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January 21, 2008

The Drug War as Part of a Perfect Storm (Personal, Historical)

In the wake of the powerful 1991 Halloween Nor’easter, author Sebastian Junger's conversation with weatherman Bob Case led him to came up with the term “perfect storm” to describe how several rare circumstances had combined to produce a weather event of singular magnitude. That concept, popularized by Junger’s 1997 book, has since been extended beyond Meteorology as shorthand for similar combinations of rare events leading to generally unforeseen, and often profound, changes in the status quo.

It now appears that the rapid dismantling, forty years ago, of the century-old system for managing “mental illness” that had gradually evolved into a large, diverse, state hospital system by the Nineteen Fifties may have been one of several unique events responsible for some of the serious social problems presently disrupting schools, prisons, and urban life. In other words, we may now be in the midst a complex and slowly developing perfect storm traceable to erroneous policy decisions which, although receiving solid federal endorsement and a correspondingly large allocation of tax dollars, are really based on nothing more than blind faith; lacking even minimal confirmation from unbiased research.

In fact, similar charges of incompetence and inhumanity have been leveled against the same system of state psychiatric hospitals we began gradually abandoning  in the Sixties. The travesty is compounded further because the state hospital system has gradually been replaced by an even more expensive and brutal expansion of federal and state prisons that has quadrupled the combined prisoner/inmate population since 1970.

As for the connection between key policy weaknesses and the current mess, the problem policies have been stubbornly defended by the very bureaucracies they have nourished with billions of tax dollars, especially after American drug policy was recast as a “war” on drugs under the Controlled Substances Act in 1970. Other contributing factors have been Psychiatry’s uncritical adoption of a DSM system of classification that has literally been breeding new conditions for treatement with the steady stream of psychotropic drugs so important to the balance sheets of a Pharmaceutical Industry which itself has  evolved one of the pillars to our economy over the same four decade interval.

In addition, the number of school and pre-school children now receiving powerful psychotropic drugs for presumed “mood disorders” has grown alarmingly , as have reports of suicide and other untoward consequences of aggressive pediatric Psychiatry. Ditto, the number of young people acquiring criminal records through plea bargains for “drug crimes” (mostly marijuana offenses).

My own perspective is admittedly unusual; in addition to the six years spent profiling pot users, I'm a physician who just turned 76. I’d had a brief, but intense, month of clinical experience living among thousands of patients (inmates) at a large Eastern VA hospital during my senior year in medical school. The following year, a similarly intense month was spent as an intern admitting and observing the disposition of patients passing through San Francisco General’s Psych unit and thence into California’s network of psychiatric hospitals. That had given me an overview of the system that would start disappearing, even as I was starting a four year residency in General Surgery in Texas. I then served in Japan, where I eventually played a role in the development of a (still unknown) network of Army Hospitals set up around Tokyo to treat thousands of American casualties evacuated from Viet Nam. After returning to San Francisco during the 1967 “Summer of Love,” to begin training as a chest surgeon, I still had no way of knowing how the state hospital system I’d been introduced to 10 years earlier was halfway through its disappearing act.

What had enabled that rapid change were two developments: the near simultaneous availability of the first  psychotropic drugs able to modify dangerous behavior and the passage of Medicare, which, by unwittingly defunding existing state hospital programs, had pushed Psychiatry almost completey out of inpatient care.

The final component required for a delayed perfect storm seems to have been the war on drugs which, by criminalizing effective and newly available self-medication with cannabis, has created a youthful drug culture that has itself evolved into a global complex of illegal markets with generally noxious consequences that tend to be either denied of minimized by the same government agencies supported by perennial policy failures.

Ironically, the California governor under whom state hospital closures began was Ronald Reagan. His successor, under whom the exodus continued, was Jerry Brown, now the state AG. Also ionically, there is no evidence that either man ever tumbled to the  significance of the profound changes in Psychiatric care that occurred during their combined sixteen years in office.

The same could be said of ONDCP, the cabinet-level entity that has evolved to oversee the war on drugs since passage of the CSA in 1970. That same massive inertia produced by deep beaureaucratic commitment to flawed policies is not uniquely American; it’s mirrored everywhere in the modern world.

We don’t yet know how all this will end, but as most working doctors know, illnesses complicated by patient denial are difficult to treat successfully. To make matters worse the denial in this instance seems to be by both patients and physicians (the public and government).
Doctor Tom

Posted by tjeffo at January 21, 2008 05:20 PM