For Smokers, Nowhere to Run and Nowhere to Hide

(With love and apologies to Martha and the Vandellas.)

That wonderful song goes on to declare:

'Cause I know
You're no good for me
But you’ve become
A part of me.

The song is not about cigarette addiction, but it could be. Full Disclosure: I smoked cigarettes myself for almost 25 years. And then, after several failed attempts, I quit. I out myself on this subject because a paper from the May 25 issue of the New England Journal of Medicine (NEJM) decries what the authors call the “denormalization” of smoking—and I find myself agreeing with them, smokeless though I may be. I recently visited New York, coincidentally on the day that smoking outdoors in New York City became illegal. Okay, that’s not quite fair to say—it became illegal to smoke in Central Park, or at Brighton Beach, or along the newly pedestrian mallways of Times Square. There is no smoking along the High Line. There is no smoking at any park, beach, or pedestrian mall. As both the tobacco industry and anti-smoking activists well know, this was an iconic victory that has the potential to change smoking laws in virtually every other American city.

It’s a fascinating progression, starting in the 70s when the Civil Aeronautics Board decreed non-smoking sections on domestic airline flights, to the recent New York City Council Decision to ban smoking en plein air, so to speak. Thomas Farley, New York City Health Commissioner, summed it up as follows in a public hearing: “I think in the future, we will look back on this time and say ‘How could we have ever tolerated smoking in a park?’”

I’m not so sure on that, myself. James Colgrove, Ronald Bayer, and Kathleen Bachynski of the Mailman School of Public Health at Columbia University wrote the paper, entitled “Nowhere Left to Hide? The Banishment of Smoking from Public Spaces,” in the NEJM. The authors note that more than 500 towns and cities in 43 different states have already enacted laws banning smoking “in outdoor recreation areas.” At first, as the authors summarize the history, it all seems like a sensible compromise, built on common courtesy. First airplanes and buses, then restaurants and bars, began setting aside seats for non-smokers. By the early 90s, the first data on secondhand smoke was rolling in. Schools, convention centers, and finally even private workplaces either banned smoking or created smoke-free areas. But even then, the primary motivator, according to the researchers, was that secondhand smoke was “unpleasant and annoying,” not deadly. Smokers weren’t being asked to refrain from public smoking for the good of their own health, but as a courtesy to others.

The solid scientific evidence kept accumulating, however—even though tobacco cigarettes were, and still are, completely legal products for adult Americans to purchase and consume if they so choose. Now the arguments shifted to the innocent bystanders, those within the six-foot ring, the immediate smoke zone surrounding a smoker, and the elevated risk of lung cancer, heart disease, and asthma that smokers were subjecting them to. In 1993, the Environmental Protection Agency (EPA) classified secondhand smoke as a Class A carcinogen, and more school, stadiums and offices proscribed smoking.

So far so good, really, from a public health standpoint. But now comes the bend in the road. Suddenly, parks and beaches were being added to the no-smoking roster. “As the zones of prohibition are extended from indoor to outdoor spaces, however, the evidence of physical harm to bystanders grows more tenuous.” In 2008, the authors report, “The editor of the journal Tobacco Control dismissed as ‘flimsy’ the evidence that secondhand smoke poses a threat to the health of nonsmokers in most outdoor settings.”

This confusion was much in evidence at public hearings last fall on the proposed outdoor smoking bans. While Health commissioner Farley argued that 57% of New Yorkers showed nicotine by-products in their blood, he also argued that exposing young children to adults in the carnal act of smoking was detrimental to the public health and welfare. “Families,” he said, “should be able to bring their children to parks and beaches knowing that they won’t see others smoking.” This is really quite an astonishing assertion, given the range of bad habits youngsters are exposed to as they go about a normal day in the adult world. The authors are particularly concerned about this push to stigmatize smokers. “Given the addictive nature of nicotine and the difficultly of quitting smoking, strategies of denormalization raise both pragmatic and ethical concerns.” Furthermore:

The decline in U.S. smoking rates since the 1960s has coincided with the development of a sharp gradient along the lines of socioeconomic status. Whereas about one fifth of all Americans are smokers, about one third of those with incomes below the federal poverty level smoke. These data are especially pertinent to the question of bans in parks. Since smokers are more likely to be poor and therefore dependent on free public spaces for enjoyment and recreation, refusing to allow them to smoke in those places poses potential problems of fairness.

The anti-tobacco movement, frustrated by the slow pace of gains over several years of active efforts, with rates of smoking remaining essentially unchanged, has to face the fact that an outright ban on cigarettes is a ticket to black market, crime syndicate hell. But a de facto ban is something altogether different, and “steadily winnowing the spaces in which smoking is legally allowed may be leading to a kind of de facto prohibition.” More and more employers prohibit smoking in doorways, within ten feet of doorways, anywhere on university campuses, and so on. No one has voted to make cigarette smoking illegal. But the public space in which this legal activity can be pursued is disappearing. And here is where the tough questions start: “In the absence of direct health risks to others, bans on smoking in parks and beaches raise questions about the acceptable limits for government to impose on conduct,” the authors conclude. Not to mention issues of personal autonomy, individual choice, and the stigma attached to addictive behavior. Perhaps the ACLU will soon take an interest in the civil rights of outdoor smokers, where the only health being hazarded is the smokers’ own.

Colgrove J, Bayer R, & Bachynski KE (2011). Nowhere Left to Hide? The Banishment of Smoking from Public Spaces. The New England journal of medicine PMID: 21612464

Photo Credit: www.thinkstock.com

Steve Earle and the Ghost of Hank Williams

Book Review: I’ll Never Get Out of This World Alive

Musician Steve Earle made a solo name for himself with Guitar Town and Copperhead Road after playing in legendary country and bluegrass bands as a young prodigy. He was nominated for a Grammy, his reputations soared, he added rock and roll to his range—until 1991, when Earle put out the aptly named live album, Shut Up and Die Like An Aviator. Shortly thereafter, he was dropped by his record label for long-standing drug problems, and landed in prison with a heavy sentence for possession of heroin. He completed rehab successfully, earned his parole in 1994, and has gone on since then to make several highly successful albums, guest star in the TV series The Wire, and write music for the New Orleans-based series Treme.

And now he has written a novel called I’ll Never Get out of This World Alive, set mostly in San Antonio, with a main character who is an aging doctor and a heroin addict. Doc’s specialty is quick but relatively safe and sterile backroom abortions, commonly performed on illegal immigrants. His license to practice long ago taken away, Doc takes in enough to make his daily pilgrimage to the parking lot where his longtime dealer works the streets. The book’s title is taken from the name of a Hank Williams song, which is appropriate, because whether or not you enjoy this novel may depend upon your reaction to Hank’s ghost hanging around the main character, begging for a drink and some attention. Things get even stranger when a young Mexican girl, Graciela, falls under the doctor’s care, and begins to exhibit signs of stigmata and the power to heal drug addicts. Rather than choosing to tell his tale straightforwardly, Earle is working more in the tradition of Latin American magical realism. This is no One Hundred Years of Solitude, but a lot hangs on belief, and the power of unseen forces to organize events in unforeseen ways.

Earle has a fun, quick touch with character description and the telling anecdote, explaining, for example, that local narcotic detective Hugo Ackerman “rarely hurried even when attempting to catch a fleeing offender. He had worked narcotics for over a decade, and in his experience neither the junkies nor the pushers were going far. He caught up with everybody eventually.”

Set in 1963, the book carries us through the Kennedy assassination and other cultural events as background. And we get a nice, deft description of what starts the doctor down the road toward smackdom: “Then in the first year of his residency he befriended a crazy old pathologist who worked the midnight shift in the county morgue, and it was he who introduced Doc to the miracle of morphine. From that very first shot it was as if he’d discovered the one vital ingredient that God had left out when He’d send Doc kicking and screaming into the cold, cruel world.”

I won’t say that Mr. Earle should give up his day job on the basis of this outing, but I do think that critics who have dismissed his efforts have overlooked some of what the author is attempting to say about addiction, and about recovery--that recovery involves all kinds of intangibles like faith, hope and charity, and that these attributes can present themselves in myriad disguises. (And a lot of critics got it: Michael Ondaatje wrote that this “subtle and dramatic book is the work of a brilliant songwriter who has moved from song to orchestral ballad with astonishing ease.”)

I think this book is, in fact, written very much with addicts in mind. The shade of Hank Williams doesn’t dog Doc everywhere just because Steve Earle is a huge fan. Hank Williams was also a vicious, go-to-hell alcoholic and drug addict who could not make the turnaround Steve Earle has made, and therefore could not even get out of his twenties alive, let alone this world.  Earle has Doc stand in for him when it comes to lessons learned: “Doc was immediately sucked in by the big lie that all junkies want to believe in spite of daily evidence to the contrary, that this shot was going to be like that first shot all those years ago. He tied off, found the money vein in the back of his arm, well rested now because he had always reserved that one for the big shots, the teeth rattlers, and it stood at attention like a soldier on payday.”

I won’t give out any spoilers here, as the miraculous Graciela bleeds from her wounds and lays hands on dying addicts to save them. It’s the stuff of, well fiction—but fiction informed by the author’s firsthand voyage into heroin bondage. Steve Earle is living proof of the overarching theme of his book: redemption in its many guises.

Photo Credit:  http://www.troubashow.com/

An Assortment of Drug-Related Articles

Misc. Stuff Etc.

In this post, I offer up an assortment of links to articles, mostly by me, and other related material, so that I can put checkmarks after a few items on the official Addiction Inbox to-do list, here on the official Addiction Inbox plexiglass clipboard. So let’s see….

* Here’s an article I wrote awhile ago for Brain Blogger, called "Why Do Schizophrenics Smoke Cigarettes?" The comments alone are worth a look. Spoiler: Schizophrenics smoke cigarettes because nicotine helps quell both audio and visual hallucinations.

* One of the very early posts here at Addiction Inbox, called "Marijuana Withdrawal," transformed itself into a self-help support board over time, with lengthy and enlightening comments appended to a short original post about the symptoms of marijuana dependency. The post has accumulated more than 1,000 comments at this writing, and is still going strong. Have a look here.

* The title of the Dutch study, published in the journal Alcohol and Alcoholism, is unambiguous: “Alcohol Portrayal on Television Affects Actual Drinking Behaviour.” But the dirt, as always, is in the details. My article at Adi Jaffe’s All About Addiction site.

* This feature of mine about synthetic marijuana products like “Spice” ran last month at The Fix, where I am now serving as senior contributing editor. 

* I contributed a comment or two to this follow-up piece on synthetic cannabis that ran in the New York Daily News.

* Also at The Fix, that irritating fraud James Frey gets his ass totally kicked by Time Healthland’s Maia Szalavitz, who demands that he apologize to addicts for all the harm he has done their cause in this article. Great stuff. 

* Here’s a hard-hitting excerpt from James Brown’s phenomenal addiction memoir, This River, which redeems the entire genre from the likes of James Frey. Read the harrowing “Instructions on the Use of Heroin.”

* Science of Blogging is a great site that regularly features interviews with, you guessed it, science bloggers. Travis Saunders was kind enough to do a Question and Answer session with me recently.

And here are a dozen recent blog posts by yours truly over at the The Fix:

Deaths Linked to Botched Batch of Designer Mescaline

2C-E, a research hallucinogenic best left to the professionals, may have killed two people in Oklahoma.

GOP Goes Gaga for Drug Testing

Almost 30 states now intend to test welfare recipients for drug use.

Top 10 (or 20) Recovery Songs

From the Hold Steady to the Rolling Stones to Nine Inch Nails: best all-time recovery songs.

Saving OD Victims May be Illegal in Your State

Lawmakers argue over how to do the right thing for people who do the wrong thing.

Mexico's Massacred Kids

As bodies pile up in Mexico's drug war, murdered children account for over 1,000 deaths.

Google Faces Fines for Pill Mill Ads

The internet giant may pony up some serious dough for promoting prescription-pill abuse.

Former Assistant Drug Czar Slams the Medical Establishment

Provocative Penn psychologist wonders what would happen if our health care system treated diabetics like it treats most addicts. Nothing good.

Drug Criminals See Cigarettes as the New Black Market

Cigarette trafficking is now so lucrative that organized drug and gun smuggling operations want in on the action.

Do Alcoholic Students Score Better on Tests if They Stay Drunk?

How does alcohol affect memory? New research suggests that students perform much better on tests when their "memory states" match.

A Toast to the Black Monk of Thamkrabok

For over 30 years, a charismatic Vietnam vet and mercenary named Gordon Baltimore helped hardcore addicts recover with a controversial regimen at a Thai monastery. A former heroin addict, he died last week at the age of 60

Charity Pays Thousands of Addicts to Get Sterilized

An American "charity" is paying thousands of U.S. drug addicts not to have children. Buoyed by its success, the group has moved on to Britain. Now Denmark may be taking up the trend.

Vancouver’s Supervised Shooting Up Site: 2,000 ODs, 0 Deaths

An officially-sanctioned injection site for heroin and cocaine addicts in Vancouver prompts a dramatic fall in death rates. So why is the Canadian government so dead-set against it?

Thank you and good night.

Photo Credit: http://www.thinkstockphotos.com/

Bill Manville’s Booze Book

A “professional bar fly” who flirted with death and Helen Gurley Brown.

"From the drinking man's classic, Saloon Society, back in the Sixties, to his sadder but wiser Cool, Hip and Sober, Bill Manville has consistently provided an honest, insightful first-person account of where alcoholism begins--and where it ends.”  So said the respected Keith Humphreys of Stanford University’s School of Medicine, when Manville’s account of beating booze was published some years ago. What makes his book unique in the annals of addiction books, so far as I know, is the additional blurb on Cool, Hip and Sober from none other than Cosmopolitan Magazine founder and Sex and the Single Girl author Helen Gurley Brown, who wrote: “I never read anything like this and am thrilled to recommend the book to anybody with the problem himself or with a suffering family member.”

That represents a pretty wide spectrum of opinion makers, so I took a look—and had fun with it. Written in a breezy, question-and-answer style based on his call-in radio show in Sonora, California, Manville represents an older generation of addicts whose distilled experience is as timely now as ever. Novelist, newspaper journalist, radio host, and a self-confessed “professional bar fly” on the New York City circuit who has been sober now for more than twenty years, Manville has been in the game long enough as a professional writer and practicing alcoholic to have seen a thing or two. “Those were the days when I was living on the Five-Martini Diet—writing for Helen Gurley Brown at Cosmopolitan Magazine by day, and passing out before dinner more nights than I like to remember,” Manville wrote in a recent piece for TheFix.com.

“Addictions and Answers,” the widely-read column he currently co-authors for the New York Daily News, takes personal questions and gives out useful, straightforward, evidence-based advice. So does his book. Some excerpts follow:
----------

--“Take an alcoholic or drug addict without a penny in his pocket. Deposit him, friendless and alone, in a bluenose town. Dump him there at 6AM Sunday morning, broke and hungover, the bars and liquor stores closed.  He’ll find a way to get high before noon. That’s will power.”

--"In vino veritas?  No. ‘In vino bullshit,’ says John A. Mac Dougall, D. Min., a United Methodist Minister who is also Manager of Spiritual Guidance for Hazelden in Center City, Minnesota.”

-- “‘Each time your addiction brings you smack up against trouble or grief,’ says Brian Halstead, a Program Director at the Caron Foundation, ‘you are being presented with a choice. Do you want this to be your bottom, or do you want to be hit harder?’”

--“Sobriety makes you a more competent player; it does not guarantee you will be a winner. You’re still a dress size too large, and your husband is going bald. Your wife doesn’t understand you, and you’re in a dead end job. You’ll be able to address these problems with a cool, sober brain, yes… with a bit of detachment, yes… but they are still there. You’ve discovered that even glorious sobriety has realistic limits. The pink cloud begins to float down, closer to earth. Very dangerous time.”

--“The essence of addiction is: it SPEEDS up. That’s why it’s called progressive.

--"The phrase I like is that the genetic type of alcoholic was born two drinks behind."

--“Says Scott Munson, Executive Director, Sundown M Ranch, one of the top rehabs in the country, ‘I think it is important for psychologists and psychiatrists to understand the mistrust of those professions by many people in AA. Chemical dependency is a primary illness, not the result of another disorder.’" 

 --“There are pharmaceuticals, like insulin, that correct a deficiency in the body's mechanism. When the patient takes them, he does not get high… any diabetes sufferer will tell you that is a small price. And if taking a daily pill will end your enthrallment to addiction, that's not a high price either."

--Let me end with this, a kind of self-test I heard during a lecture when I was a facilitator at Scripps McDonald: Do you remember your first drink?  How did it make you feel? If you reply, ‘For the first time in my life it made me feel normal, like other people’--take it as a warning bell. In the UC Berkeley "Alcohol & Drug Abuse Studies" catalog, it estimates "that more than one half of clients in alcohol and drug treatment have coexisting psychiatric disorders."

Photo Credit: http://www.sabredesign.net 

Does Menthol Really Matter?

Nicotine experts say menthol makes addiction more likely--but differ over what to do about it.

Back in the 1920s, Lloyd “Spud” Hughes of Mingo Junction, Ohio, was working as a restaurant cashier when, legend has it, he smoked some cigarettes that had been casually stored in a tin that contained menthol crystals. Menthol, a compound found in mint plants and also manufactured synthetically, is used medicinally, and as a food flavoring. Back in Spud’s day, menthol was mostly derived by extracting crystals from the Japanese Mint plant. What we know for certain is that the mentholated cigarettes tasted so good to Spud that he patented the mixture. In 1925, the Spud Cigarette Corporation of Wheeling, West Virginia, was born, and Spud Cigarettes quickly became the 5th best selling cigarette brand in America. 

Dr. Neal L. Benowitz, Professor of Medicine and Bioengineering & Therapeutic Sciences, and Chief of the Division of Clinical Pharmacology at the University of California in San Francisco, says that Spud Hughes had “accidentally identified an additive whose pharmacologic actions reduce the irritating properties of smoke generally and nicotine specifically.” Menthol accomplishes this because it acts on receptors involved in the detection of physical stimuli like temperature and chemical irritation. “Menthol contributes to perceptions of cigarettes’ strength, harshness, or mildness, smoothness, coolness, taste, and aftertaste.” That would seem to just about cover it. But no: In their article for the New England Journal Of Medicine—“The Threat of Menthol Cigarettes to U.S. Public Health"—Benowitz and Jonathan M. Samet also claim that “menthol has druglike characteristics that interact at the receptor level with the actions of nicotine.”

And nicotine hardly needs much help establishing its grip over addiction-prone individuals. “It’s not that it’s so intensive,” Dr. Benowitz told me some years ago, when I was researching my book, The Chemical Carousel, “it’s just that it’s so reliable. Nicotine arouses you in the morning; it relaxes you in the afternoon. It’s a drug that you can dose many times per day for the purpose of modulating your mood, and it becomes highly conditioned, more than any other drug, because it’s used every single day, multiple times per day.” Benowitz, along with Dr. Michael Siegel of the Boston University School of Public Health, recently sparked intense debate when they both championed electronic cigarettes as a safe alternative to smoking tobacco cigarettes, despite the FDA’s earlier wish to keep e-cigarettes out of the country. And last month, an advisory report for the FDA by a group that included Benowitz and Samet concluded that mentholated cigarettes were no more harmful, and no more likely to cause disease, than regular cigarettes. A study in the Journal of the National Cancer Institute of 440 lung cancer patients and more than 2,000 matched patients without lung cancer showed no correlation at all between menthol and cancer. In fact, the researchers were surprised to discover that menthol smokers appear to have a lower risk of lung cancer than other smokers. Asked whether menthol cigarettes are more toxic than non-menthol cigarettes, the study's author William Blot of Vanderbilt University definitively responded: “The answer is, no, they are not.”

However, the advisory report suggested that, while menthol cigarettes may not be more dangerous, they might be more addictive than regular cigarettes.  In the May 4 New England Journal of Medicine article, Benowitz and Samet argue that because menthol cigarettes attract younger smokers by making tobacco easier to smoke, and because more of these smokers go on to become lifelong nicotine addicts due to this same cooling effect, "menthol cigarettes increase the likelihood of addiction and the degree of addiction in new smokers." Further adding to menthol’s tendency to create lifelong smokers is the fact that “some consumers, particularly blacks, hold beliefs about implicit health benefits of menthol cigarettes that may interfere with their quitting."

This is a substantial indictment of menthol as a component of cigarettes, despite the belief among some experts that it is much ado about nothing. But if that’s the case, Benowitz and Samet suggest, why has the tobacco industry fought so ferociously to exempt menthol from the list of banned flavorings over the years? And why has the industry so consistently linked its marketing of menthol cigarettes to images of “freshness” and health? The authors estimated that “by 2020 about 17,000 more premature deaths will have occurred and two million more people will have started smoking than would have been the case if menthol cigarettes were not available.” Two million additional cigarette smokers by the end of the decade does not sound especially trivial. Nonetheless, the FDA advisory report that Benowitz helped to shape stopped short of recommending an outright ban on nicotine, saying only that removal of menthol would “benefit public health.”

While not disputing the findings of the FDA Advisory Committee, Dr. Michael Siegel of Boston University expressed dismay that “despite these conclusions, the [committee] did not recommend a ban on menthol cigarettes.” There are almost 20 million menthol smokers in the U.S., Siegel argues. If even a fraction of them quite smoking due to a ban on menthol in cigarettes, “it would have a profound effect on public health.” This is, Siegel insists, precisely why politicians managed to exempt menthol from bans on various flavor additives in the first place. The Black Congressional Caucus had “vigorously denounced the exclusion of menthol” at the time, while Lorillard, maker of Newports--the leading brand of menthol cigarettes--argued that banning menthol would result in the creation of a huge black market.  Because of all this, Seigel charges, Benowitz and the committee simply “punted the issue back to the FDA.” And if anyone harbored doubts about who benefited from this non-action, in Siegel’s view, one need only look at the fact that Lorillard’s stock enjoyed a nice run-up of about 8% after the public announcement of the FDA panel’s recommendations.

Because of all this, Siegel does not believe the FDA will ever ban menthol cigarettes. In his view, the Obama administration doesn’t need the grief of added health care complexities just now, and there is no movement in Congress to make additives an issue. And since the FDA has chosen not to demand the banning of menthol, Siegel thinks the committee’s findings will serve as a convenient smokescreen for Congress. And for the makers of menthol cigarettes, it will be business as usual. A window of opportunity on the menthol issue is now closing, says Siegel, who confesses to difficulty understanding a policy that bans “every other type of cigarette flavoring—including chocolate, strawberry, banana, pineapple, cherry, and kiwi—yet exempts the one flavoring that is actually used extensively by tobacco companies to recruit and maintain smokers… Menthol is a major contributor to smoking initiation and continued addiction, and for this reason, it will continue to enjoy the protection of a federal government that seems afraid to alienate any corporation, whether it’s part of Big Pharma, Big Insurance, or Big Tobacco.”

Photo credit: http://www.nysmokefree.com/

Falling Down and Getting Up: Nic Sheff’s New Addiction Book

 

Sheff jumps back on the carousel, lives to tell about it.

What would it be like to have written a drug memoir and an autobiography before you turned 30? Would it seem like the end or the beginning? Are there any worlds left to conquer?

The last decade has brought us fleshed-out young examples by Augusten Burroughs, age 37 (Dry); Joshua Lyons, 35 (Pill Head); and Benoit Denizet-Lewis, 33 (America Anonymous). This more or less fits the pattern established by the doyenne of the genre, Elizabeth Wurtzel, who, at age 35, wrote the addiction memoir More, Now, Again. And now along comes Nic Sheff to put them all to shame, making geezers out of every one of them.  Sheff wrote Tweak at 24, telling the world about addiction and how he’d conquered it. Well, as it turns out, not really. But for twenty-somethings, a week is like a year, so two years later, in actual time, comes We All Fall Down, in which we learn—if we didn’t learn it the first time—that the author is still learning about addiction, doesn’t have it figured, and isn’t really qualified to give out lessons to anybody just yet. Or perhaps I should wait for We All Stood Up Again two years from now before drawing any conclusions.

I know I am being a bit unfair to this well-intentioned young author. I blame it on the flood of weighty pronouncements found in the addiction memoirs that have flooded the market lately. God bless ‘em all, but Amazon, by listing Sheff’s book as “Young Adult,” probably gets it about right. You can’t go into these projects expecting great literature. Sheff’s text, perhaps in a deliberate appeal to younger readers, is peppered with whatevers, and clauses that begin with “like.” His favorite adjective, without question, is “super.” Too many one-sentence paragraphs give the book an irritatingly staccato effect at times.

But let’s get beyond that. There are good things here, and Sheff is certainly qualified to tell an addiction story: “We stayed locked in our apartment. I went into convulsions shooting cocaine. My arm swelled up with an abscess the size of a baseball. My body stopped producing stool, so I had to reach up inside with a gloved hand and….” And so forth.

There is a standard tension in addiction memoirs by young writers. The dictates of group therapy and 12-step treatment programs clash mightily with their innately sensitive bullshit detectors. It is hard—understandably—to buy into some of the more narrow-minded and coercive treatment programs they’ve been tossed into along the way. I was chilled to hear Sheff quoting substance abuse counselors threatening to commit him to lockdown psych wards, or blackmailing him into signing contracts about who he could or could not be friends with in the compound. For a free-spirited, open-minded young artist, the distinction between rehab and a Chinese re-education camp is pretty much lost entirely when personal freedoms are arbitrarily limited by lightly qualified drug counselors. One of the more compelling themes of the book is that rehab, as practiced in many treatment centers across the country, is something of a cuckoo’s nest joke.  It is a mutual con, where everybody fools everybody in order to turn a profit, on the one hand, and discharge legal or parental obligations, on the other. “Infallible institutions,” as Sheff derides them, “that know, absolutely, the difference between right and wrong.”

So Sheff plays along, he shucks, he jives, he lies, and it’s hard not to sympathize with him as he summarizes one counselor’s admonitions: “We don’t allow any non-twelve-step-related reading material, and you won’t be able to play that guitar you brought with you—so we’ll go ahead and keep that locked in the office.” Much like prisoners who leave prison chomping at the bit to commit new and more lucrative crimes, these kids are coming out of misguided drug rehab centers with nothing but an urgent desire to wipe away the bad memories of mandatory treatment by getting wasted as soon as possible.

And yet, and yet… “Once I had some knowledge about alcoholism and addiction, it was impossible to go back to using all carefree and fun,” Sheff writes. “The meetings and the things people told me had pierced the armor of my fantasy world. Somewhere inside I knew the truth.”

Maybe there won’t be a need for a third memoir. The book has a provisionally happy ending. Sheff found the right doctor, got on the right medications after a diagnosis of Bipolar Disorder (comorbidity, the elephant in the rehab room), and, when last seen, is clean and optimistic.

Sheff does have an appealing, Holden Caulfield-type persona, and this Catcher in the Rye mentality perhaps excuses the litany of things in this world that are phony, fucked up, and lame to this endlessly hip kid. All carpets are faded, all motel rooms are dingy. Even his airline boarding pass is “stupid.” But the style sometimes works for him: “Thinking, man, even that cat’s got enough sense not to jump on a hot grill twice, no matter how good whatever’s left cooking on there might look to her.” Or the time when he realizes that, like any old alkie, it was time to “start switching up liquor stores. That goddamn woman makes me feel as guilty as hell. And, I mean, who is she to judge? Christ.” And he’s got some nice truisms to deliver: “The most fucked-up detoxes I’ve ever seen are the people coming off alcohol. It’s worse than heroin, worse than benzos, worse than anything. Alcohol can pickle your brain—leaving you helpless, like a child—infantilized—shitting in your pants—ranting madness—disoriented—angry—terrified… You don’t go out like Nic Cage in Leaving Las Vegas, with a gorgeous woman riding you till your heart stops.”

Photo Credit: http://www.goodreads.com/

Addiction in the Courtroom [Guest Post]

Forensic psychology and the paradox of addiction.

Allison Gamble says she has been a curious student of psychology since high school. Though her studies ultimately led her to writing and editing, she keeps her understanding of the mind close at hand in the weird world of internet marketing.

The paradox of addiction presents a legal conundrum when it comes to determining the extent of a defendant’s guilt in criminal court. Although addiction is generally considered a mental health condition, it does not lie within the parameters that typically define mental illness in the courts. Though defense lawyers may present addiction as a mitigating factor--in some cases influencing the jury to vote for a lesser conviction--addiction does not excuse the defendant from being legally responsible for the crime.

Forensic psychology is a field that weaves together psychology and the criminal justice system. Oftentimes these insights prove useful for determining legal guilt or innocence. For example, if a defendant is found not guilty by reason of insanity, it is likely due to the work of a forensic psychologist. However, when it comes to crimes involving addictive behavior, forensic psychology is faced with paradoxical truths regarding addiction, and the relationship between addiction and responsibility for one’s actions.

A commonly held view of addiction is that it is a disease marked by lack of control. An alcoholic cannot stop himself from drinking. Likewise, a drug addict will do things no one in their right mind would ever do just to get the next high. All of these people may thoroughly regret their behavior when the high wears off, but that does not stop them from doing it again. Indeed, they often cannot stop without help.

Paradoxically, however, addiction is all about choice. A crucial part of treatment for addiction requires the addict to take full responsibility for his or her behavior. Addicts must recognize that their addictive behavior is, on some level, a choice, and that they can choose differently. It is not clear to what extent biology plays a role in starting an addiction. Social and emotional factors also play parts, both in forming an addiction and in continuing it.

This creates a huge gray area when an addict commits a crime related to his or her addiction. Did the person have control over their behavior? Is the addiction itself a choice, or something the addict can’t help any more than they could help catching the flu? Especially in cases where the addiction itself is a crime, such as compulsive shoplifting or narcotic use, these questions are crucial in determining the defendant’s responsibility for the crime and an appropriate sentence. Generally if these questions can be answered at all, the answer is often both yes and no, and the legal system often reflects this dichotomy: People convicted of addiction-related crimes may be ordered into treatment as part of their sentences. In some cases, especially for crimes not involving violence or repeat offenses, criminal charges are dropped if the defendant agrees to treatment. However, a defendant being treated for addiction may also be sentenced to jail time, probation, fines, community service, and/or restitution, especially if the crime involved violence or property damage. Since addiction is both under and outside of the addict’s control, someone who commits an addiction-related crime should be both held responsible and offered treatment.

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