Chronicle Book Review: Opium's Orphans: The 200-Year History of the War on Drugs by P.E. Caquet (2022, Reaktion Books, 400 pp., $35.00 HB)

The history of drug prohibition is increasingly well-trodden territory, but with Opium's Orphans, British historian P.E. Caquet brings a fascinating new perspective embedded in a sweeping narrative and fortified with an erudite grasp of the broad global historical context. Although Asian bans on opium pre-dated 19th Century China (the Thai monarchy announced a ban in the 1400s), for Caquet, the critical moment in what became a linear trajectory toward global drug prohibition a century later came when the Qing emperor banned opium in 1813 and imposed severe penalties on anything to do with it, including possessing it. Precisely 100 years later, after two Opium Wars imposed opium on the empire followed by decades of diplomatic wrangling over how to suppress the trade (and for moralizing Americans, how to win favor with China), the 1913 Hague Opium Convention ushered in the modern war on drugs with its targeting not just of opium (and coca) producers or sellers but also of mere users for criminal prosecution. It urged countries to enact such laws, and they did.

What began at the Hague would eventually grow into an international anti-drug bureaucracy, first in the League of Nations and then in United Nations bodies such as the Commission on Narcotic Drugs and the International Narcotics Control Board. But it is a global prohibition regime that has, Caquet writes, straight-jacketed itself with an opium-based perspective that has proven unable or unwilling to recognize the differences among the substances over which it seeks dominion, reflexively resorting to opium and its addiction model. Drugs such as amphetamines, psychedelics, and marijuana don't really fit that model -- they are the orphans of the book's title -- and in a different world would be differently regulated.

But Opium's Orphans isn't just dry diplomatic history. Caquet delves deep into the social, cultural, and political forces driving drug use and drug policies. His description of the spread of opium smoking among Chinese elites before it spread into the masses and became declasse is both finely detailed and strangely evocative of the trajectory of cocaine use in the United States in the 1970s, when it was the stuff of rock musicians and Hollywood stars before going middle class and then spreading among the urban poor in the form of crack.

Along the way, we encounter opium merchants and colonial opium monopolies, crusading missionary moralists, and early Western proponents of recreational drug use, such as Confessions of an English Opium Eater author Thomas De Quincey and the French habitues of mid-19th Century hashish clubs. More contemporaneously, we also meet the men who achieved international notoriety in the trade in prohibited drugs, "drug lords" such as Khun Sa in the Golden Triangle, Pablo Escobar in Colombia and El Chapo Guzman in Mexico, as well as the people whose job it is to hunt them down. Caquet notes that no matter how often a drug lord is removed -- jailed or killed, in most cases -- the impact on the trade is negligible.

For Caquet, drug prohibition as a global phenomenon peaked with the adoption of the 1961 Single Convention on Narcotic Drugs. Coming as it did amidst a post-World War II decline in drug use around the world, the treaty criminalizing coca, cocaine, opium and opioids, and marijuana seemed to ratify a successful global prohibitionist effort. (In the US, in the 1950s, when domestic drug use was at low ebb, Congress passed tough new drug laws.) But before the decade was over, drug prohibition was under flamboyant challenge from the likes of LSD guru Timothy Leary and a horde of hippie pot smokers. The prohibitionist consensus was seeing its first cracks.

And the prohibitionist response was to crack down even harder, which in turn begat its own backlash. Drug use of all sorts began rising around the world in the 1960s and hasn't let up yet, and the increasingly omnivorous drug war machine grew right along with it, as did the wealth and power of the illicit groups that provided the drugs the world demanded. As the negative impacts of the global drug war -- from the current opioid overdose crisis in the US to the prisons filled with drug offenders to the bloody killing fields of Colombia and Mexico -- grew ever more undeniable, the critiques grew ever sharper.

In recent years, the UN anti-drug bureaucrats have been forced to grudgingly accept the notion of harm reduction, although they protest bitterly over such interventions as safe injection sites. For them, harm reduction is less of an erosion of the drug war consensus than all that talk of drug legalization. As Caquet notes, perhaps a tad unfairly, harm reduction doesn't seek to confront drug prohibition head-on, but to mitigate its harms.

The man is a historian, not a policymaker, and his response to questions about what to do now is "I wouldn't start from here." Still, at the end of it all, he has a trio of observations: First, supply reduction ("suppression" is his word) does not work. Sure, you can successfully wipe out poppies in Thailand or Turkey, but they just pop up somewhere else, like the Golden Triangle or Afghanistan. That's the infamous balloon effect. Second, "criminalization of the drug user has been a huge historical blunder." It has no impact on drug use levels, is cruel and inhumane, and it didn't have to be that way. A century ago, countries could have agreed to regulate the drug trade; instead, they tried to eradicate it in an ever-escalating, never-ending crusade. Third, illicit drugs as a group should be seen "as a historical category, not a scientific one." Different substances demand different approaches.

Opium's Orphans is a fascinating, provocative, and nuanced account of the mess we've gotten ourselves into. Now, we continue the work of trying to get out of that mess.

Oklahoma Republicans move to take on what they see as an out of control medical marijuana system, Afghan farmers are planting more opium poppies this year, and more.

Medical Marijuana

Oklahoma GOP Lawmakers Move to Rein in "Wild West" Medical Marijuana System. The House's Republican Caucus on Monday rolled out a package of bills aimed at reining in the state's free-wheeling medical marijuana program. The move comes after state agents seized more than 150,000 marijuana plants in a bust last month. "We have seen black market elements competing with legitimate Oklahoma businesses. They are putting our citizens at risk. They're doing things in an illegal, unethical manner," said Rep. Jon Echols (R-Oklahoma City). The package of 12 bills includes full implementation of a seed to sale system, grants to county sheriffs to fund law enforcement, making the Oklahoma Medical Marijuana Authority a stand-alone agency, provisional licensing with pre-licensing inspections, separate licensing for wholesalers, tough electrical and water data reporting by growers, annual inspection, and more. "If you're an illegal operator of the state of Oklahoma, your time is up," warned Rep. Scott Fetgatter (R-District 16).

Drug Policy

Rhode Island Drug Decriminalization, Therapeutic Psilocybin Bills Filed. Lawmakers filed a pair of drug reform bills last week, one of which, House Bill 7896, would decriminalize the possession of up to an ounce of all drugs except fentanyl, while the second bill, House Bill 7715, would allow doctors to prescribe psilocybin and would decriminalize psilocybin and buprenorphine. Buprenorphine is an opioid often used as a harm reduction tool to help people transition away from more addictive compounds. The broader decriminalization bill, would make possession of up to an ounce of any drug other than fentanyl a civil violation punishable by a $100 fine for a first offense and up to $300 for subsequent offenses.

Psychedelics

Missouri GOP Lawmaker Files Therapeutic Psychedelics Bill. State Rep. Tony Lovasco (R) on Tuesday filed House Bill 2850, which would legalize a range of natural psychedelics for therapeutic use and decriminalize small-time possession. Under the bill, patients with specified conditions such as treatment-resistant depression, PTSD, and terminal illnesses access to substances such as psilocybin, DMT, mescaline, and ibogaine at designated care facilities or the patients' or caregiver's residence. Patients would be allowed to possess and use up to four grams of the substances. The bill decriminalizes the possession of less than four grams outside the medical model but makes possession of more than four grams a class A misdemeanor punishable by up to a year in jail.

International

Afghan Opium Production Surges in Kandahar and Helmand. Opium and other drugs are being sold in open markets, and farmers in the country's opium heartland of southern Helmand and Kandahar provinces are sowing more poppies this year amidst the country's economic collapse after the Taliban's seizure of power last summer and the subsequent withdrawal of all Western assistance to the country. "There is nothing else to cultivate. We were growing wheat before. This year -- we want to cultivate poppy. Previously they were asking for bribes every day but we don't have that problem this year," one farmer said. "If we don't cultivate poppy, we don't get a good return, the wheat doesn't provide a good income," farmer Mohammed Kareem said. "There are no restrictions this year. If the Taliban wanted to ban it, they must let us grow it this year at least," added farmer Peer Mohammad.

Myanmar Militias, Rebel Armies Ramp Up Drug Dealing Amidst Civil War. Armed groups on both sides of Myanmar's civil war are ramping up drug production amidst the turmoil, with much of the methamphetamine and heroin supply going to Asian countries through the porous Laotian border, a UN Office on Drugs and Crime (UNODC) official said this week. The $60 billion trade based largely in Shan state is now going into overdrive, he said. "Seizures in Laos and Thailand are off the charts and it is not because of suddenly improved law enforcement -- some other countries' seizures are up too, but in Thailand and Laos the connection to trafficking patterns and locations in Shan is very clear," said Jeremy Douglas, UNODC representative for Southeast Asia and the Pacific.

Drug Use for Grown-Ups: Chasing Liberty in the Land of Fear, by Carl Hart (2021, Penguin Press, 290 pp., $28.00 HB)

Dr. Carl Hart is a one-man drug and drug user destigmatization machine. In his new book, Drug Use for Grown-Ups, the Columbia University psychology professor blasts drug prohibition as both an affront to the American dream of the pursuit of happiness and as a tool of racial oppression. And he makes a strong, informed argument that recreational drug use can be, and usually is, a good thing.

You could hardly find someone more qualified to make the case. Hart has spent years in the trenches of neuropsychopharmacology research, handed out drugs (or placebos) to thousands of research subjects, published numerous scientific papers and popular articles in the field, and risen to the top of his profession along the way. And here is his bottom line:

"[O]ver my more than 25-year career, I have discovered that most drug-use scenarios cause little or no harm and that some responsible drug-scenarios are actually beneficial for human health and functioning. Even 'recreational' drugs can and do improve day-to-day living... From my own experience -- the combination of my scientific work and my personal drug use, I have learned that recreational drugs can be used safely to enhance many vital human activities."

Hart is refreshingly -- and deliberately -- open about his own recreational drug use. Given the stigmatization and persecution of people identified as "drug users," he feels that justice demands privileged partakers come out of the closet and give voice to their own, non-destructive drug use histories as a necessary remedy for that demonization. He certainly does so himself, revealing a disciplined yet curious mind most definitely not averse to sampling various substances.

Those substances include heroin, which he describes as his current favorite drug, one that he's been using episodically for years now: "There aren't many things in life that I enjoy more than a few lines by the fireplace at the end of the day... Heroin allows me to suspend the perpetual preparation for battle that goes on in my head... The world is alright with me. I'm good. I'm refreshed. I'm prepared to face another day, another faculty meeting, another obligatory function. All parties benefit."

But Hart is not quite so mellow when it comes to people and institutions he sees as helping to perpetuate overly negative depictions of various drugs or the persecution of drug users. He rips into Dr. Nora Volkow, head of the National Institutes on Drug Abuse (NIDA) over her "addiction is a brain disease" mantra and the rigid ideological control she has over research funding. He rips into journalists for uncritically and sensationally reporting salacious scientific findings about the evils of drugs that he argues are not supported by the evidence they are supposedly based on. He even calls Bernie Sanders "ignorant" (that word shows up more than a few times) for complaining that marijuana shouldn't be in the same drug schedule as "killer drugs like heroin."

Hart doesn't deny the potential dangers of drug use but makes the case that they are dramatically overstated. In that sense, Drug Use for Grown-Ups is a corrective to more than a century of anti-drug propaganda. In a deep dive into opioids, for instance, he notes that most opioid overdose deaths are actually opioid/benzodiazepines/alcohol deaths, and that a large number of them are due to ignorance (there's that word again) -- in that, in the black market that currently exists, drug users do not and cannot know what exactly is in that pill or powder they purchased.

As long as we are in a prohibition regime, the least we can do is widespread drug testing for quality control, as is done at some European music festivals, Hart argues. But that's the only kind of drug testing he's down with; he calls the urine drug testing industry "parasitic," a sobriquet he also applies to the drug treatment industry.

But hang on, he's not done yet. Although he is an advocate for harm reduction practices, he has a bone to pick with the term itself: It's too damned negative! Drug use doesn't typically involve harm, he argues, but pleasure-seeking. As I pondered this, I came up with "benefit enhancement" as an upbeat alternative to harm reduction, but Hart went with "health and happiness."

And he's got a bone to pick with "psychedelic exceptionalism," the notion, dear to folks like Decriminalize Nature, that psychedelics, or better yet, "plant entheogens," are somehow "better" than dirty old drugs like meth or heroin and thus deserve to be treated differently, more gently. He also snarks at the notion that taking drugs for spiritual or religious purposes is of a higher order than taking them for fun and rebels at the notion of having a shaman or guide during a tripping session: "Some people find this comforting. I find it creepy and have never done so myself."

Drug Use for Grown-Ups is bracing, informative, and provocative contribution to the literature. Even the most ardent drug reformers and defenders would benefit from reading it and reexamining their own assumptions. Maybe Carl Hart is onto something.

RX Appalachia: Stories of Treatment and Survival in Rural Kentucky, by Lesly-Marie Buer (2020, Haymarket Books, 264 pp., $22.95 PB)

Death in Mud Lick: A Coal Country Fight Against the Drug Companies That Delivered the Opioid Epidemic, by Eric Eyre (2020, Scribner, 289 pp., $28.00 HB)

White Market Drugs: Big Pharma and the Hidden History of Addiction in America, by David Herzberg (2020, University of Chicago Press, 365 pp., $27.50 HB)

America remains in the grip of what is arguably its third great opioid addiction and overdose crisis. It began in the late 1990s as doctors tried to address an historic problem of under-prescribing and unavailability of opioids for chronic pain treatment that affected many patients. But mistakes were made along the way, and a massive tide of not always well targeted prescription opioids swamped the country. As regulators and law enforcement cracked down on pain pills, that morphed into a deadly wave of heroin addiction. And then we got fentanyl, which quickly took first place as a cause for overdose deaths. Produced mostly in China and Mexico, fentanyl is used by some hardcore addicts with high tolerance, but mainly appears as an adulterant added to heroin or in counterfeit prescription pills.

The authors of the three books reviewed here take on various aspects of the phenomenon, from the granular nitty-gritty of the lives of poor, white, female drug users ensnared in the treatment and rehab system in present-day Appalachia, to a state-level look at how drug distribution companies flooded West Virginia with literally billions of prescription opioids, to a long-term overview of the effort to regulate drugs and the subsequent -- and enduring -- historic division of drug use and users into markets black and white. (And by white markets, we are referring not only to legality but also, sadly yet unsurprisingly, skin color.)

Taken together, the three books weave a damning indictment of pharmaceutical companies, the people and entities that are supposed to regulate them, and the moral crusaders who -- too often, successfully -- use the issue of drug use to call for repressive policies, especially aimed at people who aren't "good people;" that is, poor and/or non-white people.

There are also some things the books don't do more than tangentially. They don't touch on the issue of access to pain medications for chronic pain patients. These are people who often suffer not from too-easy access to prescription opioids, but from obstacles to access, and who have suffered even more as politicians and regulators moved to rein in what they argue is massive overprescribing of such medications.

Whether it's being prosecuted for seeking their medicine in the black market or being forced to jump through hoops to obtain their medicine or being refused it altogether in the white market, these are people whose access to the medicines they need is encumbered. Their story is an important part of the debate over opioids (and drug policy more generally), but it gets only a side mention in one of these three works. But over-prescribing of opioids and under-prescribing of them continue to coexist.

The books also don't attempt to disentangle supply-driven opioid abuse, from the so-called "deaths of despair." The same social and economic factors that have driven up the suicide rate in recent decades, and which arguably helped to elect Donald Trump, increase the rates at which drugs are used and abused, including opioids. That in turn leads to more overdose deaths, and some apparent overdoses actually are suicides.

And the authors don't ask their readers to question whether any given "pill mill" or seemingly too large prescription, is really what it looks like. If we accept that abuses in the supply system have played a role in the opioid crisis, that doesn't mean that any given doctor or pharmacist or distributor is guilty as charged. A medical practice with patients treating patients from hundreds of miles away, could be a "pill mill," but it could also have the one doctor who understands pain treatment and is willing to work with poor people whom other doctors view as too risky. A prescription that seems huge because of the number of pills, could represent diversion to the underground market – or it could mean that a long-term pain patient who needs a large dosage because of tolerance built up over time, and who doesn't use technology like a medically-inserted morphine pump, is reliant on pills and their standard-sized dosages that are designed for less tolerant patients. Without considering those contexts, pill numbers can be a misleading metric, at least some of the time.

The books do discuss some options for making effective opioid addiction treatments more easy for more patients to obtain, or for reducing the likelihood of a user coming to serious harm. But the most effective treatment for this type of addiction is the use of other opioids, in what's known as Medication Assisted Treatment (MAT). Through controlled use of methadone or buprenorphine supplied by clinics, people with opioid addictions are able to stabilize their lives and avoid catastrophic physical harms, while maintaining responsibilities like work and family needs. Making MAT available through a doctor's office, while training doctors in their use, would reduce the harm of opioid addiction by providing a legal alternative that works -- in this case a quality-controlled opioid. Offering HAT, too -- heroin assisted treatment, or heroin maintenance, as Canada and some European countries do for people who have tried methadone or buprenorphine without succeeding -- would do more.

And that begs the question about prohibition itself. Though some may find it counterintuitive to talk about legalization as a solution to a problem driven by increased drug availability, it is the case that this opioid crisis in its entirety has transpired under the current system – a system in which all drugs of this type are illegal unless one has a prescription, and in which most people are usually not supposed to be given prescriptions. Fentanyl, which today accounts for 2/3 of US opioid deaths and has room to spread geographically and increase further, is a textbook example of the consequences of prohibition -- most people taking it, and nearly all of those who die from it, thought they were taking something else. If people who developed addiction problems had access to predictable, (relatively) safe, easy to access and financially affordable options, that might be better even than a less heavy-handed system but still prohibition-based system.

All that said, there is an opioid crisis. These three books provide an eye-opening and important look at some critical sides of the phenomenon.

Lesly-Marie Buer is a Knoxville-based harm reductionist and medical anthropologist whose RX Appalachia is a compelling examination of the socially constructed suffering of mainly poor, white women who use drugs in a cluster of eastern Kentucky counties. She spent months living in the area, followed the women to court, to drug treatment, and opioid maintenance programs, and interviewed them extensively over time.

The result is a nuanced portrayal of these women's lives and struggles as they contend with the demands of institutions of social control even as they have to deal with poverty, child custody issues, and their stigmatization as drug users and therefore bad mothers. In that very important sense, RX Appalachia gives voice to the voiceless.

It also voices an unrelenting critique of a social and political system that provides unequal access to resources, chronically underfunds services to the poor and needy -- including but not limited to drug treatment and mental health services -- and is more willing to impose social controls on these women than to help them deal with the complexities of their lives. Appalachia RX is an important contribution to our understanding of the way drug policies, as well as broader social and economic trends, play out on the bodies of these multiply oppressed women.

How some of those women got strung out in the first place is the subject matter of Death in Mud Lick, still in Appalachia and just across the West Virginia line from those Kentucky women. Charleston Gazette-Mail reporter Eric Eyre won a Pulitzer Prize for his years of doggedly chasing down the story of how drug distribution companies pumped billions of opioid pain pills into the state in just a few years, and here, he puts that reporting in book form. It's quite a tale.

Eyre starts with a single drug overdose death, and by the time he's done, has unraveled a tangled tale of negligence, indifference, and profit-driven decision-making that left 1,728 West Virginians dead of drug overdoses in a six-year period. Thanks to Eyre's journalistic persistence and to a legal team determined to get to the bottom of the flood of pain pills that overwhelmed the state (and the region and the nation), we now know that drug companies dumped some 780 million hydrocodone and oxycodone tablets into the state during that same period.

There's plenty of blame to go around. Pharmaceutical corporations such as Purdue aggressively promoted their opioid products, doctors turned medical practices into pill-prescribing machines, pharmacies blithely filled numberless prescriptions, and drug distribution companies such as Cardinal and McKesson just as blithely delivered all those pills to the pharmacies, despite warning signs.

And regulators failed to regulate. Whether it was the state Board of Pharmacy or the DEA, regulators were asleep at the switch as an opioid epidemic grew right in front of them. And state officials were compromised by ties with the pharmaceutical industry and the distributors.

Eyre tells his tale with journalistic panache, taking the reader with him as he and his struggling newspaper take on the state political establishment and the distributors in the court battles that ultimately forced the companies and the DEA to release the records that documented the deluge of opioids. Death in Mud Lick is a real eye-opener.

But for David Hertzberg, an associate professor of history at the University of Buffalo and author of White Market Drugs, Eyre's story is just the latest chapter in the long history of America's effort to control drugs. Hertzberg begins with the opioid crisis of the late 19th Century and ably describes how the competing forces seeking to deal with it -- therapeutic reformers, repressive moral entrepreneurs, pharmaceutical companies, the medical profession -- created a class- and race-based bifurcation of the world of psychoactive substances into "medicines" and "drugs."

If it was prescribed by a physician, it was medicine. If not, not. The world of legal, regulated drugs became Hertzberg's white market. The world of repressed, prohibited drugs is the familiar black market. One serves middle-class white people and is concerned with consumer safety. The other serves the poor, the unconnected, the immigrant, the people of color, whose drug use and sales are considered crimes.

The history of drugs in America is well-trodden ground, but Hertzberg brings both new revelations and a new perspective to the subject. The drug reform movement's archvillain, Harry Anslinger, the master of Reefer Madness propaganda, becomes more than one-dimensional as Hertzberg tells the story of his strict scientific approach to opioids. As head of the Federal Bureau of Narcotics, Anslinger enlisted a Committee on Drug Addiction to closely study opioids, and those scientists even developed their own new opioids (they were market flops), as well as closely measuring the addictive potential of other potential new opioid products. Here, Anslinger was acting not as the heavy-handed lawman, but as the protector of white market consumers.

And as he tells the story of pharmaceutical companies continually coming up with new psychoactive products, patterns begin to occur. After the original drug prohibition laws a century ago effectively suppressed opioid use for decades, the pharmaceutical companies came up with barbiturates in the 1930s, amphetamines in the 1940s and 1950s, benzodiazepines in the 1970s and 1980s, before hitting it big again with opioids in the OxyContin-led bonanza beginning in the 1990s and lingering like a bad hangover to the present day. In all those cases, the profit motives of the drug makers overwhelmed regulatory structures designed to protect those good, deserving consumers of the white market -- even as the drug companies demonized black market drug users for causing the problems.

Given this history of pharmaceutical and regulatory fecklessness, Hertzberg comes to a shocking, but not really surprising conclusion: Left to their own devices, profit-drive drug companies peddling addictive products will function in ways that are incompatible with the public health. In Hertzberg's words:

"Profit-driven drug markets follow a predicably damaging cycle. Companies hype new medicines as safe and beneficial and sell with insufficient regard for consumer safety; a health crisis ensues as consumers are left ill-equipped to make informed decisions; authorities respond with consumer protections and destructive drug wars; the pharmaceutical industry devises strategies to circumvent the new restrictions and start the cycle again. After umpteen repetitions of this cat and mouse game, it may be time to acknowledge the impossibility of establishing a safe, for-profit market for addictive drugs. Alternatives exist: state monopolies, for example, or public utility models. We need to consider these and other creative ideas for dramatically minimizing or even eliminating profit from psychoactive capitalism."

Whether a shift to models of that type is what's needed, or just better regulation, is a question for debate. But it's clear that ending drug prohibition isn't enough. Reimagining the white market is necessary, too.