During the question and answer period following a recent talk at the University of Minnesota, psychiatrist David Healy wondered aloud about why one needs a prescription for Prozac yet one can easily obtain cigarettes and alcohol with no such regulation. At the time, Healy offered no answer yet I recall being enticed by the question, as well as a related one. Why the big stink over drugs like Prozac while nobody, to my knowledge, has ever written a book entitled Listening to Lucky Strikes or Thunderbird Diary? Surely other drugs are as transformational, dangerous to oneself and society, and addictive as Prozac is claimed to be. Their histories are likely to be as rife with political intrigue and greedy capitalist manipulation as those told about contemporary psychiatric drugs. Couldn't we possibly learn something about our present concerns regarding psychoactive drugs from looking at the history of other drugs? I wanted an answer to Healy's question.
Thus primed, I happened across David Courtwright's Forces of Habit: Drugs and the Making of the Modern World. This history of drug consumption and commodification provides an interesting perspective from which to examine the questions I had asked. It begins with a history of the globalization of what Courtwright calls the big three: alcohol, tobacco and caffeine, and the little three: opium, cannabis and coca. Other drugs make cameo appearances (including kava, qat, betel quid and chocolate) but for the most part, the story revolves around these six, with tobacco playing the lead role.
Courtwright's history gives details the intricate and complex personal and social relationships that exist between drugs and humans. Pleasure, poverty, morality, commerce, and economics are but a few of the forces that have determined the fates of the drugs Courtwright considers. Which particular forces were most significant for any given drug, and why those forces existed rather than others, make for fascinating reading. The richness of this book lies in these particulars. The fact, for example, that tobacco was denounced by early Englishmen. King James I, himself, reasoned that since tobacco played a large role in Amerindian rituals, obviously inducing hallucinations and since the Indians were not Christians, the hallucinations must be the work of the devil. No good Christian would partake in such evil.
To search for generalizations from which to examine new drugs or drugs not considered in this history is perhaps beside the point. However one does begin to see patterns emerging. A drug's discovery (or invention) is soon followed by an increase in use, along with a simultaneous and seemingly inevitable concern with the social and personal ramifications of their use. All drugs have had their detractors. (Even tea has been looked upon suspiciously. It was argued that tea was of benefit only to those who lived within the regions where it was grown. For others, drinking tea violated a natural order and had negative consequences, among these was sterility.) As the history is told, such concern rarely, if ever, has the effect of decreasing the demand for the new drug, and thus use, as well as abuse, continues to rise. At this point, one of two things occurs: either the drug becomes a commodity, traded (and taxed) legally, or it is outlawed and becomes a commodity, traded illegally.
The point being, drugs, once `discovered', rarely fade into oblivion. The interesting question, then is why a small number of drugs have failed to become global commodities. Courtwright considers three reasons: initial adverse reaction, the undesirable cosmetic effect of long term use and logistical drawbacks of growing and shipping which in turn effect cost. The least likely of these, Courtwright suggests, is the initial adverse reaction that, he claims, all drugs elicit. Not only does it seem an unlikely reason, but the claim also arouses my suspicions: do all drugs really have initial adverse reactions? We're not given any evidence to back the claim. I can't remember back to when I had my first cup of tea or ate my first chocolate bar. But the claim (along with a number of others) arouses my suspicions about the accuracy of the book when it strays from the historical straight and narrow.
The claim also raises another concern that is left unanswered throughout the book: what, exactly counts as a drug? Courtwright occasionally drops names - sugar, herbal additives - but does not give an explanation of how a substance comes to qualify for consideration. The book is, in fact, about psychoactive drugs in particular, rather than drug in general. Yet, I wonder if the history that Courtwright does give us wouldn't be better served if the reader was given a broader picture of what counts as a drug in general and why some drugs qualify as psychoactive. Why should we think psychoactive drugs warrant special consideration in this way? If we had such a picture then, perhaps, the larger social issues that are the focus of discussion in Parts II and III of the book -- issues such commodification, taxation, restriction and prohibition and the link with economic hard times and prostitution -- might prove a bit more enlightening.
As it stands, however, the claims made about the links between drugs and larger social issues raise questions of a causal sort. Drugs, we are told, have figured prominently in sexual bartering. But, of course, so have money, jewelry and other gifts. Drug use has historically been an impediment to upward mobility. Is that a cause, effect or correlation? Lack of education is also an impediment to upward mobility. Industrialization has made drug abuse more likely and more visible. Is that a fact about drugs or a fact about globalization and commerce? Industrialization has also made eating Big Macs more likely and more visible.
My fear is that these historical observations might be mistaken for generalizable assertions about the causal properties of psychoactive drugs. While the second two parts of the book can be read as interesting social history, one should hesitate to draw any broad conclusions regarding what sorts of properties are inherent in drugs or what outcomes one might be able to ascribe to future psychoactive drugs. Read for the history, this book is a thorough examination of the most widely distributed psychoactive drugs currently available without a prescription - a tour de force of the social pressures that created the market for these particular drugs. But as for my question about Prozac, the main lesson is that most drugs go through a period when it's used for medical purposes and requires a doctor's approval for use. Gin, tobacco and opium are prime examples. But what happens from here with Prozac is anyone's guess. I suppose Healy was wise in declining to provide an answer.
© 2001 Patricia Ross. Patricia Ross, Ph.D., is a resident fellow of the Minnesota Center for Philosophy of Science. Her research and writing focus on foundational issue in medicine, psychiatry and psychology. Currently, she is examining the development of psychiatric classifications in Minnesota's state hospitals circa 1900, work that is supported by a Minnesota Humanities Commission grant. More generally, she is interested in how scientific research is interpreted and used in developing policies and protocols. She is serving on a Minnesota Citizens League study committee charged with examining energy affordability, reliability and environmental concerns.