. There is abundant experimental evidence in the psychological literature showing that if subjects are coached to towards belief in free will not existing, they tend towards more selfish and immoral behaviour. Perhaps those who promote addiction as disease come close to breeding the very thing they think is a fact of the world, the disease they wish to cure.

Driving in the Wedge of Choice

In less jaded times, I spent a great deal of time diving deep into the phenomenology of my patients, far more than most of my colleagues ever did. Where others would spend 45 minutes in psychiatric assessment and the standard interview, sometimes spent another 90 minutes in conversation exploring the mind of the addict who chose to admit they had a problem yet felt powerless in their use. In my own practice I have never ever met the addict who did not have those times, even a fleeting daily moment, when their consciousness and conscience did not exist at a mental crossroads. On one side of the crossroads was the drive to use. On the other the call to the duty not to, all that they said they wanted to do and be, or all they wanted not to do and not to be. There in the middle they stood. They were unable to deny that however weak and feeble they were, however much the product of habit had them pointing their feet in the direction of use, that weak and feeble person went by one name and that name was choice. My primary psychotherapeutic move for addicts is to take those times and consciously stop. Stand within that moment. Choose to rip it open ever wider and choose to stand within that time as an ongoing moment. So as not to find oneself mindlessly walking left at the crossroads, make each moment a moment of choice. Widen this moment into a state of permanent choice creates a tension one will wish to escape. But hold the tension all the same, for the tension is choice and emotional discomfort an exposure to how weakly we have exercised it. Always be aware of the temptation to collapse the choice into habit and always be aware how wily the will to use can be in presenting the mind with a lie. The house needs milk. I am going to buy milk. Is my dealer loitering near the grocery store? Is the liquor store next door to the grocery store? Will that step towards the much-needed milk bring me closer to using or further away? If so, then say no to milk or go purchase milk with each moment a meditation not on the goal of the milk as opposed to the goal not to use. Never let the guard down until a change in behaviour creates a new armour and many chapters are written into a life of different habits. Addiction is that part of yourself that will tell the little lies you want to believe, to keep you bound.

For some the fight against addiction means going a step further and changing ones set and setting. Like Odysseus resisting the sirens call, if not attending parties will sustain sobriety, then bind yourself and don’t attend another party. Or go further, question the very value of parties. If it means changing work to a lower paying less tempting job, then do that also. If it means leaving the sweetheart who keeps you in the gutter with the bottle that is a choice also. Odysseus chose to be bound to the mast and his sailors were ordered fill their ears be filled with beeswax. The sirens call is more addictive to any drug. I am Hermes to your Circe and can only offer the advice you already know to be true. The rest is up to you.

A note on Liberty and Decriminalization

Hopefully I have convinced the reader that addiction is not a medical disease, and that it ought to be uncoupled from psychiatric industry and ideology. Is this to imply it is not a social ill either, or that the user ought to be left in the gutter to rot? Not at all. There are medications that can assist the addict in the utilization of their choices to the life better lived. These act on the brain I know (and so my argument is not incoherent). These are currently the province of doctors to prescribe, though often ought to be prescribed far less than they are, as addicts can easily just exchange one drug for another. I’ve known people who spent five years on heroin and then the rest of their lives on methadone (which is not safe) or buprenorphine, making of the psychiatrist someone no different than an alternate drug dealer failing to act on the principle that a drug that is not medically required ought not to be prescribed, except as a transitional object towards no drug at all. For those wishing to escape the gutter, any healthy society would naturally foster the power of family, friends and benevolent institutions to help them, of greater connectedness to their fellow man (and woman). These are common senses. Only in a sick world would we need an experiment to prove them.  

But what of the law? In my own practice, I’ve never seen the war on drugs as seriously being fought. I am speaking of the ground level here, not denying the reality that every now and then the headline reveals large scale networks being smashed and small level dealers with them. Certainly, the western world has never done as Singapore does and never did as Mao did. No war can be fought liberally, or it isn’t war. Our governments may wish not to fight the war, though it would be disingenuous to say it was fought and lost. It’s just a cringe abuse of a metaphor. Unless a police officer takes a particular disliking to a person or there is multiple or repeated other charges, I’ve never seen drug laws seriously prosecuted on individual users. Most of the time all a drug possessor or petty dealer need do to avoid going down the road of any minor prosecution is to threaten suicide. They will be dumped off at the hospital and that will be the end of it, the police thanking their lucky stars they dodged some extra paperwork. To such an allegedly suicidal person I ask them please quid quo pro. Be kind to the psychiatric team. When the police leave the emergency department recant the insincere threat. Should the user happen to face the magistrate for drug offences there may be a fine they have no intention of paying. The state will not pursue the fine, or the individual charged might claim to a history of mental illness. The judge will then assume drug use is part and parcel of their illness. They will then be leaving the dock to enter not a prison cell, but the sunshine outside, if not the rooms of a psychiatrist. And so, the cycle will repeat. The street will know that apart from some fancy seizures of supply and arrests of middle and top tier dealers and distributors, that there is no real risk to the user from state, regardless of what the law might say.

Does this imply the war on drugs ought to be fought? Not necessarily. My own inclination is towards a radical liberty and to remind the reader of Mills axiom.

“The only purpose for which power may be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant.”

Of course, it is possible to argue that the addict has left the civilized community and so is in forfeit of liberty. However, that would place us on the slippery slope where could arbitrarily divide people on its own terms, some labelled civilised and some not.

The problem is not entirely resolved either by the question of “what works”, neither by cherry picking statistics from the pro drug Portuguese statistics favourable to the libertarian decriminalization cause, or by appeal to the pure principal of carte blanche libertarianism itself. For the libertarian, a mereological problem arises with the accretion of liberties within the one person. Sure each liberty can be argued to be valid on its own. But might there not arise problems from combinatorial freedoms?

Moreover, the problem is the effect this necessarily has upon others in the liberal society simply from the exercising of these multiple liberties. Let us imagine the case of the cannabis addict who fritters away their day in an unmotivated haze, this mixed with occasional paranoia. Now we might be able bring ourselves to the callousness of turning our back on them, especially if they wish us to. But they will break their family’s heart and purse. Are we to be callous to this also? Are we expecting that their family enter that nirvana state of liberal individualism, to harden their own hearts, to “look after number 1” and simply cease to be attached to kin? Because it’s all about me, I am not my brother’s keeper. Or am I? And what if the product of the user’s liberty is to burden the tax payer with the cost of a disability pension resulting from choices masquerading as “a brain disease”? Ought the liberty to be perpetually stoned entail a loss of liberty to the taxpayer in having the fruits of their labour taken from them, even if this fiscal injury is just one slice in the death by a thousand cuts? And what if stoner, in or out of their paranoia, becomes violent? Cannabis alone can add to the disconnect between the potentially moral actor and the immoral act, though methamphetamine or alcohol can also clinch the deal or do perfectly well on their own. It is all well and good to speak of persons as having liberties up to the point of the fist hitting the face, though this is of little comfort to the neighbour of the ice addict waving their fist in the air. I’m still edging towards the libertarian side. But this is not because I see the drug user as harmless. Its because I see the state as far more dangerous.

Let’s take it a step further. You might own a gun for protection. I might own the same. Or I might not, the rightness or wrongness of weapons being another subject. The American reader might see this as a constitutional right, the state having no right to obstruct one who might bear the firearm to the ends of their own protection within the boundaries of their own property. I am sympathetic to the sentiment. Yet back we are to the question of combinatorial liberties. In a libertarian utopia do we defend the right of the methamphetamine user (right 1) to patrol their cannabis farm (right 2) howling at the moon (right 3) in the wee hours of the morning with shotgun and machete at their side (right 4)? The shot is not fired yet the menace is hardly trivial. Would we expect their neighbour not feel terrorised? Does it really make any difference if we take the shotgun from them if they have the machete, or more lethal still the automobile? There are dangers in potentialities prior to aggression. Or what are the elderly to do in a yet to be gentrified part of town when they do not feel safe to go outside and into the howls of drunken and drug addled masses. Though no violence has yet been done, are our sensibilities drawn to seeing them as under siege? These are very difficult questions, questions which all libertarians must imagine themselves to be placed before they take principles to autistic extremes. Yet these are neither medical nor public health questions. These are moral, social and political questions. A civil society cannot endlessly sustain a mismatch between liberty and responsibility. We cannot allow liberty to do anything and everything one wishes within the non-aggression principle without the calculus of risks increasing beyond the braking strain.

Some Small Steps Within Liberty

I do not pretend to yet have the answer to the question of what to do in law when individual liberties collide with one another. But as one experienced doctor committed to the fact that drug use a matter of choice, I think that I and any citizen ought to have the liberty to make clear what is clear; that addiction usually results in one or another kind of harm to others. The current treatment paradigm in addiction psychotherapy is the cycle of change model of Prochaska and DiClemente. This model asks us to identify how prepared the user is to change and type them according to where they are at in their journey. Are they a) pre-contemplation/not interested, b) contemplating change, c) preparing for change, d) action within change, e) maintaining abstinence. We are asked to tailor our psychotherapeutic approach accordingly. Actually, I’m quite sympathetic to the model in itself. Providing it is not dogmatized, it has much merit. As practiced, it unfortunately very often also asks us also to imagine the addict like approaching a fragile and flighty animal of the wild (my analogy, not theirs). Approach too fast or with too great a spirit of confrontation and it will turn tail and dart off into the forest. Or put another way, if the addict is not ready or putting up psychological “resistance” we are to simply invite them for a conversation when they are ready. To do otherwise is to risk frightening them off for good. And heaven forbid us being “judgmental”! Even when they are ready for change, we are told to help them identify their own reasons, as if prescribing additional reasons would be to scare them once again into the dreaded state of being “pre-contemplative to change”. Rarely if ever are moral duties part of the picture presented to them. It’s always about the pros and cons as the patient sees them, more pragmatism, more atomized “me, myself and I” ism in this case. Pragmatism be damned. I’ll submit it ought to be part of almost every therapeutic encounter that the addict is given a healthy dose of Burkian thought, a dose of reality that their use is a failure to return on the investment made by their forbearers and a failure to attend to the needs of those in the present and future. And regular users of intoxicants ought to be assumed incapable of holding a firearm or driving licence at all, not simply at times of confirmed intoxication. They ought to be told at each encounter that intoxication will not save them from the full force of the law for whatever sins of violence and mischief when drunk or stoned or high. They should know better before they use.

An exchange might go something like this, and for the materialist I’ll include some of what they are wishing to be included also. Let’s imagine the conversation is with a methamphetamine addict. We might say, as is patently obvious, that cessation is a matter of choice towards being a better version of themselves. We situate them on the cycle of change model, and they want to change. We might warn them that their mesolimbic pathway has become a tad lazy. In the excesses of its exposures to meth, its downregulated its dopaminergic apparatus, though only by about 10-15% so says the data (a similar thing can occur in medicated ADHD kids, so parents be warned). These neurological changes may persist for many months. In the abstinence they are choosing it may correlate with lower mood, craving and a lack of hedonic response to what other people experience as healthy simple pleasures (though I’m not at all sold on the notion the biology is the whole story). Not a very enticing prognosis in the short to mid-term. But they can nobly bear it if they choose. They can gain existential (though not hedonic) satisfaction that in abstinence they are not participating in a sequence of transactions that has vicious biker thugs living a life of luxury and people being fed to dogs in some Mexican cartel town. I will tell them that without drug use they can study. They can get a job. They can be someone worthy of a worthy cause if they wish, they can love and be loved.

Or what of the person in their late teens or early twenties who “self medicates” their anxiety with cannabis and alcohol binges and spends all day either playing video games, getting stoned and amotivated and occasionally loitering in the nearby skateboard park. Needless to say, they are under-employed and not in study. Each day they move closer to a future of becoming unemployable altogether, if not rarely chronically psychotic. To grant them the radical liberty to use ought we not also to grant them the radical responsibility of their actions? We can offer them the psychotherapy to help with the underlying anxiety, it being an article of faith on our part that the anxiety is anything more than an excuse to “self medicate”. To take the offer is up to them. If they don’t, surely they don’t expect the tax payer or family be burdened with a lifetime of paying for the sequelae from their chosen habit. But these users know they exist within liberal democracies with social security safety nets (even the much maligned United States as some thin tissue of social security). In this way or that, across the world the user in the fact of their using chooses to make their fellow citizens suffer. We might inform the user that every day they get stoned that their parents (if they have parents or anything approaching an intact family) suffer on account of their choices. Maybe they cannot bring themselves to be sympathetic to their parent’s plight in virtue of the parents being abusive, neglectful and failing terribly in their own duties. Fair enough. But there is that ten-year-old neighbour on one side who deserves an adequate older role model. There is the octogenarian on the other side who deserves the caring visit of someone from time to time. We should not be shy of telling this young person that the sins of their own omissions lead to the sufferings of both neighbours and suffering for the world at large. The world at large need repeat the same to them, for large scale social shaming does work and has value of its own. This user sits as a nexus between generations. To both neighbours they have responsibility, in addition to themselves. We might not punish them for being derelict in their moral duties. These are duties, nonetheless.

It makes little difference to drug addiction if the drugs are either decriminalized or legalized. Granted white collar entrepreneurs are less savage than organized drug criminals. But being able to operate and profit above or within the law does not save one from the core sociopathy of greed and callous exploitation of another. It merely tempers the manifestation of it and diffuses it such that the harms are less graphic. The user might choose to make the entrepreneur rich, just as they have made the cartel or meth lab rich. More fool them. Likewise, decriminalization will almost certainly result in a larger government bloated with layers of regulatory and taxation apparatus, with bloated social security needs and with the taxation revenue going wherever the government wishes, including military excursions that make feeding a Mexican villager to a dog look like a minor misdemeanour. The problem is this, the problem being one which the state is just all too willing to collude with the polis to bring about. Our crack addict or alcoholic or non-medicinal cannabis stoner cannot be an informed and rational actor. The state finds itself amid optimizing the outcome of two intersecting functions. The first goal is to keep the people productive enough to maximize taxation and state income to finance the grift whilst retaining political power. The second to render the people too distracted and intoxicated to exercise free thought, but not so much that they lose productivity. The addict contributes to these problems, much like the populace soaked up the drug SOMA in Huxleys Brave New World. This, along with the failure of the addict to live up to the potential within themselves and their potential to their kin and the village is what makes even legalized addiction a moral wrong. It depreciates the “rational actor” part of the equation the libertarian wishes to strengthen in order for its libertarian utopia to flourish. A libertarian political realist would see that the road to legalized carte blanche drug use is likely the road towards a larger government, this also being contra the libertarian mission. The problem with uncompromising libertarians is that, like those who do not read Kants ethics carefully, they fail to see that liberty and certain categorical imperatives exists within a civil society, not without. And why promote a change that can only result in greater barbarism? Neither is it to argue hard core state control. Strengthening the natural responsibility component of the liberty/responsibility equation is the way forward to protect freedom whilst promoting better use of it. An unmolested free market of responsibility would achieve this.

Epilogue April 2023

The perfect object of addiction would not grossly damage physical health. The law would be completely disinterested in excess use, nor would most border controls be concerned at it being trafficked. In fact, the states agenda could profit from its use. Supply would be robust across seasons. Supply would not be disrupted by war. Its use would not be easily captured in existing diagnostic nosology of psychiatric “disorders”. You could addict people early and keep them for life. Most parents would not quarrel their children using the substance. You could use it as a true “gateway drug” towards other temptations. There might be (a kind of) withdrawal but no tolerance. Outside of sleep, sex and showering people would reflexively reach for it. They would forgo human connection in preference to it. Apple and Samsung succeeded in creating this object.