Useful Pharmacology

July 28, 2022

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We love drugs. We love drugs so much that cough drops sit side-by-side with the candy in the impulse purchase section of the supermarket. But seeing the phrase 'we love drugs' feels somehow incorrect. Indeed, one could equally say we really don't love drugs. Very little principled thinking appears to go into this subject at all.

This article's ideology: We absolutely love some drugs. Others terrify us. The difference is familiarity more than any other single thing and the result is confusion. A much more principled framework for thinking about drugs is thinking of them as tools.

In front of me lies a pack of cough drops. The most interesting thing about cough drops, to me, is that they are absolutely ubiquitous even though they don't work. This pack of cough drops knows this. The active ingredient is hexylresorcinol, which is an antiseptic but is only useful for coughs because it is also an anaesthetic: your throat isn't dirty, it's inflamed. The drops don't want to fix your cough---they want to make you numb.

Another interesting feature is the fact that these cough drops are honey lemon flavour. Indeed, honey lemon is one of the most standard cough medicine flavours. This is interesting because actual honey and lemon appear to work better than cough medicine to fix a cough. This is absolutely not true of honey lemon flavour.

These cough drops are a delightful illustration of our peculiar attitude towards drugs. On one hand, it tells us that we love drugs. We love drugs so much that cough drops sit side-by-side with the candy in the impulse purchase section of the supermarket. We love drugs so much that we'll ignore the fact they don't work. Or rather, they do work if they have painkillers in them, but we love drugs so much we'll pay extra to have painkillers branded for our pain rather than resorting to more effective pain remedies like paracetamol and ibuprofen, sitting right next to the cough drops. It's like having blue and pink razors---drugs are a such a fun and integral part of our lives that companies make money by re-branding the same exact product for more money.

On the other hand, these cough drops tell us that our cultural consciousness still places a pretty heavy value on natural remedies that do work. Honey lemon is a popular flavour because honey and lemon have been used for thousands of years to treat a sore throat. Another popular cough drop flavour is blackberry, a herb recommended for sore throat in the ancient medical textbook that "formed the core of the European pharmacopeia through the 19th century". Or cherry, which goes through cycles of being known as a 'superfood'. But we don't love natural remedies. We love drugs. So we just flavour our drugs with these things instead.

In large part, our tense disposition here is due to the fact that we love the idea of medicine; little more than a synonym for drugs and perhaps surgery. We love it so much, indeed, that we adopt a strangely zealous and quixotic attitude. This reveals itself in particular in our odd cultural revulsion for the impressively effective placebo effect. To quote myself:

We accept all sorts of mystical effects from our drugs without understanding them. How do they fix the thing? Why do they simultaneously fix the problem we have, but at the risk of inducing alarming side effects that seem like non-sequiturs---common pain medication and burn-like blisters for example, or anti-depressants and nose bleeds?

What we're doing here is simply surrendering to experts in a certain kind of knowledge production.

The question is, why do we do this with drugs, but not with other things?

But this article is not about that aspect of our quixotism towards drugs. This article is about the fact that seeing the phrase we love drugs feels somehow incorrect. Indeed, one could equally say we really don't love drugs. Or perhaps more familiarly, we think drugs are bad.

Across almost all developed nations, a decades-long war on all kinds of drugs has played out. This war, of course, represents the attempts of governments to direct the moral trajectory of its people, most egregiously demonstrated in the allegations of Nixon-era advisor Ehrlichman:

"The Nixon campaign in 1968, and the Nixon White House after that, had two enemies: the antiwar left and black people," Ehrlichman told journalist Dan Baum in 1994. "You understand what I'm saying? We knew we couldn't make it illegal to be either against the war or blacks, but by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities."

But these wars also illustrate the clumsy attempts of institutions to grapple with issues of addiction and abuse, and the corollary effects of such things on communities. These are things communities care about just as much as governments. We are scared of drugs, just as much as we love them.

So what distinguishes the drugs we love from the drugs we're scared of? The obvious answer might be something like: those drugs which come from our doctor or pharmacists characterise the drugs we love. But this is not true. Despite doctor attitudes, marijuana use has remained so prevalent in the population that we're legalising it all over the world. The opiate crisis was largely the fault of lazy doctors and we are culturally very wary of opiates. Indeed, doctors are regularly criticised for over-medicating patients both anecdotally and in the findings of official investigations. So it's not simply that doctors and pharmacists approve drugs that make us love them.

Perhaps it's that we're afraid of those dreaded recreational drugs? But we love those too! We love nicotine so much that we invented a better(?) way of administering it than flaming poison. We love alcohol so much that despite the US obsession with the inviolability of their constitutional amendments, their 21st amendment simply exists to repeal the 18th---the amendment prohibiting alcohol. We love nootropics, something most people will recognise as 'vitamins and supplements' but which has extended into a complex landscape of performance enhancing legal and illegal compounds. We're even starting to come to love psychedelics again, despite the apparently unwarranted and heavy-handed institutional response which led to a high level of cultural fear around the issue merely 50-odd years ago.

Also, there is the question of what, precisely, is meant by 'recreational'. Does it mean doing drugs for fun? Many people use drugs for fun. But much of what we call 'recreational use' is actually not at all fun. Opiate users managing psychological and physical pain. Tobacco users managing stress. Even alcohol users, apparently drinking for a good time, are often managing the symptoms of social anxiety.

Rather, it seems that 'recreational use' is simply shorthand 'drug use not according to instructions'. And what determines our fear or love for drugs is something closer to mere familiarity. Cough drops are eminently familiar---no one is scared of them. The average person is much less familiar with heroin, and the fear is high. Prescribed drugs are often unfamiliar, but under the catch-all banner 'prescribed drugs' they become a familiar, and therefore comfortable idea.

The point of all this, I suppose, is just to highlight that our thinking about the issue of drugs is often rather odd. It would not surprise anyone to encounter someone who'll reach for the cough drops at the first tickle in the throat because they love some drugs but refuse a joint passed around at the poolside because they're scared of others (while drinking a beer, no less). In many such cases, it seems to be simply the cultural familiarity with the drugs in question that determines behaviour---what one has been told is OK. Very little principled thinking appears to go into the subject at all.

So what might be a better framing? People are often not using drugs for fun. More often it's to change their somatic experience---their states of mind and of body. These things we value very highly, particularly when it's advertised as medicine. Indeed, using drugs for fun is simply one version of us altering our somatic state---an attempt to change the nature of our experience.

With that in mind, perhaps the better framing is something like 'drugs are tools'. This seems to me a much better way to think about the problem that appealing to law, medicine, or our peculiar cultural quixotism. Thinking of drugs as tools gives us a principled way to think about use-cases, risk-tolerances, and even to characterise abuse. If one uses alcohol for fun, but can't have fun without alcohol, then the drug is no longer a tool to enhance an experience but a crutch. In both cases, a tool, but where we might be happy about one use-case, we might be alarmed by the other. No one should be pressured into taking a drug, like no one should be pressured into using a hammer. But hammers are often recommended to enhance certain experiences, as are drugs, and if one wanted to explore whether a drug might change their experience for the better, then we can quickly move past a conversation about how acceptable it is to a question of what trade-offs might exist.

It's not really that novel, to be honest. It's really just how we use drugs now sans the cultural fear. It'll certainly make for better conversations.

This article's ideology

Ideology: We absolutely love some drugs. Others terrify us. The difference is familiarity more than any other single thing and the result is confusion. A much more principled framework for thinking about drugs is thinking of them as tools.

We love some drugs enormously. Cough drops for example. They occupy the same 'impulse purchase' section that the candy does in the supermarket. This despite the fact that they are well known medically to be ineffective. We hate natural remedies though, or the dreaded 'placebo effect'. We also hate drugs---some drugs. This strange quixotism about appropriate remedies has something to do with our love of the idea of medicine. But this is not all there is to it. For example, we think we don't like 'recreational drugs', but only when they aren't well accepted. Nicotine, we love so much we invented vaping to get around the effects of smoking. Alcohol we love so much prohibition in the US failed. And many times such 'recreational use' is merely self-medication---alcohol for social anxiety for example, or nicotine for stress. So even our love for doctors and medicine has a thin veneer. This love for some drugs and fear of others, viewed without adhering to the distracting frameworks of medicine, law, or our cultural quixotism, transparently leads us to confused thinking on the subject of drug use. Rather, all that really seems to matter is our familiarity with the drug, and this is a poor way to reason about a subject. A better framework to think in a principled way about drugs is to think of them as tools. Tools have use-cases and risk-profiles. Applying this lens to the use of drugs allows us to better understand when they're useful, and when they're being abused.

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