Notebooks Esteve Foundation 42

notebooks Esteve Foundation 42

Television fiction viewed from the perspective Medicine in Television Series of medical professionals

House and Medical Diagnosis. Lisa Sanders Editor: Toni de la Torre The Knick and Surgical Techniques. Leire Losa

The Sopranos and Psychoanalysis. Oriol Estrada Rangil

The Big Bang Theory and Asperger’s Syndrome. Ramon Cererols

Breaking Bad and Methamphetamine Addiction. Patricia Robledo

Mad Men and Tobacco Addiction. Joan R. Villalbí

The Walking Dead and Epidemics in the Collective Imagination. Josep M. Comelles and Enrique Perdiguero Gil

Angels in America, The Normal Heart and Positius: HIV and AIDS in Television Series. Aina Clotet and Marc Clotet, under the supervision of Bonaventura Clotet

Nip/Tuck, Grey’s Anatomy and Plastic Surgery. María del Mar Vaquero Pérez

Masters of Sex and Sexology. Helena Boadas

CSI and Forensic Medicine. Adriana Farré, Marta Torrens, Josep-Eladi Baños and Magí Farré

Homeland and the Emotional Sphere. Liana Vehil and Luis Lalucat Series Medicine in Television

Olive Kitteridge and Depression. Oriol Estrada Rangil

True Detective and the Attraction of Evil. Luis Lalucat and Liana Vehil

Polseres vermelles and Cancer. Pere Gascón i Vilaplana

ISBN: 978-84-945061-9-2 9 788494 506192 42 Notebooks of the Esteve Foundation Nº 42

Breaking Bad and Methamphetamine Addiction

Patricia Robledo

If any series has garnered close to unanimous approval among both critics and viewers, it is without a doubt the story told over five seasons about a common chemistry teacher’s descent into hell, a man who becomes the largest methamphetamine distributor in New Mexico. Thanks to Bryan Cranston’s outstand- ing acting, the character of Walter White has become a TV icon. Having won sixteen Emmys, the series, along with Mad Men, has turned cable channel AMC into a serious competitor with the all-powerful HBO. After the show’s 2013 finale, its creator Vince Gilligan presented Better Call Saul, based on a secondary character from the original series.

The main theme of the series Breaking Bad is accidents, convulsions, agitation and hyperther- synthesis and distribution of methamphetamine mia, and they are mostly the cause of abuse and in a small US town on the border with Mexico. addiction to this substance as well.1 The subject In a highly realistic way, the series depicts how of addiction presented in the series agrees with the methamphetamine market can be a lucrative scientific evidence and clearly shows the addict­ business, since there is huge demand for this ive process. So, according to one of the most product and because its synthesis is inexpensive, influential theories, addiction to abusive drugs is its chemical precursors being relatively cheap established by the interaction of a vulnerable indi- and easy to purchase legally. Meanwhile, the vidual with the neurobiological changes the drug series deals with two crucial problems linked to causes, which depend on the amount of expos­ methamphetamine trafficking. The first is the vio- ure. Addiction is a recurring illness that consists lence associated with the war for absolute market of different phases, including the intensification of control, and the second, abusive consumption of consumption or escalation, increase in the need this substance and its negative consequences. to consume, loss of control and relapse into us- On the latter point, the series faithfully shows how ing even after prolonged abstinence.2 methamphetamine is a highly addictive abusive drug which is mainly consumed for its long-lasting The three faces of methamphetamine euphoria-inducing properties. It produces its psy- synthesis and distribution chostimulant effects by increasing monoamine extracellular concentrations in the brain. The fast, Jesse Pinkman is a young high school dropout constant increase of noradrenaline is the cause with substance abuse problems, who is rejected of its known “toxic syndrome”, characterized by by his family because he cannot get off drugs tachycardia, hypertension, mydriasis, diaphoresis and back into society. and psychomotor agitation. Prolonged release of Though he failed chemistry at high school, he central monoamines and activation of the sym- has the formula for preparing methamphetamine pathetic nervous system produce most of the –or crystal meth as it is called on the streets– acute neurological complications associated with which he prepares in a secret lab in his garage. methamphetamine use, such as cerebrovascular Jesse’s formula, which is based on chemically re-

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ducing pseudoephedrine, is the method used in This method of methamphetamine synthesis is real life. Jesse’s friends, Badger and Skinny Pete, shown in episode “Seven Thirty-Seven” of the se- are also drug addicts and undertake to source ries, the first in the second season. Walter’s broth- the raw material by buying the nasal deconges- er-in-law, who works for the US Drug Enforcement tant Sudafed, which contains pseudoephedrine, Administration (DEA), is surprised to see the video from different pharmacies. Once the pseudo- of a theft of methylamine and comments: “P2P ephedrine is extracted, it is reduced using iodine –they’re cooking old school biker meth”. His com- and red phosphorus to form methamphetamine ment refers to the fact that during the 1970s and or N-methylamphetamine. Jesse’s methamphet- early 1980s, methamphetamine was produced amine distribution is small-scale, using his drug- by this method and distributed by the Hell’s An- addict friends as pushers, who mainly sell the gels motorcycle club in northern California, until drug locally. According to the Spanish National it stopped being used due to the classification of Plan on Drugs, in Spain, methamphetamine is P2P on the list of controlled substances.3 By the known by the names speed, meth, chalk, ice or mid-1990s, most P2P labs had been substitut­ crystal, and is consumed by smoking. It can also ed by pseudoephedrine/ephedrine-based labs.3 be taken orally, inhaled or injected, which deter- However, the law relating to methamphetamine mines the type and magnitude of the effects it precursors in the years 1993, 1995 and 2005 in produces. the US meant that both ephedrine and pseudo- Walter White is a highly intelligent man whose ephedrine also became controlled substances.4 creative aspirations in the chemistry field are This fact contributed to a decrease in the market foiled, so he ends up as a high school chemis- and the recovery of the old P2P method of synthe- try teacher. The situation makes him deeply bitter sizing the drug. So, in late 2010, 69% of American because of the lack of incentive and his financial and Mexican samples examined showed that they problems. Moreover, he has serious health prob- were produced using the P2P method.4 lems involving costly treatment. By chance, Wal- Some discrepancies between the TV fiction ter finds out that Jesse, a former student of his, and reality have to do with the incredible purity is synthesizing methamphetamine under danger- that the methamphetamine prepared by Walter ous conditions. He decides to suggest a more seems to have. So one feature of Walter’s meth- efficient manner of synthesizing a large quantity amphetamine is its blue color, which in strict of extremely pure methamphetamine. His idea chemical terms does not agree with its claim to is to earn a lot of money so that his family can be 99% pure, given that this color is a sign of im- live comfortably after his death from lung cancer. purity. Another discrepancy with real life is related Walter is a disciplined, well-organized man, with to the fact that the ultra-pure methamphetamine an astonishing ability in chemistry, traits which that Walter prepares is found on the streets in will serve him well to improve the purity of the equal purity, which does not normally happen meth and set up a lab in a van that can travel because distributors tend to adulterate the drug out to desert regions to effectively elude the city’s with other compounds to increase its volume and police controls. In the series, Walter stops using earn more profit. the pseudoephedrine-based method because of Walter also changes the means of metham- the difficulty of acquiring large quantities of this phetamine distribution to make the business more precursor. Instead, he suggests using a meth- lucrative, associating with an extremely danger- amphetamine preparation method known as ous Latin distribution network. These two means “reductive animation” or “2P2 method”, which of methamphetamine distribution are faithfully re- consists of reducing phenyl-2-propanone (P2P) flected in the series. The first, on a small scale, using phenylacetone and methylamine. Methyl- carried out locally by drug addicts, and the other amine is used in industry, but it is a substance on a large scale, controlled by mafia. that is tightly controlled by the anti-drug law en- Gustavo Fring is a Latin drug trafficker who forcement agencies. controls the business in the American west in an

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Medicine in Television Series

organized way. He passes completely under the by dysphoria, restlessness and anxiety. Further- radar because he has an infallible money laun- more, he displays bruxism (clenching or grinding dering system. Walter and Jesse are associated his teeth for no reason) and the shakes. In the with him to synthesize big amounts of meth in a series, Jesse is the typical meth addict who little large secret lab that Fring sets up for them in the by little loses control of his life and the support of city where they live. This fact is similar to the real- his parents due to his addiction. So, in “Down”, ity of the so-called super-labs, that are known in the fourth episode in the second season, we see Mexico and which probably also existed in the US how Jesse becomes homeless because his par- at some point. In the tenth episode of the fourth ents have found out he has set up a meth lab season, called “Health”, Gus Fring takes Jesse in the house he inherited from his aunt. In Jesse to Mexico by force to make him try his hand at we see the relapse into seeking out the drug synthesizing ultra-pure methamphetamine in the and returning to using after adverse situations Juárez Cartel. There, he sees one of these super- or depressing episodes, such as in “Mandala”, labs, run by this criminal gang. Fring is a dan- when he feels guilty and sad about the death of gerous man who does not hesitate to eliminate his friend Combo and starts to shoot up heroin the boss of the Mexican cartel, who is compet- with his addict girlfriend. This episode offers fair- ing for the trafficking and distribution of metham- ly realistic scenes about the effects heroin has, phetamine on American turf. The methamphet- in clear contrast to the effects of methamphet- amine trafficking by Mexican criminal gangs as amine. Injected heroin induces a wholly pleasant described in the series is plausible, given that sensation, characterized by a marked indiffer- the decrease in methamphetamine production ence to internal and external stimuli. The peak of in the US noted since 2003 was countered by euphoria occurs seconds after injecting the drug an increase in Mexican production. The Mexican and tends to last several minutes, while the feel- drug cartels became more involved in that traf- ing of well-being can last from four to six hours. ficking, and the amount of methamphetamine However, heroin does not induce psychomotor confiscated on the border between the US and action, given that it is a depressant of the central Mexico increased considerably in 2003.4 In 2008, nervous system. Large amounts of heroin can Canadian trafficking organizations increased their cause extreme drowsiness, with the risk of in- participation in meth production worldwide, while ducing a state of coma or decreasing the cough Mexican cartels invaded the market in the US.4 and expectorant reflex, which can cause one to choke on one’s own vomit. This is reflected in the tragic case of Jane, Jesse’s girlfriend, who dies in The different profiles of meth addicts precisely this way. The second season of Breaking Bad depicts in a On the other hand, methamphetamine also fairly realistic manner some of the existing patterns induces a fast peak of euphoria that can last for among methamphetamine users. On one hand, many hours, depending on whether it is inhaled, Jesse and his friends generally sniff or smoke smoked or injected, through activation of the the drug, so that moderate doses produce quick central nervous system by its effect of releasing effects such as euphoria, heightened attention, monoamines. At the end of the second season, a loss of appetite, increased libido and self-es- in episode thirteen, “ABQ”, Walter takes Jesse to teem, and improved mood. Yet Jesse appears in rehab. We see his affective deterioration, feeling the series as a true addict who does not limit the guilt at his girlfriend’s death. The situation Jesse amount of methamphetamine he uses because finds himself in is no doubt because of the af- he has unlimited access to it. In a scene from the fective deterioration characteristic of those who second season’s eleventh episode “Mandala”, chronically abuse methamphetamine, who fre- when Jesse meets Walter to talk business, we quently have problems experiencing pleasure see the effects associated with consuming high (anhedonia) and fall into deep depression from doses of methamphetamine as Jesse is stricken the exhaustion of cerebral reserves of dopamine

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and serotonin in the neuronal terminals.1 Through they consume meth because it is cheaper. They Jesse’s character, the series shows addiction will do anything to get the drug, even prostitute truthfully, since the affective problems and possi- themselves, as Spooge’s girlfriend does. The epi- ble cognitive deficit that Jesse experiences con- sode “Peekaboo”, in the second season, shows tribute significantly to perpetuating the addict- the marginal conditions in which this couple ive cycle, characterized by abuse, loss of control live, with a small child who is totally uncared for. and relapse.2 These two characters suffer from serious side ef- The third episode, “Open House”, in the fects that truly occur after chronic meth use; for fourth season, shows how Jesse increasingly example, both show evidence of malnutrition and loses control over his actions and seems quite poor dental health associated with serious cavi- unbalanced when, after killing Gale, he throws an ties and the loss of teeth. The latter is due to the interminable party in his house with other drug drug’s acidic properties combined with a lack of addicts, consuming huge amounts of metham- oral hygiene. Xerostomia (dry mouth) also adds phetamine. The situation degenerates, evolving to the dental problems resulting from metham- from dancing to violence. This episode shows phetamine use. Spooge and his girlfriend also the reality of methamphetamine use in the form have skin damage as a result of the compulsive of binges, which can last several days, and scratching that accompanies methamphetamine where the euphoric effects of the drug progres- use. Such injuries tend to get infected, resulting sively decrease over time, while dysphoria and in a bacterial cellulitis that spreads to become compulsive and repetitive behaviors increase. bacteremia and sepsis in some cases. This use profile is perfectly captured by Jesse’s In addition to these examples of methamphet- party, where after several days of euphoria and amine users in the series, two other individuals dancing, the guests start to become violent and use the drug but do not become addicts. This engage in risky sexual behavior. The behaviors aspect, which the series does not examine, is described in the series (which Jesse dramatizes) linked to existing differences in the population in are linked to pathological deregulation of the ce- terms of individual vulnerability of entering the ad- rebral circuits involved in pleasure and motiva- dictive cycle after sporadic or recreational drug tion caused by the addiction. So, taking most use. Experts believe that 12 to 20 out of every abusive drugs, including methamphetamine, 100 people who begin to use drugs will develop increases dopaminergic transmission in specific addiction. Yet the risk that these addicts relapse cerebral centers that reinforce the behavior of into using the drug, even after prolonged per­ seeking and consuming the drug, facilitating the iods of abstinence, is extremely high.2 In 2013, reiteration of learned behaviors and encouraging the Washington Post 6 published an article on the addiction. From the uncontrolled need to obtain type of person, known as a “functional addict”, the drug stems the relapse, the basis of which is who consumes methamphetamine and seems a pathological form of neuronal plasticity in the able to remain socially active. Some of the exam- excitatory glutamatergic system. Such deregu- ples mentioned were working mothers, or people lation means that the individual addict places holding down several boring and poorly paid jobs excessive motivational importance on stimuli who use meth to boost their energy and alleviate that predict drug availability and it reduces his the tedium of their social and working conditions, or her ability to stop using it.5 or university students wanting to improve their Meanwhile we have the characters of Spooge cognitive capacities. As has been mentioned, and his girlfriend, two addicts on the fringes of the addictive process depends on the drug use and disconnected from society. These characters and its interaction with the individual’s preexist- show the reality of chronic methamphetamine ing genetic­ or behavioral vulnerability. So some of addicts, who are often multi-drug addicts. But these people, perhaps the most vulnerable, enter because they cannot pay for cocaine or heroin, the spiral of addiction and lose control over their

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Medicine in Television Series

drug use to the point of failing at work and dis- Republic and the Russian Federation, as well as connecting socially. developing countries in Africa and Central Amer­ ica.9 In Spain, methamphetamine consumption is Could Breaking Bad encourage low due to its high price, and seems to be linked methamphetamine use? above all to elitist use on the gay scene.7 Though the series deals realistically with meth- amphetamine addiction and its devastating ef- References fects, some believe that Breaking Bad may have 1. Rusyniak DE. Neurologic manifestations of chronic encouraged consumption of this drug. In 2014, methamphetamine abuse. Psychiatr Clin North Am. several articles appeared in the Spanish press in- 2013;36:261-75. dicating an increase in the confiscation of meth- 2. Piazza PV, Deroche-Gamonet V. A multistep general amphetamine in the UK and rising use in Ger­ theory of transition to addiction. Psychopharmacology (Berl). 2013;229:387-413. many in the past five years. For some, this fact 3. Drug Enforcement Administration (DEA). Metham- could be related to the series, while others claim phetamine situation in the United States. Drug intel- that “it is more correct to say that the series has ligence report. Washington, DC: U.S. Department of made people aware of this drug”.7 On the other Justice; 1996. 4. Drug Enforcement Administration (DEA). Office of hand, a report from the DEA indicated that the Forensic Sciences, Special Testing and Research number of methamphetamine-related incidents Laboratory. Methaphetamine profiling program, fourth in the US in 2012 was the lowest since 2008, the quarter CY2010. Washington DC; 2010. year the series started. So it does not seem to 5. Kalivas PW, Volkow N, Seamans J. Unmanage- have influenced in the consumption of this sub- able motivation in addiction: a pathology in prefron- tal-accumbens glutamate transmission. Neuron. stance. 2005;45:647-50. Though methamphetamine use could be 6. Matthews D. Here’s what ‘Breaking Bad’ gets right, dropping in the US, it remains high in Asia, and and wrong, about the meth business. The Washington worldwide consumption has become an epi- Post; 15 August 2013. 7. Navarro M. La devastadora droga de ‘Breaking Bad’ demic. According to the UN Office on Drugs and ya se toma en Catalunya. El Periódico; 21 November Crime (UNODC), it is estimated there are 25 mil- 2014. lion amphetamine users worldwide, a larger num- 8. UNODC. Annual Report 2008. Available at: www. ber than cocaine (14 million) and heroin users unodc.org/documents/wdr/WDR_2008/WDR_2008_ eng_web.pdf 8 (11 million). Furthermore, studies indicate that 9. UNODC. Annual Report 2013. Available at http:// methamphetamine synthesis and distribution has www.unodc.org/unodc/secured/wdr/wdr2013/ increased in countries such as Poland, the Czech World_Drug_Report_2013.pdf

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