Drug, Set, and Setting
Norman E. Zinberg, M.D.
7 Reflections on Social Policy and Drug Research
INDIVIDUALS WHO EITHER DO NOT USE intoxicants (whether alcohol
or illicit drugs) or who use them only infrequently in order to
keep up with their friends often fail to recognize that others
may benefit from regular, controlled use because it brings them
relaxation and a sense of freedom from inhibition. This lack of
understanding does not necessarily mean disapproval. At a cocktail
party someone who has an extra drink or two may be treated with
amused tolerance and, especially in middle-class circles, may
be looked after and even seen home safely. In other social groups
permission may be granted to "turn on" with marihuana,
take a sniff of white powder, or tell of an experience with a
psychedelic. Nevertheless, the general lack of understanding of
those who use intoxicants, particularly the illicit variety, has
led to public disapproval and moral outrage and to a desire to
prohibit drug use rather than find out how to bring it under control.
This prohibitionary attitude presents a major problem for contemporary
America in at least two ways.
First, the prohibition mentality directly opposes the interests
of most users, who place intoxicants near the top of their hierarchy
of values. According to interviews conducted with people who were
not specially selected because of their drug use, intoxicants
(and food) rank next to the two activities that Freud claimed
were the most important in life: "to work and to love. "
It is undoubtedly true that our commitment to work and thus to
self-esteem and our relationships with others are our overriding
daily concerns; much of our energy is spent in balancing, developing,
and at times deprecating them. Religion used to be considered
the third most important interest; but now the interest in intoxicants
and food has begun to claim that position. This concern for ingesting,
however, differs from interest in work and love in that most people
disapprove of it and hesitate to admit it to others or even to
themselves. Because society and therefore government reflect this
personal ambivalence, they have refused to invest the time and
thought that are needed to formulate coherent personal and institutional
policies about such substances.
The second aspect of the cultural problem results from the recent
very rapid growth of the use of intoxicants other than alcohol
and the timing and pace of their acceptance (or rejection) by
society. Since about 1962, America has been in the throes of a
drug revolution in which millions of people (in the case of marihuana,
57 million; psychedelics, 16.5 million; and cocaine, 22 million)
(Miller & Associates 1983) have tried substances that previously
had been used only by a very small minority who were easily dismissed
as deviant. By the early 1970s the enormous growth in the use
of psychedelics, marihuana, and especially heroin had led to the
creation, in the White House itself, of a Special Action Office
for Drug Abuse Prevention (SAODAP), and to the appointment of
the National Committee on Marihuana and Drug Abuse (the Shafer
Commission). The Shafer Commission, made up of distinguished and
acknowledgedly conservative (anti-drug) professionals from various
fields, issued two reports—Marihuana, A Signal of Misunderstanding
(National Commission on Marihuana and Drug Abuse 1973) and Drug
Use in America: Problem in Perspective (National Commission
on Marihuana and Drug Abuse 1972)—which considered the terrible
difficulties that could arise from the new and extensive use of
illicit substances. Nevertheless, their main message was a plea
that society come to grips with phenomena that were not going
to go away in the foreseeable future. These reports (whose antihysteria
message is central to this book) were also noteworthy because
they paid only slight attention to the use of cocaine. When they
were written, no one could have predicted that interest in cocaine
would expand as it has in the last few years.
Yet in the last twenty years use has not been confined to the
four drugs mentioned. Significant interest has also been shown
in amphetamines, PCP, and a variety of "downers" such
as Valium and Quaaludes. But the four waves of psychedelic, marihuana,
heroin, and cocaine use have been the most prominent, and they
have given rise to the speculation that our culture, in an unconscious
and inchoate way, is engaging in a vast experiment. A sustained
effort is being made by at least parts of the culture to "find
out" about various intoxicants and to see whether they can
be used in a controlled and reasonable manner, despite the public
wish that the use of such substances will go away.
Critique of Current Social Policy
Because this vast social experiment is going on, the question
of what our society is willing to pay for the regularization of
the use of any intoxicant must be raised and answered. It is certainly
clear that our present prohibitionist policy, which requires society
to regard all illicit drug users as criminals, deviants, or even
"miscreants," and which encourages physicians to diagnose
all such users as mentally disturbed, is being maintained at a
heavy cost. Nor has it been successful, if success is measured
by the number of smugglers and traffickers arrested, the number
of individuals who have been persuaded not to try illicit drugs,
the number of users who have been prevented from becoming compulsive,
and the number of compulsive users who have been induced to take
treatment. Moreover, debates over drug policy continue to ignore
two related factors that make the issue of permanent prohibition
largely academic. First, although drug use, like pregnancy, could
be avoided by abstinence, mankind has not yet opted for total
continence in the case of either drugs or sex. And second, the
attempt to prohibit the use of drugs in this country has not been
any more effective than the attempt to outlaw alcohol use in the
1920s.
The framers of current social policy, who hope to reduce the number
of users by restricting drug supplies and punishing any use, argue
that if there are fewer users there will automatically be fewer
cases of dysfunctional use (Moore 1982). For example, if there
are l0,000 users and 10% of them get into trouble, there will
be l,000 cases of misuse; but if the number of users is reduced
to 2, 000, there will only be 200 cases of misuse. This argument
implies a straight-line arithmetical relationship between use
and misuse, which does not exist. If the same type of argument
were applied to alcohol use, it might lead to the highly debatable
decision to raise the price of alcohol in order to discourage
use! A rise in price would discourage some use, which supposedly
would result automatically in fewer misusers. This, of course,
ignores the strong probability that only the less committed moderate
users who propound the social sanctions would be the ones discouraged.
Interfering with existing alcohol consumption patterns with the
aim of promoting reduced overall consumption rather than promoting
moderate controlled using patterns is different from the use of
formal legal controls with intoxicants where there has been little
opportunity for informal social controls to develop, as with heroin,
for example. However, by following the same mathematical argument
and adding the assumption that all users are misusers, advocates
of current social policy conclude that total prevention
of use is crucial because of the large number of users. What is
needed, they say, is not a reassessment of policy but more of
the same policy— that is, better law enforcement and stricter
penalties for trafficking and consumption .
But what have been the results of our present drug policy? Unsophisticated
anti-drug legislation has led to a loss of respect for the law
and the persistent flouting of it, to increased corruption among
enforcement and other public officials, and to a virtual consensus
among informed persons that although they may support these laws
in principle, they will go to great lengths to circumvent them
if a close friend or relative is involved. The labeling of individuals
as criminal who would otherwise not be so considered has been
more widespread under the drug laws than under the Volstead Act.
The huge majority of those affected are young, the penalties are
more severe and therefore more life-changing, and often the offender
is forced to choose either to be branded as a criminal or to submit
to "treatment." This choice, which ties the therapeutic
process to criminal justice, has bastardized and denigrated a
significant aspect of the mental health system and has had a profound
effect on the way the individual drug-taker functions in society
and views himself. These legal and social conditions have actually
affected mental health more severely than has the controlled use
of drugs themselves, and in some instances just as destructively
as compulsive use. Finally, it is likely that current social policy
is discouraging primarily those who use drugs only moderately,
while heavy users, to whom the substance is more vital, are flouting
the law in order to make their "buys." Thus, since it
is the moderate, occasional users who develop controlling sanctions
and rituals, the policy whose goal it is to minimize the number
of dysfunctional users may actually be leading to a relative increase
in the number of such users.
In 1972 the Shafer Commission recommended a change in our drug
policy in the direction of dealing with each intoxicant individually
and realistically. The Liaison Task Panel on Psychoactive Drug
Use/Misuse of the President's Commission on Mental Health made
a similar recommendation in 1978. In addition, the government's
White Paper on Drug Abuse (1975) and the Strategy Council
on Drug Abuse's Federal Strategy for Drug Abuse and Traffic
Prevention (1977), both of which were aimed at the elimination
of drug abuse, called for more distinctions between types of use,
acknowledging that the elimination of "drug abuse" from
our society was an unrealistic goal (1975) and that drugs were
"dangerous to different degrees" (1977). But the Shafer
Commission to a certain extent, and the President's Commission
on Mental Health to a much greater extent, went further. These
two commissions, which were well funded and had large staffs,
concluded not only that it was important to make distinctions
among different types of drugs and different types of use but
also that the failure to make such distinctions had resulted in
an extremely costly social policy, just as the Volstead Act had.
After the publication of the Shafer Commission's report in 1972,
about a dozen states decriminalized marihuana use; that is, while
continuing to impose criminal penalties for selling the drug,
they reduced the first-offense penalties for possession of small
amounts for private use to a fine similar to that for illegal
parking, without labeling the individual a criminal. Few authorities,
including the Shafer Commission, believed that this policy, which
punished the seller more than the buyer, would resolve the marihuana
issue. Decriminalization was intended as an interim solution:
it would buy time to see whether the use of this particular drug
could be integrated by society—that is, whether serious health
and social consequences could be avoided.
The Shafer Commission also gave the traditional conservative response
to the drug dilemma. Its members sought to delay major decisions
by calling for more research. They assumed, or hoped, that researchers
would come up with new facts that would provide clear, complete
answers to difficult issues of social policy—that new data would
magically eliminate the necessity for difficult intellectual or
moral choices. Research might even show that the nonmedical use
of drugs was severely damaging to health!
The experiment of decriminalization itself did provide critical
data. Studies done in several states, notably Oregon (Marihuana
Survey—State of Oregon 1977), California (Impact Study
of S. B. 95 1976), and Maine (An Evaluation of the Decriminalization
of Marihuana in Maine 1978; Maine: A Time/Cost Analysis
of the Decriminalization of Marihuana in Maine 1979), indicated
that the use of marihuana had not increased at a significantly
greater rate since decriminalization and that some law-enforcement
resources had been freed to deal with more serious criminal activities.
But in spite of this evidence, drug policy did not change in such
a way as to encourage the establishment of formal social controls;
that is, it did not encourage the passing of new laws and institutional
regulations. Instead, it tended to move in the opposite direction.
Several papers appeared claiming that marihuana presented greater
health hazards than had been previously supposed. The validity
of these studies, apart from those showing that the drug may cause
lung damage as severe as that caused by tobacco and that it is
probably bad for heart patients, is at best debatable (Marijuana
and Health 1982). But even more damaging to those who hoped
to move away from the policy of total prohibition was the appearance
of survey research indicating that the age of first use of marihuana
had dropped substantially and that heavy use among the younger
groups had increased substantially. These findings led to the
formation of parents' organizations that worked to "save"
their children by campaigning for "education and prevention"
(anti-marihuana indoctrination and prevention of all use) and
by advocating stricter penalties and more stringent law enforcement.
These groups were very effective in bringing direct pressure to
bear on political officials to put their wishes into action.
Interaction of Formal and Informal Controls
One of the implications of my research on the controlled use of
intoxicants is that in the absence of reasonable formal social
controls, the age of first use will tend to drop. This is because
informal social controls—sanctions and rituals—are
less effective when there are no acceptable formal social controls
to support them. (As it happened, in 1979, 1980, and 1981 the
earlier drop in the age of first marihuana use was reversed; whether
this resulted from increased anti-marihuana activity or whether
even under unfavorable circumstances some informal social controls
were beginning to function is a question for later evaluation.
)
The relationship between formal and informal controls is astonishingly
complex. There are two kinds of formal controls: those enacted
by law and those provided by controlling institutions. A high
school, for instance, can forbid the consumption of alcohol at
a senior prom and punish those who disobey—even if some students,
according to state law, are old enough to drink. Similarly, such
an institution can expel a marihuana user even though the state
has decriminalized use. An example of the interaction between
an informal control and a formal control is the case of the boy
who is nineteen and legally entitled to drink, who happily gives
a beer to his eighteen-year-old brother but will not give one
to his thirteen-year-old brother.
The absence of any clear formal standard for marihuana use, such
as an age limit, has led youngsters to think that they can lower
the actual age of first use without arousing concern or opposition.
These youngsters know that even though society has outlawed marihuana,
the effect is not the same as if the drug were socially unavailable.
Very different degrees of deviance and of punishment are involved.
At the same time, official disapproval of marihuana use, for example,
by those under eighteen may be more effective than all-out prohibition
in setting discriminating standards. The high-school rule that
forbids the consumption of alcohol at a senior prom does not forbid
students to drink on all social occasions. The rule does indicate,
however, that it is neither safe nor appropriate for them to drink
if they cannot control their use. In the same way, the social
sanction "Know your limit" does not condemn drinking
but does condemn drunkenness.
The interaction of formal and informal social controls is most
crucial in the case of young adolescents . In the first place
it has been traditional in our society for this age group not
to be allowed to use any intoxicants, licit or illicit. Second,
when they do experiment with illicit drugs (and such use always
goes on underground), it is particularly difficult to set standards
for use, either formal or informal (parental). Many parents have
said that they can deal more easily with their children's tobacco
smoking than with their marihuana smoking. As one parent put it,
"We can at least talk about cigarettes. I can bribe, wheedle,
cajole, or threaten. But with illicit drugs there is a code of
silence. I'm afraid that this attitude may move over to alcohol,
which we used to be able to talk about." As has been noted
in earlier chapters, parents today are in a very difficult position
in relation to illicit drug use. In regard to the licit drug,
alcohol, they have a much easier task, for the formal social controls
associated with it (such as a legal age limit), insofar as they
promote safety, often match the parents' aims, and thus many families
can inculcate and strengthen their own informal sanctions and
rituals about its use.
In the case of illicit substances, institutional controls can
at least offer some help. A secondary school, by enforcing such
formal controls as the banning of illegal alcohol and drug use
while at the same time offering a reasonable educational program
about these substances, can strengthen the parents' hands. Then
youngsters eager to experiment cannot claim, ' It must be OK any
time, any place, because even the school doesn't make a fuss."
Such attempts at institutional regulation give the parents the
opportunity to think through with their children such questions
as what intoxicants to use, where, when, how, and with whom—questions
that are critical to the development of both formal and informal
controls.
Drug Research and Social Policy
Because current social policy is aimed at decreasing the use of
illicit substances (Report of the Liaison Task Panel 1978),
the question arises whether research efforts must adhere to this
policy in order to be considered ethical. If research is to be
judged in ethical terms, and to a large extent it is, what effect
does this have on the selection of research projects to be funded,
how the research is done, and how the findings are treated by
the public, as represented by both professionals and the media?
Almost everyone doing drug research would agree that it is extremely
difficult to have one's work in this field perceived as objective
and relatively value-neutral. Not only do popular presentations
of any information about drugs insist on a "balance"
that includes specific "anti-drug" material, but often
scientific programs have been obliged to follow a similar procedure.
In this kind of climate almost any work or any worker is quickly
classified as being either "for" or "against"
use, and halfway positions are not acknowledged. A diehard advocate
of the National Organization for the Reform of Marihuana Laws
(NORML), for example, will dispute any evidence that marihuana
use can be disruptive. At a recent scientific meeting, when it
was suggested that marihuana users should not drive when intoxicated,
several floor discussants were quick to point out that some experienced
users claim they can drive better when intoxicated. Conversely,
a later statement that no deaths had been attributed to marihuana
use during the past fifteen years, although over fifty-seven million
people had used the drug in that period, was greeted by a retort
from the floor that marihuana is not water-soluble and therefore
is retained in the body. This reply was obviously not intended
to counter the original statement but merely to show that no one
could get away with saying something good about marihuana.
It is easy to ridicule these extreme positions, but the ethical
issues themselves are serious; and the results of publicizing
and exploiting drug effects in order to make use glamorous, in
the Timothy Leary fashion, have given rise to grave concern. There
is little doubt that the explosion of LSD use in the sixties was
touched off by the wide publicity given such use. Although this
explosion did not result primarily from the presentation of drug
research, the drug hysteria very quickly affected research, as
was evidenced by the declaration of one previously objective inquirer
that he was setting out to prove the drug's potential for harm
(Cohen, Marinello & Bach 1967; Cohen, Kirschhorn & Frosch
1967). Since the appearance of this kind of attitude—and it
has surfaced in many places, including even the premises of the
National Institute on Drug Abuse (1977, 1980; Johnston, Bachman
& O'Malley l982)—every researcher has had to consider whether
his work is more concerned with discouraging use than with looking
for the facts.
Truth in its basic sense is not the issue. Probably no one in
the field, no matter how misguided he or she may be thought to
be, has set out purposely to falsify the facts. But within a certain
framework of values—the outlook that any illicit drug is so
bad that efforts to prove it so are legitimate and serve the greater
good—the search for truth tends to become deductive rather than
inductive. And since all scientific inquiry must begin with an
operating hypothesis, the issue of the aims of research is not
a black and white matter. It raises the subtle question whether
the culture's current policy of attempting to reduce illicit drug
use should be allowed to outweigh objectivity. Researchers who
treasure objectivity and neutrality and who accurately present
their data, whatever these are, may end up carrying on work that
contravenes dearly held cultural beliefs. These beliefs are felt
to be sacrosanct because they supposedly help to prevent something
bad from taking place, namely, an increase in illicit drug use.
As mentioned in the preface, in 1968, when Andrew T. Weil and
I with Nelsen began to conduct the first controlled experiments
in administering marihuana to naive subjects in order to study
the effects of acute intoxication (Weil, Zinberg & Nelsen
1968), we were heavily criticized. Our critics thought that if
marihuana should prove to be as dangerous to health as many people
believed it was, we would be running the risk of addicting or
otherwise damaging innocent volunteer subjects. But we were also
told by many (most amazingly, including a senior partner in the
law firm representing Harvard Medical School) that if marihuana
should not turn out to be so deadly, our findings could be morally
damaging because they would remove the barrier of fear that deterred
drug use. It is, of course, impossible to say whether these experiments
and others that produced similar findings were significant in
increasing the popularity of drug use. Even in 1968, when the
experiment took place, it was clear that marihuana was not the
devil drug of "Reefer Madness. " During that initial
period of criticism (and ever since then) Weil and I believed
that supplying credible and responsible information about the
drug was essential, whether that information supported our biases
or not.
In this field, those who either withhold or distort information
in order to support the current social policy run the risk that
potential users will detect this falsification and then will tend
to disbelieve all other reports of the potential harmfulness of
use (Kaplan 1970; Zinberg & Robertson 1972). Conversely, those
presenting the information that not all drug use is misuse, thus
contravening formal social policy, run the equally grave risk
that their work will be interpreted and publicized as condoning
use.
It is a frightening dilemma for a researcher, particularly for
one who cannot believe that the truth will set one free in some
mystical, philosophical way. Of course, neither can one believe
that hiding facts, hiding the truth, will make everything come
out all right. And when the research concerns powerful intoxicating
substances, abstract principles about truth and objectivity are
not all that is involved: human lives are at stake.
It was relatively easy to face up to the criticism of our marihuana
research. The growing popularity of the drug was evident, no fatalities
from its use had been reported, and there was a need for more
precise information about its effects in order to differentiate
myth from fact. For example, at that time police officers and
doctors believed that marihuana dilated the pupils, and this misconception
had to be cleared up because it was affecting both arrests and
medical treatment. But when it came to studying drugs like heroin,
whose physical properties, unlike those of marihuana, can cause
disastrous effects if control is not maintained, the ethical problem
grew more serious. Moreover, the effort to inform the professional
community and also the public (by way of the media, to which anything
in the drug area is good copy) that heroin use is not inevitably
addicting and destructive involved the risk of removing that barrier
of fear that might have deterred someone from using. This has
been and continues to be a tormenting possibility. However important
knowledge may be, research cannot be countenanced if subjects
are not protected from the harm that may be caused by it, either
directly or by withholding information—as, for example, in the
case of the unfortunate U.S. Public Health Service research on
syphilis, which withheld a treatment long after it had been proved
effective (Hershey & Miller 1976).
Nevertheless, even my preliminary investigations of heroin and
other opiate use confirmed what had been found in every other
investigation of drug use: that the reality was far more complex
than the simple pharmacological presentation given in medical
schools. Certainly, heroin is a powerfully addicting drug with
great potential for harm, but some users managed to take it in
a controlled way, and even those who did get into trouble displayed
patterns of response very different from those of the stereotypical
junkie. In addition, other investigators, such as Leon Hunt and
Peter Bourne, were beginning to report similar phenomena (Abt
Associates 1975; Bourne, Hunt & Vogt 1975; Hunt & Chambers
1976). Once it became clear that these phenomena were extensive
and significant, it was also clear that any attempt to remove
such behavior patterns from the scientific purview because they
were morally reprehensible or socially disapproved would reduce
the credibility of all scientific enterprise. Further, it was
possible that these heroin users, in the process of controlling
their use, had developed a system of control that could be an
extremely valuable basis for designing new approaches to the treatment
of addiction (Zinberg, Harding & Winkeller 1981; Zinberg,
Harding & Apsler 978; Zinberg et al. 1978; Zinberg & Harding
1982).
That such research has a potentially positive application and
is not for information alone does not, however, figure in the
principle of what makes work scientifically acceptable. Basic
research needs no defense here. But the way in which the work
is received and treated, particularly by the media, can raise
grave problems. Though researchers may be as accurate and careful
in their statements as possible, they cannot control what others
say or do with the information. Yet in the present climate of
emotionalism about drug research, they would be naive indeed if
they did not realize that certain findings are susceptible to
distortion by the press. Unfortunately, several researchers have
called press conferences before publication in order to herald
their findings (New York Times 4 February 1974 and 9 April
1974), and they have not been unwilling to venture into far-reaching
speculations that go well beyond the published data.
It is not enough to avoid carelessness in one's work and the reporting
of it. Researchers must also do their best to avoid causing those
who would not otherwise use drugs to do so. One way to shift attention
away from the preoccupation with illicit use is to emphasize the
potentially positive application of the work. Even here, however,
the researcher who discusses his work as a therapeutic aid can
run into another brand of sensationalism and misrepresentation.
The difficulty of defining and maintaining objectivity and the
ethical problems associated with carrying out certain research
and imparting its results are not confined to research on illicit
drugs. Few investigators today, when individuals are faced with
an overwhelming number of choices, are able to preserve the image
of the disinterested scientist actuated solely by dedication to
the purity of science. A searching article by a prominent jurist,
David L. Bazelon, published in Science in 1979, comments
on matters that are pertinent to this discussion even though it
does not mention illicit drug use specifically:
In reaction to the public's often emotional response to risk,
scientists are tempted to disguise controversial value decisions
in the cloak of scientific objectivity, obscuring those decisions
from political accountability.
At its most extreme, I have heard scientists say that they would
consider not disclosing risks which in their view are insignificant,
but which might alarm the public if taken out of context. This
problem is not mere speculation. Consider the recently released
tapes of the NRC's deliberation over the accident at Three Mile
Island. They illustrate dramatically how concern for minimizing
public reaction can overwhelm scientific candor.
This attitude is doubly dangerous. First, it arrogates to the
scientists the final say over which risks are important enough
to merit public discussion. More important, it leads to the suppression
of information that may be critical to developing new knowledge
about risks or even to developing ways of avoiding those risks.
Who is willing today to assume the responsibility for limiting
our scientific knowledge? The consequences of such limitation
are awesome. The social risk of opening up areas of research on
heroin use can hardly be equated with the frightening consequences
of failing to disclose problems associated with nuclear reactions,
but the principles are similar. It is understandable that government
agencies, already overwhelmed by the number of factors that must
be considered before reaching a decision, and buttressed by the
righteous sense that what they are doing is for the public good,
would want to protect society from the confusion that might be
engendered if still more controversial information were made public.
In principle, a bureaucracy wants to get all the information possible,
but once it has settled on a course or a value position, it believes
that new information raising further doubts may lead to greater
risks and therefore should be kept quiet. As our cultural belief
in the disinterested scientists wanes and our disillusion with
the omnipotent court decision as a righter of wrongs grows, bureaucratic
paternalism becomes the obvious alternative. But unfortunately,
when the governmental acceptance of responsibility for a decision
shifts to the assumption that the belief that supports a decision
(illicit drug use is bad) is more important than the decision
itself, there is bound to be difficulty in achieving a flexible
social policy. This is exactly what has happened to the policy
on illicit drugs.
Bazelon (1979) makes another point that upholds my position as
well as that of John Kaplan (1970, 1983) and other researchers
(McAuliffe & Gordon 1975; Herman & Kozlowski 1982; Waldorf
& Biernacki 1982). Regulations that attempt to limit risks
have their own social cost. This does not mean that we should
not have regulations. But there must be a keen assessment of the
risk cost of the regulations themselves. This is especially true
in the area of drug use, where much of the damage being done today
results from the illicit status assigned to marihuana and heroin
and not from their pharmacology.
Policy Proposals
Many experts who have offered critiques of our current drug policy
have made the radical proposal that all illicit drug use should
be either decriminalized or legalized. A case in point is Thomas
Szasz's laissez-faire approach (Szasz 1975). However, as John
Kaplan (1982) and Mark H. Moore (1982) have pointed out in recent
articles, such an approach would increase the number of drug users
and consequently, at the very least, the absolute number of drug
casualties. Because of this risk a more cautious approach to change
is needed, and one that offers a responsible and workable alternative
to the present policy of prohibition.
The leading recommendation to come from my years of research on
controlled drug use is that every possible effort should be made—legally,
medically, and socially—to distinguish between the two basic
types of psychoactive drug consumption: that which is experimental,
recreational, and circumstantial, and therefore has minimal social
costs; and that which is dysfunctional intensified, and compulsive,
and therefore has high social costs (Report of the Liaison
Task Panel 1978). The first type I have labeled "use
and the second type "misuse" or "abuse."
In order to distinguish use from misuse, greater attention will
have to be paid to how drugs are used (the conditions of
use) than to the prevention of use. Researchers must study both
the conditions under which dysfunctional use occurs and how these
can be modified and the conditions that maintain control for the
nonabusers and how these can be promulgated. The goal of prevention
should not be entirely abandoned, but emphasis should be shifted
from the prevention of all use to the prevention of dysfunctional
use. When this new focus is adopted, policymakers may decide not
to treat all intoxicating substances as if they were alike. Careful
studies of the use of various kinds of drugs and of the varying
conditions of use may reveal the need to create a different policy
strategy for each type of drug.
To study the conditions of use for each drug will require consideration
of the following topics: dosage, method of administration, pattern
of use (including frequency), and social setting, as well as the
pharmacology of the drug itself. Consider, for example, the question
of frequency of use. It is only at the extremes that frequency
is not necessarily related to the harmfulness of a drug, as described
in chapter 2. A policy aimed solely (or mainly) at reducing frequency
would not only mask the significant differences between the drugs
themselves but would deny the importance of the social setting,
including when, where, and with whom the drug is used. These social
factors, which may vary across cultural and ethnic lines, combine
with frequency and quantity of use to determine the quality of
use. A policy aimed at encouraging a shift from those drugs that
are generally considered to be the most harmful to those that
on all counts are the least harmful (even though some may at present
be illicit) would result in a considerable reduction in social
cost.
Further study of those conditions and patterns of drug consumption
that enable users to establish and maintain control will underscore
what my research has already suggested—that significant informal
social controls over illicit drug use are now in the process of
development. Drug policy should encourage the development and
dissemination of these controlling rituals and social sanctions
among those who are already using drugs, while at the same time
continuing to discourage the general use of illicit drugs. The
aim of this strategy would be to alleviate the worst effects of
the current social setting on drug-takers without greatly increasing
access to drugs.
Informal social controls cannot be provided to users ready-made,
nor can formal policy create them. They appear naturally in the
course of social interaction among drug-takers, and they change
gradually in response to changing cultural and subcultural conditions.
This is the primary reason why any abrupt shift in present policy
would be inappropriate. The sudden legalization of marihuana,
for instance, would leave in limbo those who have not yet had
the time to internalize informal social controls. There are, however,
several steps that can be taken now to demystify drug use and
thus to encourage the development of appropriate rituals and sanctions.
These steps include disseminating information (education), improving
treatment programs, encouraging medical research, correcting negative
attitudes toward drug users, and undertaking legal reform. The
first two of these steps, education and treatment, will be discussed
in some detail.
Education and Prevention
Many policymakers have assumed that behavior can be shaped by
providing individuals with "information" on the consequences
of behavioral decisions. The emphasis, however, has always been
placed on the prevention or avoidance of behaviors presumed to
have a negative impact on the individual or society. Such information
has frequently been laden with ethical and moral judgments so
that the "proper" decision for the individual has been
preordained.
Drug abuse education and prevention efforts in the United States
have burgeoned since 1968, coinciding with the rapid increase
in the use of illicit psychoactive substances, starting with marihuana
and LSD. Between 1968 and 1973, for example, the National Institute
of Mental Health produced and distributed more than twenty-two
million pamphlets on drug abuse and supplemented this effort with
a continuing mass-media public-service campaign. During that same
period departments of mental health in the individual states initiated
drug education programs, and many of the 17,000 school districts
in the United States followed with their own drug education efforts.
The Advertising Council, a national body representing the advertising
industry, estimated that the value of time and space donated by
the private sector for the dissemination of drug information approached
$937 million in 1971. In addition, numerous drug education programs
were conducted by churches, civic groups, businesses, national
voluntary organizations, and the military services. It was, as
President Nixon had proclaimed, an all-out war on drugs, with
education and prevention efforts centering on the elimination
of illicit psychoactive drug use.
Both the private and the public agencies that promoted drug education
added their own values to their educational materials, often distorting
the information and discrediting its sources. In 1973, when the
National Coordinating Council on Drug Education reviewed 220 drug
education films for accuracy and appeal (Drug Abuse Films
1973), it found that 33% of the films were so inaccurate or distorted
as to be totally unacceptable, 50% were not suited for general
audiences unless a skilled instructor was present, and only 16%
were scientifically and conceptually acceptable. Another government
publication, Federal Strategy (1977), noted that even the
best factual information often helped to stimulate curiosity about
drugs, and that curiosity was becoming a major cause of experimentation.
According to the Shafer Commission, these massive efforts, focused
exclusively on promoting abstinence, may have actually increased
psychoactive drug use.
In 1973 the Shafer Commission drew two conclusions about drug
education and prevention programs: most information in the field
was scientifically inaccurate; and most education programs were
operating in total disregard of basic communication theory. The
commission recommended a moratorium on all drug programs in the
schools until existing programs had been evaluated and a coherent
approach with realistic objectives had been developed. A federal
moratorium on drug abuse prevention materials was ordered in the
same year.
New federal guidelines were issued in 1974, emphasizing the notion
that it was possible to develop "discriminating" materials
that could reinforce or encourage drug-free behavior. Presumably,
these materials would delete all references to the positive reasons
given by individuals for using drugs, would avoid differentiating
between the relative benefits and harms of a variety of drugs
and patterns of use, and would emphasize the values of a drug-free
existence. This sounded strangely like the approach abandoned
in 1973, except that the new thrust would be labeled "discriminating
and sophisticated."
A discussion of recent national education and prevention strategy
is contained in an interagency report, Recommendations for
Future Federal Activities in Drug Abuse Prevention (Cabinet
Committee 1977), prepared in 1977 with the National Institute
on Drug Abuse as the lead agency and presented as a "major
refinement" in federal prevention-policy development. The
federal strategists suggested three ways to reduce what they called
drug casualties: limit the variety of drugs used, reinforce the
drug-free experience, and reduce the frequency of use. The focus
on prevention activities, they believed, should be on the drug
use that had the highest social cost, as well as on the general
drug-taking experience; the main efforts should be directed toward
moderating the effects of taking drugs. The strategists, accepting
adolescent experimentation with psychoactive drugs as part of
the normal maturing process, did not view such experimentation
as particularly distressing. The overall objectives of the federal
government, they said, should be to reduce the number of new users
(incidence), to delay incidence, and to reduce frequent or daily
use. Their report suggested the following specific targets (Report
of the Liaison Task Panel 1978):
to reduce the percentage of frequent users of three gateway drugs
(tobacco, alcohol, and marijuana) by 15% among 8- to 20-year-olds;
to reduce the destructive behavior associated with alcohol and
other drug abuse by 20% among 14- to 20-year-olds as evidenced
by a reduction in overdose deaths, emergency room visits, DWI
[driving while intoxicated] arrests, and other alcohol/drug-related
accidents;
to promote and reinforce restraining attitudes toward the use
of psychoactive substances, especially use of the gateway drugs,
by maintaining current levels of awareness regarding the addictive
nature of heroin and alcohol, and by raising the awareness level
of the addictive nature of tobacco by 50%.
That drug education and prevention programs should be broadened
to include alcohol and tobacco (the first two psychoactive substances
used by most youngsters) has also been indicated by my research.
To ignore them would destroy the credibility of such programs
because, although these drugs are legal, they are certainly drugs,
are certainly intoxicants, and are certainly psychoactive—and
yet alcohol may be useful. Moreover, the reasons why society is
able to exercise some control over alcohol use but is not able
to exercise control over tobacco use should be made an important
focus of educational efforts.
My research findings also suggest that attention should be given
to the various patterns of use that may be followed for different
types of drugs, and to the consequences of these differing use
patterns. Then more sophisticated educational efforts can be made
to reduce destructive drug-related effects, such as overdose deaths,
accidents, and arrests for driving while intoxicated; and these
efforts can be conjoined with those aimed at reducing alcohol-related
effects. For such campaigns to be credible and successful they
must recognize that there is an enormous difference between drug
use patterns that have potentially dangerous consequences and
those more common, controlled patterns of use that are not destructive
per se. Drug-using behavior that impinges upon public safety must
be strongly discouraged, but this presumes public acceptance of
the notion that not all psychoactive drug use is destructive.
In those health and mental health areas that are unrelated to
drug use it is common for prevention efforts to be aimed at positive
outcomes as well as at the avoidance of deleterious consequences.
For example, although our society does not condone teenage sexual
activity, it has decided that those who are unwilling to follow
its precepts should be given the basic information needed to avoid
disease and unwanted pregnancy. Drug education and prevention
efforts should do no less. They should provide information on
how to avoid the effects of destructive drug combinations (for
example, barbiturates and alcohol), the unpleasant consequences
of using drugs of unknown purity, the hazards of using drugs with
a high dependence liability, the dangers of certain modes of administration,
and the unexpected effects of various dose levels and various
settings. These potential hazards are a particular threat to youthful
experimenters, who unwittingly expose themselves to a wide range
of untoward drug reactions. Does society really wish to continue
tolerating education and prevention strategies that suppress information
which could help hundreds of thousands of youngsters stay out
of trouble? The posture that "they deserve what they get"
is no longer tenable, and it is no longer officially espoused.
Yet the fear still remains that if our education and prevention
efforts do not condemn intoxicating substances, then potential
users may interpret the lack of condemnation as tacitly condoning
drug use. This dilemma has inhibited effective teaching in the
drug area.
These recommendations for a change in the purpose and content
of drug education programs apply equally well to some of the "new"
prevention efforts that claim to represent a major departure from
traditional approaches. One of the most prominent of these programs
advocates the theory of a drug-free existence by promoting interest
in such "natural highs" as yoga, meditation, and other
nonchemical experiences. But many parents would rather have their
children receive information on the responsible use of marihuana
than be encouraged to seek "higher" states of consciousness.
These parents may be skeptical about drug use, but they are also
uneasy when traditional education promotes nonchemical highs.
A further problem with the so-called natural high is that it may
not be regarded by adolescents as equivalent or superior to a
drug-induced high. And even when the two are experienced as similar,
many adolescents may seek to expand their repertoire of ways to
get high rather than abandon drugs. Several years ago, when an
exclusive preparatory school was considering the pros and cons
of building an expensive swimming pool, it was persuaded that
swimming would provide a recreational alternative to drug use.
After the decision to build was announced, the administration
was shocked to hear several students expressing joy at the prospect
of swimming while stoned! It is not surprising that if adolescents
find they cannot get high on swimming or in some other "natural"
way, they may turn to drugs to achieve that well-advertised state.
Another relatively new drug education strategy has turned away
from the earlier emphasis on the direct transmission of information
through drug courses by offering the same information in courses
on family development, nutrition, hygiene, safety, or interpersonal
relationships. Although this diffuse educational approach relies
upon different techniques, the message is the same. The older
line that psychoactive drug use is destructive has simply been
carried over into "values clarification." This new approach
also overlooks distinctions between drug use and misuse, and it
does not offer information on how to minimize or avoid drug-related
difficulties.
If the "facts" about the consequences of drug use fail
to convince the potential consumer of the impending peril, should
these so-called facts be doctored to fit the policy, or should
the policy be changed to fit the real facts? Prevention strategies
talk about the need to develop more "persuasive" lines
of communication and more "discriminating" materials.
But doesn't this mean not just presenting the facts in a more
attractive package but also altering them or suppressing helpful
information? Wouldn't it be better to recognize explicitly the
benefits some individuals get from some psychoactive drugs, licit
or illicit? Or are we to continue to accept the notion that illegal
drugs are ipso facto harmful, quite apart from the way in which
they are used? Understandably, the legality-illegality quandary
is especially difficult for drug educators to handle.
Several obstacles must be overcome before drug education and prevention
can proceed from realistic premises. The foremost obstacle is
the lack of knowledge on the part of those who are the most involved
in educational efforts, particularly the physicians. Medical students
are trained to view all nonprescribed drug use as misuse or abuse.
A survey of medical school courses has shown that they deal only
with the pathology of extreme drug consumption, including alcoholism,
and neglect the possibility of controlled use and moderation.
Hence physicians are often unable to answer patients' inquiries
concerning different patterns or frequencies of use. Unless physicians
are taught to differentiate between the various drugs and their
effects, their patients' questions will remain unanswered. Medical
education should be broadened to include comprehensive information
on the effects of psychoactive drugs, the various patterns of
use (including alcohol use), and the factors that promote control,
as well as the signs and symptoms of dysfunctional use. Physicians
would then be in a position to predict positive outcomes, counsel
the avoidance of deleterious consequences, and give early diagnoses
of drug-related dysfunctional behaviors. Physicians and other
health professionals must be taught to recognize the subtle, individual,
drug-related behavioral changes that foreshadow serious dysfunctions.
They must also learn to identify the consequences of the differing
patterns of use, ranging from the experimental to the compulsive,
and to understand that not every nonmedical use of drugs is necessarily
dangerous.
It is important that the use of psychoactive drugs for mind and
mood alteration be considered in a social, scientific, and literary
context. Educators should be familiar with the historical importance
of the opium wars, the traditional ritualistic use of various
psychoactive drugs, and the literary allusions to drugs by such
great writers as Homer, Ovid, Baudelaire, de Quincey, and Coleridge.
Then students will learn that man has always had psychoactive
drugs at his disposal, that attitudes toward them have been constantly
shifting, and that such drugs have been used for a variety of
purposes. As the emotionalism surrounding drug use recedes, it
will be possible to build such an approach into the educational
process.
Treatment Systems
Because the focus of my research was on controlled use and controlled
users relatively little attention has been paid in this study
to dysfunctional users and their obvious need for treatment and
regulation. My long-term contacts with such users have revealed
that today the drug treatment system is caught in a confusing
dilemma about what it is supposed to be treating. The formal institutional
structures of the system are not only unwilling to explore the
distinction between the use and misuse of psychoactive drugs but
do not know whether they are treating drug abuse or crime. Who,
in fact, is to identify and pass judgment on the adverse consequences
of drug use—the patient, the physician or counselor, or the
agencies affiliated with the criminal justice system? The law
labels any use of illegal psychoactive substances misuse (or abuse),
while the medical establishment calls only nonmedical use misuse.
Thus, by legal definition, any psychoactive drug use is seen as
demanding legal intervention, while by medical definition any
nonmedical use necessitates medical treatment.
All treatment programs, including so-called methadone maintenance,
are abstinence-oriented, differing only as to the time period
permitted to achieve that goal. This has not always been the case.
The pioneer Dole-Nyswander projects on methadone maintenance (Dole
& Nyswander 1965, 1966, 1967; Dole, Nyswander & Warner
1968) were designed as genuine maintenance programs. Although
the patients' addiction to opiates (especially heroin) was initially
replaced by addiction to methadone, the project workers expected
that eventually the compulsive use of methadone would change to
controlled use and that this improved situation would become the
basis for social and psychological rehabilitation. Thus the use
of a substitute drug was not the dominant factor. Methadone had
several advantages: it could be taken orally, was long-lasting,
seemed not to interfere with the individual's capacity to function,
and, above all, was legal. But the basic aim of the program was
to establish a clinical situation (controlled use of a substitute)
in which patients freed from heroin addiction would be able to
think through their problems and gain confidence in their capacity
to manage their inner state and function reasonably well in society.
From the start, maintenance programs were highly controversial
because of their retreat from abstinence and the introduction
of a synthetic opiate. Since it was necessary to present some
justification for their use, and since crime and drugs were being
linked as the nation's number one domestic problem, it seemed
reasonable to measure "treatment success" in terms of
a reduction in arrest rates and criminal activity. Justifying
treatment in this way made the use of a synthetic drug to treat
heroin addiction more acceptable to those who saw abstinence as
the only acceptable solution.
As a matter of fact, the initial evaluative studies showed that
patients on methadone maintenance did improve considerably according
to most social indicators. These studies, coupled with political
pressure to do something about crime, led to a tremendous expansion
of this treatment system. Methadone maintenance, which had been
conceived originally as a medical treatment for voluntary patients,
was presented to the public as a means of stopping drug abuse
and crime by getting deviants off the streets.
Today the term methadone "maintenance" is a misnomer.
Methadone treatment clinics have changed radically in that they
have become openly abstinence-oriented. By federal regulation
they are required to have physicians and nurses to dispense the
medication. Some also offer a variety of ancillary services, such
as vocational rehabilitation and individual and group counseling.
The other broad class of treatment programs, the various nonprofessional
therapeutic communities, have always had goals that are wholly
compatible with those of the larger society. They have aimed to
eliminate drug use and have assumed that once abstinence was achieved,
the client would become a model citizen. The early communities
dealt with a few carefully selected, voluntary, heroin-dependent
clients; but when enrollments burgeoned in the late 1960s under
the pressure of the "drug epidemic," these communities
began to test the client's motivation to rid himself of heroin
use by putting obstacles in the way of his enrollment, in much
the same way that a fraternity ritual screens candidates. It was
assumed that if the individual could overcome these obstacles,
his desire to become drug-free was genuine.
Therapeutic communities stress self-help, as does Alcoholics Anonymous;
and in order to reinforce drug-free behavior they encourage intense
interaction within the group and enforce firm rules of conduct
by punishing infractions. The community setting promotes reform
of the individual, not only by helping him to overcome drug dependency
but by giving him a positive image of himself. Nevertheless, becoming
socialized in the hothouse atmosphere of a therapeutic community
does not guarantee success in the larger society. Initially, during
the period of rapid growth of such heroin treatment programs,
many successful "graduates" were able to remain in the
field, working as counselors or administrators. Later on, when
the employment opportunity disappeared and "graduates"
had to return to the broader community for employment, they found
it increasingly difficult to survive. One early community, Synanon,
at one time tried to respond to this problem by developing self-contained
communities where individuals lived and worked, abandoning reentry
to society. Follow-up studies confirm that the self-help techniques
of therapeutic communities can be beneficial, but retention rates
are far lower than those of methadone programs.
The confusion about the goal of drug treatment programs—whether
it is to cure drug dependency or to reduce criminal activity—worsened
in the 19705 because of the increasing use of the nonopiate psychoactive
drugs (cocaine, Quaaludes, Valium). These were assumed to have
the same effects and consequences as the opiates—dependence
liability, amotivation, and crime—and therefore the solutions
were seen as the same: either to send users to jail or to remand
them to treatment. The spread of such drug use among youth, added
to the continuing heroin "epidemic, " led to the rapid
expansion of what the Shafer Commission termed a "drug abuse
industrial complex." The budget for treatment services funded
by NIDA grew from $18 million in 1966 to $350 million in 1977,
shrinking to $155.4 million for fiscal 1981, with a total of 3,449
drug treatment centers and a static treatment capacity of 208,000
slots, of which federal funding provided approximately 102,000.
But unfortunately the commitment to treat all psychoactive drug
users ignored the essential differences among the various types
of drugs and their using patterns.
The treatment services required for opiate dependents differ from
those needed for users of other drugs. Services are also needed
for those clients with emotional difficulties that are unrelated
to drug use. With the trend toward polydrug use, there is a greater
need than ever to integrate and coordinate drug treatment services
with the broader health and mental health delivery systems to
meet a variety of diverse client problems. According to data from
the National Institute on Drug Abuse (Miller & Associates
1983), for the year 1981, 15.1% of all clients entering drug treatment
programs reported no use of their drug during the month prior
to admission; 5.9% had used it less than once a week; and an additional
5.1% had used it only once a week. Among those clients who did
not take opiates, 19.1% used marihuana, 8.5% alcohol, 7.7% amphetamines
(nonprescribed), and 5.8% cocaine; the use of inhalants (1.1%),
barbiturates (nonprescribed) (2.9%), hallucinogens (4%), and other
sedatives and hypnotics (3.1%) ranked lowest (Miller & Associates
1983). All of these nonopiate users required treatment that was
drug-free.
Similar treatment problems exist with regard to the legally prescribed
amphetamines, barbiturates, and minor tranquilizers. Users of
these drugs, which have a high dependence liability, may require
hospitalization for detoxification. Because they tend to be far
more emotionally disturbed than opiate users (Benvenuto &
Bourne 1975; Khantzian 1978; Smith l975b; Vaillant 1978), their
needs are only superficially addressed by the typical drug treatment
program; and yet they do not readily fit into any of the other
conventional areas of mental health treatment. It is likely that
they could be more effectively served in a community mental health
setting if space and expertise were available. Then drug treatment
slots and funds could be exclusively devoted to providing services
for clients who are suffering from the dysfunctional effects of
chronic and long-term use of the opiates.
Opiate users in treatment centers usually live in areas characterized
by glaring poverty, unemployment, and discrimination, where the
use of drugs may seem to be the only alternative to despair. As
of 1981 (Miller & Associates 1983), about 64% of these patients
were black or Hispanic, although these two ethnic groups together
made up only 18.1% of the national population (11.7% black and
6.4% Hispanic) (U. S. Bureau of the Census, 1980a, 1980b). Nearly
74% of these groups in treatment were black males, nearly 50%
had had less than a high-school education, and 60% were twenty-six
years old or over. Slightly less than half had been arrested within
the past twenty-four months; about half of those with an arrest
record had had one or more arrests.
The minority groups have often viewed drug treatment as a noxious
form of social control, particularly if it substitutes one chemical
dependency for another. This concern becomes even stronger when
long-term maintenance programs are proposed. But recently many
minority group leaders have begun to be less preoccupied with
the evil magic of drug use per se and more concerned with the
quality of treatment programs and the need for staffing patterns
that are diverse enough to fit a range of cultural differences.
The increased emphasis that minority leaders are placing on the
quality of treatment services may be an important factor
in improving these services.
Although treatment programs that are targeted at interrupting
illicit drug use are important, treatment can be considered successful
only if it prevents clients from returning to destructive drug
use and gives them the emotional stability and technical skills
needed to function adequately in society. The records show that
this is not taking place. In 1981 65% of opiate users under treatment
were unemployed at admission and at discharge; only 3.5% completed
a skill-development program during treatment, while an additional
11.5% were in an educational or skill-development program at the
time of discharge. Two-thirds of the clients entering treatment
had been in treatment previously, and nearly two-thirds were discharged
from the program for noncompliance, were incarcerated, or dropped
out before completing treatment. Obviously, the rehabilitation
needs of these drug treatment clients simply were not met.
In 1977 V. P. Dole and H. Joseph surveyed a stratified random
sample of 85,000 current and former methadone-treatment clients
in New York City. The results, which were consistent with reports
from comparable studies, indicated that treatment "success"
(defined as abatement of illicit opiate use accompanied by good
functioning) was most likely for those patients who remained in
treatment for the longest time, but that the overall level of
success was low. The follow-up data on those who left the treatment
program showed that although there was a dramatic reduction in
their illicit opiate use during treatment, the majority relapsed
after leaving treatment. This was also true of those who reentered
treatment for a second or even a third time. In general, then,
maintenance treatment is effective while the medication is being
taken, but it usually does not cure the underlying problem, whatever
that may be.
Obviously, those who have a long history of intractable heroin
use should remain in treatment, whether drug-free or chemotherapeutic.
Their earlier immersion in a deviant subculture has given them
an identity, a community, and a way of life that have isolated
them from the mainstream culture. Retention in treatment is essential
in order to establish the kind of therapeutic relationship these
people need to begin the long, slow process of working through
their personal, social, and economic problems.
The indications of a need for long-term treatment are less clear
for those with a favorable cluster of attributes—for example,
for responsible young people who have a job, a stable home situation,
and no history of alcoholism. For such a group, which is somewhat
similar to the sample of controlled users described in this book,
the expectation of a good outcome after detoxification is significantly
higher than it is for all patients as a whole.
It is not easy to define "quality care" in terms that
satisfy everyone who is concerned with the health, mental health,
and drug treatment services. The difficulty of reaching a consensus
on what constitutes such care in a health or mental health setting
is multiplied in a drug treatment setting by the common practice
of using abstinence as the criterion for success. If the less
demanding criterion of controlled use were substituted, these
programs would be able to achieve a much higher degree of success.
This conclusion, at least, is suggested by the fact that almost
50% of the controlled opiate users in my research project were
former addicts. It is clear that many individuals who have long
histories of getting high and who do not want to give up an experience
they find pleasurable may still be shown how to control their
use. Unfortunately, such a criterion is unrealistic today and
will continue to be so as long as the present policy of prohibition
remains in force. Any program adopting it could be justly accused
of condoning an illegal act—the use of illicit drugs.
Nevertheless, once it is clear that the purpose of drug treatment
is to alleviate drug abuse, particularly dysfunctional aspects
of opiate dependency, then the false hopes that have been raised
regarding the elimination of all drug use and the reduction of
criminality will be replaced by more reasonable criteria for success—such
as reduced use, increased employment, and more adaptive social
relationships.
The narrow and unreasonable assumption underlying the goal of
abstinence—namely, that any drug use is misuse or abuse—not
only has given society a drug policy with an unrealizable goal
but has often prevented those in authority from recognizing dysfunctional
use and dealing with it constructively. This is particularly true
in the case of young adolescents. Recently a group of parents
expressed concern about the frightening extent of drug and alcohol
use in a regional public high school. A survey was made and the
stories were found to be exaggerated: intoxicant use in that school
turned out to be somewhat below the national average. When in-depth
interviews were held with teachers, parents, administrators, and
students, only a very few students were found to be in real trouble,
and there was high consensus in regard to their identity. Then
it became clear that the exaggerated reports of use had so preoccupied
parents and administrators that constructive efforts had not been
made to get those who were in serious trouble into treatment.
Overconcern about use by the many had stood in the way of active
attention to the misuse and serious difficulty of the few.
Future Research
It is my hope that this research will stimulate other investigators
to undertake long-term, longitudinal studies of psychoactive drug-using
behavior as a socially evolving process which develops controls
that affect a majority of the using population. Since such studies
will require careful selection and special training of researchers,
modest budget increases for research may be required; but the
focus of the research rather than the total dollar amount should
be the primary concern.
To date, five large and important areas of longitudinal research
have been either neglected or treated only superficially: (1)
the sequence of drugs used and the development of different drug-using
patterns; (2) the individual, group, and cultural factors influencing
low-risk and high-risk outcomes among equivalent drug users; (3)
the changing attitudes of both users and nonusers toward psychoactive
drug use; (4) the impact of the media on drug use and drug choice;
and (5) the process of socialization as it applies to patterns
of drug use. Three other topics need to be investigated by prospective
studies: how drugs influence individual health and behavior, what
use is being made of drug research, and how its findings influence
public policy decisions.
Because of the expense of identifying illicit opiate users, who
make up less than 1% of the U. S . population (see appendix C),
it might be wise to adopt the suggestion made by Lee N. Robins
in 1980. She proposed that when survey researchers identify an
opiate user, they should ask if he or she "would be willing
to be followed [up] at another time," thus permitting the
creation of a pool of randomly selected subjects for intensive
longitudinal study. This subject population would be more representative
of the normal population than either the groups of subjects commonly
used now, who are drawn from institutional settings, or the group
analyzed in this book, which was a collected rather than a random
or representative sample.
Besides the expense of conducting research on use of illicit drugs,
there is the definitional problem. It is often very difficult
for one researcher to know exactly what another researcher means
by his terminology (see chapter 3). To minimize this problem,
investigators could include detailed case studies to illustrate
the category of use or user under discussion. To a certain extent,
my study has employed that method, as have other investigators
such as Bruce D. Johnson and P. J. Goldstein (1979). They interviewed
their subjects daily for at least twenty-eight days at intervals
of a few months. Their preliminary data include valuable details
about the patterning, stability, and consequences of use (for
example, the amount of money spent on drugs), which make it easier
for other investigators to understand the meaning of their categories.
Many of their subjects, incidentally, resemble my sample of controlled
users.
Comprehensive and detailed case studies, tedious as they are to
compile, would also supply the natural history of use called for
by L. G. Hunt and others (Hunt 1977; Zinberg & Harding 1982).
Today misconceptions abound about the patterns of use of all the
illicit drugs, most particularly the opiates. At the least, what
is needed is some knowledge about the change or transition from
one stage of opiate use to another. For example, the latest data
(Johnson & Goldstein 1979) show that, contrary to the popular
view that heroin addicts inject themselves at least once a day
throughout their using career, only 10% to 20% of the entire using
careers of most addicts is spent using.
These kinds of data have powerful implications for treatment programs.
Unfortunately, not many program evaluators attempt to identify
the using styles of clients prior to and following treatment.
It should be possible, however, to identify those in treatment
who have the potential for controlled use. If a number of variables
pointing to that potential (such as the ability to keep drugs
on hand for some time without using them) could be isolated, questions
relating to those variables could be incorporated into the screening
procedures employed by drug treatment programs. Similarly, the
characteristics of addicts who have been unable to achieve control
over their opiate use could be identified and compared with the
characteristics of ex-addicts (like those in our sample) who have
managed to change their addictive pattern to one of controlled
use.
When the proportion and characteristics of addicts who seem to
have a reasonable chance to become controlled users have been
determined and some understanding of the factors that facilitate
the transition to controlled use has been gained, the stage will
be set for a small, experimental program in which a few carefully
selected addicts can be helped to establish control, and their
capacity to maintain controlled use can be evaluated. Such an
experiment is feasible; it could be done with some dispatch; and
it would provide an enormous amount of useful information about
heroin use and the treatment of those who are addicted to it.
In the current climate of opinion about drugs, the major obstacle
to launching such an experiment would be the reluctance of government
agencies to support research on a treatment program condoning
the continued, recreational use of heroin or some other opiate.
Probably the most convincing demonstration that control breeds
control comes from the longitudinal studies of George E. Vaillant
(1983). Through a variety of circumstances he had access to data
on two groups of subjects from quite different economic backgrounds,
collected over forty years ago, and he has continued long-term
follow-up on these groups. On measures such as capacity to relate
to others, to maintain close friendships and family ties, and
to continue in good physical and mental health, the abstinent
or near-abstinent score as poorly as the serious problem drinkers
or the alcoholics. Statistically, moderate drinkers score significantly
higher on each item. Vaillant says, only partially in jest, that
his ''findings have caused me to increase my drinking."
This approach to research—the development of long-term samples
for study, the publication of detailed case histories, and the
analysis of controlling and noncontrolling variables—would go
a long way toward answering questions raised concerning the changing
historical patterns of use. Some questions about the past are,
of course, unanswerable. How can we find out, for example, whether
occasional opiate use and the influence of the social setting
on users' behavior have a long history or are relatively recent
phenomena? Nevertheless, such an approach could still reveal important
information about changing use patterns—what drugs are being
used, how they are being used, and how that use is being socially
integrated. Certainly, if our understanding of drug use is to
improve, we must obtain more information about the social context
of use including a knowledge of how group customs and norms operate
to shape different styles of use, how these customs (controls)
arise, and how new users acquire them. Further research can discover
ways to strengthen these informal social controls (sanctions and
rituals) that encourage abstinence, promote safer use, and discourage
misuse.
A final caveat. Throughout the duration of my project my subjects
continued to make one point clear: at certain times, if not during
the whole of their using careers, they experienced benefits from
their intoxicant use and from different patterns of use. Thus,
despite the reigning cultural morality, future studies of intoxicant
use should take into account not only the liabilities but also
the benefits of drug use itself and also of the differing patterns
of use.