Editor’s Note: Today’s post comes from contributing editor Brooks Hudson, a PhD student in history at Southern Illinois University. As part of our Points Bookshelf series, he reviews Ten Drugs: How Plants, Powders, and Pills Have Shaped the History of Medicine (Abrams Press, 2019), and breaks his findings down into a few major takeaways.
Drug Use, Bipartisan
Drug policy historians, academics and the press more generally often present drug use as though it were a marginal activity. We can fault a lot of this confusion on the arbitrary distinctions that are commonly made, starting with categories like legal and illegal use, which are then further subdivided and sliced into even more granular classifications.
Thomas Hager’s Ten Drugs whose focus is on prescription “medications,” opens the book by highlighting drugs’ ubiquity in American life: “More than half of all Americans take at least one prescription drug on a regular basis, and most of those who fall into that group take more than one (somewhere between four and twelve prescriptions per person per year, depending on which study you look at). One expert estimates that Americans takes an average of ten pills per person per day. Add in nonprescription drugs—over-the-counter vitamins, cold and flu remedies, aspirin, and other supplements—and run the numbers: Let’s say a low-ball estimate of two pills per day per American over an average of seventy-eight plus years of life. The total outcome comes to somewhere more than 50,000 pills, on average, in the average American’s lifetime. And there’s a good chance it’s a lot more. Americans constitute less than 5 percent of the world’s population but spend more than 50 percent of the money that flows into the world’s drug companies. And that’s not even counting illegal drugs.”
Once you throw in recreational and illegal drugs, this leaves no segment of society untouched. These figures could be interpreted as troubling, as our society grows ever reliant on psychological crutches to get through the day. Of course, while that’s partially true, there are also serious issues that have been left unresolved, to say nothing of the precarious state millions wake up to. Setting that aside, the larger point is our discourse is divorced from this underlying reality.
Mistaking Molecules for Magic
Hager touches on themes that also appear in Barbara Ehrenreich’s Natural Causes, including our pathological obsession with the elimination of risk, and the elevation of health into a virtue. In the case of Ehrenreich, she points out we’ve become accustomed to using health and wellness as a signal for self-control and self-worth. It is almost religious. Those most devoted to and fanatical about adhering to fad diets and who purge themselves through strict diets and vigorous exercise divine through medical tests—body weight, blood pressure, cholesterol—whether they are “good” or “bad,” which becomes a stand-in for the self. “Wellness” language is a virus that has infected everyday speech. We speak of tasty foods as “tastefully delicious” and health foods as “guilt-free.” A similar impulse runs through Hager’s description of the holy grail of medicine: “humanity’s search for magic bullets, medicines that can unerringly seek out and destroy diseases in our bodies without doing any harm to our health along the way. The goal has always been to find medicines that are all-powerful, but without risk.”
Hager wavers between optimism and skepticism about inching ever closer to developing an all-powerful drug that is absolutely safe. Our continual emphasis on risk and its associated features misses the point. We speak of “risk” as if they were the only value. It is odd that this standard, while continuously applied to drugs, isn’t applied to any other domains. If it were, we’d all be freaking out over something like pollution, which globally is responsible for as many as nine million deaths per year. Safety is a value, but it’s not the only value. There are values like autonomy and respecting the individual choice that rarely enter the conversation.
Hager and Ehrenreich’s work tie into discussions of the larger social value placed on avoiding pleasure and euphoria. This concept originates from Puritanical roots, the “outward signs of the elect,” and generally manifest in self-denial. It’s at the core of the idea that the body must be controlled, mastered, and disciplined. We applaud “sobriety” and “fitness,” but it is unclear why we should recognize these features as making people good or bad; these are, after all, just choices with morality layered on top. As Ehrenreich writes: “We would all like to live longer and healthier lives; the question is how much of our lives should be devoted to this project, when we all, or at least most of us, have other, often more consequential things to do.” Hager agrees. “Soldiers seek physical fitness,” he writes, “but are prepared to die in battle. Health workers risk their own lives to save others in famines and epidemics. Good Samaritans throw their bodies between assailants and their intended victims.”
These ideas often individualize risk into a matter of personal responsibility or failure, whereas in reality, most contemporary issues related to health or problematic drug use entail systemic failures which are far larger and more complex than individual choices. Our discourse remains heavily geared toward the individual, but we can at least take Hager’s advice when he writes, “If there’s one overarching lesson I hope you come away with, it is this: No drug is good. No drug is bad. Every drug is both.”
We have all read one of those “we’ve been here before” articles comparing the enthusiasm for OxyContin in the 1990s to the parallel trend in the 1890s when physicians touted heroin as a nonaddictive substitute for morphine. The promotion of a pharmaceutical gamechanger turned out to be too good to be true in both cases. After the release of Limitless starring Bradley Cooper, news anchors giddily speculated whether Provigil might be NZT-48 come-to-life. What is this phenomenon—hype followed by disappointment—called?
Hager writes it is “what’s called the Siege Cycle.” This is the stage the public goes through when “an astounding drug is released” and received with intense enthusiasm and wide adoption (stage 1). This honeymoon period is followed within a few years by increasing numbers of negative news articles about the hot-selling new drug’s dangers (stage 2). Suddenly everyone is alarmed that yesterday’s wonder drug is today’s looming threat. Then that, too, passes, and we get to stage 3, a more balanced attitude with a more sober understanding of what the drug can really do, as it settles into moderate sales and its proper place in the pantheon of drugs.”
One reason this happens, as Hager goes into, is pharmaceutical companies, so invested in their products and desperate for profit, are incentivized to shape the surrounding research in favorable ways, while often omitting the downsides. As mentioned above, we are all susceptible, and maybe even hard-wired, to desire a miracle cure that can fix all of our problems. These factors, plus the lethal combination that miracle cures are good for by circulating stories of hope and filling doctor’s offices with prospective patients, suggest that the “Siege Cycle” won’t end any time soon.
In the last chapter, Hager outlines the future of drug development, especially digital drugs which have only recently emerged on the market. Digital drugs involve “linking computers to drugs [and] can work in a number of ways. The simplest is to put a tiny sensor into each pill that sends out a signal when the drug is taken. In early models now being tested, the sensor is about the size of a sesame seed, the power comes from chloride ions in the stomach, and the signal is picked up by a patch on the stomach. From there it can be sent to a smartphone or some other kind of transmitting device and fed into other computer systems. The first digital drug of this sort to receive FDA approval (in late 2017) was Abilify MyCite, an antipsychotic with a sensor designed to show that the drug is being swallowed on schedule.”
Hager flaunts the benefits. Digital drugs would help populations that might be inclined to miss doses, “like people with mood disorders and mental illness or the elderly, where the combination of a lot of medications plus failing memories can result in serious side effects from missed or doubled pills.” This sounds benign, actually a pretty positive development. Then he writes: “If you’re a conspiracy theorist, you might imagine some Big Brother future, where pills of potential pharmaceuticals of abuse, like OxyContin and fentanyl, are enriched with nanotechnology sensors and transmitters, allowing authorities to track them wherever they go—even through someone’s digestive tract.”
The conspiratorial version will happen, but not like that. After all, the U.S. government already uses third-parties doctrine to obtain our data, thereby avoiding pesky issues like constitutional rights. Big tech and insurers are salivating at the opportunity to reap the rewards of new raw material–that is, our personal data. Companies, rather than authoritarian Big Brother-type governments, will be the ones that “own” our biodata, store it, and sell it for profit to anyone who wants to use it, including employers, commercial advertisers, or law enforcement. If there will be a conspiracy, it will operate right out in the open; in fact, it already has. In 2017, police used smartphone devices, the Amazon echo, and iPhone audio to investigate a murder case. From the Time magazine story that covered it two years ago:
Data from his “smart” utility meter, for example, indicated that someone had used 140 gal. of water between 1 a.m. and 3 a.m., a detail that seemed to confirm investigators’ suspicions that the patio had been hosed down before they arrived. Records from Bates’ iPhone 6s Plus, which required a passcode or fingerprint to unlock, suggested he had made phone calls long after he told police he’d gone to sleep. And audio files captured by Bates’ Echo, Amazon’s popular personal assistant that answers to “Alexa,” promised to offer police a rare window into Bates’ living room the night Collins died.
This is hardly the only example. After it hit the market, a Fitbit was used in a personal injury case. In The Age of Surveillance, Harvard business professor Shoshana Zuboff writes how marketing consultants are already devising communication strategies to overcome people’s reluctance to share intimate information, especially health data. Zuboff cites consultants advising “offering cost savings significant enough that people are willing to make the [private] trade-off.” And if that doesn’t work, “insurers are counseled to present behavioral monitoring as fun, interactive, competitive.” Digital pills like wearables allow insurance companies to “improve the traceability of compliance,” and “track compliance with dietary and medication schedules, providing higher truth and better granularity than a monthly refill.”
Hager’s predictions about digital drugs may not be so far off. In fact, they’re already here.
Profits & Patents
Toward the end of his book, Hager asks an important question, and answers it with a question of his own. “What’s the future of drug development? In one line: great things are coming?”
Fingers crossed. One undercurrent of the book is that we haven’t reconciled whether profits should undergird pharmaceutical research and development. Addressing that is at the heart of most systemic failures. The patent system best exemplifies one aspect of policy failure. Patents exist to spur research and encourage innovation to bring better outcomes. Without pharmaceutical patents or the profit motive, there would be little incentive to develop new drugs—so we’re told. Today’s best-selling drug, the monoclonal Humira, was made possible because of research by a pair of scientists in the UK, Georges Kohler and Cesar Milstein. But they didn’t patent it; a firm in the United States did. This follows in step with the “patent disaster” in which a British scientist discovered penicillin, but Americans were the first to mass produce it. Once granted a pharmaceutical patent, companies equipped with the highest paid legal representation extent it. With Humira, its “initial patent expired in 2016, but the company making it since 2003 has secured around one hundred additional patents covering various aspects of the drug’s manufacturing processes and techniques—a wall of patents reinforced by some very highly paid lawyers.”
Final Decision: Recommend
The book’s structure doesn’t lend itself to a neat review. It covers an expansive history, encompassing early quacks with oddball theories experimenting alone, into the modern era, which captures credentialed chemists toiling in laboratories chasing false leads and stumbling on breakthroughs through trial and error. Even without the storytelling and untapped histories he highlights, Ten Drugs would be worth the purchase price for the hilarious anecdote of Giles Brindley. (Imagine if you will: a scientist, some sweat pants, a “tumescent” erection, and a conference presentation.)