It is refreshing to have three new books which demonstrate, in their separate ways, how much we have yet to learn about drugs. The millions of words published about cocaine and amphetamines during the last twelve years suggest that most people, including health professionals, cling to familiar myths and stereotypes that cover up the contradictory facts.
The books under review show that doctors and medical societies alike have failed the public by being frightened of cocaine because of a few extreme cases, while being sanguine about the more dangerous amphetamines because of their popularity. Ashley as well as Grinspoon and Hedblom document the irresponsible or ignorant misuse of these drugs by modern doctors, while Byck’s collection of Freud’s papers suggests that the self-serving pettiness of the medical profession when faced with psychoactive substances goes back at least a century.
Both cocaine and amphetamines are stimulants of the central nervous system. The leaves of the coca plant have been chewed for thousands of years by the Indians of Central and South America. The plant appears to be a complex substance containing several alkaloids, vitamins B and C, and other elements. Its principal alkaloid, cocaine, was isolated in the 1850s. Coca users seem to tolerate their habits well and feel few, if any, noticeable side-effects. Some pharmacologists explain this by saying that the various elements of coca may oppose or activate one another. The effects of coca are quite different from those of the more powerful alkaloid, for the natural plant contains only from 0.5 to 1.5 percent cocaine. (One should no more equate the potencies of coca and cocaine than one should equate the potency of marijuana with that of pure delta-9 tetrahydrocannabinol [THC], marijuana’s most active ingredient.)
But even in its pure—that is, chemical—form, cocaine (when snorted) produces a relatively brief effect on the user. In most cases, a rush of euphoric feeling is followed in minutes by a half-hour high, with some effects lingering on for as long as two hours. The cocaine high can be so subtle that many users feel no particular response at all, apart from some numbing of the nose and mouth, and a general feeling of well-being. Freud wrote that one-twentieth of a gram of cocaine cured a bad mood and gave him the impression of “having dined ‘well so that there is nothing at all one need bother about,’ but without robbing [me] of any energy for exercise or work.” Except for those who take extremely large doses, most people who snort cocaine develop no tolerance for the drug, can fairly easily stop using it, experience little metabolic change, and are not subject to toxic responses or to psychoses.
Still, as Ashley points out, “if cocaine is not the addictive, dependence-producing, dangerous drug it has been made out to be, it nevertheless can create serious toxic or adverse reactions” for those who abuse it. Each user, he observes, has a limit—and this varies widely—beyond which such evident warning symptoms as cold sweats, insomnia, anxiety, and aggres-siveness begin to appear. If they are foolishly disregarded, they become more severe. Paranoia and hallucinations can result, although reported cases of these are rare. A search “of the relevant literature,” Ashley writes, “fails to show a single case of a serious toxic reaction in the past forty years or so.” However, snorting the drug can irritate the mucous membranes of the nose; and ignoring such irritation can lead not only to nose bleeding and sores but to a perforated septum, a serious condition indeed.
Ashley interviewed some eighty-one users of cocaine. He found that a small number of people, who took cocaine every day, sometimes had the “cocaine blues”—a condition similar, psychologically, to an alcoholic hangover, in which more “cocaine seems to be the last thing anyone wants when feeling this way.” But most of those who take the drug, he contends, do so infrequently, treating it as something for “special” occasions. For such users, he concludes, cocaine is neither dangerous nor extremely potent, “when taken in the usual social doses of 20-30 mg repeated every 30-60 minutes, and administered in the most common way—by snorting.” More extensive inquiry into the effects of cocaine is certainly needed. But Ashley’s research seems to me valuable, and he makes a strong case against the sinister view of the drug traditionally taken by doctors and pharmacologists.
Ashley emphasizes the widespread use of coca preparations in the United States and Europe between 1865 and 1914, among them an all-too-famous cola drink. They were popular, even fashionable, and endorsed or used by Pope Leo XIII, Thomas Edison, and William Howard Taft. Two eruptions of panic in the United States helped to discredit the coca drugs. The moralistic campaign against intoxicants that led to the Volstead Act took a dim view not only of spirits but of coca and cocaine. But the charge against the drug that aroused the most furor, and led to its being classified as a “hard” drug and banned, was a racist one—and was spread by doctors.
Just before World War I, Dr. Christopher Koch of Philadelphia wrote of the dangers the country faced from cocaine-using blacks, asserting that “most of the attacks upon white women of the South are the direct result of a cocaine-crazed Negro brain.” In The New York Times of February 8, 1914, Dr. Edward Huntington Williams, drawing largely on Koch’s conclusions, charged that “Negro cocaine ‘fiends’ are a new Southern menace.” These doctors believed that “bullets fired into vital parts [of a black man under the influence of cocaine], that would drop a sane man in his tracks, fail to…weaken his attack.” Not long after, black crime became so closely associated with cocaine use, and cocaine linked to the demented and the violent, that most Americans welcomed a ban on the drug.
Cocaine was anathematized by the medical profession not because of any reasonable proof that it was dangerous, but because it became a vehicle for fears of blacks and a metaphor for excessive self-gratification. Doctors feared, and still fear, losing their privileges to grant or withhold drugs. They must prove to themselves and to their patients that they use that power solely for the benefit and protection of the public. To prescribe something pleasurable might reduce their status to something akin to that of a beautician or a wine merchant, catering to whims, not needs. Jealous of their authority, alarmed by the hedonism that is inherent in cocaine use, the medical profession ignored the possible therapeutic uses of coca and cocaine, and assented to their being prohibited.
Freud was one of the few doctors who thought that cocaine could be medically beneficial. In Cocaine Papers, Robert Byck collects the essays and letters on cocaine that Freud wrote at the beginning of his career, as well as the writings of other experts about Freud’s experiences. Freud believed that his discovery of cocaine’s therapeutic possibilities—its enhancement of a person’s sense of well-being, its usefulness in aiding digestion, its temporary suppression of lassitude—was important. In his enthusiasm, he made improbable claims for the drug, insisting that it would cure morphine addiction. He pressed it on his fiancée and friends in Vienna, who, except for his senior colleague Dr. von Fleischl-Marxow, found it pleasurable.
Von Fleischl-Marxow was a morphine addict who took large injections of cocaine in an attempt to cure his addiction and relieve his pain. His disastrous reactions, which included hallucinations, did much to invalidate Freud’s work in the eyes of the Viennese doctors. One of them, Dr. Erlenmeyer, called cocaine “the third scourge of the race, worse than the first two [alcohol and morphine].” Such attacks were based on the ineffectiveness of cocaine as a means of halting the addiction among morphine users—they either remained addicts or switched from morphine to large doses of cocaine. But Freud’s other claims for the drug were ignored, and the “grave reproaches” he incurred—as Ernest Jones later wrote—were “a poor background from which to shock Viennese medical circles a few years later with his theories on the sexual etiology of the neuroses.”
It is unfortunate that Byck fails to inquire into the social and psychological reasons for the vehemence of the attack on Freud’s work. Byck gets sidetracked, I think, by the claims made by Carl Koller, a fellow experimenter in the laboratory in which Freud worked. Koller saw in Freud’s description of cocaine what Freud had overlooked: that the drug was effective as the long sought-after local anesthetic needed for eye surgery. The essays in Byck’s collection show that Freud was willing to give Koller full credit for his discoveries, while Koller—anticipating one of Freud’s later discoveries about the fallibility of memory when people are vexed—kept mixing up the dates of the cocaine work. Eventually it was as if his work occurred no later than Freud’s, although he never actually claimed to have preceded him. If Byck wishes to stress Freud’s contribution to the study of drugs (he contends that Freud was one of the founders of psychopharmacology), it is puzzling that his book includes so much on this incident while doing little to analyze the broader cultural reasons why organized European medicine became so hostile to cocaine.
The countless reports on the efficacy of cocaine in the treatment of gastrointestinal disorders have never been given proper clinical trials. (Until recently, a similar closed-mindedness prevented marijuana’s effectiveness in combating nausea and restoring appetite from being scientifically validated—although both effects are well known to users.) In the case of cocaine, the medical profession rejected a possibly useful drug for self-serving reasons, while welcoming the amphetamines, another “feel-good” drug with potentially far more dangerous effects.
Amphetamines were first synthesized by L. Edeleano in 1887. Though he himself failed to examine the pharmacological properties of his discovery, the advent of modern pharma-cology, with its idea of completely synthetic medicines, led to a revival of interest in Edeleano’s work in the 1920s. While searching for a synthetic substitute for ephedrine—an herbal stimulant to the central nervous system used to treat asthma and other respiratory diseases—Gordon Alles found that Edeleano’s original compound (benzedrine) and its even more active dextro isomer (dexe-drine) would, when taken orally or inhaled, markedly alleviate fatigue and create a euphoric sensation of confidence and alertness.
Ironically, Alles established that amphetamines could be an effective substitute for ephedrine just as ephedrine itself was being synthesized. A large pharmaceutical company—Smith, Kline, and French—acquired Alles’s patents and had little difficulty in convincing the medical establishment that amphetamines had a range of therapeutic applications far beyond those of a substitute for ephedrine. The firm developed the inhaler device for benzedrine and extolled the drug’s usefulness as a nasal decongestant, an antidote for depression, and, eventually, as an appetite depressant.
The five articles in the medical literature of the 1930s cited by Smith, Kline, and French as justifying these uses of amphetamines describe research involving fewer than 150 subjects under highly questionable conditions. No attempt was made during the tests to conceal from the subjects the results that the experimenters expected, although it is well known that suggestion can strongly influence response to any psychoactive substance. In The Speed Culture, Grinspoon and Hedblom insist that these anecdotal articles, denying any adverse effects of the drug, would not be published today by any reputable medical journal.
Despite the flimsiness of the medical evidence about the effects of amphetamines, the medical profession welcomed this new example of “better living through chemistry” and prescribed it more and more indiscriminately. Reports of harmful side-effects, including some deaths directly connected with amphetamine use, began to appear in 1939, but they made no impact on the drug’s steadily increasing popularity. Amphetamines produce a sharp, almost frantic stimulation and euphoria lasting between four and six hours per dose; the tolerance of users grows rapidly and forces them to take progressively higher and higher doses. (The average daily therapeutic dose is usually 10-15 mg, but some users have consumed spectacular quantities. In 1968, I saw a patient who was using over 1,000 mg a day.) The depression following use—the “crash”—is only a myth among most cocaine users but is both real and severe after an amphetamine high has worn off. The toxic potential of amphetamines for physical disorder and psychosis is marked; sleeplessness, loss of appetite, over-activity, compulsively repetitive behavior, and garrulousness interfere with and upset the entire metabolic cycle.
From the pharmaceutical companies to the doctors, amphetamines have been developed, marketed, advertised, and over-prescribed completely within the system of organized medicine. No one has exact information about the quantity of pills manufactured during the last forty years but in 1970 over 225,000 pounds, ten billion tablets, of amphetamines and amphetamine substitutes had been manufactured legally. In 1971, when production was allegedly being cut back, twelve billion pills—sixty 10 mg tablets for every person in the United States—were produced.
Since the early 1940s, amphetamines have been a staple in the diet of armies. The amount of benzedrine supplied to American troops stationed in Britain during World War II has been estimated at 180 million pills, and army doctors helped in planning that prodigal distribution. Nor can military doctors be said to have learned much since then. Between 1966 and 1969, the American army consumed more amphetamines than the combined British and American armies of World War II. (The navy during those years averaged 21.1 10 mg doses per person, the air force 17.5 10 mg doses, and the army only 13.8.) And this was happening while warnings against amphetamines were featured in both medical journals and the underground press.
American society supports and admires those qualities which amphetamines create with such poisonous facility: endless energy, restless motion, optimism, and, above all, being thin. The drugs have a nickname which virtually sums up the modern passion: “speed.” Grinspoon and Hedblom have interesting comments to make about the fantasies current in American society which impose strong pressures on doctors to prescribe the drugs. They also document the amounts of money that general practitioners make from prescribing amphetamines and the enormous revenue derived by the American Medical Association from advertisements for the drugs in medical journals. The profits of the pharmaceutical companies from amphetamine sales have been stupendous; their lobbying among physicians, FDA officials, and legislators is described in a particularly revealing and disturbing chapter in The Speed Culture.
Only two uses of amphetamines can be seriously defended: in the treatment of narcolepsy—a rare kind of “sleeping sickness”—and in treatment of hyper-kinetic children. Grinspoon and Hedblom question these now widely recognized uses as well, and are particularly suspicious of administering amphetamines to children. They rightly call attention to the dangers of inaccurate diagnoses (for example, confusing the troublemaking child with the “brain damaged’ child) on the basis of superficial observations by a teacher or a juvenile officer. Although there is serious controversy within the medical community about the nature and treatment of hyperkinesis, there should be no disagreement about the danger of such practices.
Cocaine still remains an almost completely forbidden drug, incorrectly classified as a narcotic, like heroin (which is not a stimulant but a depressant of the central nervous system). Recently, however, there have been some significant changes in official attitudes. In 1973 the FDA somewhat restricted the right of the doctor to prescribe amphetamines. The National Institute for Drug Abuse has been taking ads soliciting help in cocaine research. Both Ashley and Byck are cautiously optimistic about such developments since, until now, much-needed research on such highly restricted drugs as cocaine has been all but impossible.
Yet I wonder if the attitudes of medical researchers toward drugs like cocaine and marijuana have changed enough for their work to be effective. Faced by the gigantic illicit drug consumption of the last twelve years, government-financed drug researchers have aimed their work mainly at proving how harmful these drugs are and at finding better ways of prohibiting them. They have not acknowledged how difficult, if not impossible, prohibition has proved to be. Or how damaging our expensive efforts to enforce the drug laws have been, not only to relations between the generations but to respect for the legal system itself.
A different and a more considered attitude is necessary. Researchers should be in a position to warn society that a drug is dangerous but also has its limited uses; they should be able to distinguish among lethal and dangerous drugs, such as heroin and the amphetamines, and relatively innocuous drugs, like marijunana and cocaine. But only when they cease to be infected by moral hypocrisy and self-interest will the conclusions reached by the medical profession about drugs deserve trust.
October 30, 1975