The other day I was in an introductory training session for my new job. We were going over the procedures for administering psychiatric meds. One of the questions we were asked was: ‘What’s the difference between a medicine and a drug?’
I thought this was quite an interesting discussion. I’m sure plenty has been written on it. I’m going to neglect to read any of it and write down some ideas I had that sound fun. I’m currently sticking to this weird plan I germinated that I’m going to one day understand Heidegger without suffering an aneurysm of effort in the process, and it’s quite time intensive. So it might be a while until I glect to read some of that literature.
The problem was that all we could ultimately whittle it down to was the issue of approval. Even the manager running the training just admitted it came down to the approval of an expert. She claimed that experts like Psychiatrists or Psychiatric Nurses know exactly how meds work in certain doses relative to certain body-weights and conditions and so on and so forth.
That’s what apparently makes the difference; the difference between drugs and medication is that one has been given the stamp of approval by an agent we have invested with the confidence to take such actions, and the other has not.
Okay, so she also said it had something to do with the preparation, but I don’t think anyone is going to tell me street valium isn’t a drug just because it’s been prepared in an analogous way to prescribed generic diazepam. It all comes down to an issue of authority.
Who is invested with the authority to make judgements about medication? Who is invested with the authority to make judgements about how best to alter the physical chemistry of suffering individuals to help them orient themselves back to a form of sanity?
These questions are pretty easily answered with common sense in the case of the violently delusional schizophrenic who happens to be super lovely when he’s not having an acute episode and also doesn’t happen to particularly mind being on anti-psychotics. That seems like a clear cut case of just give him the damn meds! But common sense doesn’t always do the job.
I’m not going to get into the debate around anti-depressants right now. Suffice it to say that a bunch of studies isn’t certain they’re any better than placebo over the standard six-week window used in RCTs. Plenty of people swear by them, but plenty of people also swear by crystal healing, for example. That people swear by things doesn’t make them worth trusting.
Yet, we as a collective decide– or at least tacitly support– the notion that only certain properly trained individuals are allowed to prescribe them. What makes them more qualified? Well, we might say they know what they’re doing. But that definitely isn’t a requirement. You could get prescribed Modafinil right now for narcolepsy if your Doctor thought it was appropriate, and if anyone tells you they know how Modafinil works, they’re probably lying.
Even SSRIs are a little confusing. We know they make serotonin stick around in a synapse for longer, but beyond that, we have no idea why they seem to make people less depressed. In fact, the chemical imbalance theory of depression was basically reverse-engineered from the observation that boosting serotonin seemed to help people who were depressed. It made them feel less bad.
You know what else makes depressed people feel less bad? I would venture that a big joint/lightbulb full of meth/charge of heroin makes some depressed people feel less bad. I’m not trying to say that doctors are doing the equivalent of actual drug dealing. I’m not saying that at all.
The point I’m trying to make is that there appears to be a relevant difference between drug dealers and doctors, but that the relevant difference isn’t that what they provide is understood in its effects, and that relevant difference isn’t that what they provide is necessarily intended to fix the problem with the patient.
As far as I can see, the difference seems to be that we’ve ritually invested the doctor with the magic of trust. The upside for the doctor is that they get a lot of status, and they get the power to control the spice, and they get lots of nice television shows made about them and so on. The downside is that they have to do things they don’t necessarily understand just because we think they’re the best qualified to do so and because we have very powerful tools in place to ensure they don’t mess up.
There’s a reason we treat a medical professional losing their licence like it’s such a big deal. It’s a lot worse than simply flunking out of medical school because losing your licence implies you broke trust. It’s the trust that works. That’s why the trust has to be protected.
That’s why SSRIs aren’t useless. They work because we believe they work. I get really agitated when people say that something only worked because of placebo.
WHO CARES? IT WORKS.
But again, let’s not forget that we haven’t left witch-doctors behind. There’s a reason we imagine doctors in a special robe with a special necklace-qua-stethoscope. It’s because they’re magic. They can do things that most people can’t do. You let them do things like touch your organs. You do this because you assume– usually in a completely justified manner– that they want to help you. More importantly, you let them do this because if they mess up then they suffer horrible shame and dismemberment. Much like in the case of witch-doctors, I assume.
One interesting possible consequence of my view would imply that drug-dealers in more violent areas might be less likely to engage in shady practices like cutting cocaine with adulterants if we control for all other relevant factors. It’s like the saying ‘a polite society is an armed society.’ That would be funny if it was true, but I have absolutely no desire to test it.
Another interesting consequence of my view is that you should probably not trust drug-dealers who operate in more ‘straight/square’ areas.
Back to the main point: if the same dose and purity of a given substance is a drug if I hand it to you right now in a baggy, but it’s a medicine if a doctor prescribed it to you and you picked it up from the pharmacy– and that sure seems to be the case in the way we think about this, especially from a legal perspective– then the only thing I can see is that the skin-in-the-game of the doctor entails all the ghetto-uncertainty demons have been shoo’n out of the amphetamines. Probably because he waved some stats on them.
And if there’s one thing society hates, it’s uncertainty. The point of society is arguably the avoidance of uncertainty, but that’s a summary for another day.