-Caveat Lector-
The Economist, April 6, 1996 v339 n7960 p87(2)
Better than well: society's moral confusion over drugs is neatly
illustrated by its differing reactions to Prozac and ecstasy.
Abstract: MDMA, known in street parlance as ecstasy, is illegal, and
Prozac, an anti-depressant, is legal. Both have a similar elevating
effect on mood by altering serotonin levels. Societal views of
chemically induced happiness are examined.
Full Text: COPYRIGHT Economist Newspaper Ltd. (UK) 1996
EVERY week, according to the most conservative estimates, half a
million Britons take a pill to make them happy. This pill was
originally developed as an appetite suppressor. Now it is an
adjunct to partying. In America, some 5 million people regularly
take a different sort of pill. This one was developed as an
anti-depressant. Now it is widely used as a chemical accessory by
those who think it is unfair that they should ever feel low.
The British users are breaking their country's law. The Americans
are not.
Which raises an important question. If it is not acceptable to
take a drug with the awkward name of 3,4--methylene-dioxy-
methamphetamine (better known as MDMA, and even better known as
ecstasy) to make you feel happy when you just want to have fun,
why is it acceptable to take the anti-depressant fluoxetine
(better known as Prozac) to make you feel happy if you are not
actually clinically depressed?
When Prozac--made by Eli Lilly, an American pharmaceutical
firm--came on the market in 1987, it was hailed as a "wonder-drug".
Unlike previous anti-depressants, it appears to have no serious
(and few trivial) side effects.
Its sales have soared. They are expected to hit $4 billion a year
by 2000, according to analysts at Lehman Brothers, an American
investment bank.
Ecstasy is older. It was developed in 1914 and became popular in
the 1970s as an adjunct to psychotherapy because of its ability to
reduce anxiety and facilitate communication. German marriage-
guidance counsellors regularly recommended it. It, too, is good
business. A tablet can cost as little as 3.50 ($5) to make and
sells on the streets for around 15. This suggests that the
British market alone is worth well over 300 million a year.
Both drugs affect the level of serotonin, a neurotransmitter in
the brain that is thought to influence sleep, appetite, aggression
and mood.
Neurotransmitters are chemicals that carry messages between nerve
cells. They are secreted by one cell and picked up by receptor
proteins on the surface of a neighbour. Once the message has been
delivered, a neurotransmitter is either destroyed or sucked back
into the cell that made it--a process known as re-uptake.
Both Prozac and ecstasy work by inhibiting the re-uptake of
serotonin. This means that the messenger molecules hang around in
the gap between the cells and the message gets amplified. Ecstasy,
in addition to blocking re-uptake, causes a surge of serotonin to
be released into the gap--so that not only is it not removed, but
there is more of it there in the first place. Since clinical
depression seems to be associated with a lack of serotonin at
certain receptor sites (extremely low levels of serotonin have
been found, for instance, in some suicides), the idea of using
serotonin re-uptake inhibitors as anti-depressants has been
popular for some time.
So there are parallels. But there is also an important difference
between the drugs--one which might be thought to justify banning
one but not the other.
Though it has been accused of causing violence in rare cases (the
"Prozac defence" was once fashionable among lawyers, but 65
consecutive convictions have dampened their enthusiasm) Prozac
does not seem to harm its users. Very occasionally, ecstasy (or,
more particularly, dehydration associated with its use) kills.
This does not, however, seem to have been the reason why MDMA
actually was proscribed. In 1971, when the drug was banned in
Britain, this problem was almost unknown. Things had not changed
much by 1985, when the drug was first scheduled in America. This
is hardly surprising. Death is rare--it occurs in only one per 3
million uses. Fatal dehydration generally happens in a hot
environment. And it is preventable by drinking a judicious,
though not excessive, amount of water (too much can kill you, too).
The formal reason for the drug's proscription was fear of
neurotoxicity--that it might cause a persistent drop in serotonin
levels in the brain. But America's Drug Enforcement Agency (DEA),
instead of placing it in schedule three, which would have allowed
continued medical use, put it in schedule one--denying it even to
doctors.
Better living through chemistry
The neurotoxic effects of MDMA are real. Regular users may suffer
a drop of a third in the level of serotonin-derived chemicals in
the fluid of their spinal cords, according to research by George
Ricaurte, a neurologist at Johns Hopkins University in Baltimore.
But such effects do not appear to be very troubling--at least not
in the doses that people actually use. Slightly reduced sleep,
less impulsive behaviour and less hostility are the main symptoms.
And other drugs which are neurotoxic in laboratory experiments
do not seem to cause difficulties in the outside world.
Fenfluramine, another appetite suppressor, has been in use for 25
years and been taken by around 50 million people without any sign
of a problem.
The decision to put MDMA into schedule one, therefore, seems odd.
It came despite the opinion of Francis Young, a federal judge who
was asked to review the evidence, that it should have gone in
schedule three. The explanation seems to be that the mid-1980s
also saw MDMA's recreational use change from small groups of
people taking it in private, to large groups of people taking
it in public. Ecstasy was being born and the DEA wished to
strangle it.
The history of Prozac casts the propriety of the ban into sharp
relief. Strictly, America's Food and Drug Administration
recognises Prozac as suitable for the treatment only of depression
and obsessive-compulsive disorder. In practice it is being
prescribed (quite legally, if warnings are given) for panic
disorders, premenstrual tension, premature ejaculation and chronic
back-pain. But, increasingly, people are being prescribed it
simply because they want it. And those who are unable to find a
friendly doctor to fill in a prescription are turning to the black
market.
Peter Kramer, a psychiatrist at Brown University, in Providence,
Rhode Island, says Prozac users feel "better than well"--a
sentiment no doubt echoed by many a user of ecstasy. As Dr Kramer
puts it in his book "Listening to Prozac"*,
"until the advent of Prozac most ethical questions involving
psychotherapeutic drugs turned on clinical trade-offs." But because
Prozac has proved so safe, it is much more widely prescribed than
previous anti-depressants. The question is whether a line can be
drawn between therapeutic and non-therapeutic use of the drug. And
if it can be, should it be?
There are two ways of dealing with this question. One is to duck it.
Some doctors argue (with a certain circular logic) that if
something is treatable with an anti-depressant then it must, by
definition, be depression. The drug is then restoring a state which
would "naturally" exist if the person were well. So, the argument
goes, unlike ecstasy (where the act of taking the drug provides
immediate pleasure) Prozac does not actually create pleasure. It
merely restores the capacity for pleasure. In the words of a
spokesman for Eli Lilly, the drug does not make people into
super-people.
The other way of answering the question is to admit that Prozac,
like ecstasy, is often used recreationally, to enhance pleasure,
rather than to treat depression--and, if this is not approved of,
to ban its use in these cases.
But why ban the recreational use of drugs?
The motive often seems to be what Dr Kramer refers to as
"pharmacological Calvinism". The use of drugs for fun rather than
therapy is widely disapproved of. There is, too, a feeling that
doctors--who, it is to be hoped, know what they are doing--should
be in charge of the process of giving drugs out. But, in that case,
why not let doctors give out MDMA as well?
There is also a belief that, at least with mental problems,
behavioural therapy is morally superior to chemotherapy. But the
two are intimately linked. Eric Hollander, of the Mount Sinai School
of Medicine, in New York, for example, recently showed that treating
obsessive-compulsive disorder with drugs produced the same changes
in the activity of patients' brains--uncoupling the action of four
groups of nerves that are unhealthily locked together--as treating
them with psychotherapy. It hardly seems that one method is morally
inferior just because it is easier.
Nor does it seem reasonable to stop people taking drugs to achieve
easily an effect which might be won in other ways with difficulty.
Good information about the risks and benefits, and proper
supervision of manufacture, are always important (and are a good
argument for legalising what people clearly want). But given these,
it is not clear that pills should always be popped under a doctor's
supervision. So, when Calvinists ask if people taking Prozac to
eliminate elements of their personalities, such as shyness, is so
very far removed from the recreational use of ecstasy, the answer
appears to be "no".
But what is wrong with that?
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