Drug of choice

This month brings publication of the revised paperback edition of Romancing Opiates: Pharmacological Lies and the Addiction Bureaucracy (Encounter Books). It's an extraordinary look at heroin addiction, based on British author Theodore Dalrymple's experience as a prison doctor and hospital psychiatrist.

Dalrymple is used to turning standard assumptions upside down. In an extraordinary book published in 2001, Life at the Bottom: The Worldview That Makes the Underclass, Dalrymple notes that today's poor are not particularly poor "by the standards of human history," but many are trapped in "a special wretchedness" of passivity: The classic statement is that of the murderer who says "the knife went in." Dalrymple explains that liberal social determinism has taught many among the poor to ignore personal responsibility for actions.

In Romancing Opiates Dalrymple even more strikingly contravenes the conventional. He explains that heroin is not highly addictive, withdrawal from it does not require medical assistance, addicts do not become criminals to feed their habits, and heroin addiction is often a spiritual problem. His observations concur with the experience of some Christian anti-addiction programs such as Teen Challenge (see WORLD, July 12).

Dalrymple argues that many addicts have learned to game the medical system, and many doctors make things worse by medicalizing a moral issue.

WORLD: What is the standard, orthodox view of heroin addition?

DALRYMPLE: I think it is this. The man who becomes the addict stumbles across heroin somehow or other, takes a few doses, is "hooked," has to continue to avoid the dreadful symptoms consequent upon stopping. He finds himself unable to pay for the heroin he needs so he commits crimes, and then, if he is lucky, finds medical assistance for his condition which consists largely of a substitute drug. Without assistance, he is doomed; with it he is saved. All this is nonsense.

WORLD: Is the view that it's easy for people to fall into addiction also nonsense? You quote novelist William Burroughs: "You don't wake up one morning and decide to be a drug addict. It takes at least three months' shooting twice a day to get any habit at all." If an addiction is not easy to develop or sustain, what implications does that have for treatment?

DALRYMPLE: It means that the very concept of treatment is probably wrong. The addict has made a determined effort to become an addict. It is something he does, not something that has happened to him. For example, most heroin addicts in Britain have taken the drug for 12 months intermittently before taking it regularly, and furthermore know full well some of the consequences of taking it regularly. They are not victims; they are active agents. They want to be addicts; therefore, they must want not to be addicts also if they are to stop.

WORLD: Then how have addicts come to be considered blameless patients, creatures without choice?

DALRYMPLE: This is the result of a long historical process, which I date back to the English Romantics of the first quarter of the 19th century, particularly Thomas De Quincey and his very influential Confessions of an English Opium Eater. This book (the two editions published in his lifetime are very different, and the differences themselves expose the untruthfulness of De Quincey) contains all the misconceptions that have been faithfully handed down by authors ever since, including the odious Burroughs. Every fictional and cinematographic representation of heroin addiction has repeated uncritically De Quincey's equivocations, falsifications, and exaggerations.

WORLD: So why do we hear that withdrawal from heroin is physically dangerous when so many people beat their addictions without medical assistance?

DALRYMPLE: This is an interesting cultural phenomenon. People are often very surprised to learn that withdrawal from opiates (unless combined with other drugs, and with the single rare exception of withdrawal in pregnancy) is a trivial medical condition, unlike withdrawal from alcohol when it results in Delirium Tremens. The misconception arises because of the repeated misrepresentations in books and films. Of course, the myth of the horrors of withdrawal serves the interests of addicts who do not want to stop, and the professionals who want to "treat" addicts.

WORLD: What's the key evidence that heroin addiction is a spiritual or moral condition?

DALRYMPLE: There is lots of evidence. First, there are historical examples of thousands and indeed millions of opiate addicts giving up their addiction because of motivation to do so. Mao Tse Tung took a very dim view of opium addicts and threatened in the end to shoot them. When Mao threatened to shoot you, you took it seriously. Millions of people gave it up. It would not have made sense for Mao to say to people with rheumatoid arthritis, "I will shoot you if your joints don't become normal." It did make sense, even if it was wrong, to threaten to shoot addicts. There is therefore a conceptual difference between the two conditions.

Second, it is perfectly obvious from talking to addicts that their habit is usually a response to the dissatisfactions of their lives, a totally unconstructive one, but a response nonetheless.

WORLD: So what do you think of groups like Teen Challenge that advocate religious conversion as a way to end addiction?

DALRYMPLE: It has long been known that religious conversion often effects a change in behavior. Of course, it is not for everyone, nor can it be forced upon people. But textbooks of addiction medicine acknowledge that religious conversions, or crises, effect changes.

WORLD: Why do you call heroin use more a consequence than a cause of criminality?

DALRYMPLE: Most heroin addicts who end up in prison have long criminal records before they ever take heroin. Therefore, their propensity to crime pre-exists their addiction. It is clear also that the mass addiction that we have seen in Britain in the last two decades has taken hold in precisely the same population in which criminality had become firmly established. Whatever inclines people to crime inclines them also to addiction to heroin.

If you take someone like Burroughs, it is clear that his attraction to crime preceded his addiction.

WORLD: What do you think of the arguments for legalizing drug use?

DALRYMPLE: I think the debate is a rather sterile one. I can see the arguments in favor of legalization, but I think they are mistaken. If it is true that addiction is a consequence or a co-variant of criminality and not a cause of it, one of the supposed benefits of legalization will not accrue. The dealers, moreover, will not beat their needles into ploughshares and become respectable members of society. Furthermore, so long as there are restrictions on the sale of drugs, there will be a black market, and no one (as far as I know) suggests there should be no restrictions whatsoever.

The Netherlands, the most liberal country in Europe with regard to drugs, is also one of the most crime-ridden. I do not think this is a consequence of its drug policy, but it suggests that a liberal policy does not necessarily reduce crime.

On the other hand, it is perfectly possible that a liberal policy would not be a catastrophe by comparison with what we have now.

I think it is far more important to change the conception we have of addiction, and make people understand that it is not what we have thought it was for so long. Perhaps the most important thing is to stop pretending to addicts that their addiction is an illness in itself, and try to get them to see that they are agents, not victims.