Addiction: From Biology to Drug Policy by Avram Goldstein

The Search for Rational Drug Policy Informed by Advances in Neurobiology:

A Review of Addiction: From Biology to Drug Policy by Avram Goldstein

In his book, Addiction: From Biology to Drug Policy, addiction scientist Avram Goldstein lays out the biology behind addiction and uses this biology to make suggestions for what he considers rational drug policy in the United States. According to Goldstein, in his 25 years of “laboratory and clinical research and teaching about the addictive drugs” he witnessed an enormous gap “between our growing scientific knowledge and the ever more heated debates about drug policy” (Goldstein, vii). Goldstein’s book is an attempt to bridge this gap—to make suggestions about drug policy based on science. He first published this book in 1993 at a time when significant advances in neurobiology were helping scientists better understand how addictive drugs affect the brain. He published a second edition in 2000 with updated scientific information. Goldstein’s book seeks to use this new scientific knowledge about drug addiction to inform rational drug policies.

Goldstein divides his book into three parts: “Drugs and the Brain,” “The Drugs and the Addicts,” and “Drugs and Society”. In the first two sections Goldstein explains in detail the biology of addiction. In the third section he uses this scientific knowledge to discuss current drug policy and make suggestions for more rational drug policy.

In the first and second sections of the book, Goldstein is highly technical in his discussions of the neurobiology behind addiction. He begins by explaining the way molecular biology helps neurobiologists study addictive drugs. According to Goldstein, “addiction is a behavior, and all human behavior has a biologic basis in the workings of the brain” (Goldstein, 20). Science is beginning to be able to explain this biologic basis. It is important to understand that addiction has this basis in neurobiology. Goldstein discusses research that explains the way addictive drugs alter brain chemistry, and, in turn, how the brain adapts to those changes in brain chemistry. Scientists have used various methods of direct experiments to understand “how the neurochemical effects of the drugs cause changes of mood and behavior—changes that lead to compulsive drug use” (Goldstein, 53).

Goldstein also introduces the ideas of tolerance and sensitization—how for most addictive drugs, the addicted person develops an increased tolerance and becomes desensitized to the drug over time, requiring the addict to use more of the drug and more frequently in order to achieve the same effect. In the brain, there are two different types of tolerance: metabolic and cellular. Goldstein explains that “tolerance is very important because of the problems it creates for the untreated addict and society” (Goldstein, 90). When people are addicted to a drug and their tolerance to the drug increases, they need greater quantities of the drug. This is often what leads many addicted people into crime and has other negative effects on society as a whole. Goldstein also identifies seven different types of addictive drugs: nicotine; alcohol and related drugs; heroin, morphine and other opiates; cocaine and amphetamines; cannabis; caffeine; and hallucinogens. He details the specific neurobiology behind each of these seven drug types.

In the third section of his book, “Drugs and Society,” Goldstein discusses the impact addictive drugs have on society, evaluates responses to drug addiction in the United States and abroad, and makes suggestions for rational drug policy in the United States. Goldstein beings this section with the chapter “Prevention: Just Say No?” in which he describes use of addictive drugs by children and the effect of that use on society. Because most people first use addictive drugs as children, preventative efforts have to target people beginning at a young age. He explains that “the degree of social deviance represented by first use” depends on the drug and the culture (Goldstein, 236). For instance, a middle school student trying a cigarette for the first time in the United States is fairly common and is not especially deviant. However, first use of a drug such as cocaine or heroin at an early age is more rare because “first use of these drugs requires a high degree of deviance” and the illicit status of these drugs “forces the first-time user into criminal behavior at the outset” (Goldstein, 237). Goldstein explains that “behavior is shaped in a social context” and therefore preventative measures (which keep children from experimenting with drugs in the first place) must involve the whole community (Goldstein, 240).

In the next chapter, “Treating Addiction, Preventing Relapse,” Goldstein describes the wide range of drug treatment options available. According to Goldstein, drug treatment is not only effective, but it is cost-effective for society as a whole compared to no treatment or incarceration. Goldstein argues, “every addict in jail or prison should be treated, to reduce the likelihood of relapse after release” (Goldstein, 260). He also suggests the possibility of science developing some sort of “pharmacological agent to block the rapid progression from craving to relapse” (Goldstein, 260).

In the following chapter, “Three Lessons From the Street,” Goldstein calls for policies that minimize the harm “street addicts” cause to themselves and society as a whole. Three types of harm he discusses in detail include crime, social stigma that impedes treatment, and the spread of AIDS. He argues for policies that balance the rights of society as a whole with humane treatment of the addicts themselves.

The next chapter, “Three Lessons from Abroad” evaluates policies from Great Britain, the Netherlands, and Switzerland. Based on these examples, Goldstein concludes that what is needed are “pragmatic harm-reduction policies based on the disease concept of drug addiction” (Goldstein, 291). This disease concept is grounded in the biology he has laid out in the beginning of the book. He claims that society has a right to be protected from addicts, but also an obligation to provide services.

In the following chapter, “Prohibition vs. Legalization—A False Dichotomy,” Goldstein explains that the solution to current drug problems lies in reducing supply as well as demand. He explains how these ideas are “not mutually exclusive alternatives,” rather, “both strategies have the same goal, to reduce the total consumption of addictive drugs” (Goldstein, 294). He admits that both supply reduction strategies have a social cost. According to Goldstein, the ultimate goal of drug policy should be to “achieve the greatest degree of harm reduction by means of the least necessary degree of regulation” (Goldstein, 305).

In the final chapter, “New Strategies for Rational Drug Policies,” Goldstein offers concrete policy guidelines which are as follows: “consider drug addiction to be primarily a public health problem”; “make demand reduction the primary strategy”; “address the spread of AIDS and other infectious diseases by intravenous drug users”; “address the problem of fetal damage caused by addictive drugs”; “enact and implement laws that support social norms”; “consider actual crime—whether or not drug related—to be a law enforcement problem”; and “increase funding for basic and applied research” (Goldstein, 308-315).

Goldstein’s book addresses many important sociological concepts related to social control. For instance, he addresses the way regulations and social norms influence each other. He describes how “regulations can promote attitudinal change, and how attitudinal change, in turn, can make ever tougher regulations more acceptable” (Goldstein, 313). Laws can reinforce social norms and those social norms in turn make the laws acceptable. He also addresses the sociological idea of claims-making and the way scientific claims have lead to changes in social norms. He uses the example of smoking and the way biomedical science and education about smoking by claims-makers changed the way society viewed smoking.

Goldstein’s book stresses the importance of society and social norms as they relate to drug use. Society makes artificial distinctions between addictive drugs, and these distinctions do have tremendous importance. Drugs which are considered not, or less, socially deviant (such as caffeine, tobacco, and alcohol) are far more widely used than illicit drugs such as cocaine and heroin which are regarded as socially deviant.

Goldstein’s book also addresses the sociological importance of historical context. For example, he discusses how in the nineteenth century drug addiction was seen as a disease affecting mainly middle class women who deserved sympathy. After the temperance movement at the beginning of the twentieth century drug use started to spread to “inner-city populations, to lower socio-economic classes, and to ethnic minorities” and this “demographic change” changed the public perception from the disease model to the idea of drug addiction as character defect and drugs as a force threatening society (Goldstein, 275).

Overall, Goldstein accomplishes what he set out to do—he offers compelling arguments for rational drug policy based on decades of research about the science of drug addiction. Goldstein has made an important contribution to debates on drug policy—one that advocates scientific knowledge as the basis for reformed drug policy in the United States.