5.14/The Lived Worlds/Drugs

Functional Addiction and the Prescription Underworld

The Prescription in Plain Sight

The oldest channel was weight. Dextroamphetamine had been sold as Dexedrine since 1937, phentermine since 1959, both approved for short-term treatment of obesity and both easy to obtain from a cooperative general practitioner.² A patient with ten pounds she wanted gone before a wedding walked out with a script that ran her through a season of work; the internist, the gynecologist, and the ear-nose-throat man could all write it. Federal controls existed — the Controlled Substances Act of 1971 had placed the amphetamines on a schedule — but enforcement operated almost nowhere at the level of the accommodating doctor writing a modest prescription to a patient who paid and did not complain.³ The diet-pill economy was the adult stimulant economy under another name.

The pharmacopoeia turned over across the decade. Mixed amphetamine salts were approved by the Food and Drug Administration for attention-deficit disorder on February 13, 1996, rebranded from an older diet pill and sold as Adderall.⁴ Modafinil, marketed as Provigil, was approved for narcolepsy on December 24, 1998, and classed in Schedule IV, which meant a prescriber could phone a refill straight to the pharmacy — a lighter regulatory touch than the amphetamines carried, and an easier path to a standing supply.⁵ The diet drugs kept their own darker ledger. The fenfluramine-phentermine combination known as fen-phen was prescribed to millions before the Mayo Clinic reported valvular heart damage in the summer of 1997 and the FDA asked that fenfluramine be pulled from the market on September 15 of that year.⁶ The over-the-counter appetite suppressant phenylpropanolamine, sold as Dexatrim and Acutrim, was withdrawn in November 2000 after it was linked to hemorrhagic stroke.⁷ Each drug had been unremarkable while it lasted, on a desk or in a medicine cabinet, until the day it was not.

The Society Doctor

The prescription channel had a physical geography, and it ran along Madison and Park Avenues in the East Sixties, Seventies, and Eighties — a corridor of cooperative internists, weight-management specialists, and “vitamin therapy” practitioners in the blocks north of the magazine offices in the East Fifties. Its founding figure had been gone for years by the start of the period. Max Jacobson, the Manhattan physician the Secret Service had code-named Dr. Feelgood, ran a Madison Avenue practice for three decades on injection cocktails of methamphetamine, steroids, hormones, and vitamins administered to a client list that had included a sitting president. The New York State Board of Regents revoked his license on April 25, 1975, on eleven counts of unprofessional conduct and one of fraud, after finding he had bought at least 29.7 pounds of amphetamine over five years.⁸ He was denied reinstatement and died in 1979. The template survived him. Robert Freymann, a German-born physician working the same Upper East Side blocks, gave B-12-and-amphetamine injections to artists and society patients — he is the doctor John Lennon and Paul McCartney are widely held to have had in mind for “Doctor Robert” on Revolver — and lost his own license in the same 1975 crackdown.⁹

The type outlived the crackdown too. Stuart Berger, the six-foot-seven author of Dr. Berger’s Immune Power Diet, a number-one bestseller, and a health columnist for the New York Post, ran a high-volume East Side practice that wrote diet-pill scripts in quantity through the early 1990s. He was found dead in February 1994 at the age of forty, weighing 365 pounds, of causes an autopsy attributed to cocaine and cardiovascular disease.¹⁰ The doctor who dispensed the regimen and the patient who lived on it were, in his case, the same person.

The practices ran on a small set of arrangements. Payment was cash, which kept the transaction off the insurers’ books and out of any utilization review. A single visit could produce the day’s stimulant, the meeting’s anxiolytic, and the night’s hypnotic on one chart entry, with no follow-up beyond the next script. New patients arrived by referral and understood that the relationship was not a standard one; the number was passed along, not advertised, and the practice carried no listing beyond “general medicine.” Enforcement, as the Jacobson case had shown, was triggered almost exclusively by a death or a complaint; a physician could write Schedule II prescriptions in volume for years and draw no attention so long as no one died on the schedule. The system ran on paper — handwritten charts, no central database, no flag on a prescription that had been renewing since the Johnson administration.

Managed care narrowed the channel without closing it. As health plans through the 1990s increasingly pressed for utilization review, the cash-pay practice tended to concentrate among those who could still afford discretion: senior editors, contract writers, contributors with expense accounts. The clearest documented case belonged to Dan Peres, who took over Details in 2000 at twenty-eight, having begun on Vicodin in the 1990s as a reporter at Women’s Wear Daily after a back injury. By his own later account his intake reached as many as sixty pills a day, supplied through emergency-room visits on a kidney-stone complaint, prescriptions filled at scattered pharmacies, out-of-town doctors billed to corporate travel, and pills carried north from Mexico — and through it he ran the magazine.¹¹ The product covered the practice. He filed; the magazine shipped; the intake stayed in the body and out of the masthead.

The User Who Held

The standard drug story of the period ended in collapse, because collapse was the only ending on which the addict, the obituary, and the moralist agreed. It left out the larger population: the user who kept a stable dose, held the desk, and produced. What that user shared with the next was rarely the drug. It was a routine that turned the substance into a schedule, an income that absorbed the price without strain, and a product that stood in for an explanation — the filed column, the shipped issue, the proof that whatever was happening could not be that serious. The arrangement could last years, sometimes decades, and the damage — cancer, heart disease, a failing liver — surfaced only after the work was long done.

The literature of the era carried its own correction. Pete Hamill’s A Drinking Life, published in 1994, was the memoir of a New York newspaperman who had written novels and a daily column straight through the drinking decades and quit, cold, in 1972 — and who set down what the drink had given him before what it took.¹² The magazine world furnished the live examples. Christopher Hitchens, filing for Vanity Fair and The Nation across the decade, drank, in the words of the writer who later profiled him, “like a Hemingway character: continually and to no apparent effect,” and turned in the copy regardless.¹³ The functional case was hard to see precisely because nothing legible happened on the way through it. A writer could be sober and exact from ten to noon, lubricated through the afternoon, and spent by evening, and the morning’s pages were the pages the office remembered.

The office absorbed it without a vocabulary for it. A senior editor’s desk drawer held a tin of mints, a bottle of Famous Grouse, and a vial or two of prescription pills; the drawer was private, and the privacy was an asset, the sign of a person managed rather than a person in trouble. Pills were bummed the way cigarettes were bummed, in the same syntax and under the same social rules. A plastic seven-day organizer on a writer’s desk was the socially acceptable form of the addict’s vigilance — evidence of a regimen under management, not of a problem. None of it registered as trouble, because the person doing the work was doing the work.

What changed across the decade was not the fact of use but its pharmacology. The magazine floor ran, in the late 1980s, on a stimulant culture keyed to production: cocaine, cigarettes, black coffee. By the late 1990s it ran increasingly on an anxiolytic culture keyed to survival, as clonazepam and alprazolam entered the drawer of nearly every senior editor with sleep trouble or nerves, and someone at the water cooler filled a paper cone to take a Klonopin before the afternoon meeting. The pattern underneath was a substitution — cocaine to alcohol, alcohol to a benzodiazepine, a benzodiazepine to whatever the internist wrote next. The substance changed and the function held. When one drug failed, another took its place, and the identity built around the habit went undisturbed.

The Weekend Habit

The illegal drugs followed the same logic as the legal ones, and heroin followed it most exactly. By the mid-1990s a supply of increasingly pure Colombian heroin had reached the retail markets of the Lower East Side, and rising purity made snorting viable where a decade earlier a serious habit had meant a needle.¹⁴ The bags sold from tenement doorways around Stanton and Ludlow for roughly ten dollars. The cost and the skill of entry both fell, and the population that took up the drug was not the one the addiction memoir described. An ethnography of non-injecting heroin users on the Lower East Side in 1996 and 1997 found them white, college-educated, employed, in their mid-twenties to mid-thirties, renting in Manhattan, using once to a few times a week and not progressing to the needle within the study’s window.¹⁵ It was, almost exactly, the demographic of a magazine’s junior and middle editorial floor.

The clearest first-person account came from Ann Marlowe, a critic who snorted through a controlled seven-year habit that ran from the late 1980s into the mid-1990s, worked as a Wall Street consultant and a music critic for the Village Voice the whole time, kept to no more than a bag a day, and quit by walking away — the book she made of it, How to Stop Time, arrived in 1999.¹⁶ The economics were unremarkable to a salary that already carried a Manhattan rent: a weekend habit at the going retail price ran to a few thousand dollars a year, less than many of the same users spent on restaurants. The drug became a regularity rather than a rupture, a fixed part of a Saturday-night commute from the Upper West Side or Park Slope down to the Lower East Side and back — the trip to Stanton Street a feature of the weekend, not a break from the working life, and a habit its owner disclosed, over years, to exactly two people, neither of them family.

The evidence that this was the ordinary case, not the exception, was decades old and inconvenient. The clinical literature on controlled use went back to the methadone-maintenance trials Vincent Dole and Marie Nyswander began in 1965, and the largest natural experiment on record — the study of 898 Vietnam veterans published in 1975, which followed enlisted men who had used heroin heavily in Southeast Asia — found readdiction after their return home to be far lower than the inevitable-relapse model predicted.¹⁷ Set and setting governed the outcome more than the drug itself did. The users who quit did so on a life event — a pregnancy, a job change, the end of a relationship — and left no paperwork. The ones who did not quit became the memoir. The larger number who did quit became invisible, which is why the record reads the way it does.