NIDA Didn't Invite Me to the Heroin Conference and as a result, they got it all wrong

On September 29, the National Institute on Drug Abuse convened a group of over 500 drug experts to discuss the latest heroin epidemic (or at least rising heroin use among the young). Drug Czar General Barry McCaffrey estimated that the United States now has 600,000 heroin addicts.

This latest anti-heroin campaign forms a part of a regular cycle of such scares, beginning with the Nixon Administration's 1971 war against the drug (and actually extending early into the century and the Harrison Act and its antecedents). Of course, as announced in the title of David Musto's classic work, The American Disease, large-scale heroin addiction is a peculiar feature of American culture.

American policy towards heroin has remained largely unchanged since the passage of the Harrison Act and the closing of clinics which provided addicts with the drug. This policy is in part punitive and in part pegged to the concept of heroin addiction as an intractable disease. (Whereas some see medical treatment and police action to be antagonistic approaches to the problem, they in fact are built on the same assumptions.)

But our policy is acknowledged as a failure by those who maintain it. According to McCaffrey, "We have a failed social policy and we have to correct it" (by which McCaffrey means we need to pile more treatment on top of imprisonment of heroin users).

Alan Leshner

In order to bring the assembled experts up to snuff, NIDA director Alan Leshner called on a venerable figure in American drug research—Avram Goldstein, a retired Stanford pharmacologist, who "described in detail the process by which heroin causes a euphoric rush of the biochemical dopamine" (according to the New York Times account of the conference).

Goldstein conducted his major work on the drug in the 1970s, when he noted that the body produced its own opioids, called endorphins. This caused him and others to speculate that addicts were deficient in this endogenous substance (which has never been shown), and that injecting addicts with endorphins would eliminate their need for illegal opiates. Alternately, Goldstein focused on drugs which block heroin from producing the effects that addicts seek from the drug as the best treatment for addiction.

This theorizing and research has had no practical impact on addiction treatment, for reasons I made clear in The Meaning of Addiction. Indeed, Goldstein has still not learned (as I and others such as Norman Zinberg patiently explained to him) that addicts do not seek "euphoric rushes." At the NIDA conference, Goldstein cautioned that almost nothing was known about "the central problem, which is relapse." He said that the relapse rate among heroin addicts was nearly 100 percent and that "if we didn't have relapses, we could cure an awful lot of problems."

In other words, while he can describe how heroin acts on the brain, this tells us nothing about why addicts seek the drug out in the absence of its current, or recent, presence in their bodies. Steven Hyman (the director of the National Institute of Mental Health) authored an article in Science claiming that, based on brain imaging, we are "shaking out the cause of addiction." My reaction was that "brain images tell nothing about addiction"—that is, addiction as the urgent pattern of seeking, and resisting withdrawal from, immersion in the narcotic experience.

Maybe at the next such conference I can give the featured speech so that we can finally turn the corner in our understanding and treatment of, and policy towards, heroin.