Cult of Pharmacology: How America Became the World's Most Troubled Drug Culture (review)

American policy toward psychoactive drugs has its origins in two related areas of Progressive Era reform: the effort to curb hedonistic drug use among the working class and the transformation of medicine into a prestigious profession epistemologically grounded in the laboratory. Ever since then, government policy has classified psychoactive drugs as either too dangerous to touch or as safe and effective medicines for a broadening array of psychiatric disorders. In psychopharmacologist Richard DeGrandpre's view, this artificially sustained boundary masks profound similarities between the drugs that fall on each side and hampers our understanding of the meanings and effects of drug use. The dichotomy, he argues in The Cult of Pharmacology, is not only inaccurate; it also gives rise to injustice on the one hand and poor medical treatment on the other.

Few of the specifics in DeGrandpre's critique are new, but the synergistic whole organizes them into a framework that simultaneously indicts "the medicopharmaceutical industrial complex . . . and the drug-abuse-prison industrial complex" (p. 173) as interlocking sets of interests that profit from incarcerating drug users and medicating malaise. Thus, cocaine and methylphenidate (Ritalin) have almost identical pharmacological effects, but one is demonized while the other is freely prescribed to school children. DeGrandpre traces a sequence of calming drugs that have gained and lost medical popularity, from barbiturates in the early twentieth century through meprobamate and the benzodiazepines to the SSRIs. His critique of the latter relies heavily on the work of David Healy. DeGrandpre charts a similar penetration of stimulants into diverse therapeutic niches. On the illicit side, portrayals of extreme cases of addiction belie the reality that the vast majority of drug users do so at moderate levels without experiencing significant harm.

DeGrandpre marshals evidence from behavioral pharmacology and sociology to argue that drug use is best understood as a dynamic process in which the drug functions as a stimulus that the user infuses with meaning, based on cultural messages and personal history. He rejects prevailing views of addiction in favor of Jerome Jaffe and Bruce Alexander's seven forms of drug involvement.¹ These range from abstinence to addiction, which is defined as drug use that dominates a life. Dependence, in which a smoker, say, has difficulty giving up the habit but nonetheless functions well at work and at home, is a more benign category.

DeGrandpre hopes to persuade a broad readership to abandon a paradigm that has become an ideology, its believers forming the cult of his title. Yet that audience seems inconsistently conceived. The same reader is expected to be familiar with the basics of neurotransmission yet to require a simplistic definition of stimulus. The tone is alternately that of a science reporter and a polemicist.

Historians of medicine will find the discussion of behavioral pharmacology most useful. Yet however much he invokes history to set the present in a century-long context, DeGrandpre remains a scientist who feels the need to support every sociological point with a parallel laboratory study. The sociological discussion relies almost entirely on Alfred Lindesmith and Howard Becker. As foundational as their work was, their key insights were published decades ago. The ethnographers who have elaborated Lindesmith's and Becker's insights into a nuanced understanding of the relationships between drug use and the user's social surroundings and identity go largely unmentioned.

Despite these problems, the book deserves to be widely read. As DeGrandpre notes, a century of differential prohibition has done little to curb Americans' psychoactive drug use and has contributed to the medicalizing of a broad array of human discontents. We need new perspectives that transcend these categories, and this book should provoke many useful conversations.