Lessons from Prohibition

 

This is inspired by Ken Burns 4½ hour documentary aired October 2-4, 2011, on Public Television.  Temperance enthusiasts were so confident that The Eighteenth Amendment would not be repealed because no constitutional amendment had ever been repealed and thereby missed an opportunity to modify the Volstead Act, the legislative implementation of prohibition.  The Volstead act had some unfortunate consequences and needed some compromises such as permitting wine and beer but not distilled spirits.  What lessons can we learn to help us with modern proposals to legalize marijuana (and other “hard” drugs)?

Marijuana is less harmful than alcohol or tobacco--a fact emphasized by our Surgeon General fifty years ago; there has yet to be reported a fatal case of acute marijuana overdose.  Perhaps the worst thing you can say about pot is that it may bring symptoms of schizophrenia before they would have appeared otherwise.  So, if pot becomes legal, how do we avoid its being advertised?  Answer: create a new category of things neither legal nor illegal.

There is a long and successful precedent for limiting advertising of drugs.  Prescription drugs could not be advertised except to doctors until the policy was reversed in the early 1990s by executive decree without legislative activity.  No hearings were held.  New Zealand followed our example, but reversed course in 2007 as part of negotiations with Australia to promote more uniform policies.  Now we are the only developed country that permits advertising of prescription drugs to the general public.  The latest drugs should be used only on patients not doing well on existing regimens to permit adequate time for post-marketing safety surveillance.

It is encouraging that most, if not all, of the jurisdictions experimenting with partial legalization of marijuana are requiring a doctor’s prescription.  This is a good temporary way to limit unnecessary and indiscriminant promotion.  I suggest a method that is better in the long term and has other beneficial side effects.  Again, create a new category of things that are neither legal nor illegal, thus permitting the prohibition of advertising.

For example, as the world struggles to promote modifying life styles to limit climate change by limiting greenhouse gas emissions, how much more humane and effective it would be to merely prevent promotion of frivolous activities that consume unnecessary  fossil  fuel--or bio-fuels  for that matter.  Jet skis, snowmobiles, all terrain vehicles come to mind.  People with a real need for these items would acquire them in spite of no advertising.  Consider snowmobiles for rescuing injured cross-country skiers.  Gradually the public would be educated, not coerced. 

Perhaps it would have been appropriate to institute this change when prohibition was repealed in the 1930s--better late than never, and maybe start with hard liquor instead of including wine and beer right away.  Tobacco is increasingly less socially acceptable.  Prohibition of advertising it would help prevent subtle promotion to young people to get them started using tobacco.  Efforts to limit tobacco advertising a generation ago stubbed their toes on the legal concepts of commercial free speech and corporate personhood.  These two concepts rest on very shaky legal precedents.  For more details see Corporate Personhood on  www.frantzmd.info.  

Incidentally, here is an interesting story of why tobacco is not advertised on TV.  Very soon after the introduction of commercial television, the Cancer Society devised some very effective spots about the health hazards of smoking.  These were so immediately effective that the tobacco interests “spontaneously” and collectively agreed to cease TV advertising in return  for the withdrawal  of  the  Cancer  Society’s  public interest airings.  The voluntary ban on advertising tobacco on TV was codified in 1969 by the FCC (Federal Communications Commission). 

Bottom line: we need a new word for the new category such as quasi legal.  Other suggestions for naming are welcome. These limits on promotion will enhance the public’s health and wellbeing including reduced climate change.  Initially at least legal street drugs including nicotine, hard liquor, and devices for frivolously releasing carbon dioxide into the atmosphere belong in this new category.  As our economy inevitably becomes less dependent on consumerism, much more advertising will become redundant regardless of how it is labeled.  Facetiously, "Why should we limit advertising of marijuana?"  "Because smoking pot might lead to the use of tobacco, and we know that is harmful."   Should all other habit forming drugs in addition to tobacco be placed in our new quasi legal category?  This makes sense for heroin and cocaine as we contemplate avoiding the enormous revenue to the underworld from bootlegging whether alcohol during prohibition or modern street drugs.  Caffeine is in a special category because addiction to it is relatively harmless.

Soon after settling in Wisconsin in 1955, I was introduced to real coffee drinking.  A Norwegian patient asked me if he could drink coffee.  He thought I was joking when I told him, “Sure, just hold it to less than  17 cups per day”.   His face fell because he drank almost twice that much.  Then there was a barber who complained of headaches every Thursday for ten years.  After a rather extensive get acquainted conversation, the cause of this unusual complaint was revealed.  He had not been a coffee drinker prior to marriage and finishing barber school.  Thursday was his day off and there was no business partner or wife to offer coffee.  He followed my advice to carry two thermoses of coffee everywhere he went on his day off.  His Thursday headaches ceased.

Headache as the withdrawal symptom of caffeine addiction is not sufficiently known.  For instance, the mother of a teenage daughter brought the young lady in because of sudden onset of severe headache.  The crucial information: the mother had recently told the daughter that she would have to buy her own soft drinks but this child’s allowance was insufficient to support her habit.  Neither of them was aware of the connection.  The headache of caffeine withdrawal is not relieved by morphine in doses adequate to relieve the pain of war wounds.  This is illustrated by a lady with pancreatitis causing severe abdominal pain relieved by large doses of morphine.  The second day of intravenous feeding and nothing by mouth, she got a severe headache not relieved by the large doses of morphine.  She was not a coffee drinker, but a few more questions revealed that she drank a gallon of iced tea per day.  Some caffeine injected into her IV tubing relieved her headache before the injection was complete.

When people state that only Anacin and Excedrin relieve their headaches, this usually means they have caffeine withdrawal headaches.  Some of them take their caffeine containing pills in anticipation of trouble.  This results in the caffeine in the headache pills becoming part of their drug requirement. 

Ironically, the aspirin or other ingredients also present may proceed to cause stomach pain, a potential “foot in the door” for Christian Science.

So caffeine has a stereotyped withdrawal syndrome (the headache), a characteristic of addiction.  The withdrawal syndrome of narcotics is goose bumps, sweating and diarrhea.  Quitting “cold turkey” refers to the goose bumps similar to the appearance of leftover turkey skin.  Much of slang originated in drug and criminal circles.  Another characteristic of addiction is that former addicts, even years after stopping the drug use, become re-addicted on fewer, smaller doses than naive users (users without prior drug experience).  I became aware of this after returning from 2 years in Asia where I drank tea, even though I do not like it, in order to get boiled water and avoid dysentery.  I could easily wean off but I would get withdrawal headaches in late afternoon after 3 to 4 days of a cup of coffee  for lunch, a much smaller dose  than would produce this result in someone who had not been severely addicted.  I had been such a person prior to the 2 years in Asia.  Remember, I did not even like tea.  My addiction was purely physical, not psychological.

Caffeine demonstrates that drug addiction does not necessarily cause health problems or social problems.  These depend on the toxicity of the drug and the consequences of attempts at prohibition.  Not long after I started thinking about poisons, herbs and drugs derived from natural sources in terms of chemical warfare between plants and animals, it occurred to me that caffeine is so low in toxicity it is hard to explain why plants bother to make it.  In the summer of 2002 I ran into an item in Nature, the British scientific journal, reporting that a very small concentration of caffeine kills slugs and snails.

When other addicting drugs escape total “illegality” as caffeine has for a long time (except for Mormons), consider putting caffeine on the list along with all the previously illegal drugs if only to prevent promoting it to children.  Addiction to caffeine by significant numbers of the general population is quite a modern phenomenon judging by my experience with my patients.  I don’t recall seeing caffeine withdrawal headaches in anyone consuming less than the equivalent of 5 or 6 cups of coffee or tea per day and over a period of weeks (caffeine containing pain pills can be part of the quota).  Preserving one’s non-addict status sustains caffeine’s usefulness in staying awake while driving or studying some urgent but perhaps boring matter.  Putting caffeine in our new quasi legal status would help in educating the public about public health and recreational drugs. 

My 60 years (not counting 5½ years of retirement) of experience as physician has led me to conclude that we need to blur the distinction between legal and illegal drugs.  It is clear that nicotine as a motive for exposure to the carcinogenic tobacco tars that accompany it is more harmfu1 than pure, uncontaminated heroin in reliable doses. The grip of the habit in each case is quite similar. We have made great strides in reducing the number of smokers in the United States with special credit for this progress going to Surgeons General Luther Terry and C. Everett Koop. Considering the unintended consequences (such as bootleggers) of attempts to prohibit alcohol, education is a more effective deterrent than prohibition in the long run, but the fact that tobacco is a legal substance confuses the courts with the idea of "commercial free speech". Some blurring of this "legality" of tobacco seems entirely appropriate because advertising tobacco is comparable in its public health consequences to advertising heroin.  Compare the public health result to the delay in incarcerating typhoid Mary 100 years ago. Typhoid Mary was a carrier of typhoid fever who insisted on continuing to work as a food handler until she had caused one hundred thirty-some deaths from typhoid fever. Her 'epidemic' ceased when special laws were passed in New York State permitting her to be jailed.  Do we need to limit tobacco sales to certain government licensed stores to help control tobacco use by minors?   Some states already have such stores for alcoholic beverages.  

Treating heroin addiction as a public health problem is likely to be more successful than treating nicotine addiction because of the well-known experience with methadone maintenance. We need outreach to poor heroin addicts instead of waiting lists to start treatment.  A daily dose of methadone for former heroin addicts blunts their drug craving and eliminates withdrawal symptoms for years if necessary   (The longest acting drugs in all categories of addicting drugs are the least habit-forming.)  

The problem of cocaine is more difficult because of the lack of a long-term substitute to blunt withdrawal cravings. Some urgent research about cocaine receptors, long acting agonists and antagonists is needed.  Meanwhile, maybe some stopgap products comparable to nicotine chewing gum, patches, and inhalers might be commercially viable if cocaine were less “illegal".  After all, we are succeeding with nicotine mitigation without long acting agonists or antagonists.

Addiction to caffeine is scarcely a public health problem because of its lesser toxicity.  But should we permit adding caffeine to food as an aid in marketing soft drinks?  Even if caffeine should turn out to benefit some children, it is unlikely that the net effect would benefit this population considering the empty calories and escalating obesity.  Following are some suggestions regarding caffeine addiction:  

1) Only permit promotion of products that contain caffeine naturally such as coffee, tea, cola nuts and matte.  2) Prohibit selective breeding of those natural sources to increase caffeine content when this is the sole motive (as recently came to light concerning Brazilian tobacco).  3) Require labeling that specifies the actual content of caffeine in the product, not just that caffeine has been added.

Basically we have been talking about harm reduction. Another very important item of harm reduction is to eliminate sharing needles by drug addicts.  This is currently not widely implemented because of "sending the wrong message."  Mature consideration tells us the message, "We don't care if you get AIDS, because of our puritanical hang-ups" is an even more wrong message.  There are other examples where promoting public health goals to solve medical problems has been successful, but the puritanical approach  has failed.  Venereal disease is a salient example, and elimination of excess mortality by decriminalizing abortion is another. Incidentally, in the 19th century criminalizing of induced abortions was a public health measure because, at that time, any induced abortion was much more dangerous to the mother than a completed pregnancy.

In conclusion,  I would like to emphasize that my support for blurring the distinction between legal and illegal drugs does not imply condoning criminal activity motivated by drug use such as purse snatching, sales of illegal drugs, or doctors or pharmacists diverting legal drugs.   But we urgently need a new approach. The "Drug War" supplies criminal elements with enormous revenues, a corrupting influence on society comparable to bootlegging during prohibition..  Spending obscene amounts of money jailing nonviolent addicts (as opposed to drug dealers) is not a public health measure. These moneys would better be spent on treatment of addictions and other public health benefits.  Some of those jailed for long periods for simple possession of marijuana would actually be good citizens or even good parents, * if they were not in jail (marijuana does not foster violence in users as does alcohol).  Quasi legal may not be the best name for the new category.  I have no hang ups about that because I remember Harry Truman’s statement, “It is remarkable what you can accomplish if you don’t care who gets the credit.”

An afterthought: when we legalized gambling a few years ago, would we have had the foresight to put gambling in the quasi legal category even if that category had existed since the repeal of prohibition?  

John A. Frantz, MD

October 11, 2011

      * We could use a new word for this.  I suggest “incarceromania.”   (The jail workers union favors the war on drugs---many easy-to care-for inmates.)