Psychoactive substances and the political ecology of mental distress

16 Pages·2012·2.13 MB·English

by  Sunil K Aggarwal

Psychoactive substances and the political ecology
of mental distress
Aggarwal et al.
Aggarwaletal.HarmReductionJournal2012,9:4
http://www.harmreductionjournal.com/content/9/1/4(18January2012)
Aggarwaletal.HarmReductionJournal2012,9:4
http://www.harmreductionjournal.com/content/9/1/4
REVIEW Open Access
Psychoactive substances and the political ecology
of mental distress
Sunil K Aggarwal1*, Gregory T Carter2, Craig Zumbrunnen3, Richard Morrill3, Mark Sullivan4,5 and
Jonathan D Mayer6,7,8,9,10
Abstract
The goal of this paper is to both understand and depathologize clinically significant mental distress related to
criminalized contact with psychoactive biotic substances by employing a framework known as critical political
ecology of health and disease from the subdiscipline of medical geography. The political ecology of disease
framework joins disease ecology with the power-calculus of political economy and calls for situating health-related
phenomena in their broad social and economic context, demonstrating how large-scale global processes are at
work at the local level, and giving due attention to historical analysis in understanding the relevant human-
environment relations. Critical approaches to the political ecology of health and disease have the potential to
incorporate ever-broadening social, political, economic, and cultural factors to challenge traditional causes,
definitions, and sociomedical understandings of disease. Inspired by the patient-centered medical diagnosis
critiques in medical geography, this paper will use a critical political ecology of disease approach to challenge
certain prevailing sociomedical interpretations of disease, or more specifically, mental disorder, found in the field of
substance abuse diagnostics and the related American punitive public policy regimes of substance abuse
prevention and control, with regards to the use of biotic substances. It will do this by first critically interrogating
the concept of “substances” and grounding them in an ecological context, reviewing the history of both the
development of modern substance control laws and modern substance abuse diagnostics, and understanding the
biogeographic dimensions of such approaches. It closes with proposing a non-criminalizing public health approach
for regulating human close contact with psychoactive substances using the example of cannabis use.
Giving ‘Substances’ substance and place conflated due to a variety of cultural-historical reasons
‘Substance’ is a shorthand term used in common par- suchasscapegoating,xenophobia,and‘culturewars’over
lance for ‘psychoactive substance’, a pharmacologically the years,which an extensive literature has documented
active, consumable material, usually self-administered, (see, for example:[1-3]). Nosology and diagnostics for
that canreliablyhave,among other physiological effects, substance-related mental disorders developed in health
a discernible impact on one’s mood, emotions, feelings, professional social circles and codified in standard psy-
sensations,perceptions,and/orthinking.Forthelastcen- chiatry manuals have similarly shifted over time, with
tury,consumptionofaselectgroupofpsychoactivesub- earnest attempts made in recent years at their summary
stances has been a matter of pressing political concern de-politicizationbymentalhealthprofessionalsand‘dru-
formodernStatebureaucracies,andinthattimeallman- gabuseologists’. But notwithstanding these efforts at
ner of popular conceptions concerning substance use, putative ‘scientific sanitization’, this paper argues that
abuse,dependence,andaddictionhavehadampleoppor- long-hardenedcommitmentstothenormalizedideology
tunity to be race-baited, red-baited, even gay-baited, of pharmacologicalism, eloquently described by
chauvinistically slanted, politicized, inflated, and DeGrandpre [4]asproviding“ascientific foundation for
the moral ordering of drugs” (p. 27), as in the good vs.
bad/angel vs. demon/legal vs. illegal psychoactive sub-
*Correspondence:[email protected]
1DepartmentofPhysicalMedicineandRehabilitation,NewYorkUniversity, stancedichotomiesenshrinedinhigh-levelpublicpolicy,
RuskInstituteofRehabilitationMedicine,400E34thSt,NewYork,NY10016 have uncritically been allowed to take root in medical
USA
diagnosticscreeningcriteriaforsubstance-relatedmental
Fulllistofauthorinformationisavailableattheendofthearticle
©2012Aggarwaletal;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative
CommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and
reproductioninanymedium,providedtheoriginalworkisproperlycited.
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disorders.Underthecurrentofficialdiagnosticnosology, inner cities. While most studies of morbidity, morality,
codifiedin the internationally used fourthedition ofthe andsocialcostwillexaminesocialfactorssuchaspoverty,
AmericanPsychiatricAssociation’sDiagnosticandStatis- deprivation, and glamour surrounding problematic use
ticalManualforMentalDisorders(DSM-IV)[5],whena andlocaldistributionofthesubstance,rarely,ifever,will
personengagesinapatternofsubstanceusethatleadsto a study trace the crack-cocaine used by subjects to the
mentaldistressasmanifestedby theirrecurrentoryear- thousands of pounds of coca leaves which were planted,
long persisting substance possession-related legal pro- grown,andharvestedfromwhichthecocainealkaloidwas
blems,thatperson’ssubstanceuseisseenasmaladaptive, extracted and later reacted with baking soda (sodium
issummarily labeledpathologically self-abusive, and the bicarbonate) and heat to produce crack ‘rocks’ that
individual is judged to be mentally disordered. While a ‘appear’ in glass vials in the inner city for consumption.
fifthedition ofDSM(DSM-V)isin the workswhichhas Nor will such studies earnestly question the normalized
proposed removal of diagnostic consideration of such contrabandstatus ofthe coca leafbotanicalandtheche-
legal problems, it is still undergoing revisions and not micals extracted from it, and what impacts that contra-
dueforpublicationuntilMay2013[6]. bandstatushasonthechainofeventslinkingproblematic
Onemaypausehereandask:whatdoesanyofthistalk consumption of the substance in an urban inner city in
abouttheuseofpsychoactivesubstanceshavetodowith theUnitedStatesto,forexample,cultivationpracticesina
a politics of the environment? Why address substance NorthernPeruvianruralvillage.
abusediagnosticquestionswithapoliticalecologyframe- Understandably, the contraband status of such botani-
work?Shouldthisnotbelefttocriticalculturalstudiesof calslimitsdepthof inquiry.However,the problem could
mental illness and psychiatry? That such questionseven also be one of obfuscating terminology. While humans
bubble to the surface is indicative of how successful the havelivedandevolvedwithinaworldcomposedofmate-
socialmystificationsthathavearisenaroundpsychoactive rial substance (andenergy),psychoactive portionsofthis
substanceusehavebeeninobscuring itsbasisinhuman substance have come to be known, with no effort at
relationships with the natural environment. Though semiotic clarity, simply as ‘substances’. For the sake of
often overlooked, many of the contested psychoactive rational grounding, let us divide these into biotic sub-
substancesincurrencytoday(e.g.,opium,coca,andcan- stances and abiotic substances. Biotic psychoactive sub-
nabis) are botanicals found in the natural environment stances are naturally occurring organisms that are an
thatevolvedtensofmillionsofyearsago.Verybasicand integralpart ofthebiosphere and web of lifeinthesame
well-definedhuman-environmentrelationshipsunderpin sense that any other terrestrially-evolved organisms are.
the discovery,production,andconsumptionofallbiotic Theyhaveuniquesecondarymetabolitebiochemicalpro-
psychoactive substances. Ultimately, it is argued here, filesthatsetthemapartfromotherbiotainthattheycon-
addressing questions abouthumanadaptation (ormala- tainchemicalsthatcanrobustlyinteractwithendogenous
daptation) to psychoactive substance-replete natural systems ofmoodregulation, pleasure, muscle relaxation,
environments, both at the societal and individual levels, and brain reward (among others) in humans and often-
iscentralforanyclearheaded,scientificunderstandingof times otheranimals. They are thefocusofthispaper.As
agivenindividual’ssubstanceusepatternsandattendant farastheabioticsubstancesareconcerned,some,butnot
mentaldistressthatmaybemanifested,inordertojudge all of them, are unmodified or slightly modified concen-
whetherthatdistresshasafirmbasisinpsychopathology trates of chemicals that were naturally biosynthesized in
ornot. The critical political ecology of disease approach biotic substances. Others are novel products of the syn-
isasuitablelenstousetoaddressthisquestion.Applying theticage.
therubrictosuchissuesisnotwithoutprecedent,asone
veteranpoliticalecologist, PaulRobbins,hascalledfora A political ecology of mental distress
“political ecology of the drug trade” [7](p. 215), the Across cultures and throughout history and pre-history
beginnings of which have been sketched by Steinberg [10], human beings have known about biotic organisms
etal.[8,9]. livingintheirnaturalenvironmentsthat,whenintention-
Bioticsubstances usage can quite literally be grounded allyingestedinwholeorinpart,could“stimulate,sedate,
inpreciseandparticularlocales,yettheprevailingconcep- [palliate,] or elate” [11](p. 356). In the modern era, an
tions ofsubstance use are anything-butgrounded. It is a arbitrary subgrouping of these living organisms, be they
marvelthatpracticalscholarship,tosaynothingofpolicy, plants or fungi, along with the unique chemicals they
regardingawholeclassofhuman-biotaconsumptiverela- produce and their related congeners, have become the
tionsremainstothisdaytobewhollydivorcedfromcon- locusofintensemedical,publichealth,andinternational
siderations of environmental ethics, co-evolution, and lawenforcementfocus.Today many whousebioticsub-
ecology. Take for example academic studies on proble- stances are vigorously pursued by law enforcement and
matic crack-cocaine consumption in American urban punishedby criminaljusticesystemsusingmethodsand
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tactics that increasingly undermine human dignity. For clinical scenarios who might benefit from the medicinal
example, in the United States, the penalty for cannabis useofcontrabandbiotawithpotentialtherapeuticutility,
possessioncan beassevere asone yearin federalprison suchascannabis,andfeltthe frustration ofbeing unable
forpossessionofanyamountofmarijuana,anduptofive toofferortrythesetherapeuticoptionsdueto theillegal
years in federal prison for growing one marijuana plant status of these substances. He has met people who were
[12]. The death penalty is routinely used abroad and facingorhavefacedlifesentencesfortheircannabisculti-
available to prosecutors in some cases in the US, multi- vationpractices–evenwhenthatcannabiswasbeingused
decadalmandatoryprisonsentencesareroutinelymeted formedical purposes. He hasmet others who have faced
outtodrugoffenders,andotherviolationsofdrugoffen- grave legal consequences and attendant distress such as
ders’ privacy and family integrity are normalized. This, lengthyincarceration oritsthreatrelatedtotheirposses-
understandably, produces significant mental distress for sion and consumption of other biotic psychoactive sub-
thoseinvolvedwiththesecontrabandbioticsubstances. stances, such as Psilocybe fungi. This author is also
The ultimate stated purpose of the entire medico-legal familiarwithmany other cases thathe has read about or
apparatus positioned against these substances derives its learnedaboutfromtrustedsources.Insharprelieftothis,
final justification from a claim to act towards the ‘pre- he has also met people who have complete amnesty and
vention and control’ of ‘substance abuse’ by individuals. sanctuary from prosecution related to their contraband
A critical political ecology of disease perspective can biota consumption or production practices. He has met
shed light on the origins of substance use mental dis- the grower who produces cannabis for the UnitedStates
tress as manifested by biota possession legal problems federal government and who holds the patent on single-
and help address the central question: must this mental cannabinoid medicine marketed as a legal alternative to
distress necessarily be viewed as a pathological sign of a contrabandcannabinoidbotanicals.Hehasmetthreeout
maladaptive substance use pattern? After all, consump- offouroftheillanddisabledAmericanpatientswho,asa
tion, possession, or close proximity to biotic substances resultofalandmarklawsuit,aresuppliedcannabistocon-
are all instantiations of particular human-environment sumebythefederalgovernmentbecausetheirphysicians
relationships of close contact which, for now, are crimi- attestedtoitsprofoundtherapeuticvalueforthem,andhe
nalized. When the latter fact is made manifest in one’s has also met chronically ill patients in Canada who have
life through encounters with some form of law enforce- been granted amnesty by the Canadian government to
ment, it is understandably mentally distressing consider- produceandconsumecannabis.Finally,hehasmetindivi-
ing the harsh punitive consequences that are allowed by dualsinvariouscafesinVancouver,BritishColumbiaand
law and routinely meted out. Amsterdam,Hollandwhoenjoyrelativefreedominpublic
Onapersonalnote,thefirstauthorcanattesttotherea- spacesthatgrantthemasanctuaryforcannabisandPsilo-
lity of this mental distress, as he has personally experi- cybe fungi consumption. The existence of such widely
enced the mental distress of potential contraband biota divergentscenariosofamnestyandterrorhelpstounder-
possession-relatedlegalproblemsandhasbeenatargetof scorethecriticalroletheenvironmentplaysinproducing
a harassment episode where the threat of exposing his or preventing mental distress related to contraband psy-
pastconsumptionpracticestolawenforcementandother choactivebiotaconsumption.
authority figures was used to terrorize him. This author Applyingapoliticalecologyofmentaldistressapproach
has feared arrest, losing funding, being disqualified for can helptounderstandhowindividualsandgroupsreact
professionallicensure,beingexpelledfromcollegiateand tosuchenvironments.Theclashbetweenlocalizedunder-
professionaltrainingschools,andhasfearedforhisloved standings of particular human-environment interactions
onesbeingcaughtinharm’swayforhisactions.Giventhe and medical and public policy interpretations of those
extensiveuseofinformantsindruglawenforcement,not same interactions creates stressful conditions to which
knowing whom or how much to trust someone has also individuals and groups adapt. The modern concept of
beenasourceofmentaldistressforhim.Thisauthorhas human adaptationhas itsroots inthe cultural ecological
alsopersonallymetindividualswhowerehuntedandcap- workofthemid-1950sspearheadedbyJulianSteward,stu-
tured by lawenforcement officialsat local, county, state, dent of the renowned anthropologist Alfred Kroeber
andfederallevelsfortheircontrabandbiota-relatedactiv- [13,14]. The geographer Bennett [15] in his book on the
ities. Hehasmet peoplelivingwithseriousillnesses(e.g., inhabitantsoftheGreatPlainsofNorthAmerica, helped
rheumatoidarthritis,failed-backsurgerysyndromes,can- to bring the human adaptation concept into geography.
cers, chronic pain) who have literally been terrorized, Heoffersvaluableinsighttothenatureandtypeofadapta-
whose bodies have been tortured when incarcerated or tion patterns that individuals and groups practice when
pulledfromorgantransplantationlists,orforciblydenied responding to problems and stressors. He sees adaptive
accesstotherapeuticandpalliativecannabisconsumption behaviorsascopingmechanismsthat takeamultitudeof
orothermedicaltreatment.Hehasmetmanypatientsin forms including “problem-solving, decision-making,
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consuming and not consuming, inventing, innovating, raiding...exactionsoftributeandtaxes...oractsofreligious
migrating, staying”(p. 11). Todefineormeasureadapta- persecution” (p.294). Those affected by the psychoactive
tion,Bennettsuggestslookingintermsofgoal-satisfaction substance prohibitions under a policy commonly known
and resource conservation (p. 13). He insists on making asthe‘warondrugs’,variouslyreferredtobyitsdetractors
theveryusefuldistinctionbetweenadaptivestrategiesand as‘thepharmacraticinquisition’or‘psychopharmacologi-
adaptiveprocesses.Adaptivestrategiespertainto“thepat- cal Calvinism’ [19-22], do certainly perceive their life
ternformedbythemanyseparateadjustmentsthatpeople hazardswithtermssuchaspredations,raiding,andperse-
devise in order to obtain and use resources and solve cution. These hazards form the backbone of the adapta-
immediate problems” and are generally conscious deci- tionpressurestoconsiderinapoliticalecologyofmental
sions. Adaptiveprocessespertainto “changesintroduced distressatfacingpossession-relatedlegalproblems.
overrelativelylongperiodsoftimebytherepeateduseof
such strategies or the making of many adjustments” and Substance-related disorders diagnostics and
usuallycanbeseenonlybyoutsideobservers(p.14).The possession-related legal problems
studyofhumanadaptationpatternsisasignificantpartof The‘substance’nomenclaturewasfirstwidelypopularized
work in human geography and has been examined in asaresult ofsweeping, comprehensive, andinternational
diversecontexts,fromnaturalhazardsandthreatstosub- template-settingUnitedStatesfederallegislationpassedby
alternstudiesofpeasantresistancestrategies. theCongressin1970andstillineffecttoday.Thislegisla-
Giventheuniversal,embodiedhumanexperienceofdis- tion, known as the Controlled Substances Act, created a
tress and threat, it shouldbe no surprise that adaptation chapterunderTitle21“FOODANDDRUGS”ofthefed-
tovarioustypesofenvironmentally-induceddistressmay eralcode:“CHAPTER13-DRUGABUSEPREVENTION
take similarforms.Mitchell[16], inareview on the geo- AND CONTROL.” Note the clear and explicit language
graphic study of natural hazards, states as much: “the thatidentifiesthisasapublichealth-styleddisease“preven-
insightsofnaturalhazardresearchmayaidindeveloping tion and control”regulatoryschema.Under this policy, a
generaltheoriesofman-environmentrelations.Thepossi- system of five ‘Controlled Substance’ Schedules was cre-
bility exists that models of human response to environ- ated.InmovingfromScheduleVtoScheduleI,increasing
mentalthreatmayalsofunctionasanalogsforresearchon degreesofcriminalprohibitionapply,withScheduleI‘sub-
man’sadjustmenttomorepervasiveformsofsocialstress” stances’fallingforallpracticalpurposesintothecategory
(p. 312). Medical geographer Mayer [17] also recognizes oftotalprohibition(withexemptionsgrantedforextremely
the relevance of socially stressful stimuli for a political limited medico-scientific research, religious use, and
ecologyofdiseaseframework:“itisimportantinthecon- ‘instruction’).SubstancesinSchedulesV,IV,III,andIIare
textofpoliticalecologytoascertainthecauses,bothinten- allowed for progressively restricted medical use and
tional and unintentional, of social isolation and research but are otherwise prohibited. According to the
marginalization”(p.451).It isadditionally equally impor- regulations, Schedules I and II apply when “The drug or
tant toascertainthe responsesandadaptationsof indivi- othersubstancehasahighpotentialforabuse.”Bioticpsy-
dualsandgroupstoconditionsthatproducethesesortsof choactive substances appear only in Schedules I and II.
socialstress. They either appear directly by name (e.g., “Marihuana”,
Literature in ecological anthropology, such as work by “Peyote”, “Opium poppy”), or by implied identification
Vayda and McCay [18], has made significant headway in withauniquesecondarymetabolitemadebytheorganism
showinghowthecategoryofhazardscansubsume“social (e.g., “Psilocybin” referring to a metabolite made by 186
and psychological insults” such as mental distress which speciesofPsilocybefungi).Onanofficialgovernmentweb-
producedemonstrable“psychologicalandbehavioradap- site,thenameoftheorganismthatproducesthescheduled
tations strategies.” In their review of work in this area, metaboliteislistedalongsidethechemicalname[23].To
they write broadly about the nature of various hazards giveanideaofsize,currently132substancesarelisted in
thatfaceorganismsandgroupsandtheirresponses.They Schedule I, 62 in Schedule II, 31 in Schedule III; 70 in
areparticularlyconcernedwiththosehazardsthatleadto Schedule IV; and 10 inSchedule V–305‘controlled’ sub-
“the risk of losing an‘ existential game’ in which success stance in all [24]. These can be referred to as the ‘Con-
consistssimplyinstayinginthegame”(p.293).Thisaptly trolled 305’. In this vast controlled substance-scape, the
describes the hazards faced by those who produce and focusofthispaperisinonbioticpsychoactivesubstances,
consumeorotherwisecomeintoclosecontactwith con- whichhaveafarmoreextensivehistoryofhumanuseand
trabandbiota,suchascannabisandotherforbiddenbiotic are far more easily studied with a political ecology lens
substances. Indeed, Vayda and McCay see the notion of comparedtoabioticones(thoughthetwoaresurelyinter-
‘hazards’ to encompass not only “extreme geophysical connected). The number ofdistinctbiological organisms
eventssuchasfloods,frosts,droughts,hurricanes,andtor- representedinthe‘Controlled305’probablynumberinthe
nadoes” but also “predation by warfare, plundering or lowhundreds(withpsilocybin-,dimethyltryptamine-,and
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related tryptamine-containing organisms making up the extensive process yet of reworking the Substance Use
vastmajority[25,19].Itisworthnotingthatseveralofthe mentaldisorderssectionbegan.Thisreworkingwascom-
305 substances appearendogenously in the humanbody, pleted 6 years later with the release of the DSM-IV in
suchasdimethyltryptamine[26]andmorphine[27].Ifone 1994. With regards toSubstance Usedisorders,themost
is charged for this internal possession of controlled sub- significantchangeintheDSM-IVwasthespecificdefini-
stances or worried about it, perhaps one can mount the tionandclearenumerationoffourfree-standing,pathog-
defense of ‘guilt by association’! All absurdities aside, the nomonic diagnostic criteria for Substance Abuse mental
finaldownstreamtargetofthisentireenforcementschema disorder, as distinguished from Substance Dependence
hastodowithparticularsituationsinwhichhumanbodies mentaldisorder[29].
make close contact with one of these politicized plants, Steppingbackforamoment, itappearsthatinthehis-
fungi,orchemicals,andtheensuingembodiedexperiences toryofSubstanceAbusenosology,therewasatimeinhis-
that follow as a result of the body’s absorption of active tory whenthe psychopathological category of ‘Substance
chemicals into its bloodstream. Given this context, do Abuse’itselfwasonthechoppingblock,justbarelyescap-
theseconsumptive experiencesamountto‘drug’ or‘Sub- ing deletion during the period between the DSM-IIIand
stance’Abuse? DSM-III-R. Schuckit [29] and Helzer [30], respectively,
InthecurrentfourtheditionoftheAmericanPsychiatric writingintheDSM-IVSourcebook,relaythefollowingbits
Association’sDSM(DiagnosticandStatisticalManualfor ofpsychiatriclore:
Mental Disorders) [5], Substance-Related Disorders are
divided into two groups: the Substance Use Disorders The change between DSM-III and DSM-III-R repre-
(Substance Dependence and Substance Abuse) and the sentedanentirereorientationintheconceptofabuse
Substance-Induced Disorders (Substance Intoxication, anddependence...thetermdependencewasbroadened
SubstanceWithdrawal,Substance-InducedDelirium,Sub- considerably.Asaconsequence,theframersofDSM-
stance-Induced Persisting Dementia, Substance-Induced III-R originally proposed to delete the concept of
PersistingAmnesticDisorder,Substance-InducedPsycho- abuse, feeling that the entire spectrum of substance-
tic Disorder, Substance-Induced Mood Disorder, Sub- relatedproblemswasnowincorporatedintothebroad
stance-Induced Anxiety Disorder, Substance-Induced concept of dependence. At the last minute, however,
Sexual Dysfunction,andSubstance-InducedSleepDisor- pressure from the field required that the term abuse
der). Of these, the mental disorders that will be focused be reinserted into the manual. However, abuse was
onherearetheSubstance Use Disorders,especiallySub- now viewed as a residual diagnosis that was to be
stance Abuse but also to some extent Substance Depen- applied only to individuals who still had some sub-
dence.SubstanceIntoxicationdisorders,whichalsomerit stance-relateddifficultiesbutwhodidnotfitintoeven
attention, will not be addressed here due to space abroadapproachtodependence[29](p.7)
constraints. ...
TobeginabriefmodernhistoryofthenosologyofSub- In a personal communication to the Substance Use
stanceAbuse,onemuststartin1952,withthepublication Disorders Committee, Richard Frances recalled that
of the original DSM. There, Substance Abuse or drug there was an attempt to drop the term abuse in the
abusewaslistedasaSociopathicPersonalityDisturbance– DSM-III-R criteria, but that it wasreinstituted at the
the same category that homosexuality was placed in timeofthefieldtrialsbythepopulardemandofthose
(whichwasfinallyremovedin1973butits“treatment”not attempting to use the new DSM-III-R criteria. [30]
fully repudiated until 1998 [28]. Both the DSM-I and (p.25)
DSM-IIwerevirtuallyidentical to theICD(International
ClassificationofDisease)nosologydevelopedbytheWHO Whomighthavebeenthemostvocalopponentsofthe
(World Health Organization). The DSM-III, released in Substance Use Disorders Committee’s planned deletion
1980, was a significant break from this; it incorporated –the ‘squeakiest’ wheels? It is unclear. Nevertheless, this
approaches that were developed by researchers at category of mental disorder known as ‘substance abuse’
Washington University School of Medicine during the has persisted, notwithstanding how ever so tenuously it
1970’s. It introduced the multiaxial system of diagnostic survived near-deletion or protestations about the essen-
evaluation.Inthisschema,SubstanceAbuse,asaclassof tially pejorative nature of the diagnosis recorded in the
SubstanceUsementaldisorders,wasclassifiedunderAxis American Journal of Psychiatry [31,32]. The question
I, which was reserved for syndromes such as depression remains:howtogoaboutcharacterizingit?Adefinitionof
and schizophrenia. For the first time, DSM-III classified substanceabuseemergedbyconsensuswhenthequestion
Substance Use mental disorders in a separate diagnostic was posed to a panel of 99 substance abuse experts by
categorydistinctfromthepersonalitydisorders.DSM-III- Rinaldiandcolleagues[33].UsingthisDelphicapproach,
R (revised) was released in 1987, and in 1988, the most theexpertpanelconcludedthat‘drugabuse’is“anyuseof
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drugsthatcausesphysical,psychological,economic,legal, persondrivesorbuys.Behavioralfrequencycutoffsare
orsocialharmtotheindividualuserortoothersaffected notsufficientlyclear regarding‘legal’or‘driving’pro-
by the drug user’s behavior” (quoted in [30](p.24)). The blems with marijuana to allow consistent clinical
currentDSM-IV-TR(2000,TR=“TextRevision”)defini- agreement that a ‘recurrent’ ‘maladaptive’ pattern
tionofsubstanceabuse,withitsfourfree-standingcriteria exists.(p.622)
of distress or impairment manifestations accompanying
substance use patterns–shirking of work/school obliga- Another commentator, Earleywine, a well-known aca-
tions,engaginginphysicallyhazardousbehavior,recurring demic psychologist who studies cannabis-related issues,
substance-relatedlegal problems, and social/familial dis- writesinaresponseletterquestioningtheconclusionsofa
putes–isessentiallybasedonthepanel’sconsensusdefini- study published in the Journal of the American Medical
tion. Thisfour-criterionalgorithm allows for 15 possible Associationaboutrisingratesofcannabisabusedisorders
criteria combinations (1only, 2 only, 3 only, 4 only, 1+2 in a particular urban population that “recurrent mari-
only, etc.) that will satisfy the diagnosis for Substance juana-related legal problems qualify users for the abuse
Abuse. The focus of this paper’s inquiry is only on the diagnosis.Marijuanaarrestsincreaseddramaticallyinthe
thirddiagnosticcriterionforsubstanceabusementaldis- decadestudied(1991-2001)...whichcouldaccountforthe
order which describes persons engaged in a patterns of observed increases in the disorders” [41]. Earleywine’s
substanceusewhopresent“clinicallysignificant...distress” pointrestsonthenecessityofestablishingananalytically
“as manifestedby...recurrent substance-related legal pro- usefuldistinctionbetweencannabisusedisordersandcan-
blems”whichhave“occurredrepeatedly”or“beenpersis- nabisarrests, showingthat more aggressive enforcement
tent” inthe past year(Criterion A3).The DSM-IV states of cannabis prohibition laws may better account for the
thatifpersistentorrecurrentsubstance-relatedlegalpro- “observed increases in the disorders”, rather than any
blems arise in conjunction with substance use, then that uptickinunderlyingincidenceofpsychopathology.
substance use pattern is maladaptive and a Substance Whatismostproblematicaboutthecriterionisthatthe
Abusementaldisorderisthelikelyunderlyingdiagnosable psychopathology-manifestingsubstance-relatedlegalpro-
psychopathologythatexplainstheperson’s“clinicallysig- blemsthattheDSM-IVdescribes includethosethatarise
nificant...distress.” fromnonviolent,‘victimlessinfractions’ofsubstanceprohi-
Ratherthanuncriticallyacceptingthiscriterionasafac- bition laws–in other words, legal charges or other legal
tualdescriptionofpsychopathy,theanalysishereisdirec- problemsrelatedtothepossession,production,andphar-
ted towards potential depathologizationof this criterion. macological delivery of contraband substancesordiscov-
Suchanorientationfollowstheleadofnumerousmedical ered metabolic evidence of their consumption. For
geographersinthefield,suchasParr[34-36], Stock[37], shorthand,thesecanbecalledsubstance-possessionlegal
Gesler [38], andJonesand Moon [39], who advocate the problems(withmetabolitesbeingaformof‘internal’pos-
necessity of maintaining critical perspectives on highly session).Thatsuchlegalproblemsarealsoincludedinthe
socially-contingent disease-like states and giving due criterion’s assessment is absolutely indisputable as the
attention to alternative explanations for such states by manualspecificallyenumeratesthem.ShowninTable1is
patient-subjects.Thispaperattemptstoquestionthebasis acomprehensivecompilationofalltheoccurrencesofthe
oftheA3diagnosticcriterionanddepathologizethemen- concept of “legal problems” in the DSM-IV, all of which
tal distress described therein on the grounds that addi- appearinSubstance-relateddisorderssectionoftheman-
tional, unaccounted social variables influence the ual with the sole exception of a single reference made to
manifestationofmentaldistressbysomesubstance-related “legal difficulties” in the manual’s descriptionof conduct
legal problems.Issues withthis‘legal problems’ criterion disorder.Italicshavebeenaddedtohighlightspecificrefer-
have,infact,beenraisedbyothersinsubstanceabuseand encestolegalproblemsthatarisefromnonviolentinfrac-
general medical literatures. Forexample, Alexander [40], tions.Simplyreadingtheitalicizedwordsbringsintorelief
in a paper in The American Journalof Drug and Alcohol howthesedistressinglegalproblems,fortheframersofthe
Abuse that presents a “Marijuana Screening Inventory”, DSM-IV,translateintomentaldisorder.
notes some difficulties with criterion A3, in the case of To recap, the codified, canonical diagnostic criteria
CannabisAbuse: foundintheDSM-IV-TRthathealthcareprovidersuseto
evaluatepatients’substanceconsumingpatternsforSub-
Subjective clinical judgment enters into Cannabis stance Abuse disorder require providers to take careful
Abusecriteriondistinctionsregardingthemeaningof note,ideally (butoftennot)inthe course of a structured
‘recurrent’or‘maladaptivepattern.’Forexample,legal interview,of“clinicallysignificant...distress”.TheDSM-IV-
consequencerisksarepresentwithanymarijuanause TR states that this “distress” and the “maladaptive” sub-
level,butmayremainlatent,orriskexposureonlyifa stance use pattern that led to it can be “manifested by...
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Table 1Substance Abuse Mental Disordersand Possession-Related Legal Problems in DSM-IV-TR
a SubstanceAbusementaldisorder,diagnosticCriterionA3:“recurrentsubstance-relatedlegalproblems(e.g.,arrestsforsubstance-related
disorderlyconduct)”
b AlcoholAbuse(305.00)mentaldisorder:“Legaldifficultiesmayarisebecauseofalcoholuse(e.g.,arrestsforintoxicatedbehavioror
fordrivingundertheinfluence).”
c CannabisAbuse(305.20)mentaldisorder:“...legalproblemsthatmayoccurasaconsequenceofarrestsforcannabispossession.”
d CocaineAbuse(305.60)mentaldisorder:“Legaldifficultiesmayresultfrompossessionoruseofthedrug.”
e HallucinogenAbuse(305.30)mentaldisorder:“...legaldifficultiesmayariseduetobehaviorsthatresultfromintoxicationorpossession
ofhallucinogens.”
f AmphetamineAbuse(305.70)mentaldisorder:“Legaldifficultiestypicallyariseasaresultofbehaviorwhileintoxicatedwith
amphetamines(especiallyaggressivebehavior),asaconsequenceofobtainingthedrugontheillegalmarket,orasaresultofdrug
possessionoruse.Occasionally,individualswithAmphetamineAbusewillengageinillegalacts(e.g.,manufacturingamphetamines,theft)
toobtainthedrug;however,thisbehaviorismorecommonamongthosewithDependence.”
g InhalantAbuse(305.90)mentaldisorder:“Userscanalsobecomeagitatedandevenviolentduringintoxication,withsubsequentlegal
andinterpersonalproblems.”
h OpioidAbuse(305.50)mentaldisorder:“Legaldifficultiesmayariseasaresultofbehaviorwhileintoxicatedwithopioidsorbecausean
individualhasresortedtoillegalsourcesofsupply.”
i PhencyclidineAbuse(305.90)mentaldisorder:“Legaldifficultiesmayariseduetopossessionofphencyclidineortobehaviorsresulting
fromIntoxication(e.g.,fighting).”
j “ThecategoryofSubstanceAbusedoesnotapplytocaffeineandnicotine";
k “Thetermabuseshouldbeappliedonlytoapatternofsubstanceusethatmeetsthecriteriaforthisdisorder;thetermshouldnotbeusedasa
synonymfor“use,”“misuse,”or“hazardoususe";
l “TheessentialfeatureofSubstanceAbuseisamaladaptivepatternofsubstanceusemanifestedbyrecurrentandsignificantadverse
consequencesrelatedtotherepeateduseofsubstances.InorderforanAbusecriteriontobemet,thesubstance-relatedproblemmusthave
occurredrepeatedlyduringthesame12-monthperiodorbeenpersistent“;
m Theremayberecurrentsubstance-relatedlegalproblems(e.g.,arrestsfordisorderlyconduct,assaultandbattery,drivingundertheinfluence)
(CriterionA3)";
n “Substance-RelatedDisordersaredistinguishedfromnonpathologicalsubstanceuse(e.g.,“social”drinking)andfromtheuseofmedicationsfor
appropriatemedicalpurposesbythepresenceofapatternofmultiplesymptomsoccurringoveranextendedperiodoftime(e.g.,tolerance,
withdrawal,compulsiveuse)orthepresenceofsubstance-relatedproblems(e.g.,medicalcomplications,disruptioninsocialandfamily
relationships,vocationalorfinancialdifficulties,legalproblems);
o “AlthoughadiagnosisofSubstanceAbuseismorelikelyinindividualswhohaveonlyrecentlystartedtakingthesubstance,someindividuals
continuetohavesubstance-relatedadversesocialconsequencesoveralongperiodoftimewithoutdevelopingevidenceofSubstanceDependence.”
Italicsadded.
recurrent substance-related legal problems” which have Banning biota and sowing the seeds of distress
“occurredrepeatedly”or“beenpersistent”inthepastyear Medical anthropologists have long reminded medical
toqualifyforthedisorder.Theideaisthatbecausesome- social scientists to beware of slippage between pathology
oneisengaginginacontinuingbehavioralpatternofsub- and expressions of cultural and social difference. Merrill
stance use despite the adverse consequence of legal Singer warned of this when he wrote: “the adaptationist
problems, s/he must be mentally disordered. The DSM- perspective appears to assign inequities in social rela-
IV-TR diagnostic criteria for substance use disorders do tionships to the environment, thereby not only legitimiz-
not interrogate the substance control criminal sanction ing those inequities as natural, but implying that the
systemsinwhichpatientslive;substance-relatedlegalpro- noxious consequences of exploitation are indicators of
blems are never themselves seen as the problem. Under the maladaptation of politically and economically subor-
thisrubric,one’sexperienceofdistressthatismanifested dinate groups” [14](p.226).
by pending or year-long persisting legal problems is This paper’s contention is that current medical think-
understoodasmentallydisorderedinlightoftheordinary ing on substance abuse has acquiesced to what could be
andubiquitousnatureoftheglobalizedcontrabandbiotic called ‘drug war diagnostics’. Consider an alternate
substance prohibitionenforcementregimes–i.e.,thepre- explanation to account for a substance-using patient’s
vailingorder.Theseregimesareunderstoodtobenatura- mental distress as manifested by recurrent or persistent
lized and normalized aspects of the environment; for biotic substance possession legal problems. What if their
someone to run counter to them is understood as mala- mental distress is a normal response to a system of sub-
daptive,andanyresultantdistressisinterpretedasadiag- stance/social control that has itself set up a maladaptive
nosticsignofmentalillness. relationship with the psychoactive substance-replete
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global environment? If this may be the case, might it be their geographies are shaped by ecological and sociopoli-
unreasonable then to expect people to adapt to a system tical forces and thus easily lend themselves to the analy-
of biotic substance control committed to eradicating tic frame of political ecology. When a human being
whole botanical species, not only from their personal comes into close contact with a banned botanical life
lifeworlds, but also entirely from the face of the planet, form in her or his environment, experienced psychoso-
save for a handful of authorized sites and personages? cially at this most local scale is the rule of global scale
Thefollowing sectionofthepaperwillcriticallyassess international and national prohibition laws that encircle
how this biotic substance control system spreads itself the botanical biota with boundaries which historically
biogeographically and sociospatially at multiple scales, have been shaped by sociopolitical forces of power,
from a broad, global environmental level to the ultra- influence, and authority–basic issues that concern politi-
local perspective of the individual consumer. In the so- cal economy–that have the effect of alienating indivi-
called “public health” campaign to prevent and control duals from freely associating with these elements of the
substancesabuse,State governingbodiesthe world over natural world. These are exactly the sorts of boundaries
have essentially extraprocedurally taken ownership of that Robbins [7] is referring to when he writes:
entire species of naturally occurring, pharmacologically
active biota from the plant and fungal kingdoms–out of In recent history, powerful modern institutions and
thehundredsoftypesofnaturallyoccurringpsychoactive individuals ([e.g.,] environmental ministries, multina-
biota–andcriminalizedtheirconsumptionoutsideofnar- tional corporations, corrupt foresters) have gained
row,officialchannels.TenspeciesthatevolvedonEarth’s undue and disproportionate power by explicitly
biosphere are currently at the heart of this policy, attempting to divide and police the boundaries
throughdirectorindirectreferenceininternational,fed- between human and non-human nature, even while
eral or state-level Schedules. They are: Papaver somni- allying themselves and building new connections to
ferum L., Erythroxylum coca Lam, Cannabis sativa L., the non-human world, leading to unintended conse-
Lophophora williamsii J.M.C., 186 Psilocybe fungi spp., quences and pernicious results. In the process, resis-
Catha edulis Vahl, Tabernanthe iboga L., Banisteriopsis tance emerges from traditional, alternative, and
caapiC.V.M.&PsychotriaviridisRuiz&Pav,andSalvia progressive human/non-human alliances margina-
divinorum Epling & Játiva. More commonly, these are lized by such efforts (usually along lines of gender,
known as opium, coca, cannabis, peyote, mushrooms, class, and race) (p.213).
khat, iboga, ayahuasca, and salvia. Of these, the first
three–opium,cannabis,andcoca–havethelongeststand- Contactwithbannedpsychoactivebiotaisalsoecologi-
ingownership-bansinthemodernerawiththemostfar- callymediatedthroughthe organic distributionofliving
reachingconsequences.Theseareinfactownership-bans species,mutualadaptation(e.g.,health-relatedbehavior),
becauseglobalbioticpsychoactivesubstanceprohibitions andco-evolution(e.g.,selectivecultivation),whichinflu-
grant legitimate, monopoly ownership of the biota–or, ence how often and in what context human and non-
at root, select germplasms (plant genetic resources) humanspecieswillcomeintogrossand“deep”consump-
(Figure 1)–wherever they may occur and at whatever tive contact, the latter understood through the logics of
generationalageofthespecies–toStateauthoritieswhile pharmacology, physiology and metabolism. It is readily
prohibitingsafeaccessbyothers,literallybioimpoverish- apparent, then, that the overall effects of the consump-
ing unauthorized billions through force or the threat of tion of banned biotic substances wherever they may
force.Thosewhocivillydisobeytheseregulationsbycon- occur locally, such as those related to psychoactivation,
sumingorfacilitatingconsumptionofcontrabandbiota– are never determined solely by material or biophysical
possession law violators–are, in effect, stealing from forcesalone;rather,agency,culture,context,andpsycho-
world governments, hence, getting “busted”, and many logicalsetplayequallyvitalroles.
are routinelychargedforsuchcrimes.Theinstitutionof Biogeographic State ownership and control of whole
suchbansonnaturerequiresahistoricalactofbiocoloni- speciesoflifeintheserviceofsubstanceabuseprevention
zation:apriorpoliticalcallofspecies-wide,claimstaking, andcontrolhasaqualitativepolicyparallelonlyintheare-
i.e., a depletion of the commons pool of plant genetic nasofbiologicalweaponscontrolandendangeredspecies
resources through decree. It is this historical act that preservation.Intheformercategory,unauthorizedpersons
allowsthepastparticipleformoftheverb‘control’inthe foundinownershiporpossession of entirespeciesoflife
phrase‘controlledsubstances’toassertitselfasabsolutely (or quasi-life) such as plague (Yersinia pestis), tularemia
commonplaceandnormalized. (Francisellatularensis),Ebola virus, orprocessed deriva-
The points in space of interaction between Homo tives of these and other species are subject to criminal
sapiens and these elements of banned non-human nat- sanctions.Inthelatterarena,unauthorizedpersonsfound
ure are points of material and sociocultural significance; in ownership or possession of threatened or endangered
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Figure1KeyContrabandGermplasms.(fromtopleft,rightward)Coca:http://web.archive.org/web/20061018053434/http://www.ethnogarden.
com/cart/index.pl/catid_77/proid_292/_/_/CocaSeeds/ErythroxylumCoca,Khat:http://www.shamanica.com/Catha%20edulis.asp,Chacruna:http://
web.archive.org/web/20061018155352/http://www.ethnogarden.com/cart/index.pl/catid_77/proid_250/_/_/Chacruna/PsychotriaViridis,Yage:
http://www.shamanic-extracts.com/xcart/shamanic-products/banisteriopsis-caapi-seeds.html,Cannabis:http://www.cannabisculture.com/articles/
4477.html,Opium:http://www.plantcultures.org.uk/plants/opium_poppy_traditional_medicine.html,Peyote:http://tryptamind.com/grow_peyote.
html,Iboga:http://www.shamanic-extracts.com/xcart/shamanic-products/tabernanthe-iboga-seeds.html,SalviaDivinorum:http://www.
sagewisdom.org/sdseeds.htmlPsilocybe:http://www.erowid.org/plants/mushrooms/mushrooms_cultivation_az2.shtml.
speciesoflifesuchastheSaltCreektigerbeetle(Cicindela prohibitions are balanced against the fulfillment of peo-
nevadica lincolniana), the African violet (Saintpaulia ple’sdesirestoownbiologicalweaponsforself-defenseor
ionantha), and the White Rhinoceros (Ceratotherium people’sdesirestoconsumeandpossessendangeredspe-
simum)arealsosubjecttocriminalsanctions.Exceptions ciesforaphrodisiaorsport.
arecommonlygrantedinbothcases,andcriminalpenal- Ontheotherhand,thebanningoftenbiotaoutofthe
tiesarerarelydelivered.Governments’exertionofauthori- hundreds with psychoactive potential, while heavily and
tative biogeographic control as per their international yetoftenduplicitouslyenforced,do notfurtherthegoals
treatyorconventionobligationsoverpotentiallymassvio- of public health and safety as they are purported to do.
lence-causing biological agents and species threatened Onthecontrary,theyhaveled,overthecourseofseveral
withextinctionhasnotledmassivecivil/politicalunrestor decades,toasignificantamountofcorruption,chaosand
strife, mainly because these policies do not undermine instability (secondary to money laundering), structural
basicsocialgoalsofpeace,development,andsustainability. violence, direct violence (secondary to black markets),
Inessence,thereisnovaluedbenefittoexposingpeopleto morbidity (such asuntreated problematic substance use
highly virulent pathogens or to wiping out endangered andthesignificantspreadofHIVandHCVduetoneedle
species that is being undermined, although these sharing and inaccessible clean injection equipment),