“an orgasm can’t kill you, though.”
April 30, 2021 8:24 AM   Subscribe

The addiction researcher [and heroin user] Carl Hart argues against the distinction between hard and soft drugs. He describes using heroin in carefully managed doses, with product he trusts, in the company of friends, at times when being in an altered state does not interfere with his life, and achieving “a dreamy light sedation, free of stress.”

It’s difficult not to notice that Hart is also experimenting with a different public character—one that is more pugnacious and extreme. Having so recently been broadly celebrated, he has now made himself a case study—of whether liberals, presented with an apparently exemplary heroin user, might be willing to see drug policy from his perspective. In so doing, he had also remade himself as one of scientific liberalism’s discontents. Hart told me recently, “In ‘High Price,’ I’m clearly on the left, I’m clearly a good Democrat. And I also subscribe to that ‘up from slavery’ narrative. And I think that’s what a lot of liberals really like. And life is not that neat, obviously.”
posted by craniac (65 comments total) 27 users marked this as a favorite
 
This reminds me of stories of decriminalization in Portugal, where heroin was a real problem.

When addicts didn't have to commit crime to be able to get heroin, when it was suddenly being safely administered by medical professionals, you had a lot of people who continued to be addicts, but whose quality of life shot up dramatically, and their ability to do things like hold a job shot up dramatically.

I wouldn't necessarily say all those former addicts are cut out to become white collar working professionals, but I'm willing to say it's a possibility for some, at least.

---

Also, we've known forever that rich twats who do shitloads of drugs "succeed." Just look at the coke-jaw of nearly every member of the fucking Trump clan. The fact that there are two justice systems, one where the poor are abused for using illicit drugs, and one where the rich are ignored for using them ("they worked hard, they deserve it!") and the result is the lives of the poor are ruined while the lives of the rich and connected continue like nothing happened.

So this idea that the rich can't be successful while taking drugs has always been the biggest load of fucking bullshit. We know Wall Street tools snort cocaine off of hookers assholes, like why the fuck are we still splitting hairs acting like "you can't be successful while doing drugs," bullshit some of the richest fucks in this country probably do heroin and/or cocaine every fucking day of their lives and they are rolling in money and will keep rolling in money. The whole idea is a fucking joke.

---

In other words, I agree that it's quite possible to be an addict and be functional and of course, like every American news publication, it has to spend most of its time being completely surprised and incredulous at the idea that people might be able to function while on drugs.

Up next, the author of the piece orders his three martini lunch while chuckling at how pathetic "drug users" are.
posted by deadaluspark at 8:38 AM on April 30 [53 favorites]


Just about any drug that doesn't cause you immediate physical harm is fine right up until it isn't. For some people, that tipping point never comes, others don't notice until it's long past.

The stigma and criminalization doesn't help at any point, to be sure, but it's not like literally 100% of the problems stem from that. Just the worst ones that will really fuck up your life.
posted by wierdo at 8:42 AM on April 30 [11 favorites]


I -hate- prohibition and generally think all drugs should be not-prohibited by a government agency.
posted by kfholy at 8:44 AM on April 30 [8 favorites]


Huge respect for this guy.
posted by flamk at 8:50 AM on April 30 [1 favorite]


Coming back to chime in with wierdo, because I don't think I made it explicitly clear: I think some addicts are capable of this, but in no way would I argue that all addicts are capable of this nor that it is a good solution for all of them to be "functioning addicts." 100% agree on the fact that drugs are not inert, and they can fuck you up bad, and some people's lives would absolutely be better if they could kick the habit. I just think some people are capable of it. In general we need to stop legally punishing people for having an addiction, especially those whom addiction truly has reduced their quality of life. They're already suffering enough.
posted by deadaluspark at 8:53 AM on April 30 [8 favorites]


So originally (in 2013), he endorsed decriminalization: "To promote the book, and this idea, Hart travelled overseas. During those trips, he said that he favored decriminalization and the regulation of all drugs from a perspective of harm reduction, positions that put him on the far left of the American debate."

Now, as decriminalization is gaining acceptance, he's moving toward full-on endorsement: "liberals found themselves moving toward his point of view, Hart was moving away from theirs." he now believes that "even the hardest drugs can serve as tools for a more balanced life."

Even if there are people who can responsibly use heroin, that doesn't mean that it doesn't, in the real world, create huge harms. After all, I use alcohol responsibly and still realize that there are lots of people whose lives are being destroyed by alcohol abuse. That's why I'd be happy to pay a higher tax on my alcohol purchases. (If you're bothered by a higher tax on booze, you're drinking too much booze.)

I can't understand why anyone would move away from a harm-reduction model - which might or might not include decriminalization.
posted by Mr.Know-it-some at 9:02 AM on April 30 [22 favorites]


deadaluspark: i agree w/ your larger points. a small request to reconsider some word choices (hookers == sex workers, addicts = people w/ substance use disorder) as a strategy for harm reduction and stigma reduction, as well.
posted by lazaruslong at 9:44 AM on April 30 [14 favorites]


Having some personal experience here, I don’t think there’s any question that it’s better for opioid users to have access to a stable supply of opioids than not. The tricky part might be how do you balance that with retaining some barrier to picking up the habit in the first place? I suppose the first step is just making prescription heroin for maintenance a thing (as it is in a few places).
posted by atoxyl at 9:49 AM on April 30 [9 favorites]


@lazaruslong

Thanks for the constructive input, while I'm an old fart I'll try to keep that in consideration for the future. Sorry that it's past the edit window or I'd throw in an edit.
posted by deadaluspark at 10:02 AM on April 30 [13 favorites]


Simply making buprenorphine more widely available is a step that the current administration could make this afternoon that would make a huge impact on the problematic aspects of opioid abuse in the US. It's damn near impossible to find a doctor who is allowed to prescribe maintenance therapy in much of the country and has been for years and years because everyone who is willing to go through the process required to write prescriptions already has and is at their limit.

Methadone is less restricted in numbers, but the way the programs are administered makes them functionally impossible to access for anybody who actually has a job.
posted by wierdo at 10:07 AM on April 30 [13 favorites]


appreciating lazaruslong's point, "insufflating benzoylmethylecgonine off the anuses of sex workers" doesn't really convey the same... wait, it does though, doesn't it. nevermind.

also: decriminalize.
posted by 20 year lurk at 10:12 AM on April 30 [3 favorites]


(If you're bothered by a higher tax on booze, you're drinking too much booze.)

Apparently only alcoholics can oppose regressive taxes?
posted by We put our faith in Blast Hardcheese at 10:20 AM on April 30 [13 favorites]


making buprenorphine more widely available is a step that the current administration could make this afternoon

Done. Biden administration will allow nearly all providers to prescribe buprenorphine (Tuesday).
posted by Mr.Know-it-some at 10:22 AM on April 30 [38 favorites]


Done. Biden administration will allow nearly all providers to prescribe buprenorphine (Tuesday).

Whoa.
posted by atoxyl at 10:37 AM on April 30 [3 favorites]


The tricky part might be how do you balance that with retaining some barrier to picking up the habit in the first place?

It's probably not as tricky as it intuitively seems. The evidence of Portugal suggests that decriminalisation, in the context of harm-reduction programmes and drug education, at the very least does not increase habitual drug-use, and may, in fact, reduce it.
posted by howfar at 11:31 AM on April 30 [5 favorites]


The tricky part might be how do you balance that with retaining some barrier to picking up the habit in the first place?

I'd suggest trading off curiosity from chippies by making waiting lists for detox treatment more available to those who ask for them. Of course this requires more investment in public health, so...
posted by ovvl at 11:32 AM on April 30 [2 favorites]


Funny timing on this, because I've been joking with my coworkers that I am going to take up heroin as a "hobby".

Thing is, I've never liked the sleepy-time drugs, but the stay-up-days-at-a-time ones will kill me at this age.

I can't even drink beer any more because of the goddamn GERD.

(shuffles off grumbling)
posted by Xoebe at 11:37 AM on April 30 [2 favorites]


Tbh, I would love to try heroin, as it is described as a sensation of deep pleasure. And maybe psilocybin would have an effect on treatment resistant depression.
posted by Mom at 11:47 AM on April 30


Done. Biden administration will allow nearly all providers to prescribe buprenorphine (Tuesday).

You got my hopes up. In reality, it's half done. The article says there is a limit of 30 patients per provider. That will help many people, but doesn't go nearly far enough, especially in rural areas where providers are few and far between. At least it's not limited solely to doctors.

The thing that really gives me pause, though, is that the previous rules allowed for any provider with a DEA number to make an emergency prescription with no training and a post-facto notification. Not many will actually do it, though. The new rules might work a bit better since the notification isn't per-patient.
posted by wierdo at 12:00 PM on April 30 [5 favorites]


Providing good quality opioid is pretty cheap via a national health mechanism. The evidence from a study in my hometown a couple of decades ago was that providing even a very limited number of addicts with access to a regular supply meant a massive impact on local criminality, with substantive savings for potential victims of crime. Of course this avoids the people being criminalised for drug use also being criminalised for burglary, b&e, etc. Added to the the health outcomes it just makes sense.
posted by biffa at 12:05 PM on April 30 [4 favorites]


For the record, there are much more interesting opioids than heroin. The current epidemic is less about heroin and more about the sharp decrease in the supply (and increase in street price) of the stuff made by pharmaceutical companies causing people to substitute heroin for oxycodone, hydromorphone, etc.
posted by wierdo at 12:13 PM on April 30 [3 favorites]


It's probably not as tricky as it intuitively seems. The evidence of Portugal suggests that decriminalisation, in the context of harm-reduction programmes and drug education, at the very least does not increase habitual drug-use, and may, in fact, reduce it.

I’m talking about going a lot further than decriminalization of possession, here.

For the record, there are much more interesting opioids than heroin. The current epidemic is less about heroin and more about the sharp decrease in the supply (and increase in street price) of the stuff made by pharmaceutical companies causing people to substitute heroin for oxycodone, hydromorphone, etc.

I’d argue at this point it’s about the substitution of (cost-effective, easily-smuggled) fentanyl analogues for heroin.

(Not sure what you mean by “more interesting.”)
posted by atoxyl at 12:48 PM on April 30


One of the books I read when young was something like "Making of a Woman Surgeon". She practiced in some of the rougher areas of New York city. One of her patients was an elderly man in his 60s in good health and when she examined him she found needle track marks over a lot of his body. He said he'd been a lifelong heroin user.

First time I realized heroin use wasn't a fast track to the bottom (just mostly one). Since then I've seen (my brother, others) that the lifestyle contributes to that slide quite a bit. What you have to do to get the drug and what it closes off for you (jobs, etc).
posted by aleph at 1:04 PM on April 30 [1 favorite]


(If you're bothered by a higher tax on booze, you're drinking too much booze.)

Two beers or a shared bottle of wine with dinner maybe once a month is too much?

You can be poor enough to be priced out of alcohol altogether without having a drinking problem. Taxes are a blunt fucking tool here, unless you're charging them as a percentage of income (4% of your weekly income on top off
the purchase price of a bottle of wine seem reasonable to you? That's what someone living on carer's allowance is currently charged in the UK for example), rather than based on sale price or alcohol volume.
posted by Dysk at 1:17 PM on April 30 [6 favorites]


I’m talking about going a lot further than decriminalization of possession, here.

I think one can draw some reasonable extrapolations from the Portuguese data (falling last month + last year use rates despite increasing lifetime use rates, and a period of severe and protracted economic hardship). These don't suggest an inverse correlation between prohibition and use, or, a correlation between last month/year use rates and lifetime use rates. While we can't know in the absence of direct data, I think it's fairly reasonable to think it unlikely that a cautious, non-market lead approach to legalisation (looking something like restrictions on alcohol sales in Norway, plus treatment, education, etc) would cause a significant increase in habitual use.

In particular given the very sizeable global benefits of reducing the activites of and income generated by the international illicit drugs trade (in particular because of its relationship to illicit arms trading), I think legalisation is, on a purely utilitarian basis, likely to be the best policy.
posted by howfar at 2:06 PM on April 30


Apparently only alcoholics can oppose regressive taxes?
1) Alcohol taxes would reduce alcohol abuse and save lives (see below).
2) Alcohol taxes - like any per unit consumption tax - are regressive. So people who don't abuse alcohol but are poor would be harmed unfairly. On the other hand, poor people who abuse alcohol and respond to the higher taxes would be helped the most - as would the people around them who suffer from their violence.

You can do fancy math to figure out the optimal tax, and you could also in theory simultaneously adjust other taxes to be more progressive to offset the increased sin tax.

Or you could recognize that we're never going to get close to the optimal tax because of the power of the alcohol lobby (or the lobby for whatever "sin"ful product you're considering) and just try to get the tax as high as politically possible, which will still be too low and leave tens of thousands of people dead and many more suffering from violence, drunk driving, partner abuse, and all the rest. And simultaneously work on other efforts to help poor people.


_____________________
"raising alcohol taxes. When something costs more, people use less of it, especially people who use enough of it so its price matters in their personal budgets. Most of the damage from alcohol-related violence comes from heavy drinkers, not casual ones. So higher alcohol prices will lead to less drinking by heavy drinkers and therefore fewer drunk-driving deaths and fewer drunken homicides.

Philip J. Cook’s Paying the Tab estimates that a 10% increase in the price of drink (which could be achieved by doubling the current federal alcohol tax) would reduce all violent crime – not just alcohol-related crime, but of course including a lot of gun crime – by about 3%. The effects on traffic fatalities are of about the same magnitude. The effects seem to be roughly linear.

So tripling the alcohol tax – which would cost the median drinker less than 20 cents a day, and which wouldn’t be nearly high enough to create a black market – would eliminate about 6% of the 13,000 murders we suffer each year, saving about 800 lives. It would also eliminate about the same proportion of 32,000 traffic fatalities, saving something more than 2000 additional lives. In other words, a simple change in the tax code could eliminate about one 9/11’s worth of sudden death per year."
posted by Mr.Know-it-some at 2:11 PM on April 30 [7 favorites]


So, back in the day when I was deeply involved with a junkie, I did a lot of reading. And, as it turned out, the UK had policies about heroin in the 60s and 70s that made the drug easily available to registered users and severely prosecuted the illegal trade. This had several effects:

1. It made it unprofitable to introduce people to the drug
2. It was possible to be a user and still lead a life
3. The average age of users crept up
4. Heroin was seen as sort of unfashionable

I read that only about 30% of the population are particularly vulnerable to opiate addition, so anything that keeps opiates relatively unattractive and keeps the users fairly safe is OK with me. Honestly, there are cases where numbing the pain is the best you can hope for, but we should strive for better.
posted by GenjiandProust at 3:49 PM on April 30 [11 favorites]



So higher alcohol prices will lead to less drinking by heavy drinkers

Lol have you ever met a human being? This isn't how it works. People don't give up their addictions when those addictions get too expensive, they spend the fucking rent money on it and go about funding it in increasingly destructive ways. See: the literal subject of this FPP.
posted by We put our faith in Blast Hardcheese at 4:22 PM on April 30 [20 favorites]


So higher alcohol prices will lead to less drinking by heavy drinkers

Lol have you ever met a human being? This isn't how it works.


I feel like populations do respond to pricing changes, and they may be inconsequential to individuals in the throes of addiction. So kind of a little bit of both.

Separately, it is really terrifying to see what % of total alcohol is consumed by a very small number of hardcore drinkers/alcoholics. I feel like if you have a glass of wine with dinner you’re already in the top 20% and it accelerates from there like income inequality.
posted by snofoam at 5:25 PM on April 30 [1 favorite]




. I feel like if you have a glass of wine with dinner you’re already in the top 20%

What does that even mean? If you have a glass of wine a day, it’s an issue? The US is a land of madness.
posted by GenjiandProust at 5:59 PM on April 30 [1 favorite]


It means that, in the US (as of 2018), having 4+ drinks weekly is enough to put you in roughly the top 20% of the country for alcohol consumption, with 46% averaging three or fewer drinks weekly and another third not drinking at all. That distribution doesn't imply anything about whether or not it's an issue for any individual person.
posted by eponym at 6:18 PM on April 30 [5 favorites]


I just realized that these "May 1" posts are not in my time zone, and it's interesting to see the international perspective start to pop up in this discussion.

@genjiandproust I read that only about 30% of the population are particularly vulnerable to opiate addition, so anything that keeps opiates relatively unattractive and keeps the users fairly safe is OK with me.

One point that Hart made in another interview is that mental illness + opioids is a gazilion times worse.

So do we structure society to protect the most vulnerable from crippling addiction, while denying the rest from the supposed benefits of heroin?

I want a version of fentanyl that gives me what Hart describes, "“a dreamy light sedation, free of stress.” without all the bad parts. I suppose I could huff whippets, but that sort of permanent detachment has its own drawbacks. Jackson Browne was right when he wrote "Nobody rides for free"
posted by craniac at 7:20 PM on April 30 [1 favorite]


I feel like if you have a glass of wine with dinner you’re already in the top 20%

If you're having one a day maybe, sure. But one a month? (Which you'd still be effectively priced out of on carer's allowance, for example.)
posted by Dysk at 7:44 PM on April 30


People on a carer's salary in the United States are priced out of any number of the trappings of life we consider essential for comfort and dignity. Alcohol consumption, even as things are now, is but one "discretionary" expense of many. Odd to focus on it as such when we're talking about reducing the societal harm of excessive drinking overall.
posted by tigrrrlily at 8:08 PM on April 30


It's unquestionable that much of the harm of opioid abuse is a consequence of its illegality. But, having known a couple of "functional" addicts, I have to say that there's an irreducible minimum there, at least for certain users, who don't seem to be readily identifiable in advance.

I want a version of fentanyl that gives me what Hart describes, "“a dreamy light sedation, free of stress.” without all the bad parts.

The first time I can remember having any sort of narcotic painkiller, in the ER, when the Dilaudid abruptly kicked in, I was like, "...is this enlightenment?" Because I was liberated of all desire. But even if there were no physical harm done by use, the psychological risk of entering into that state was far too plain.
posted by praemunire at 8:31 PM on April 30 [1 favorite]




opioids take away physical pain. and every other sort of pain. I've enjoyed them, but at least for me: I'd never change anything about myself (evolve as a being) if i never got an up-close and well-lit look at my pain.

imvvho: a real problem with energy leaks like some recreational drugs and alcohol is, they make intolerable situations seem tolerable. all those deferred choices end in a life that may not be what it might have been.

now I'll rtfa.
posted by j_curiouser at 9:08 PM on April 30 [4 favorites]


Legalize it all. Everything. Some certain percentage of human beings are going to get lost into addiction no matter what. It is a piece of human behavior. I read a book once that pretty much insisted that there has been alcoholism since man first crushed grapes, and I have no reason to believe otherwise. Some people are going to get lost to alcoholism. Some people are going to get lost to drug addiction. It's in the weave. It's human. Any and all high-minded thought that it "shouldn't be" that way is pretty much avoiding looking at the facts of the matter.

Counterpoint: one Sackler empire is enough.

There is no possibility that capitalism doesn't sell us fully legalized drugs in a way that causes the absolute maximum of harm.
posted by praemunire at 9:31 PM on April 30 [9 favorites]


Stupid timezone. I'm late to this discussion and this is totally my wheelhouse.

When I found this post I had coincidentally just finished listening this lovely podcast where Dr. David Nutt interviews Dr. Carl Hart, and Dr. Hart is very upfront and unapologetic about having changed his stance w.r.t. decriminalization/legalization as he has learned more.

My personal views on addictive drugs are informed by a story my father once told me when I was younger. He told me that my great-grandfather was a doctor in Cuba, and he developed a morphine addiction, but because he was a doctor (pre-DEA), he had access to as much cheap, pure morphine as he wanted, so he continued to lead a normal, productive life until he died in his 90s.

Another story: when I was in college, I had my wisdom teeth pulled, and I was prescribed Tylenol 3 with codeine. I found out (on Erowid?) that you could filter out the liver-destroying Tylenol by exploiting its low solubility in cold water. I am from the "Just say no" generation, so I remember the DARE officer telling us that drugs get you hooked the first time you try them, but I was incredulous so I wanted to test it personally. Long story short: it was pleasurable and I had really cool Xanadu-style hypnogogic "visions", but overall the experience wasn't nearly as interesting as, say, psilocybin, so I never really had the urge to try opioids again. Myth busted.
Bertha K. Madras, a professor of psychobiology at Harvard, argued that the U.S. had just run this experiment, and it had ended very badly. “What we have learned from the current opioid crisis is that it is very easy to promote a drug as safe and effective and harmless, as was done with prescription opioids,” she said. “The end result was that we had millions of people misusing opioids.”
This almost made me throw my mouse at the screen. The opposite of "locking human beings in cages" isn't "promot[ing] a drug as safe and effective and harmless", it's creating a regulated market where promotion/marketing is strictly forbidden, providing honest education about how to minimize drug harms without assuming abstinence, and tackling the real problems in society that cause people to become the "sad rats" in the Rat Park experiment.

Even Dr. Hart isn't saying that heroin is harmless! Look at the strict rules he enforces on himself to avoid addiction. Anyone who is educated about drugs and has something or someone to live for is capable of that kind of self-discipline, but those who aren't capable should be helped, not punished.

If you'd like to learn more about how legalization should be done, see this free pdf, Legalizing Drugs: The Key to Ending the War from the Transform Drug Policy Foundation. (I'm not affiliated with them, I'm just a fan.)
posted by The genius who rejected Anno's budget proposal. at 9:38 PM on April 30 [13 favorites]


People on a carer's salary in the United States are priced out of any number of the trappings of life we consider essential for comfort and dignity. Alcohol consumption, even as things are now, is but one "discretionary" expense of many. Odd to focus on it as such when we're talking about reducing the societal harm of excessive drinking overall.

I'm not really talking about the US, but the UK where minimum pricing has been all the vogue recently, which is even more "thou shalt not drink (unless you are monied, in which case no amount of drinking is problem drinking)". It's discriminatory as hell.

And I thought this was a thread about how not restricting access to drugs was actually the most effective form of harm reduction, but a thread about reducing alcohol deaths by financially ruining alcoholics who aren't sufficiently middle-class.
posted by Dysk at 10:58 PM on April 30 [5 favorites]


There is no possibility that capitalism doesn't sell us fully legalized drugs in a way that causes the absolute maximum of harm.

But isn't the reality that capitalism is already selling us drugs in the way that causes the absolute maximum of harm? It's not like drug cartels aren't capitalist enterprises.
posted by howfar at 12:21 AM on May 1 [6 favorites]


Tbh, I would love to try heroin, as it is described as a sensation of deep pleasure. And maybe psilocybin would have an effect on treatment resistant depression.

No joking, ketamine is showing real promise as a treatment for major depression, particularly for treatment resistant depression. It supposedly works very quickly, and the effects last long after the initial treatment. How and why exactly it appears to work so effectively is still very much unknown.

Clinical studies are ongoing to develop safe(ish) guidelines, as dosage and duration of treatment are still somewhat at the experimental stage. There are private medical services that offer it off-label for this purpose, though again long-term side effects are under active investigation.
posted by Absolutely No You-Know-What at 1:19 AM on May 1 [1 favorite]


it's quite possible to be an addict and be functional

and it's quite possible to use any drug without becoming an addict.

My personal plan is to work up a solid heroin habit, one that I don't need to be disciplined about keeping reined in, once I'm so old and enfeebled as to be literally unable to enjoy anything else. From what I've read about heroin I believe it will still work well under those conditions, and this way I don't run any serious risk of acquiring a new habit that ruins any of the other things I currently enjoy and/or intend to enjoy before then, either by direct interference or by comparison.
posted by flabdablet at 3:17 AM on May 1 [4 favorites]


I found out (on Erowid?) that you could filter out the liver-destroying Tylenol by exploiting its low solubility in cold water. I am from the "Just say no" generation, so I remember the DARE officer telling us that drugs get you hooked the first time you try them, but I was incredulous so I wanted to test it personally. Long story short: it was pleasurable and I had really cool Xanadu-style hypnogogic "visions", but overall the experience wasn't nearly as interesting as, say, psilocybin, so I never really had the urge to try opioids again.

I did the same experiment and found that the fairly minimal pleasure was outweighed by distress at the extent to which the codeine suppressed my breathing. I agree that the experience was nowhere near as interesting as that provided by any of the psychedelics I've also used.
posted by flabdablet at 3:23 AM on May 1 [1 favorite]


I did the same experiment and found that the fairly minimal pleasure was outweighed by distress at the extent to which the codeine suppressed my breathing.

This didn't happen to me. Assuming you dosed correctly, did you drink grapefruit juice? Maybe you have unusual enzymes?

In my post-legalization fantasy world, you could take one of those mail-order DNA tests and find out if you dose opioids lower or higher than average, or if you are predisposed to addiction, etc. (I believe this already exists for alcohol.)
posted by The genius who rejected Anno's budget proposal. at 5:35 AM on May 1


YMMV with codeine, moreso than with most opiates: codeine doesn’t work for some people, and works too well for others. Some people don't metabolise it well or effectively at all, most people metabolise it as expected, but some metabolise it way more effectively. So a very wide range of reactions is possible.
posted by Dysk at 6:13 AM on May 1 [3 favorites]


YMMV with codeine, moreso than with most opiates: codeine doesn’t work for some people, and works too well for others.

Fascinating! Thanks for the info. At the risk of getting off topic, I found some more details on Wikipedia. Apparently codeine is a prodrug, and is converted to morphine by CYP2D6. People who are sensitive to codeine are those "who have multiple functional alleles of CYP2D6". IIUC, this means that grapefruit juice, which inhibits CYP2D6, would in fact desensitize one to codeine, which is the opposite of the sensitization that occurs when an active drug is converted to an inactive metabolite by CYP2D6.
posted by The genius who rejected Anno's budget proposal. at 7:51 AM on May 1 [1 favorite]


Yes, although it's even more complex than that, because codeine itself does bind to opioid receptors, although only weakly, and also metabolises to opioids other than morphine (most significantly codeine-6-glucuronide, which, while a less potent opioid than morphine, is produced in significantly greater quantities by metabolism of codeine and is probably responsible for the majority of its analgesia). So, while usually thought of as a morphine prodrug, codeine is not necessarily most accurately described in that way. Hence it's not necessarily as straightforward as CYP2D6 inhibition desensitizing one to codeine, especially in regards respiratory depression risks, in particular as codeine-6-glucuronide has a somewhat longer half-life than morphine.
posted by howfar at 8:21 AM on May 1 [2 favorites]


But isn't the reality that capitalism is already selling us drugs in the way that causes the absolute maximum of harm?

Nope. Review the Sackler story, if you're not already familiar with it, and imagine that general approach applied to products sold over the counter (particularly new drugs, without a popular understanding of their risks, and indeed the manufacturer actively deceiving people about their risks), without restriction. Imagine if Tylenol were actually addictive, and carrying a real risk of killing you if you take it while drunk--what kind of a world that would be.

People sometimes don't seem to be willing to entertain just how bad late capitalism will make things if traditional "vices" are fully legalized, which really complicates the approach even if, starting de novo, you'd be in favor of doing so. (Like sex work--if it's fully legalized, and you're a woman, you will have to fuck your boss, it'll be right in the job description, and if you don't like it, I guess you can find some other form of employment. Somewhere.) It's grotesque, but at this point I don't think it's terribly speculative.
posted by praemunire at 9:34 AM on May 1 [2 favorites]


To some extent, Hart’s argument is simply that the public-health establishment is infantilizing Americans, and that the more enlightened approach would be to allow them their own preferences.

Personally I don't see a difference between this and a harm-minimization stance.

If people are not harming themselves or others by using their drugs of choice then there's no harm to be minimized. If they are causing harm by abusing those drugs, then providing health support minimizes that harm; applying criminal penalties just creates further harm. If this is not the standard US liberal position, then standard US liberals are utterly out to lunch on this issue.
posted by flabdablet at 10:31 AM on May 1 [4 favorites]


Like sex work--if it's fully legalized, and you're a woman, you will have to fuck your boss, it'll be right in the job description

With respect, this is nonsense. Sex work is legal in the Netherlands and fucking the boss is demonstrably not in every woman's job description there.
posted by flabdablet at 10:50 AM on May 1 [8 favorites]


imagine that general approach applied to products sold over the counter (particularly new drugs, without a popular understanding of their risks, and indeed the manufacturer actively deceiving people about their risks), without restriction.

Active deception about risks or benefits associated with products offered for sale ought to be illegal, in my view, whether the products involved are drugs or anything else. It's long been my position that the advertising industry as presently constituted is easily the most toxic aspect of late stage capitalism and well overdue for a totally draconian reining-in.
posted by flabdablet at 10:56 AM on May 1 [3 favorites]


We already have laws on the books outlawing false or deceptive advertising. Like many other areas of law that apply to business it is very poorly enforced, largely but not entirely due to the "drown it in the bathtub" attitude toward government.
posted by wierdo at 11:39 AM on May 1




With respect, this is nonsense. Sex work is legal in the Netherlands and fucking the boss is demonstrably not in every woman's job description there.

Against a backdrop of strong labor protections and social welfare law.

If you can't get how the American context is different, I don't know what to tell you.

But this is a bit of a derail. I support decriminalization of hard drugs, but I think letting the free market loose on them will wreak even worse havoc. Creating legal and social structures that constrain that is the thorniest part of the problem to me.
posted by praemunire at 1:07 PM on May 1


strong labor protections and social welfare law.

If you can't get how the American context is different, I don't know what to tell you.


Oh, I get it. The point is that the American lack of strong labor protections and social welfare law is exactly why drugs are insane in the US, and guns are insane in the US, and healthcare is insane in the US, and employment is insane in the US, and prisons are insane in the US.

If the US devoted a tenth of the resources it's currently pissing up the wall in a pointless and counterproductive War On Drugs to enacting and enforcing strong labor protections and social welfare law, almost every aspect of US life would be greatly improved and drugs would cause far less harm than they do right now.

Land of the free and home of the brave? Fuck no. Land of the beaten-down and home of the monstrously poorly organized is what we all see from out here.
posted by flabdablet at 1:25 PM on May 1 [7 favorites]


Jackson Browne was right when he wrote "Nobody rides for free"

Wait that's from a Jackson Browne song? Ass, gas, or grass?
posted by thelonius at 1:58 PM on May 1


“an orgasm can’t kill you, though.”

yr doing it wrong.
posted by Thorzdad at 4:51 PM on May 1 [2 favorites]


This is your perennial reminder that Rat Park is by no means generally accepted as a good model of addiction.

Guilty as charged. Thanks for the reminder. This article is well worth reading.

I wish we had a better metaphor for expressing that the idea of the drug being the sole, or even dominating, factor in addiction, is bunk. (Let's call this the "NIDA/Duterte model", lol.)
It would be willfully ignorant to say that a person is equally likely to become addicted to cannabis as they are to oxycontin or fentanyl. Of course the drug in question matters. So do a plethora of other factors. In reality, there are many factors that lead to addiction, including environment, stress, genetics, life-circumstances, and adverse childhood experiences (ACEs). It is not uncommon for people with addictions to have any combination of the above factors, nor is it an exhaustive list. These factors also have different effects on different individuals. For example, people who suffer from a mental illness are twice as likely to struggle with addiction. But both Hari and Alexander still claim they’ve discovered the “real,” implying singular, cause of addiction.
I think Dr. Hart is living proof of this. Me, too! I had an uneventful childhood, I'm educated, gainfully employed and I love and am loved. I have tried, and am surrounded by, all manner of addictive drugs (I include alcohol, tobacco and caffeine here), but I don't feel the urge to use them to excess (or at all, as in the case of tobacco). It's not even something I need to expend willpower for! And yet there are still people out there who think that drugs are evil, and drug users should be punished harshly so that they'll "learn", as if that punishment isn't just contributing to the factors that drive people to addiction. (I live in Japan, so I'm likely exposed to this kind of rhetoric more than most people here, who I assume live in the anglosphere.)
posted by The genius who rejected Anno's budget proposal. at 7:04 PM on May 1 [3 favorites]


My standard advice to my kids on drugs has always been this:

Recreational drugs can be tremendous fun - that's their entire point - but to keep them that way you need to use them responsibly.

That means
  • choosing to avoid them until you're at least 25 years old so that your adult brain has mostly grown in
  • choosing to avoid them until you're in stable housing with a stable income
  • researching what you intend to take before you try it, so that you know the risks associated with it and what to do about side effects and what not to mix it with and how to space your doses
  • getting your drugs only from people who can be trusted to supply what you think you're getting and not some poisonous substitute; in particular, grow your own weed
  • making sure your first experience with any given drug is at a relatively low dosage and closely supervised by trustworthy and experienced people
  • using recreational drugs for fun and not as a means to cope with personal problems
  • not hiding your drug use from people who love you.
Everybody I know who has ended up drug-fucked has consistently ignored at least two of these principles.

Nobody I know who has followed all of them most of the time has had any trouble with drugs other than unwanted attention from law enforcement.

As a parent, my job is to keep you safe until you're competent to do that yourself and to help you get competent as fast as possible. So I'm not going to give you shit for getting drugs wrong, any more than I gave you shit for falling over while you were learning to walk or for stalling the car while I was teaching you to drive. I'm pretty sure you're going to ignore some of these guidelines some of the time, because almost everybody does, but please, please keep me up to date with what you've used and when, and how it went for you, so we can work together on fixing any trouble before it gets bad.
posted by flabdablet at 11:05 PM on May 1 [6 favorites]


These are great, flabdablet. I'm going to steal this.

I would add one rule which has served me well over the years:
  • Decide how much you are going to use before you start using.
This way you aren't compulsively redosing and you aren't making dosing decisions while your rational/analytical mind is out to lunch.
posted by The genius who rejected Anno's budget proposal. at 11:27 PM on May 1 [4 favorites]


Good one. Kind of comes under "knowing how to space your doses" for me, but pulling it out on its own like that puts the emphasis squarely on when and how to apply that knowledge, and that's valuable.
posted by flabdablet at 11:43 PM on May 1 [1 favorite]


It has always been extremely distressing that the US government has had such a vindictive attitude: that there is absolutely no positive use for illegal drugs, and had even banned research from being done. As a child, I tried to commit suicide at 12. My depression was overwhelming. I saw Timothy Leary on the Tonight Show talking about his experiences with LSD and I wanted to try it and see if the consciousness raising experience would show me a path to live. As a determined and desperate 14 year old I made the connection to LSD. My very first experience changed me forever. I felt for myself the interconnected of all being. There is beauty in life. Love is real. Live and find all that the world can show you. My acid use through my teens and twenties kept me alive and interested in living. So naturally I was appalled by government suppression and criminalization of this life affirming drug. Now, 50+ years later there is some research that shows what I have known all along, drugs have a place for great good as well as harm. And knowing that your source is clean and at a standardized dose is all to the good for unharmful use.
posted by a humble nudibranch at 12:07 AM on May 2 [4 favorites]




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