High Price (33 page)

That made him anxious. But he did want to participate in the study and possibly make some money, so he persevered. When he got near to where he thought the address was, however, he saw police outside that building, too. He began thinking that we’d set him up, that when he got inside and asked about the study, he’d be arrested. He walked around the facility a few times, trying to figure out what to do and whether he should even ask someone about the weird address. Maybe asking for that number would be the cue for the police to arrest him?

From the perspective of a nonuser of illegal drugs, of course, this sounds like sheer paranoia. When I told the story to other people working on the study, they laughed knowingly about how cocaine can make users paranoid. But from David’s perspective, there was nothing irrational about his fears. He was involved in illegal activity. Police actually were engaged in an intense war on drugs. Tens of thousands cocaine users had been arrested. And we had all seen those movies or TV shows where lawbreakers are lured to some building by promises of a prize of some sort, only to be arrested for some earlier crime.

David had been asked to go into a government building and admit his drug use, which is a crime, in order to supposedly get paid to possibly take an illegal drug. His worries were an understandable response to his experience in the cultural setting in which it took place. While cocaine and marijuana can certainly increase these kinds of fears, anyone engaging in illegal activity does need to be cautious if he wants to avoid getting caught.

It became increasingly clear to me how our prejudices about drug use and our punitive policies toward users themselves made people who take drugs seem less human and less rational. Drug users’ behavior was always first ascribed to drugs rather than considered in light of other, equally prominent factors in the social world, like drug laws.

And in reality, virtually all of us sometimes find ourselves in situations where we persist in behavior despite negative consequences, just like addicted people do. Most people can’t stick to a diet, many continue to eat fatty and sweet foods when they are gaining weight, or have had periods of heavy drinking or stayed in bad relationships and ignored the negative results, which is the same pattern of behavior seen in drug addiction. Sure, there are extreme cases where addicted people commit absurd crimes—but there are plenty of equally stupid crimes planned or committed by people who are stone-cold sober.

I thought about my friends and family back home and where they’d wound up while I was working my way up in academia. I considered behaviors that were impulsive and often seen as associated with alcohol and other drugs. I myself had shoplifted and stolen batteries and sold drugs. But while I had plenty of less than perfect qualities, I had no addictions. Many of my siblings and cousins also engaged in petty theft as teenagers, but again, this was usually unrelated to their alcohol or other drug use or lack thereof.

In my immediate family, three of my five sisters had had teenage pregnancies. One of my sisters did become a heavy drinker (although she nonetheless always met her occupational and family obligations). And she had her first child at age nineteen but married the father a few months after the child’s birth. They are still together. But she is not the sister who stabbed a woman in a fight over a man and was later stabbed herself in a similar situation. The sister who got into those altercations does not have substance abuse problems.

One of my sisters’ husbands was arrested in connection with a deadly shooting but not convicted—but that is not the brother-in-law who went to rehab for crack cocaine abuse. And the in-law who did have a crack problem? He went on to get a job in plumbing, has a house twice the size of mine, and is a loving father and husband.

Where was the connection between drugs and problems here? Among my family—just as I was beginning to understand from the research as well—the link between addiction and other forms of dysfunctional behavior was not as prominent as the stereotypes suggest. In some cases, alcohol use or its aftereffects exacerbated violence: for example, when my father beat my mother. Some of my cousins had struggled with crack. But illicit drugs and addiction were far from the greatest threats to our safety and chances of success. There seemed to be at least as many—if not more—cases in which illicit drugs played little or no role than there were situations in which their pharmacological effects seemed to matter. And if the drug highs themselves didn’t explain behavior, for me that meant behavior related to lack of drugs—that is, craving—was even further away from allowing us to predict it.

I had left my San Francisco postdoctoral position disillusioned by the whole concept of craving. Some addicts certainly reported drug craving: there was no doubt about that. But it didn’t really predict whether they relapsed, according to the majority of research. Sometimes people would report severe craving but not use drugs; other times, they’d use drugs in situations where they said they’d experienced no craving at all. It seemed to me that it would be much more useful to study people’s actual decisions about whether to take drugs, rather than focus so much on what they said about what they wanted or craved in some hypothetical future. That’s why I responded with enthusiasm when Dr. McCance-Katz had suggested I do a postdoc with her at Yale.

Although I didn’t get to study drug-taking decisions at Yale, at least with Dr. McCance-Katz, I was able to observe people’s behavior while under the influence, not just their ratings of their desires to use drugs. That brought me closer to the types of experiments I really wanted to do so I could understand the real effects of drugs, not just our projections of them.

In order to find people to participate in our research in New Haven, I also had to interview many drug users. At the time, I wasn’t even making a distinction between drug use and addiction. Despite what I was starting to learn, I still thought all illegal drug use was problematic and that most people engaged in it were headed for addiction if indeed not already there. I didn’t distinguish between addictive use that interferes with major life functions like relationships and work, and controlled use that is pleasurable and not destructive.

Like the addicted people I was studying, I was influenced by my social milieu. Everyone around me in the addiction field acted as though pathological use was more common than controlled use. Certainly if you read the scientific literature unskeptically, this is the impression with which you are left. Consequently, when I interviewed users at this time whose lives seemed unscathed by their drug use, I figured I just hadn’t yet become skillful enough to ferret out their denial. After speaking with dozens of them, though, I started to think twice. Maybe I wasn’t the one who was wrong.

I thought back on what I’d learned about behavior and how it is affected by punishment and reward, going back to B. F. Skinner. Were drugs really that different from other reinforcers or pleasures? I looked at the existing data on that question. In the animal research, the graphs representing how hard an animal is willing to work for a food or drug reward were almost identical: make access easy and provide few alternatives and animals will definitely eat a lot of sweet or fatty food or take a lot of cocaine or heroin.

However, the harder they have to work for any reward—whether it’s a natural pleasure like food or sex or a more artificial one like drugs—the less of it they will tend to seek. This is true whether the animal being studied is a mouse, a rat, a monkey, or a human being. And both in humans and in other animals, these responses will vary depending on the presence of competing reinforcers.

For example, studies have found that when rhesus monkeys have to repeatedly press levers to get either a cocaine injection or a highly desirable food (banana pellets), their responses vary with both effort and dose. Quite sensibly, the monkeys will work harder to get a higher dose of cocaine and put in less effort for a lower dose or placebo. They will also choose larger quantities of banana pellets over smaller doses of cocaine. Even at the highest dose of cocaine offered, these animals will never choose cocaine over banana pellets more than 50 percent of the time.
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Addictive behavior follows rules and is shaped by situations just like other types of behavior. It’s not as weird or special as we make it out to be.

You may say, “Yes, that’s fine with a drug like cocaine that doesn’t produce obvious withdrawal symptoms. But what about a drug like heroin?” Indeed, physical withdrawal symptoms can be seen in chronic opiate (for example, heroin, morphine) users if they abruptly stop drug use. The symptoms usually begin about twelve to sixteen hours after the last heroin dose and look something like a case of the twenty-four-hour, or intestinal, flu. Most of us have experienced these symptoms at some point in our lives: nausea, vomiting, diarrhea, aches, pains, and a general sense of misery. While this condition is most unpleasant, rarely is it life-threatening or accurately depicted in films that suggest the sufferer is on the verge of death.

Throughout the 1960s, drug addiction was defined solely on the basis of the presence of physical dependence (a withdrawal syndrome). About that same time, a group of researchers began publishing findings that questioned this dominant view. They reported that: (1) monkeys would begin and maintain lever-pressing for opiates without first being made physically dependent; and (2) monkeys who had given themselves small amounts of a drug and who had never experienced withdrawal symptoms could be trained to work very hard for their opiate injections.
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More recently, researchers have demonstrated that monkeys’ lever-pressings for heroin injections do not correspond with the timing or severity of their withdrawal symptoms.
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These findings, along with others, underscore the notion that physical dependence isn’t the primary reason for continued drug use.

I started to put these ideas together as I was trying to make my way in academia and dealing with a very unpredictable experience of reinforcers and punishers of my own. Although research careers are rarely presented this way when we are trying to attract youth to science, the reality is that the field is intensely competitive and many highly qualified people do not wind up with tenure-track jobs or even jobs in industry that take advantage of their skills. At UCSF and then even more so at Yale, I came face-to-face with the fierceness of this competition. It was extremely demoralizing at times.

This fight for status was worse than what I’d seen on the street or on the basketball court, where it was at least clear when people were competing and what territory was in dispute. In academia, no one said anything to your face: it was all sneaky stuff, all easily denied or explained away as a “misunderstanding” or “miscommunication.” Men didn’t fight like men; they stabbed you in the back instead. The rules were actually clearer and easier to follow in the hood. But one of the true advantages of my background was that it made me sensitive to social signals, no matter where I encountered them. I was able to learn those used in academia and use them to win, even on such a convoluted playing field.

Nonetheless, there were definitely times when I came close to giving up, when the low salary and grueling work hours with no guarantee of a definite payoff wore me down. The work at UCSF had been disillusioning: as James Baldwin had put it, when you learn a craft well, you get to see its ugly side, and that’s what happened to me, starting there. I felt that the research we were doing on craving was poorly conducted and not productive, that the link between what we were measuring and what happened in real-world drug-using settings was not strong enough to matter. Dr. McCance-Katz was at UCSF on sabbatical at the time and I mentioned these concerns to her, which is how I got invited to do my second postdoc, at Yale. Even there, however, I still had no clear path to that elusive goal of a real job, a permanent tenure-track position. I wasn’t sure I’d ever be able to support my family doing the work I loved. And now, I sometimes hated it. A job at Walmart started to look good by contrast.

To make matters worse, after only months, I learned that Dr. McCance-Katz was soon going to be leaving Yale, which meant my job there would end as well. The viciousness and underhandedness of the competition I experienced during this postdoc was beyond anything I’d ever been faced with before. For example, when I learned that Dr. McCance-Katz was leaving Yale to accept a job elsewhere, I met with a senior member in the department who promised me a faculty position within the department. Later, when I attempted to follow up on the position, this person claimed to have no recollection of our previous conversation, saying that I must have misremembered.

Fortunately, it was at this point that I met Herb Kleber, who was then the director of the division on substance abuse in the department of psychiatry at Columbia. I had a friend who worked with him and said that his program at Columbia was going to be expanding. She introduced us at a scientific meeting and he tried to recruit me with the promise of a faculty position. I was especially excited about the idea of working at Columbia because his wife, Marian Fischman, studied crack cocaine administration in humans. She’d published a paper in the prestigious
Journal of the American Medical Association
showing that crack and powder cocaine were pharmacologically indistinguishable.
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I eagerly prepared to visit New York for my interview.

However, when I met with Marian, virtually the first thing she said was “I don’t know what Herb told you, but we don’t have a faculty position. We can only offer you another postdoc.” Given the amnesia I was starting to see at Yale, I ultimately agreed to do a third postdoc at Columbia. I didn’t know when this job limbo would end or for how long I could stand it. I certainly wasn’t receiving the rewards of a scientific career that had been expected.

Marian, however, promised that she would do everything she could to help me get a permanent position. She was true to her word. It was at Columbia that I would ultimately get a tenure-track job and reach tenure itself. And in my research there I began finding, as I’d suspected, that humans do respond to cocaine quite similarly to how they respond to other reinforcing experiences. Like the rest of us, people who are addicted to crack cocaine are sensitive not only to one type of pleasure but also to many. While severe addiction may narrow people’s focus and reduce their ability to take pleasure in nondrug experiences, it does not turn them into people who cannot react to a variety of incentives. I began the work that illustrated this as a Columbia postdoc, a job I held from September 1998 through June 1999.