Thursday, September 16, 2021

Opium by John Halpern and David Blistein

Source of book: borrowed from the library


I chose this book in part because of my 13 year old who has been devouring all things about the Age of Sail, so the portion of this book with the Opium Wars fit in well. And I decided to read it as well. 


The book starts with our earliest evidence of opium use (and addiction) going back, well, about as long as we have human history. From the beginning, opium was both a benefit - it is still our most effective painkiller - and a curse - it is and always has been highly addictive. In addition to the history of its use, the book looks at attempts at regulation throughout history, and makes a strong case that the War on Drugs is as futile and counterproductive as every previous war on drugs has been. Related to this, of course, is an understanding of addiction as a disease, and therefore a public health problem, not a moral failing best addressed by mass incarceration. 


The book was written by John Halpern, a psychiatrist who has worked in addiction treatment for most of his career. He also taught at Harvard for two decades. The other author is David Blistein, who has been a co-writer on a number of medical books, as well as a screen writer for PBS. My guess is that Halpern provided a lot of the medical side, while Blistein did most of the writing and research. The book isn’t meant to be original, but more of a lay-person’s version of history and present challenges. Because of this, the book extensively cites other more scholarly works dating from the past couple hundred years. From the quotes, I suspect this book is much more readable than some of its sources. 


The book opens with Halpern’s account of the death of his friend from suicide after a relapse into opiod addiction. There are few of us who do not know someone whose family lost a member to addiction. Opioids are a widespread problem to be sure, and working to prevent death and dysfunction is a necessary goal. Halpern is haunted by the fact that his friend never told him of his struggles - despite the fact that Halpern could have, as a professional with expertise in that area, helped him. 


I thought Halpern’s quote of Cardinal Bernardin of what Bernardin said to Halpern once was quite good. 


“I used to think that there is something extra special about being a Catholic priest, but now that I am dying of cancer and see all the care provided to me and other patients, I recognize that this ‘specialness’ can be found in many other professions. Just as it is between priest and parishioner so it is between doctor and patient. We share a moral covenant before God.”


This is certainly the case with my wife, who sees her nursing work as her form of ministry and her calling from God. 


In the introduction, Halpern also notes that the goal is to find solutions for severe and chronic pain that are not addictive, and also find better remedies for addiction. 


Until then, the work we must do - to confront the stigma, shame, moral judgments, and self-serving political arguments that swirl around the disease of addiction, as well as create systems that make it possible to help all those who suffer - is enormous and important. 


The early chapters of the book point out that culture has always been an issue with opium. Every culture tends to assume that it was other cultures that are at fault for addiction, for example, and that other peoples are more prone to addiction. 


This is not only an academic discussion. Four thousand years later, simplistic attitudes and cultural differences continue to be major obstacles in the way of a constructive conversation between the West and the East about opioids. 


There are some fascinating characters in this book. One that was particularly interesting was Paracelsus, the talented and cantankerous physician who introduced laudanum to the West. (He gets a mention in Frankenstein as inspiration for the doctor.) Just as an example, he was no fan of religion, and referred to his contemporary Martin Luther and the Pope as “two whores discussing chastity.” 


The Brits do not come off well in this book, nor should they. In many ways, they were the original drug cartel, literally willing to wage war to ensure increasing addiction. Opium was used by the Chinese before the Brits showed up, of course, but the British habit of smoking it with tobacco was new, and quickly became popular. 


Whether it was owing to a combination of these cultural influences, the discriminating use of the drug by physicians themselves, or even the weaker variety of opium being cultivated in China, all evidence suggests that in the millennia before the European merchants arrived, Chinese opium use was limited, well supervised, and safe, belying the racial stereotypes that the West would soon foist upon the Chinese as being, by nature, incorrigible addicts committed to drawing the rest of the world into their sordid drug culture. If anything, it was the opposite. 


One chapter is about how the British took control of opium production in India from the Mughal Empire. Their tactics seem somehow...familiar. 


Different regions, particularly in the south, started fighting the Muhgals for territory and independence. That, as well as infighting between tribes, sparked a multifront war that disolved the empire. The British worked on the sidelines, offering money and weapons to groups that at various times appeared to be useful, malleable allies.


I also found the chapters on the Canton trading fun. That trade was the source of the original “Pidgen English,” the vernacular that enabled communication between merchants from China and various other European nations. We still use phrases from that today, such as “long time no see,” “look see,” and “no can do.” It is easy to underestimate the enduring legacy of the Canton trade. 


Throughout all the vicissitudes of the opium trade and upheavals in Chinese politics that have taken place over the last 400 years, many of the ways that China and the West conduct business today can be traced back to the Canton trade.


And the opium wars in particular continue to affect our world. 


[T]he noted British historian Nicholas J. Saunders called the Opium Wars among the most immoral episodes in his country’s history, concluding, “These conflicts saw the British Empire officially trafficking opium, and using military might to force narcotic addiction on the people of China. During these years, Britain created the largest, most successful and most lucrative drug cartel the world had ever seen.”

Regardless, repercussions from the Opium Wars continue to resound today. As Julia Lovell, another British expert in Chinese history put it: “From the age of opium-traders to the Internet...China and the West have been infuriating and misunderstanding each other...Ten years into the twenty-first century, the nineteenth is still with us.” 


And don’t think the United States is innocent. There is a whole chapter on the Boston traders that made obscene fortunes investing in the opium trade. 


Although the United States was a much smaller player than Great Britain in the opium trade at first, American companies would eventually use equally shameless rationalizations and brazen self-interest to invest in it and, later, collective amnesia to avoid acknowledging the damage it caused. That duplicity, combined with racial prejudice, has led to the assumption that continues to this day, that America’s opium problems in the nineteenth century were caused by China when, if anything, it was the opposite. 


While American merchants and investors - and indeed institutions - got rich off of opium, politicians leveraged racist fears to impose our first immigration restrictions. 


The Second Opium War and the treaties that followed set the stage for the resentment, suspicion, self-righteousness, and frequent outright enmity that have marked the relationship between China and the West ever since - from America’s racist Chinese Exclusion Acts of the late nineteenth century to the fact that the fentanyl crisis is often unfairly blamed on China’s allegedly lax drug controls today. 

In the end, the China trade, and the wars that resulted from it, is a cautionary tale about drugs, money, power, and greed - and the hypocrisy that inevitably hovers in the territory in between.


I should also mention a forgotten episode in American history. It is pretty well known that most “patent remedies” sold in the 1800s had either opioids (heroin or morphine) or cocaine in them as an ingredient. What is less well known is that the Shakers (of all people!) grew their own opium, and did extensive experimentation to determine the optimal dose. If you were going to take a remedy, the Shaker ones were the closest to the controlled dosage and careful formulation of modern drugs. 


The transition to the fourth part of the book, on the 20th Century, is delightful enough to quote. 


And so, we leave the rampant greed, unjustified wars, misunderstood scientific breakthroughs, and often brilliant if overwrought literature of the 1800s and move on to the rampant greed, unjustified wars, misunderstood scientific breakthroughs, and brilliant if overwrought literature of the 1900s.


I laughed at that one. I mean, you have Coleridge in one century, and Kerouac in the next, right? And the rest of it too. 


Particularly the misguided laws surrounding opium, which did little if anything to prevent addiction, but had nasty consequences for vulnerable minorities. The book starts with San Francisco’s attempt to outlaw opium dens back in 1875. (Spoiler: it didn’t work.) 


The 1875 law set the standard for several decades of California laws against smoking opium, based on inaccurate or partial assumptions: that only Chinese-Americans would be interested in importing opium that had been processed to be smoked, that opium was only smoked in Chinese opium dens, that any Americans who smoked opium only did so at these opium dens and only because the Chinese had corrupted them, that Americans wouldn’t consider processing their own opium for smoking, that American opium dealers wouldn’t do business with the Chinese, and that importers and sellers wouldn’t be able to easily find a way to get around the new laws.

Each of these assumptions proved to be wrong.

In other words, the San Francisco law reflected the same kind of ethnic prejudice that many drug laws and enforcement strategies suffer from today. By targeting certain populations disproportionately, these laws reinforce stereotypes and discrimination, while doing little to solve the problem. 


That’s the history of the War on Drugs in a nutshell. It has had essentially a zero effect on either addiction rates or on availability of drugs...but it has disproportionately incarcerated minorities and the poor, while costing a hell of a lot of money. 


One of the fist big political stories I remember as a kid was the Iran-Contra Affair. That was only one of the various War on Drugs adjacent actions that went bad during my childhood. In this case, the CIA took down a left-leaning government in Nicaragua by funding the right-wing “Contras,” who, as they well knew, were connected to the cocaine cartels.


The CIA’s justification was that, while the country considered drugs to be bad, communism was way worse and, if the lives of “a few” citizens and soldiers had to be sacrificed, along with any semblance of geopolitical ethics, one simply had to look the other way - even if “one” was the president or vice president of the United States. 


This at the same time as Reagan and Bush ramped up the War on Drugs rhetoric, and incarcerated tens of thousands of low-level drug users. Meanwhile, Oliver North, who orchestrated the deal, never did a day of time, and remains venerated (for reasons that escape me) among right-wing Fundie sorts. 


In the final chapters, the authors look at a more sensible approach to addiction. They examine the approach of Portugal in particular, which has reduced its drug-related deaths substantially. (They have a death rate that is a mere 2 percent of that in the United States.) The point is to reduce harm, not moralize. 


The effectiveness of the program may be partly due to decriminalization itself, but as important and innovative is the unconditional acceptance of addiction as a disorder rather than a moral failing, which reduces the stigma involved in seeking treatment. Plus, instead of trying to treat addiction in isolation, healthcare workers have the resources to address the wide range of physical and emotional problems that usually accompany the disease. 

While the Portuguese government accepts that completely ending drug use is impossible and advocates believe it could still be doing more, millions of dollars that would have gone to interdiction and enforcement are invested in public health services, with impressive results. 


Again, success can only happen with a shift away from a moralistic approach. In particular, harm reduction strategies are only possible when you remove the idea that addiction is a moral failing, and that punishment of that sin is the only way out. 


Objections to some or all of these treatments are based on the belief that drug use is a moral failing, abstinence is the only successful withdrawal strategy, and/or that the cost is prohibitive. Regardless, to reject proven solutions because of moral or cultural beliefs is not only counterproductive, it could be considered unethical - especially at a time when addiction often begins with the use of perfectly legal drugs. As far as cost, these strategies clearly yield long-term savings because of reductions in crime and ER use - not to mention the damage addiction does to families, businesses, and the community, as well as the positive impact of users returning to school or the workplace. 


I remember as a kid, some of our closest neighborhood friends had parents who struggled with addiction. Their mom would often disappear on a bender and they would sleep at our house. Their dad was on methadone treatments through the VA, which enabled him to be the functional parents. Unfortunately, if he had to work a night shift or an extended shift, and mom didn’t come home… The point here is that methadone enabled him to be a functional person, a good father, and a part of society. The treatment did its work. And yet, so many on the Right HATE methadone programs, because of the moralizing. Solutions be damned, we must enforce “morality.” 


[Side note: this is literally how Fundies deal with everything. Moral and cultural beliefs have become ideology, which overrides in their minds any possible challenge. Reality is irrelevant. If it contradicts the dogma, it is reality which is wrong.] 


I’ll end with a perceptive paragraph from the end of the book. We Americans tend to think that we somehow are different, that the rules do not apply to us, that we are so far better than other people that we have nothing to learn from them or from the past. 


History has a lot to teach us about this crisis, but if we’re going to learn it, we need to let go of the conceit of modernity: the notion, in other words, that this crisis is worse, or fundamentally different, than any that has come before. We have to realize once and for all how absurd it is to think harsh penalties will reduce drug use when we’ve seen how those same harsh penalties have failed time after time; how preposterous it is to imagine that eradicating one source of suppl will solve anything when we’ve seen again and again how quickly a new one will arise to take its place; how arrogant it is to think we can legislate behavior when governments have failed for centuries to do just that. 

Most of all, we have to confront the unreasonable fear and unenlightened self-interest that enables our leaders to argue that addiction is a choice to be punished rather than an illness to be cured. In addition, we have to resist the seduction of seemingly easy solutions such as guarding borders, locking up users, or telling kids to just say no. 


I could not have said it better. 




For a book specifically about the history of the War on Drugs and its failure, I recommend Hep Cats, Narcs, and Pipe Dreams by Jill Jonnes. It has some different perspectives than Opium, and I think Jonnes overestimates the possibility of restricting supply, but it has a lot of good history and thoughtful ideas. Addressing addiction requires a holistic approach, including addressing some of the root causes of addiction such as trauma, as she points out. I think my own views have shifted since I wrote that review, by the way, as the result of more life experience with how addictions have played out in the families of people I know. There are no easy answers, there is no one thing that works. But the War on Drugs certainly has been a failure by any reasonable measurement.

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