MAPS: FWD Ecstasy & Prozac (The Economist)

[LotsofHS@xxxxxxx]

 The Economist, April 6, 1996 v339 n7960 p87(2)



Better than well: society's moral confusion over drugs is neatly illustrated

by its differing reactions to Prozac and ecstasy.



Abstract: MDMA, known in street parlance as ecstasy, is illegal, and Prozac,

an anti-depressant, is legal. Both have a similar elevating effect on mood

by

altering serotonin levels. Societal views of chemically induced happiness

are

examined.



Full Text: COPYRIGHT Economist Newspaper Ltd. (UK) 1996



EVERY week, according to the most conservative estimates, half a million

Britons take a pill to make them happy. This pill was originally developed

as

an appetite suppressor. Now it is an adjunct to partying. In America, some 5

million people regularly take a different sort of pill. This one was

developed

as an anti-depressant. Now it is widely used as a chemical accessory by

those

who think it is unfair that they should ever feel low.

The British users are breaking their country's law. The Americans are not.

Which raises an important question. If it is not acceptable to take a drug

with the awkward name of 3,4--methylene-dioxy-methamphetamine (better known

as

MDMA, and even better known as ecstasy) to make you feel happy when you just

want to have fun, why is it acceptable to take the anti-depressant

fluoxetine

(better known as Prozac) to make you feel happy if you are not actually

clinically depressed?

When Prozac--made by Eli Lilly, an American pharmaceutical firm--came on the

market in 1987, it was hailed as a "wonder-drug". Unlike previous anti-

depressants, it appears to have no serious (and few trivial) side effects.

Its

sales have soared. They are expected to hit $4 billion a year by 2000,

according to analysts at Lehman Brothers, an American investment bank.

Ecstasy is older. It was developed in 1914 and became popular in the 1970s

as

an adjunct to psychotherapy because of its ability to reduce anxiety and

facilitate communication. German marriage-guidance counsellors regularly

recommended it. It, too, is good business. A tablet can cost as little as

3.50

($5) to make and sells on the streets for around 15. This suggests that the

British market alone is worth well over 300 million a year.

Both drugs affect the level of serotonin, a neurotransmitter in the brain

that

is thought to influence sleep, appetite, aggression and mood.

Neurotransmitters are chemicals that carry messages between nerve cells.

They

are secreted by one cell and picked up by receptor proteins on the surface

of

a neighbour. Once the message has been delivered, a neurotransmitter is

either

destroyed or sucked back into the cell that made it--a process known as re-

uptake.

Both Prozac and ecstasy work by inhibiting the re-uptake of serotonin. This

means that the messenger molecules hang around in the gap between the cells

and the message gets amplified. Ecstasy, in addition to blocking re-uptake,

causes a surge of serotonin to be released into the gap--so that not only is

it not removed, but there is more of it there in the first place. Since

clinical depression seems to be associated with a lack of serotonin at

certain

receptor sites (extremely low levels of serotonin have been found, for

instance, in some suicides), the idea of using serotonin re-uptake

inhibitors

as anti-depressants has been popular for some time.

So there are parallels. But there is also an important difference between

the

drugs--one which might be thought to justify banning one but not the other.

Though it has been accused of causing violence in rare cases (the "Prozac

defence" was once fashionable among lawyers, but 65 consecutive convictions

have dampened their enthusiasm) Prozac does not seem to harm its users. Very

occasionally, ecstasy (or, more particularly, dehydration associated with

its

use) kills.

This does not, however, seem to have been the reason why MDMA actually was

proscribed. In 1971, when the drug was banned in Britain, this problem was

almost unknown. Things had not changed much by 1985, when the drug was first

scheduled in America. This is hardly surprising. Death is rare--it occurs in

only one per 3 million uses. Fatal dehydration generally happens in a hot

environment. And it is preventable by drinking a judicious, though not

excessive, amount of water (too much can kill you, too).

The formal reason for the drug's proscription was fear of

neurotoxicity--that

it might cause a persistent drop in serotonin levels in the brain. But

America's Drug Enforcement Agency (DEA), instead of placing it in schedule

three, which would have allowed continued medical use, put it in schedule

one--denying it even to doctors.

Better living through chemistry

The neurotoxic effects of MDMA are real. Regular users may suffer a drop of

a

third in the level of serotonin-derived chemicals in the fluid of their

spinal

cords, according to research by George Ricaurte, a neurologist at Johns

Hopkins University in Baltimore. But such effects do not appear to be very

troubling--at least not in the doses that people actually use. Slightly

reduced sleep, less impulsive behaviour and less hostility are the main

symptoms. And other drugs which are neurotoxic in laboratory experiments do

not seem to cause difficulties in the outside world. Fenfluramine, another

appetite suppressor, has been in use for 25 years and been taken by around

50

million people without any sign of a problem.

The decision to put MDMA into schedule one, therefore, seems odd. It came

despite the opinion of Francis Young, a federal judge who was asked to

review

the evidence, that it should have gone in schedule three. The explanation

seems to be that the mid-1980s also saw MDMA's recreational use change from

small groups of people taking it in private, to large groups of people

taking

it in public. Ecstasy was being born and the DEA wished to strangle it.

The history of Prozac casts the propriety of the ban into sharp relief.

Strictly, America's Food and Drug Administration recognises Prozac as

suitable

for the treatment only of depression and obsessive-compulsive disorder. In

practice it is being prescribed (quite legally, if warnings are given) for

panic disorders, premenstrual tension, premature ejaculation and chronic

back-

pain. But, increasingly, people are being prescribed it simply because they

want it. And those who are unable to find a friendly doctor to fill in a

prescription are turning to the black market.

Peter Kramer, a psychiatrist at Brown University, in Providence, Rhode

Island,

says Prozac users feel "better than well"--a sentiment no doubt echoed by

many

a user of ecstasy. As Dr Kramer puts it in his book "Listening to Prozac"*,

"until the advent of Prozac most ethical questions involving

psychotherapeutic

drugs turned on clinical trade-offs." But because Prozac has proved so safe,

it is much more widely prescribed than previous anti-depressants. The

question

is whether a line can be drawn between therapeutic and non-therapeutic use

of

the drug. And if it can be, should it be?

There are two ways of dealing with this question. One is to duck it. Some

doctors argue (with a certain circular logic) that if something is treatable

with an anti-depressant then it must, by definition, be depression. The drug

is then restoring a state which would "naturally" exist if the person were

well. So, the argument goes, unlike ecstasy (where the act of taking the

drug

provides immediate pleasure) Prozac does not actually create pleasure. It

merely restores the capacity for pleasure. In the words of a spokesman for

Eli

Lilly, the drug does not make people into super-people.

The other way of answering the question is to admit that Prozac, like

ecstasy,

is often used recreationally, to enhance pleasure, rather than to treat

depression--and, if this is not approved of, to ban its use in these cases.

But why ban the recreational use of drugs?

The motive often seems to be what Dr Kramer refers to as "pharmacological

Calvinism". The use of drugs for fun rather than therapy is widely

disapproved

of. There is, too, a feeling that doctors--who, it is to be hoped, know what

they are doing--should be in charge of the process of giving drugs out. But,

in that case, why not let doctors give out MDMA as well?

 There is also a belief that, at least with mental problems, behavioural

therapy is morally superior to chemotherapy. But the two are intimately

linked. Eric Hollander, of the Mount Sinai School of Medicine, in New York,

for example, recently showed that treating obsessive-compulsive disorder

with

drugs produced the same changes in the activity of patients'

brains--uncoupling the action of four groups of nerves that are unhealthily

locked together--as treating them with psychotherapy. It hardly seems that

one

method is morally inferior just because it is easier.

Nor does it seem reasonable to stop people taking drugs to achieve easily an

effect which might be won in other ways with difficulty. Good information

about the risks and benefits, and proper supervision of manufacture, are

always important (and are a good argument for legalising what people clearly

want). But given these, it is not clear that pills should always be popped

under a doctor's supervision. So, when Calvinists ask if people taking

Prozac

to eliminate elements of their personalities, such as shyness, is so very

far

removed from the recreational use of ecstasy, the answer appears to be "no".

But what is wrong with that?



 Article A18163429

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