What’s the matter with Georgia? Thoughts on substance abuse statistics, policy, and history

Last month, I attended the American Public Health Association conference in San Francisco. While there were many interest groups  and high-profile lectures that appealed to my interest in the history of addiction, I wound up spending most of my time at the Public Health Expo. In a stadium-like open space, my research team’s posters competed for attention with potential employers, university recruiters, and lots of public health swag.

Public Health swag!

As I was making the rounds, I stopped by the SAMDHA table. SAMDHA —short for the Substance Abuse and Mental Health Data Archive—is a fabulous database of survey results collected by the federal Substance Abuse and Mental Health Services Administration (SAMHSA). The University of Michigan’s Inter-University Consortium for Political and Social Research (ICPSR) maintains the archive, from which researchers or quant-savvy members of the public can download datasets and run analyses using a range of different statistical software programs. They can also use the online analysis tool provided on the SAMDHA website.

Finding this tool even cooler than swag, I asked the representative to help me run some basic descriptive statistics about Georgia’s alcoholism treatment admissions, drawn from the Treatment Episode Data Set (or TEDS) survey. We clicked through the site to the analysis tool, and clicked again. No data. We tried another year—no luck. Toggling through the site, we discovered that Georgia had not reported its treatment data to SAMHSA since 2006—and that it was the only state to fail to do so.

Wait.. where’s Georgia’s data?

Since 2006, there have been big changes in Georgia’s substance abuse policies. Governor Nathan Deal (a former Democrat who switched parties in 1995) was elected in 2010 and immediately began an overhaul of the substance abuse policies that had driven Georgia’s rate of incarceration, which was among the highest in the nation. While pursuing other austerity measures for the cash-strapped state, Deal recommended over $5 million for the creation of residential substance abuse treatment centers and $10 million to support the creation of new drug courts that would divert offenders from jail and prison. The Obama administration and other media outlets hailed Deal’s enlightened drug policy. But without accessible TEDS data from previous years, it will be more difficult for the public to evaluate the impact of policies designed to increase access to residential addiction treatment or encourage treatment rather than incarceration.

The rapid expansion of addiction treatment and drug courts was accompanied, ironically, with a populist challenge to Georgia’s long-standing Blue Laws. A coalition of libertarians, fiscal conservatives, and unchurched beer enthusiasts passed ballot initiatives allowing Georgia counties to overturn the state-wide ban on Sunday alcohol sales. Of the 128 cities that placed Sunday sales on the November 2011 ballot, 105 approved the referendum. While several extra hours of access might not lead to an increase in individuals seeking alcoholism treatment, the circumstance is exactly the kind of natural experiment that has occupied alcohol policy researchers—and historians—for decades. That is, when they can get the statistics.

Georgia: finally totally red
[Source: Creative Loafing Atlanta]
Scholars will face a challenge in determining whether the new Georgia policies moved population-level treatment data. According to my later correspondence with a SAMDHA representative, the state reportedly “had issues with their data system contractors” which “caused them to have no data in the TEDS database since 2006.” The problem has apparently been solved, and figures will be reported again beginning with 2011. The five years of data from 2006-2010 is probably lost.

I admit, I was disappointed— until it occurred me that the missing survey data makes early twenty-first century Georgia a lot like the vast expanse of alcohol and drugs history. Most of the blockbuster surveys that fall under SAMHSA’s purview today—including studies like the Drug Abuse Warning Network (DAWN) and the National Survey on Drug Use and Health (NSDUH) — didn’t get underway until the 1970s, when federal officials began viewing addiction as a large-scale social problem and promoting the expansion of drug treatment.

The surveys like TEDS and DAWN work a lot like the epidemiological approach to monitoring diseases: hospitals or treatment centers report cases of drug overdose or drug treatment admission up the chain of command. When states report the cases to the federal government, officials are able to analyze particular areas of interest, identify national trends, and coordinate appropriate responses. The research process is far from perfect—there are some lively debates in early National Institute on Drug Abuse publications— but I still view the longevity of surveys like TEDS as evidence of a moment in which government officials sought to align new drug policies like the promotion of treatment with an ambitious national research agenda. The studies continue to be a wonderful resource for historians as well as policymakers.

In the absence of representative national survey data, we synthesize secondary data, estimate, and speculate. Those three useful tools have inspired provocative arguments about the validity of addiction statistics from the Anslinger era, or the hypothesis that national alcohol Prohibition was a short-lived public health success. But the systematic, national, population-based research of the last 40 years helps us say with some confidence that, for example, marijuana is making a comeback among youth or the main source for non-medical prescription drug use is doctors, not dealers. While all surveys have limitations, the insights they provide offer a useful starting point for research questions and plenty of fodder for historical interpretation.

Doctors, not dealers
National Survey on Drug Use and Health (NSDUH) 2011

One scholar summed up the importance of Census data to historians thusly:

“Imagine a history of the Revolutionary era written with Census returns. Imagine a history of the Civil War era written without them.” As an alcohol and drugs historian, you could say that the addiction treatment revival of the 1960s and 1970s is my Civil War, and surveys like TEDS are my Census.

And Georgia? It’s on the wrong side.

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Sobriety is Boring

Playlist for this post:

walking sober

“Sober” (Pink)
“Sober Song” (Noir Desir)
“Clean” (Depeche Mode)
“Straight Time” (Bruce Springsteen)
“Beautiful World” (Colin Hay)
“Vipassana” (Macklemore & Ryan Lewis)
“I’m Straight” (The Modern Lovers)
“One Day at a Time” (Joe Walsh)
“It’s been While” (Staind)
“Good Day” (Paul Westerberg)
“That’s Why I’m Here” (Kenny Chesney)
“Twist in my Sobriety” (Tanita Tikaram)
“Little Rock” (Colin Raye)
“Double A Daddy” (Wayne Hancock)

If my sober friends are any indication, sobriety is neither boring nor thrilling. As far as I can tell, sobriety involves getting up, maybe eating a little breakfast and drinking a cup of coffee, showering, going to work, having lunch, coming home, eating dinner, maybe socializing or watching a bit of television, and going to bed. Repeat with slight variations.  So when I suggest that sobriety is boring, I’m not really talking about how people live their lives sober. That seems to be a crapshoot, as it is for most of us involved with the living of our lives: sometimes boring, sometimes thrilling – or embarrassing, or scary, or annoying or fulfilling. You know, life.Read More »

The Wire at Ten: Sergio Campos, “Lambs to the Slaughter Here”

Editor’s Note: Last week in this space, guest blogger Carlo Rotella positioned The Wire in the history of the televisual crime drama, an evolution in narrative form that he argued reflects changing police practices and attitudes towards crime.  In this week’s installment of “The Wire at Ten,” Points welcomes Sergio Campos, Associate Professor of law at The University of Miami. His current official research focuses on civil procedure and federal courts topics, mostly surrounding the class action.  But his first article was on subordination, and we were able to persuade him to blog for us by promising him he could return to that subject here.

My prior article, while far from perfect, was my attempt to distinguish subordination from discrimination.  In my view, which I still hold, subordination can be understood as the prevalence of a de facto caste system.  I argued that a commitment to ending subordination (an antisubordination principle, for short) should focus not on groups, but on eradicating social positions in which persons are permanently disadvantaged.  That is, if someone is born into a social position which entails an inherent ceiling on their opportunities to live a decent life, then some form of affirmative action is needed to get rid of that position. Accordingly, I argued that while discrimination may cause subordination, subordination may also be caused by other seemingly innocent activity (and vice versa).  Moreover, eradicating subordinated social positions may entail both benefiting and burdening individuals who had nothing to do with creating the subordinated social position.

From Left: Namond, Michael, Randy, Dukie

This sounds incredibly abstract, but I think a good example can be found in fourth season of The Wire, which focused on the Baltimore public school system.  The season opens with four junior high friends, Michael, Namond, Duquan (“Dukie”), and Randy, playing together before starting eighth grade.  We learn that Namond is the son of Wee-Bey Brice, a former enforcer for the Barksdale gang who is incarcerated for multiple drug-related murders in Season 1.  The others have very dicey family situations, with Michael effectively raising himself and his little brother, Randy in a foster home, and Dukie taking care of his drug addict mother.  Dukie has it the hardest, and during the season is teased constantly for his lack of clean clothes, while kindhearted adults try to make sure that he has food and school supplies. The show, in my view intentionally, depicts Namond as the least likable of the four.  Due to his father’s reputation and his drug-related wealth, he is a spoiled brat who talks a big game but can’t back it up.  In contrast, each of the other three children try to cope with impossible situations.Read More »

Booze and Pilots: Flight

Editor’s Note: Our thanks to David Courtwright for offering this take on addiction, sobriety, and flying, sparked by the release of the film Flight

Some movie scenes, like Jack Nicholson smashing through the bathroom door in The Shining, enter popular lore from the moment they appear on the screen. Flight has two such scenes: the crash landing of a packed Boeing 727 and, no less harrowing, its alcoholic pilot contemplating a mini-bar. If you don’t like to fly, don’t see this movie.

Flight rips the scab off an old wound: fear of the intoxicated pilot. Back in aviation’s frontier days, drunken fliers mostly menaced themselves and their stunt men. One young wing-walker, Charles Lindbergh, noted the drinking habits of prospective pilots before he agreed to perform with them. When Lindbergh’s own epochal 1927 transatlantic flight, undertaken with water and ham sandwiches, opened new commercial possibilities for aviation, pilots’ sobriety assumed greater importance. Fear of flying was one of two critical problems, the other being cost, that held back the industry. Some airlines advertised that they hired only abstemious pilots, a claim for which the historical record offers scant support.

Nothing like a jammed elevator to harsh your mellow. Denzel Washington plays Captain Whip Whitman, flying high and staying stoned.

Read More »

Santa Claus, Mushroom Beer, and the Dutch

In my home country, The Netherlands, Santa Claus does not come for Christmas. By then he has already left. Santa Claus comes every year to the Netherlands to celebrate with us his birthday on 6 December. A few weeks before his birthday he sets out from his home in Spain by sea, on a steamer (he has arrived a week ago).  Santa Claus is accompanied by his assistants, the so-called Zwarte Pieten, or ‘Black Petes’. What is rather strange about Zwarte Piet or Black Pete is that his skin actually is black. To some this is offensive. To these people the fact that Santa Claus’ assistant (not himself) is a black person is a racist trait, a legacy from the age of slavery. The first appearance of the modern incarnation of Zwarte Piet in Dutch popular culture seems to date from around 1850, when slavery still existed in the Dutch colonial empire and when black slaves still worked the plantations in Dutch Suriname in the Guianas. Other interpretations seek the origins of Zwarte Piet in a more distant past. Might it already be a surprise to many children and their parents to learn that Zwarte Piet could actually be a Surinamese slave, it might be even more surprising for them to learn that he could be the descendant of a psychoactive plants or mushrooms consuming Germanic warrior.

Santa Claus and his Zwarte Pieten

Relating the Santa Claus traditions to ancient pagan beliefs and rituals is common in literature on psychoactive mushrooms – more in particular, in the literature on the fly agaric mushroom (Amanita muscaria). In this perspective Santa Claus is Odin (Wodan), the Germanic god of ecstasy, warfare and poetry. Some nights he haunts the countryside on his Wild Hunt, with his warriors and his Valkyries, the immortal maiden who inspire the mortal heroes and select them for Valhalla. In ancient and medieval times Odin’s special warriors were the bear- and wolf warriors, the Berserkers and Ulfheonar who would fight naked (that is, without armor) in an uncontrollable and trance-like fury. This trance was, it is maintained, induced by the consumption of psychoactive substances. The fly agaric is routinely mentioned as the most likely candidate for the substance used. This mushroom is also commonly used as a decoration motif in Christmas trees and on Christmas cards.Read More »

Special report: Addiction treatment growing as a financial investment

Editor’s Note: Today, we’re pleased to welcome Alison Knopf, editor of the Alcoholism & Drug Abuse Weeklyas a first-time Points guest blogger.   We’re republishing, with her kind permission, her article on addiction treatment as big business, which first appeared at A&DAW on November 5th, 2012.  Several interesting issues raised in this piece, we thought, will merit further discussion among our readership. 

In September, when Tennessee-based Acadia Healthcare Company paid $90 million for Timberline Knolls, a 122-bed inpatient treatment program in Chicago, treatment providers wondered if their programs were worth that kind of money, bed for bed. Other deals in recent months, including Foundations Recovery Network’s acquisition in early October by Nick Pritzker Capital Management for an undisclosed amount, point to the possibility that addiction treatment — at least in the commercial (non-Medicaid, nonpublic) sector — is a profitable enterprise. For this story, ADAW talked to some of the most influential leaders of the addiction treatment field in the private for-profit sector.

In early September, Michael Cartwright, founder and former CEO of Foundations, and Jerrod Menz of Forterus, which in 2008 began investing in addiction treatment programs (see ADAW, October 20, 2008), joined with Treatment Solutions to form American Addiction Centers, which announced that it would provide “a comprehensive and cutting-edge suite of treatment-related services to the masses.” Forterus’ main treatment program is A Better Tomorrow.

Cartwright, who started his career as an inner-city case worker making $16,000 a year and is now on his fourth addiction treatment company, said that the treatment business is not ready for the stock market. “Forterus went public, and that was a mistake,” he told ADAW. But it is ready for private equity, or for just personal investment, he said.

Cartwright thinks addiction treatment is a good investment — for commercially insured patients — because 3.5 million people a year go to treatment, there have been no rate decreases and the average length of stay is consistent.

Cartwright’s first company was a not-for-profit. His second was a managed care company that he sold to the employees. The third was a privately held company that he sold to private equity — Foundations. And his fourth — American Addiction Centers — now has operations in six states and a healthy revenue stream, he said. But it is not ready for an initial public offering, which he said requires $100 million, and which most addiction treatment providers — with the exception of CRC Health Group — don’t have.Read More »

The Wire at Ten: Carlo Rotella, “The Case Against ‘Kojak Liberalism'”

Editor’s Note: The first guest blogger in our series “The Wire at Ten” is Carlo Rotella, noted scholar, public intellectual, playground point guard, and, not incidentally, Director of American Studies at Boston College.  (Full disclosure: he was a couple years ahead of me in graduate school.) A regular contributor to the New York Times Magazine and an op-ed columnist for the Boston Globe, his latest book, published this fall, is Playing in Time:  Essays, Profiles, and Other True Stories.  “The Case Against Kojak Liberalism” is excerpted from his piece of the same name in the University of Michigan Press collection The Wire:  Race, Class, and Genre, edited by Liam Kennedy and Stephen Shapiro (2012).  Unlike last week’s commentator Joe Spillane, Carlo has actually watched The Wire.

Carter: “Wars End”

In his commentary on the DVD version of episode one of the first season of The Wire, David Simon notes that it was Ed Burns who wrote Detective Carver’s line about why the war on drugs isn’t really a war:  “Wars end.”  Simon says that Burns is “entitled” to have written it after having fought in two losing wars, first as a soldier in Vietnam and then as a police officer in the war on drugs.  The collapsing New Deal order spent much of its remaining force in these pyrrhic struggles.  When I talked to some of the creators of the show in 2008, they were explicit about their interest in this historical and political big picture against which they set The Wire’s action.

When I asked Burns about the war on drugs he pointed out that Kurt Schmoke, the former mayor of Baltimore who turns up on The Wire in a minor role as a health commissioner, was “crucified for questioning the war on drugs.”  Burns told me, “People are fed up with it.  We wanted to make it permissible to talk about that.  The police have become an army of occupation.”  Simon added, “We wanted to highlight the fact that the drug war is actually destructive to law enforcement.”

For Dennis Lehane, the chance to address the big picture in politically “simpatico” company—which also included the novelists George Pelecanos and Richard Price—was part of the attraction of writing for The Wire.  “I felt that a lot of 80s crime fiction was shit and it wasn’t about anything,” he told me.  “It was, ‘Let’s have nine serial killers.’  I felt it has to be about something, some kind of social document.  If there was a place where we all agreed, it was that the war on drugs was a farce, a de facto war on the poor that drove our incarceration rate through the roof.”  In formulating their response to this disaster, the writers wished to steer clear of both the conventional anti-crime right and what they regarded as a weak, unappealing left.  “I’m not a kneejerk liberal,” Lehane said.  “I grew up in Boston under busing.  We’re not Kojak liberals, and we’re not kneejerk liberals.”

Whatever kind of liberals they were, they were also professional tellers of crime stories.  I want to outline how those two elements, an ideological disposition and a craft expertise in genre fiction, came together in The Wire.  In the last third of the twentieth century, the war on crime and its subsidiary war on drugs claimed so much ideological real estate that it pushed dissenters to a margin occupied by bleeding hearts, stoners, libertarian cranks, and hairsplitting lawyers for the defense like The Wire’s own Maurice Levy.  Urban liberals, especially, were squeezed into a tight corner by compulsory universal conscription in the war on crime.Read More »

Medieval Drugs III: How Do I Drug Thee? Let Me Count the Ways.

This is my third and final post about medieval drugs. A big “thanks” to Joe Gabriel for recommending Points to me and to Trysh Travis for giving me a soapbox for sharing some of my interests and original research with the Points community!

Among the favorite stock images of modern medicine are the scientifically dosed drug, measured in identical pills or graduated syringes, and the thermometer. While both are modern inventions, the hypodermic syringe and thermometer reflect a tendency, shared by later medieval Islamic and European physicians, to quantify drugs, their qualities, and medicinal actions. The tendency to quantify drugs, common by the end of the Middle Ages, is the third stage in the process I proposed in my first post, by which herbal medicines were transformed into “drugs” by physicians, pharmacists, and patients who began to look at their medicines in new ways. That transformation took a number of forms and for a variety of reasons, which I’ve grouped under the themes of individualism, exoticism, and scholasticism in these three posts.

The accurate measurement of drugs, in terms of both their strength and quantity, is central to modern medicine, and began in the High Medieval universities.

By “scholasticism” I mean the intellctual processes of subjecting pharmaceutical remedies to the philosophy and science taught in the schools and universities, especially mathematics and Aristotelian physics. Universities were an invention of the High Middle Ages, a way of organizing the already present schoolmasters and students into corporations with more effective legal, economic, academic, and even spiritual powers. By about 1225 the cities of Paris, Oxford, Cambridge, Bologna, Padua, Salamanca, and Montpellier all had thriving universities. These universities provided the social and economic foundations for novel thinking about matter and physics in general, and about drugs in particular.

One of the most important developments in the medieval university, and one with a direct impact on modern science and medicine, was the practice of applying mathematics to non-spatial concepts, like heat or speed. Before the universities, these concepts could only be measured qualitatively (that pot is hotter, that horse is faster), and not quantitatively. Since Aristotle had considered quantity and quality different categories of definition, and not to be mixed, it took a huge mental leap for mental scholars to make the connection as step out of Aristotle’s shadow. If you want to quantify speed or heat, you need to develop the idea of velocity or temperature, respectively. This may sound downright modern and “scientific”, but medieval physicists took the idea of quantification and ran with it. Masters in Oxford, especially, tried to quantify non-spatial concepts that have no place in modern science: one tried to measure doubt on a sliding scale, another to measure the amount of charity in a man, and another even the amount of Christ in the Eucharistic host (yes, these are all real).

The “modernity” of medicine is often depicted by quantification, as in dosage, or body temperature.

These are extreme examples, but they’re indicative of a broad trend in Western society outlined by Alfred W. Crosby in his book The Measure of Reality. He identifies quantification as one of the most important changes in Europe in the period 1250-1600. He doesn’t really touch on medicine, but quantification changed that field as well. In this context, it’s hardly surprising that scholars of pharmacy would also want to measure exactly the amount of hot, cold, wet, or dry (Aristotle’s four elemental qualities) in a medicinal substance. Read More »

LSE IDEAS: The Global Drug Wars

Read All About It

Recently, the LSE IDEAS program hosted a daytime conference, “Reevaluating the International Drug Control System–Historical Evolution; Potential for Reform,” along with an evening event, “The Global Drug Wars.”  Both events are worth sharing with the readers of Points.

LSE IDEAS is housed within the London School of Economics, and focuses on international affairs.  The ambition is one that readers of Points might appreciate: “understanding how today’s world came into being, and how it may be changed.”  That was certainly the animating spirit behind the daytime conference, very ably organized by LSE doctoral candidate John Collins.  If you aren’t yet familiar with John and his work, you will be, and you might get a head start on getting acquainted here.  Associated with the daytime conference is a report, Governing the Global Drug Wars, which may be read in its entirety online.  What I like about the report is that it brings together some very able historical commentary with some equally solid commentary on contemporary policy regimes.  I wish, of course, that these were more directly in conversation with one another, but reading them side-by-side produces something close.

The evening event was moderated by LSE IDEAS founding Co-Director, Mick Cox, and featured four presenters: Bill McAllister, David Courtwright, Ethan Nadelmann, and Nigel Inkster.  You can view the entire event online.  First up, McAllister, an outstanding historian of international drug control and special projects director in the State Department’s Office of the Historian.  McAllister gave a remarkably useful guide to the historical nuts and bolts of the international control system, and if you pay close attention at the end, he offers some really useful insights into the prospects for future change within the system.  Second up, Courtwright took the assembled audience on a colorful yet efficient tour of global drugs and alcohol history, sorting out the still-essential question of why we make war on some drugs but not on others.Read More »

Points Forward: Kevin Kaufmann, “‘Rigorous Honesty’: A Cultural History of Alcoholics Anonymous, 1930-1960”

Editor’s Note: Today “Points Forward,” our recurring feature showcasing recent dissertations in alcohol and drugs history, welcomes Kevin Kaufmann, who recently completed “‘Rigorous Honesty’: A Cultural History of Alcoholics Anonymous, 1930-1960” in the History Department of Loyola University, Chicago, under the direction of Lewis Erenberg.  Dr. Kaufmann is currently a Pre-Health Advisor at Loyola University; when away from his academic life he blogs about random things and the Chicago White Sox.

1) Nothing’s more popular right now than taking potshots at over-specialized, overstuffed, jargon-y academics.  Prove the haters wrong by describing your dissertation in terms that the average man in the street could understand.
My dissertation focuses on the early roots and early history of Alcoholics Anonymous, specifically from ca. 1840-1960.  It begins with an examination of how the temperance movement of the nineteenth century and the prohibition movement of the early twentieth century informed the creation of AA, especially what themes, images and cultural touchstones were used by the group that resonated with its earliest members.

The next major component is a discussion of how 1930s Great Depression culture, when AA was founded, influenced the early design of the program and finally how Alcoholics Anonymous changed through the mid part of the century to meet the new realities of wartime and post-war America.

Creating a Demand for Coffee that AA Would Later Meet

2)      It’s the rare graduate student who heads off for a phd thinking, “I’m going to write about drugs in my dissertation!”  How would you describe the genesis of your project relative to your coursework, your advisor’s work, the state of your discipline, etc.? 
I can genuinely say that I had an eureka moment when it came to my topic for the dissertation.  I was working on folk music in Chicago with every intention of writing my dissertation on the urban folk scene from 1945-present.  I hadn’t formally done anything with it, mostly just seminar papers and the like.  I was reading for my comprehensive exams and came across the work of Warren Susman, and it had a profound effect on me.  I was taking a shower and thinking about his article on the culture of the 1930s (sad that this is the kind of thing I think about in the shower, I know) and what he was describing, at least to me, was very much a description of AA.  Basically Susman went against the conventional wisdom of the 1930s as a decade of radicalism but more a turn toward a traditional view of the United States.  He primarily focused on the renewed interest in folk art and music and the work of Norman Rockwell.  Part of this idea of traditionalism in America was the need for Americans to feel like they were not alone, that they needed to belong to something, be with others.  I particularly gravitated toward that notion with regards to AA.  I literally got out of the shower sat at the computer in a towel and wrote the first draft of my dissertation proposal.Read More »