AMERICA'S ALTERED STATES (continued from Part 1)

Thus the advent of Viagra does not simply treat a disease. It changes
our conception of disease. This paradigm shift is a common occurrence
but is below our radar. Hair loss becomes a disease, not a fact of
life. Acid indigestion becomes a disease, not a matter of eating
poorly. If these examples seem to make light of the broadening of
disease, the ascent of psychopharmaceuticals makes the issue urgent.
Outside the realm of the tangibly physical, the power of drugs and
drugmakers is far greater. What we now know as "anxiety disorder," for
example, existed only in theory from Freud's time through World War
II. In the early 1950s, a drug company polled doctors and found that
most had no interest in a medication that treated anxiety. But by
1970, one woman in five and one man in thirteen were using a
tranquilizer or sedative, and anxiety was a mainstay of psychiatry.
The change could be directly attributed to two drugs, Miltown and
Valium, which were released in 1955 and 1963, respectively. The
successor to these drugs, Xanax, introduced in 1981, virtually created
a disease itself. Donald Klein had already proposed the existence of
something called "panic disorder," as opposed to generalized anxiety,
some twenty years before. But his theory was widely refuted, and in
practice panic anxiety was treated only in the context of a larger
problem. Xanax changed that. "With a convenient, effective drug
available," writes Peter Kramer, "doctors saw panic anxiety
everywhere." Xanax has also become the litmus test for generalized
anxiety disorder. "If Xanax doesn't work," instructs The Essential
Guide to Psychiatric Drugs, "usually the original diagnosis was wrong."[9]

This is not to say that all specific disorders are arbitrary, just
that there is a delicate line to be drawn. "The term 'disease' - and
the border between health and disease - is a social construct," says
Steven Hyman, director of the National In-stitute of Mental Health.
"There are some things we would never argue about, like cancer. Put do
we call it a disease if you have a few foci of abnormal cells in your
body, something that you could live with without any problem? There is
a gray zone. With behavior and the brain, the gray zone is much
larger." To Hyman's observation, it must be added that, whereas vague
dissatisfactions make money for psychic hot lines and interior
decorators, diseases make money for pharmaceutical companies. What
Peter Kramer calls psychiatric diagnostic creep is not an accident of
history but a movement engineered far profit.

We have only begun to grapple with the consequences. The example of
Prozac has been chewed over, but it's worth chewing still more -
because it is so typical of a new generation of drugs, which are being
used to treat debilitating conditions and also by people with far less
serious problems. With Lauren Slater, author of the fine memoir Prozac
Diary, we have a case anyone would regard as serious. Suffering from
obsessive-compulsive disorder, severe depression, and anorexia, she
had been hospitalized five times, attempted suicide twice, and cut
herself with razors. Prescribed Prozac in 1988, she found the drug a
reprieve from a lifetime sentence of serious illness - "a blessing,
pure and simple," she writes. The patients described in Peter Kramer's
Listening to Prozac are quite unlike Lauren Slater. They share, he
writes, "something very much like 'neurosis,' psychoanalysis's
umbrella term for the mildly disturbed, the neat-normal, and those
with very little wrong at all." The use of Prozac for these patients
is not incidental; they make up a large portion, probably a wide
majority, of people on the drug. (One good indication is that only 31
percent of antidepressant prescriptions are written by
psychiatrists.)

Throughout his book, Kramer flirts with "unsettling" comparisons
between Prozac and illegal drugs. Since Prozac can "lend social ease,
command, even brilliance," for example, he wonders how its use far
this purpose can "be distinguished from, say, the street use of
amphetamine as a way of overcoming inhibitions and inspiring zest. The
better comparison, I suggested in a conversation with Kramer, is
between Prozac and MDMA. Both drugs work by increasing the presence of
serotonin in the brain. (Whereas Prozac inhibits serotonin's reuptake,
MDMA stimulates its release.) Both can be helpful to the seriously ill
as well as to people with more common problems. Most of the objections
to MDMA - that it distorts "real" personality, that it rids people of
anxiety that may be personally or socially useful, that it induces
more pleasure than is natural - have also been marshaled against
Prozac. Both these drugs challenge our definitions of normalcy and of
the legitimate uses of a mind-altering substance. Yet Kramer rejects
the comparison. "The distinction we make," he told me, "is between
drugs that give pleasure directly and the drugs that give people the
ability to function in society, which can indirectly lead to pleasure.
If the medication can make you work well or parent well, and then
through your work or parenting you get pleasure, that's fine. But if
the drug gives you pleasure by taking it directly, that is not a
legitimate use." (Viagra, because it allows men to experience sexual
pleasure, falls on the side of legitimacy. But, Kramer said, a drug
that directly induced an orgasm would not.)

The line between therapeutic and hedonistic pleasure, however, is
awfully hard to draw. I think of a friend of mine who uses MDMA a few
times a month. His is a text-book case of "recreational" use. He takes
MDMA on weekends, in clubs, for fun. He is not ill and is not in
psychotherapy. But he will live for the rest of his life in the shadow
of a traumatic experience, which is that for more than two decades he
hid his homosexuality. Some might say the drug is an unhealthy escape
from "the real world," that the relaxation and intimacy he experiences
are illusory. But these experiences give him a point of reference he
can use in a "sober" state. His pleasure from the drug is entirely
social-being and sharing and loving with other people. Is this
hedonistic? "I found it astonishing," Kramer writes of Prozac, "that a
pill could do in a matter of days what psychiatrists hope, and often
fail, to accomplish by other means over a course of years: to restore
to a person robbed of it in childhood the capacity to play."

Perhaps I would find restrictions on MDMA more reasonable if they at
least carved out an exception for therapeutic use. Keep in mind,that's
where this drug started. After Shulgin's experiment word spread, and
thousands of doses were taken in a clinical setting. As with LSD, MDMA
was seen not as a medicine but as a catalyst to be taken just a few
times - or perhaps only once - in the presence of a therapist or
"guide." The effects were impressive. Many users found their artifice
and defenses stripped away and long-buried emotions rising to the
surface. The drug also had the unusual effect of increasing empathy,
which helped users trust their therapist - a crucial characteristic of
effective healing - and also made it useful in couples therapy. In a
collection of first-person accounts of therapeutic MDMA use, Through
the Gateway of the Heart, published in 1985, a rape victim described
working through her fears. Another woman described revelations about
her son, her weight problems, and "why angry men are attracted to me."

I can hear the skeptics shuffling their feet, wanting data from
double-blind controlled trials. But MDMA research never reached that
stage. Mindful of what had happened with LSD, the therapists,
scientists, and other adults experimenting with MDMA tried to keep it
quiet. Inevitably, though, word spread, and a new mode of use sprang
up - at raves, in dance clubs, in dorm rooms. An astute distributor of
the drug renamed it Ecstasy to emphasize its pleasurable effects.
("'Empathy' would he more appropriate," he said later. "But how many
people know what that means?")[10]

As the DEA moved to restrict MDMA, ad-vocates of its medical use
flooded the agency with testimony, pleading for a chance to subject
the drug to methodical study. The agency's administrative-law judge,
Francis Young, saw merit in this argument. In a ninety-page decision
handed down in 1986, he recommended that the drug he placed in
Schedule III, which would allow for it to be prescribed b doctors and
tested further. Young cited its history of "currently accepted medical
use in treatment in the United States" and argued that "the evidence
of record does not establish that . . . MDMA has a high potential' for
abuse."

DEA officials overruled Young and placed MDMA in Schedule I, with the
assurance that its decision would be self-fulfilling. A Schedule I
substance cannot he used clinically and can be studied only with great
difficulty. So medical use is essentially forever impossible. That
leaves illicit use, which, by one common definition, is the abuse far
which Schedule I drugs have a "high potential." Since then,
government-funded researchers have sought to document MDMA's dangers.
Here we come to the truth about the line and how it is maintained.
With rare exceptions, everything we know about legal drugs comes from
research sponsored by the pharmaceutical industry. Naturally, this
work emphasizes the benefits and downplays the accompanying risks. On
the other hand, the National Institute on Drug Abuse, which funds more
than 85 percent of the world's health research on illegal drugs,
emphasizes the dangers and all hut ignores potential benefits.

One recent NIDA-funded study on MDMA was widely reported last fall.
Dr. George Ricaurte found, in fourteen men and women who had used MDMA
70 to 400 times in the previous six years, "long-lasting nerve cell
damage in the brain." Specifically, Ricaurte found decreases in the
number of serotonin-reuptake sites. The study begs three major
questions. First, do its conclusions really reflect the experience of
heavy MDMA users? British physician Karl Jansen reports that he
referred MDMA users who had taken more than 1,000 doses and that "they
were told by Ricaurte that they had a clean bill of health" but were
excluded from his study. Second, should the brain changes Ricaurte
found be called "damage," given that a number of psychiatric
medications, Prozac and Zoloft among them, decrease the number of
serotonin receptors by blockading them? As psychopharmacologist Julie
Holland writes, "This could he interpreted as an adaptive response as
opposed to a toxic or 'damaged' response." Third, do Ricaurte's
findings have any bearing on the use of MDMA in therapy, which calls
for a handful of doses over many months?

In this climate, it's hard to know. Charles Grob, a psychiatrist at
Harbor-UCLA Medical Center in Los Angeles, has been trying to restart
MDMA research for eight years. He received FDA approval to conduct
Phase I trials on human volunteers, to see if MDMA is safe enough to
be used as a medicine. But even with his impeccable credentials, the
backing of a prestigious research hospital, and an extremely
conservative protocol - involving terminal patients, Grob has faced a
seemingly interminable wait far permission to begin Phase II, in which
he would study efficacy. Grob's struggle explains why he has little
company in the research community. "When you have a drug that's
popular among young people," Grob says, "that's the kiss of death when
it comes to exploring its potential utility in a medical context."

There is another "kiss of death": lack of interest from industry. I
asked Lester Grinspoon, a professor of psychiatry at Harvard Medical
School, who led the legal challenge to the DEA's scheduling decision,
whether he had approached drug companies about supporting the effort.
"We didn't even consider it," he said. "No drug company is going to he
interested in a drug that's therapeutically useful only once or twice
a year. That's a no-brainer for them." When you see the feel-good ads
from the Pharmaceutical Research and Manufacturer's Association with
the tag line "Leading the way in the search for cures," keep in mind
that cure - conditions in which medication is no longer required - are
not particularly high on the pharmaceutical companies' priority list.

Market potential isn't the only factor explaining the status of drugs,
but its power shouldn't he underestimated. The principal psychoactive
ingredient of marijuana, THC, is available in pill form and can be
legally prescribed as Marinol. A "new" creation, it was patented by
Unimed Pharmaceutical and is sold for about $15 per 10-mg pill.
Marinol is considered by patients to he a poor substitute for
marijuana, because doses cannot be titrated as precisely and because
THC is only one of 460 known compounds in cannabis smoke, among other
reasons. But Marinol's profit potential - necessary to justify the
up-front research and testing, which can cost upward of $500 million
per medication - brought it to market. Opponents of medical marijuana
claim that they simply want all medicines to he approved by the FDA,
hut they know that drug companies have little incentive to overcome
the regulatory and financial obstacles for a plant that can't be
patented. The FDA is the tail, not the dog.

The market must be taken seriously as an explanation of drugs' status.
The reason is that the explanations usually given fall so far short.
Take the idea "Bad drugs induce violence." First, violence is
demonstrably not a pharmacological effect of marijuana, heroin, and
the psychedelics. Of cocaine, in some cases. (Of alcohol, in many.)
But if it was violence we feared, then wouldn't we punish that act
with the greatest severity? Drug sellers, even people marginally
involved in a "conspiracy to distribute," consistently receive longer
sentences than rapists and murderers.

Nor can the explanation be the danger of illegal drugs. Marijuana,
though not harmless, has never been shown to have caused a single
death. Heroin, in long-term "maintenance" use, is safer than habitual
heavy drinking. Of course, illegal drugs can do the body great harm.
All drugs have some risk, including many legal ones. Because of
Viagra's novelty, the 130 deaths it has caused (as of last November)
have received a fair amount of attention. But each year,
anti-inflammatory agents such as Advil, Tylenol, and aspirin cause an
esti-mated 7,000 deaths and 70,000 hospitalizations. Legal medications
are the principal cause of between 45,000 and 200,000 American deaths
each year, between 1 and 5.5 million hospitalizations. It is telling
that we have only estimates. As Thomas J. Moore notes in Prescription
for Disaster, the government calculates the annual deaths due to
railway accidents and falls of less than one story, among hundreds of
categories. But no federal agency collects information on deaths
related to legal drugs. (The $30 million spent investigating the crash
of TWA Flight 800, in which 230 people died, is six times larger than
the FDA's budget for monitoring the safety of approved drugs.)
Psychoactive drugs can be particularly toxic. In 1992, according to
Moore, nearly 100,000 persons were diagnosed with "poisoning" by
psychologically active drugs, 90 percent of the cases due to
ben-zodiazepine tranquilizers and antidepressants. It is simply a myth
that legal drugs have been proven "safe." According to one government
estimate, 15 percent of children are on Ritalin. But the long-term
effects of Ritalin - or antidepressants, which are also commonly
prescribed - on young kids isn't known. "I feel in between a rock and
a hard place," says NIMH director Hyman. "I know that untreated
depression is bad and that we better not just let kids be depressed.
But by the same token we don't know what the effects of
anti-depressants are on the developing brain. ... We should have
humility and be a bit frightened."

These risks are striking, given that protecting children is the
cornerstone of the drug wars. We forbid the use of medical marijuana,
worrying that it will send a bad message. What message is sent by the
long row of pills laid out by the school nurse - or by "educational"
visits to high schools by drugmakers? But, you might object, these are
medicines - and illegal drug use is purely hedonistic. What, then,
about illegal drug use that clearly falls under the category of
self-medication? One physician I know who treats women heroin users
tells me that each of them suffered sexual abuse as children.
According to University of Texas pharmacologist Kathryn Cunningham, 40
to 70 percent of cocaine users have pre-existing depressive conditions.

This is not to suggest that depressed people should use cocaine. The
risks of dependence and compulsive use, and the roller-coaster
experience of cocaine highs and lows, make for a toxic combination
with intense suffering. Given these risks, not to mention the risk of
arrest, why wouldn't a depressed person opt for legal treatment? The
most obvious answers are economic (many cocaine users lack access to
health care) and chemical. Cocaine is a formidable mood elevator and
acts immediately, as opposed to the two to four weeks of most
prescription anti-depressants. Perhaps the most important factor,
though, is cultural. Using a "pleasure drug" like cocaine does not
signal weakness or vulnerability. Self-medication can he a way of
avoiding the stigma of admitting to oneself and others that there is a
problem to be treated.

Calling illegal drug use a disease is popular these days, and it is
done, I believe, with a compassionate purpose: pushing treatment over
incarceration. It also seems clear that drug abuse can he a distinct
pathology. But isn't the "disease" whatever the drug users are trying
to find relief from (or flee)? According to the Pharmaceutical
Research and Manufacturer's Association, nineteen med-ications are in
development for "substance use disorders." This includes six products
for "smoking cessation" that contain nicotine. Are these treatments
for a disease or competitors in the market for long-term nicotine
maintenance?

Perhaps the most damning charge against illegal drugs is that they're
addictive. Again, the real story is considerably more complicated.
Many illegal drugs, like marijuana and cocaine, do not produce
physical dependence. Some, like heroin, do. In any case, the most
important factor in destructive use is the craving people experience
craving that leads them to continue a behavior despite serious adverse
effects. Legal drugs preclude certain behaviors we associate with
addiction - like stealing for dope money - but that doesn't mean
people don't become addicted to them. By their own admissions, Betty
Ford was addicted to Valium and William Rehnquist to the sleeping pill
Placidyl, for nine years. Ritalin shares the addictive qualities of
all the amphetamines. "For many people," says NIMH director Hyman,
explaining why many psychiatrists will not prescribe one class of
drugs, "stopping short-acting high-potency benzodiazepines, such as
Xanax, is sheer hell. As they try to stop they develop rebound anxiety
symptoms (or insomnia) that seem worse than the original symptoms they
were treating." Even antidepressants, although they certainly don't
produce the intense craving of classic addiction, can be habit
forming. Lauren Slater was first made well by one pill per day, then
required more to feel the same effect, then found that even three
would not return her to the miraculous health that she had at first
experienced. This is called tolerance. She has also been unable to
stop taking the drug without "breaking up." This is called dependence.
"'There are plenty of addicts who lead perfectly respectable lives,"'
Slater's boyfriend tells her. To which she replies, "'An addict? You
think so?"'

III.

In the late 1980s, in black communities, the Partnership for a Drug
Free America placed billboards showing an outstretched hand filled
with vials of crack cocaine. It read: "YO, SLAVE! The dealer is
selling you something you don't want.... Addiction is slavery." The ad
was obviously designed to resonate in the black neighborhoods most
visibly affected by the wave of crack use. But its idea has a broader
significance in a country for which independence of mind and spirit is
a primary value.

In Brave New World, Aldous Huxley created the archetype of
drug-as-enemy-of-freedom: soma. "A really efficient totalitarian
state," he wrote in the book's foreword, is one in which the "slaves
... do not have to be coerced, because they love their servitude."
Soma - "euphoric, narcotic, pleasantly hallucinogenic," with "all the
advantages of Christianity and alcohol; none of their defects," and a
way to "take a holiday from reality whenever you like, and come back
with-out so much as a headache or a mythology" - is one of the key
agents of that voluntary slavery.

In the spring of 1953, two decades after he published this book, Huxley
offered himself as a guinea pig in the experiments of a British
psychiatrist studying mescaline. What followed was a second masterpiece on
drugs and man, The Doors of Perception. The title is from William Blake:
"If the doors of perception were cleansed every thing would appear to man
as it is, infinite. For man has closed himself up, till he sees all things
thro' narrow chinks of his cavern." Huxley found his mescaline experience
to be "without question the most extraordinary and significant experience
this side of the Beatific vision ... it opens up a host of philosophical
problems, throws intense light and raises all manner of questions in the
field of aesthetics, religion, theory of knowledge."

Taken together, these two works frame the dual, contradictory nature
of mind-altering substances: they can he agents of servitude or of
freedom. Though we are deathly afraid of the first possibility, we are
drawn like moths to the light of the second. "The urge to transcend
self-conscious selfhood is," Huxley writes, "a principal appetite of
the soul. When, for whatever reason, men and women fail to transcend
themselves by means of worship, good works and spiritual exercises,
they are apt to resort to religion's chemical surrogates."

One might think, as mind diseases are broad-ened and the substances
that alter consciousness take their place beside toothpaste and
breakfast cereal, that users of other "surrogates" might receive more
understanding and sympathy. You might think the executive raking Xanax
hefore a speech, or the college student on BuSpar, or any of the
recipients of 65 million annual antidepressant prescriptions, would
have second thoughts about punishing the depressed user of cocaine, or
even the person who is not seriously depressed, just, as the Prozac ad
says, "feeling blue." In trying to imagine why the opposite has
happened, I think of the people I know who use psychopharmaceuticals.
Because I've always been up-front about my experiences, friends often
approach me when they're thinking of doing so. Every year there are
more of them. And yet, in their hushed tones, I hear shame mixed with
fear. I think we don't know quite what to make of our own brave new
world. The more fixes that become available, the more we realize we're
vulnerable. We solve some problems, hut add new and perplexing ones.

In the Odyssey, when three of his crew are lured by the lotus-eaters
and "lost all desire to send a message hack, much less return,"
Odysseus responds decisively. "I brought them back ... dragged them
under the rowing benches, lashed them fast." "Already," writes David
Lenson in On Drugs, "the high is unspeakable, and already the official
response is arrest and re-straint." The pattern is set: since people
lose their freedom from drugs, we take their freedom to keep them from
drugs. [11] Odysseus' frantic response, though, seems more than just a
practical measure. Perhaps he fears his own desire to retire amidst
the lotus-eaters. Perhaps he fears what underlies that desire. If we
even feel the lure of drugs, we acknowledge that we are not satisfied
by what is good and productive and healthy. And that is a frightening
thought. "The War on Drugs has been with us," writes Lenson, "for as
long as we have despised the part of ourselves that wants to get high."

As Lenson points out, "It is a peculiar feature of history, that
peoples with strong historical, physical, and cultural affinities tend
to detest each other with the most venom." In the American drug wars,
too, animosity runs in both directions. Many users of illegal
drug~particularly kids - do so not just because they like the feeling
hut hecause it sets them apart from "straight" society, allows them
(without any effort or thought) to join a culture of dissent. On the
other side, "straight society" sees a hated version of itself in the
drug users. This is not just the 11 percent of Americans using
psychotropic medications, or the 6 million who admit to "nonmedical"
use of legal drugs, but anyone who fears and desires pleasure, who
fears and desires loss of control, who fears and desires chemically
enhanced living.

Straight sociery has remarkable power: it can arrest the enemy, seize
assets without judicial review, withdraw public housing or assistance.
But the real power of prohibition is that it creates the forbidden
world of danger and hedonism that the straights want to distinguish
themselves from. A black market spawns violence, thievery, and
illnesses - all can be blamed on the demon drugs. For a reminder, we
need only go to the movies (in which drug dealers are the stock
villains). Or watch Cops, in which, one by one, the bedraggled
junkies, fearsome crack dealers, and hapless dope smokers are led away
in chains. For anyone who is secretly ashamed, or confused, about the
ex-plosion in legal drug-taking, here is reassurance: the people in
handcuffs are the bad ones. Anything the rest of us do is saintly by
comparison.

We are like Robert Louis Stevenson's Dr. Jekyll, longing that we might
he divided in two, that "the unjust might go his way and the just
could walk steadfastly and securely on his upward path, doing the good
things in which he found his plea-sure, and no longer exposed to
disgrace and penitence by the hands of this extraneous evil." In his
laboratory, Jekyll creates the "foul soul" of Edward Hyde, whose
presence heightens the reputation of the esteemed doctor. But Jekyll's
dream cannot last. Just before his suicide, he confesses to having
become "a creature eaten up and emptied by fever, languidly weak both
in body and mind, and solely occupied by one thought: the horror of my
other self." To react to an unpleasant truth by separating from it is
a fundamental human instinct. Usually, though, what is denied only
grows in injurious power. We believe that lashing at the illegal drug
user will purify us. We try to sep-arate the "evil" from the "good" of
drugs, what we love and what we fear about them, to enforce a
drug-free America with handcuffs and jail cells while legal drugs grow
in popularity and variety. But we cannot separate the inseparable. We
know the truth about ourselves. It is time to begin living with that
horror, and that blessing.

[1] Although I am critical of the exaltation of drugs, it must he
noted that a crisis runs in the opposite direction. Only a small
minority of people with schizophrenia, bipolar disorder, and major
depression - for which medication can he very helpful -receive
treatment of any kind.

[2] Fifty-five percent of American adults, or 97 million people are
overweight or obese. It is no surprise, then, that at least
forty-five companies have weight-loss drugs in development. itlut
niany of these drugs are creatures more of marketing than of
pharmacology. Meridia is an SSRI like Proac. Similarly, Zyban, a Glaxo
Wellcome product for smoking cessation, is chemically identical to the
antidepressant Wellbutrin. Admakers exclude this information because
they want their products to seem like targeted cures - not vaguely
understated remedies like the tonics" of yesteryear.

[3] Declared Nancy Reagan, "If you're a casual drug user, you're an
accomplice to murder." Los Angeles police chief Daryl Gates told the
senate that "casual drug users should he taken out and shot." And so
on.

[4] Many people believe that this is still possible, among them House
Speaker Dennis Hastert, who last year co-authored a plan to "help
create a drug-free America by the year 2002." In 1995, Hastert
sponsored a hill allowing herbal remedies to bypass FDA regulations,
thus helping to satisfy Americans' incessant desire for improvement
and counsciousness alteration.

[5] The release describes Andrew Golden and Mitchell-John-son as
reputed marijuana smokers." No reference to Golden and pot could he
found in the Nexis datahase. The Washington Post reports that Johnson
"said he smoked marijuana. None of his classmates believed him."

[6] Such propaganda was crucial in convincing the South to allow the
Harrison Act's unprecedented extension of federal power. It would he
comforting to view this as a sad mo-ment in history, but a prohibition
with racist origins continues to have a racist effect: Blacks account
for 12 percent of the U.S. population and 15 percent of regular drug
users. But they make up 35 percent of arrests for drug possession and
60 percent of the people in state prisons on drug offenses.

[7] Overdoses always increase in a black market, because drugs are of
unknown purity and often include contaminants. Although drug use
declined between 19711 and 1994, overdose deaths increased by 400 percent.

[8] A popular argument against medical marijuana is that it is a ruse
for the "real" goal of unrestricted use, but this argument is itself a
ruse. We put aside disagreements over amnesty to allow amnesty for
victims of political torture. We - at least most of us - put aside
disagreements over abortion in cases of rape. Medical marijuana use
for the seriously ill has the same unambiguous claim to legitimacy.
Yet sick people face arrest and punishment. In 1997, there were
606,519 arrests for marijuana possession and 118,682 arrests for
sale/manufacture; in the latter category fell an Oklahoma man with
severe rheumatoid arthritis who received ninety-three years in prison
for growing marijuana in his basement. The prosecutor had told the
jury that, in sentencing, they shouId "pick a number and add two or
three zeroes to it."

[9] Defining diseases around medication pleases drug companies as well
as HMOs. From 19811 to 1997, as general health-care benefits declined
7 percent, mental-health benefits fell 54 percent. Substituting pills
for psychotherapy helps cut costs.

[10] With a street name like Ecstasy, it is hard to take MDMA
seriously as a medicine, especially compared with words like
painKILLERS, or ANTldepressants, which signify the elimination of a
problem as opposed to the creation of pleasure. Rut the faux-Latin
pharmaceutical names are also designed to suggest the drugs' wonders.
David Wood, who used to run the firm that came up with the name
Prozac, explains it this way: "It's short and aggressive, the 'Pro' is
positive, and the Z indicates efficacy." One of Wood's employees
elaborated on good drug names: "Sounds such as 'ah,' or 'ay,' which
require that the mouth he open, evoke a feeling of expansiveness and
openness." As in Meridia, Viagra, Propecia.

[11] In the 1992 campaign, Bill Clinton said, "1 don't think my
brother would be alive today if it wasn't for the criminal justice
system." Roger served sixteen months in Arkansas State Prison for
conspiracy to distribute cocaine. Hod he been convicted three years
later, he would have faced a five-year mandatory minimum sentence,
without the possibility of parole. If he had hod a prior felony or had
sold the same amount of cocaine in crack form, he would have
automatically received ten years.