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Thursday, August 2, 2012

Zinberg-Drug, Set, and Setting


Drug, Set, and Setting

  The Basis for Controlled Intoxicant Use

    Norman E. Zinberg, M.D.


    Contents

     Preface
  1 Historical Perspectives on Controlled Drug Use

  2 Addiction, Abuse, and Controlled Use: Some Definitions
  3 Research Methodology and Data
  4 Research Findings: The Beginnings and Effects of Drug Use
  5 Research Findings: Drug-Use Rituals, Sanctions, and Control
  6 Personality and Social Learning: The Theory of Controlled Drug Use
  7 Reflections on Social Policy and Drug Research     Appendixes
Drug, Set, and Setting
Copyright (c)1984 by Yale University
Published by Yale University Press
ISBN 0-300-03110-6





--------------


Drug, Set, and Setting

    Norman E. Zinberg

        Preface



    The viewpoint toward the use of illicit drugs expressed in this book has developed gradually during more than twenty years of clinical experience with drug users. Initially I was concerned, like most other people, with drug abuse, that is, with the users' loss of control over the drug or drugs they were using. Only after a long period of clinical investigation, historical study, and cogitation did I realize that in order to understand how and why certain users had lost control I would have to tackle the all-important question of how and why many others had managed to achieve control and maintain it.
    The train of thought that has resulted in the writing of this book was set in motion in 1962. At that time, after a decade of teaching medical psychology to nonpsychiatric physicians at the Beth Israel Hospital in Boston by making rounds with them each week to see both ward and private patients, I began to puzzle over the extreme reluctance these sensible physicians felt about prescribing doses of opiates to relieve pain. Their hesitation, based on a fear of addicting patients, was surprisingly consistent, even where terminal patients were concerned. So, in conjunction with Dr. David C. Lewis, then Chief Resident in Medicine at Beth Israel, I began to make a study of this phenomenon. As we surveyed clinical data and then looked into the history of drug use, a picture emerged that scarcely resembled the one we had received in medical school.
    Finding little clinical evidence to support our doctors' extreme concern about iatrogenic addiction, except in the case of one obviously demanding group of patients, we turned to the history of drug use for an explanation. There we found ample reason for the medical apprehension about opiates. A whole set of traditional cultural and social attitudes toward opiate use had apparently been internalized by our physicians and was governing their thoughts and actions, engendering fears that were undermining their capacity to relieve suffering. In addition, the doctors' attitudes were not only determining their willingness or unwillingness to prescribe opiates but were also influencing the effect these drugs had on their patients. This was my first exposure to the power of what in this book is called the "social setting" to modify behavior and dictate responses in drug users.
    I had no plans to continue investigating drugs after our Beth Israel study was finished, but two papers on our work (Zinberg & Lewis 1964; Lewis & Zinberg 1964) happened to be published just as interest in drug use was reaching fever pitch. Many physicians, confused about the new habits of "tripping" or "turning on" reported to them by patients (or by patients' parents), were looking for a psychiatrist who was knowledgeable about drugs. Some of them began referring such patients to me, even when the drug was marihuana or a psychedelic rather than an opiate.
    As my clinical experience with drug users grew, I became aware that the traditional views about marihuana and the psychedelics were even more inaccurate than those about opiates . In the case of marihuana use I found repeatedly that the drug's reputation for destroying normal personality functioning and for harming a variety of bodily processes was based on misunderstanding and misconception. It is rather ironic now, when approximately fifty-seven million Americans have tried marihuana (Miller & Associates 1983), to recall that less than two decades ago most informed citizens believed that any use of marihuana would turn the brain to jelly.
    Some of my public pronouncements in this area were made in collaboration with a valued colleague and friend, Dr. Andrew T. Weil. In the fall of 1967, during his fourth year of medical study at Harvard, he decided that if our statements were to be regarded as credible, we had to have experimental data. He proposed that we do an experiment with marihuana that rigorously followed scientific methodology, one in which neither researchers nor subjects would know whether the substance used was active or only a placebo. First, we had to find out whether marihuana had been standardized pharmacologically and whether legal obstacles could be overcome so that it could be used experimentally with human beings.
    These two aims so occupied our thought that the question of how users developed control over their drug use seemed light-years away. At the time, the notion of giving marihuana to human beings and in particular to naive subjects seemed very daring, and our fear that such an experiment would be considered presumptuous proved to be well founded. Getting permission from the Bureau of Narcotics and Dangerous Drugs (BNDD), the Food and Drug Administration (FDA), and the National Institute of Mental Health (NIM H), all of which claimed jurisdiction over this area, was a labor of Hercules. Weil, who made the experiment his senior project, had more time than I had to write scores of letters answering the minute inquiries of these agencies and also to take several trips to Washington, but we both made innumerable phone calls to unravel the "Catch-22" relationships of primacy among the agencies until, at last, permission came through.
    The authorities stipulated that our subjects must be driven to and from the experiments; that they must promise not to touch any machinery, electrical or otherwise, for twenty-four hours after using marihuana; and that they must sign an elaborate informed-consent form including lifetime guarantees that they would not sue if they became addicted.
    But even these stringent requirements did not satisfy Harvard University. The Executive Committee of the Medical School refused permission for the experiment on advice of counsel, who said to me on the telephone: "I have checked into this proposal carefully and find nothing specifically illegal. However, I have also checked my conscience and have decided that I must recommend that Harvard not countenance your giving this dangerous drug to human beings."
    Dr. Robert Ebert, then Dean of Harvard Medical School, was uneasy about this decision. So, when Dr. Peter Knapp, Director of Psychiatric Research at Boston University Medical School, generously and courageously arranged to have us do the work under his roof, Dr. Ebert procured legal counsel for us at Harvard s expense to deal with any problems that might arise in satisfying the requirements of the governmental agencies and in obtaining proper informed consent.
    The experiments, which took place the following year (1968), went smoothly and uneventfully, largely because of Dr. Knapp's thoughtful advice and the help of his talented laboratory assistant, JudithNelsen. Not one of our subjects, whether experienced or naive, was at all disturbed by the experiments, and we learned something about the effect of acute marihuana intoxication on various physiological and psychological functions. I felt then and still feel, however, that the main achievement of these first controlled experiments in giving a widely condemned illicit drug to human beings was to show that such experiments could be conducted safely (Weil, Zinberg & Nelsen 1968).
    The next year (1968-69) I was invited to lecture in social psychology at the London School of Economics, and at the same time I received a Guggenheim award to study the British system of heroin maintenance (Zinberg & Robertson 1972). I was fortunate enough to arrive in England in July 1968, just as the British were beginning to send heroin addicts to designated clinics instead of permitting private physicians to prescribe heroin for them, a change that greatly facilitated my study. I found that in Britain there were two types of addicts, both of which differed from American addicts: the first functioned adequately, even successfully, while the second was even more debilitated than the American junkie. But although the second type of junkie behaved in an uncontrolled way and did great harm to himself, he, like the American alcoholic, was not a cause of social unrest, crime, or public hysteria.
    Gradually I came to understand that the differences between British and American addicts were attributable to their different social settings—that is, to the differing social and legal attitudes toward heroin in the two countries. In England, where heroin use was not illicit and addicts' needs could be legally supplied, they were free from legal restraints and were not necessarily considered deviants. British addicts had a free choice: either they could accept drug use as a facet of life and carry on their usual activities, or they could view themselves as defective and adopt a destructive junkie life-style. Thus my year in England revealed the same phenomenon I had observed at the Beth Israel Hospital several years earlier: the power of the social setting, of cultural and social attitudes, to influence drug use and its effects. It was becoming obvious that in order to understand the drug experience, I would have to take into account not just the pharmacology of the drug and the personality of the user (the set) but also the physical and social setting in which use occurred.
    On my return to the United States in 1969, I was aware that a change had occurred in the social setting surrounding the use of the psychedelics and particularly of LSD, for public reaction to the "drug revolution" had shifted from hysteria about psychedelics to terror of a "heroin epidemic" (Zinberg & Robertson 1972). In 1971, after these feelings had been further fueled by reports of overwhelmingly heavy heroin use by the troops in Vietnam, The Ford Foundation and the Department of Defense arranged for me to go to Vietnam to study that situation as a consultant. Vietnam was a strange and frightening place for American enlisted men (EMs). Hated by the Vietnamese and hating them, the American troops were easily attracted to any activity, including drug use, that blotted out the outside world (Zinberg 1972).
    As it became clearer to me that the social setting (the EMs' Vietnam) was the factor leading either to preoccupation with the use of drugs or to feverish absorption in some other distracting activity, I decided to advise the Army to take drug users out of their existing social setting, out of Vietnam. This advice was rejected. General Frederick Weygand said that if the EMs knew that heroin use would get them out of Vietnam, there would be no nonusers and therefore no Army. He did not realize that heroin was so easy to get in Vietnam that anybody who wanted to use it was already doing so. Nor did he share my sense that the troops' interest in heroin was attributable to the bad social setting—the destructiveness of the war environment and even of the rehabilitation centers—in which controlling social sanctions and rituals had no chance to develop. At that time, my theory of the way in which groups evolve viable social controls to aid controlled use was not well enough formulated to be convincing. Hence the Army paid little attention to what hindsight indicates was basically good advice.
    Of course, the using EMs were eventually sent home, and as my small follow-up study and Lee N. Robins' large and comprehensive studies showed (Robins 1973, 1974; Robins, Davis & Goodwin 1974; Robins, Helzer & Davis, 1975; Robins et al. 1979), once the users were taken out of the noxious atmosphere (the bad social setting), the infection (heroin use) virtually ceased. About 88% of the men addicted in Vietnam did not become readdicted after their return to the United States.
    In 1972, back in America, I began to think more coherently about drug use. I had known for many years that there were old-time "weekend warriors" (those who used heroin on occasional weekends), and my study with Lewis in 1962 had confirmed the existence of numerous patterns of heroin use. The vast social experiment with psychedelics in the 19605 and the later drug scene in Vietnam had highlighted the power of the social setting and made me wonder whether that power could be applied in a beneficial way to the control of intoxicants, including heroin. My reading on alcohol use showed that the history of alcohol, like that of the opiates, was exceedingly complex and gave me some ideas concerning the further study of drugs. At the same time I had the opportunity to encourage new research on the use of opiates. As consultant to the newly formed Drug Abuse Council (DAC), I approved a small grant to Douglas H. Powell, who wanted to locate long-term heroin "chippers" (occasional users). By putting advertisements in counterculture newspapers, he turned up a group that was small but sizable enough to demonstrate his thesis that controlled users existed and thus that factors other than the power of the drug and the user's personality were at work (Powell 1973).
    During this same period, Richard C. Jacobson (with whom I had worked earlier on a drug education project) and I were planning a study of the way in which "social controls," as we called them, operated. The ideas we had then seem confused and rudimentary now, but only scattered clinical data were available to work from, and very few of them had been collected systematically. We planned to make a comparative study of the controlled use of three illicit drugs with different powers and different degrees of social unacceptability: marihuana, the psychedelics, and the opiates (particularly heroin).
    Because of what now seems a paucity of knowledge about the specifics of heroin use (not just occasional but also heavy use) (Zinberg et al. 1978), I was unprepared for the complex moral and philosophical problems this research raised. Of course, I was well aware of the difficulty of maintaining an objective stance in the field of drug research. Here the investigator is seen as either for or against drug use. On every panel, radio show, and TV show, and even at professional meetings, where one would expect objectivity, the program must be "balanced." A speaker who is seen as pro-drug is "balanced" by someone who is considered anti-drug. Since the "anti's" take the position that prohibition and abstinence are essential, any opposing view is perceived as pro-drug.
    As a result of my earlier work on marihuana, which showed it to be a relatively mild though not harmless intoxicant, I have often been classified with the "pro's." This has caused me little anxiety because I have been firmly committed, in private and in print, to principles of moderation and to a concern about such things as driving when intoxicated, age of the user, and dissemination of the drug. Undoubtedly, too, my conviction that marihuana was not a terribly destructive drug made it easier to shrug off the charge of being pro-drug. It seemed more important to make known the facts about marihuana than to cooperate in promulgating misconceptions, putting people in jail for simple possession, and creating an unnecessary climate of fear. Thus I naturally opposed the unreasonable punishment of anyone who did not agree that the Emperor's raiment was the finest ever seen—that is, that marihuana was a deadly intoxicant.
    After my research on social control and illicit drug use had been funded by the DAC in 1973, the question of placing limits on my inquiry became far more pressing. What would be the result of reporting that some people were able to control their heroin use? Might this statement lead certain individuals to try heroin who would not otherwise have done so and who might not be able to handle it?
    By 1974 Jacobson had returned to graduate school, and Wayne M. Harding had become my associate in this enterprise. We pondered these painful questions earnestly. Neither of us could accept at face value the time-honored maxim, "The truth will set you free." Both of us remembered the LSD explosion of the mid- 1960s, caused partly by the publicity given by professionals and the media to the use of LSD. At first, when we had difficulty in locating people who used heroin occasionally, we felt little concern because it looked as though such use might be insignificant. But when it became clear that there were many such users, we realized that this finding had to come to public attention. Indeed, during the course of our work, other investigators, notably Leon G. Hunt (Hunt & Chambers 1976) and Peter G. Bourne (Bourne, Hunt & Vogt 1975), began to refer to the occasional use of heroin as a stable pattern of use.
    At this point the frequency with which I was asked if I was "for" unrestricted heroin use began to bother me. The question not only revealed a misunderstanding of my position on drugs but also showed that it would be an uphill struggle to present effectively any way of dealing with heroin use that did not demand total abstinence. It is my firm conviction, however, that our findings must be reported and explained and that the possibilities they reveal for controlling drug use should be put forward as a scientifically practical way of preventing drug abuse.
    It was not an easy task to choose material from so many years' work that would do justice to the project and at the same time preserve readability. For example, it seemed felicitous to place in an appendix the review of the previous literature which demonstrates that many other workers had been aware of the kinds of people I studied but had not found a conceptual framework in which to put their findings. The literature review contains valuable and convincing material as to the historical existence of controlled users, but including it in the body of the book seemed to interfere with the flow of the presentation of the project .
    As the book stands now, this personal account of how the project developed is followed by a review of the background from which the conceptual framework of the project was derived (chapter 1).
    Chapter 2 attacks the ambiguous terminology responsible for much of the confusion surrounding discussions of intoxicant use. Then the methodology of the research and the data it produced are presented from an objective and quantitative point of view. The next two chapters (4 and 5) translate those hard figures into the subjective data by quoting extensively from the interviews. These two chapters describe qualitatively how the subjects managed to live with and maintain their controlled use of intoxicants. The subjects' own voices emerge to answer questions about use in purely human terms and at the same time indicate how such subjective research data could be translated into numbers.
    One factor that has hampered the appreciation and understanding of the interaction between the individual's personality and his or her larger and more circumscribed milieu—that is, the physical and social setting in which the use takes place—has been the ambiguity in psychoanalytic theory. Chapter 6 addresses that problem and shows how a psychodynamic personality theory can encompass both set and setting variables. The problem of developing social policies which can distinguish use from misuse and develop effective formal social controls to interact with the informal control mechanisms discovered by this research, as well as recommendations for treatment and further research, make up the last chapter.
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Drug, Set, and Setting

    Norman E. Zinberg, M.D.

        1.  Historical Perspectives on Controlled Drug Use



    CARL IS AN OCCASIONAL HEROIN USER. He is a single, white male, twenty-six years old, a graduate student who emigrated to the United States from South Africa when he was eighteen. His father died when he was two years old, and his mother remarried eighteen months later. His stepfather, a physician, already had a son and daughter, and there were two sons from the new marriage. Carl regards them all as his own family. No one in the family evidences alcoholism or heavy involvement with drugs, including prescription drugs.
    Carl's parents are both moderate social drinkers, as he is. They serve beer or wine at almost every evening meal, and Carl was permitted an occasional sip from about age ten or eleven. When he was twelve he tried tobacco and by nineteen had become the one-pack-a-day smoker he still is. At sixteen he tried marihuana and used it on weekends until he was eighteen. Now he uses marihuana up to three times a week but only in the late evening after completing his work or studies or on social occasions.
    Amphetamines were popular with one group of Carl's friends, and between the ages of sixteen and eighteen, when he left South Africa, he used these drugs with them on social occasions about once every two weeks. He has used amphetamines only two or three times since then.
    At seventeen, when Carl and his closest friend, whose father was also a physician, were experimenting with drugs, they took a bottle of morphine sulfate from the friend's father's office. They also took disposable syringes and injected each other intramuscularly. Both found the experience extremely pleasurable, and from then on they injected each other on weekends until the bottle was exhausted.
    At eighteen, after moving to the United States, Carl entered a college in San Francisco, where he became friendly with a psychedelic-using group. His initial psychedelic experience was very pleasant, and for the next year he tripped about two or three times a month. Then his interest in that sort of drug experience waned. Now he uses psychedelics very occasionally—no more than twice a year.
    At twenty, when Carl was teaching in southern California, he ran into a group of "hippies" with whom he snorted heroin. Upon returning to San Francisco he began to ask questions about opiate use. Within a short time his discreet inquiries turned up a group of occasional heroin users that included a close friend who had not told Carl about his use. Carl began using with this group once a month on average, but not on a regular basis.
    The irregularity of Carl's heroin use was due entirely to his social life. If he was otherwise engaged and did not see his heroin-using friends, he would use less frequently; if he saw them more often, he tended to use more frequently. This pattern has continued except for two periods of two weeks each when Carl was visiting Amsterdam during a European trip. In that wide-open city he used virtually every day, but this had no effect on his using pattern when he returned to the United States.
    After moving to Boston and entering graduate school, Carl, then twenty-two, met a new using group to whom he was introduced by friends from California. He likes two or three of them very much but sees them only occasionally. Neither his "best" friend, a fellow graduate student, nor his apartment mate, a thirty-one-year-old engineer who is not a particularly close friend, knows of his heroin use. "I don't want to be deceptive," Carl says, "but some people have an exaggerated fear of heroin and make a big fuss about it. I don't like to have to explain myself. I just like to get high that way once in a while. It's nobody's business what I like, and I don't want to be judged for it."
    His use takes place only in a group, and he either "snorts" or injects intramuscularly. "The trick," he says, "is to get high with the least amount possible. If I take too much, I get nauseated, constipated, and have trouble urinating. " As a member of a doctor's family, he is fully aware of the possibility of infection, is meticulous about sterilizing his needles, and never lends them to anyone. At his current level of use the high price of heroin is no hardship. One of his friends with "good connections" procures the drug, and when a good buy is made, Carl purchases a little extra to keep for another occasion. He is not sure what he would do if his friend moved away. He hopes to be able to continue use at his current level, which he has maintained for six years.
    Carl has a very active social life in which heroin and marihuana play only a small part. His parents are on excellent terms with him and have visited him recently in this country. When he first arrived in the United States, he thought he might have a problem with women because he was not aggressive; but he formed a long-term, satisfying relationship with a woman before he left California. Since moving to Boston he has dated a lot, including seeing one friend quite consistently for more than a year. When that relationship broke up, he was at loose ends for a while; but for the past three months he has been going with someone he thinks may be the most important person in his life.
    Carl liked his college in America more than his secondary school in South Africa, which he did not enjoy either socially or intellectually. He likes graduate school even more. He has a tentative job offer in the Boston area that depends on his finishing his thesis before September, and he is working very hard toward that goal.
    Until quite recently it was not recognized that Carl and others like him could use illicit drugs in a controlled manner. But the studies that underlie this book on the controlled (moderate, occasional) use of marihuana, psychedelics, and opiates bear witness to the new interest in people like Carl that began to appear during the 1970s.[1] Before then it had been assumed that because of their pharmacological properties, the psychedelics, heroin, and, to a lesser extent, marihuana could not be taken on a long-term, regular basis without causing serious problems. The unfortunate condition of heroin addicts and other compulsive users was invoked as "proof' of this "pharmacomythology" (Szasz 1975). It was also widely held that these "dangerous" substances were almost always sought out by people with profound personality disorders. Most drug research was strongly influenced by the moralistic view that all illicit drug use was therefore "bad," inevitably harmful, or psychologically or physiologically "addictive," and that abstention was the only alternative (Zinberg & Harding 1982). Not surprisingly, studies of drug consumption, which burgeoned during the 1960s, tended to equate use (any type of use) with abuse and seldom took occasional or moderate use into account as a viable pattern (Heller 1972). To the limited extent that the possibility of nonabusive use was acknowledged, it was treated as a very brief transitional stage leading either to abstinence or (more likely) to compulsive use. Researchers sought first to determine the potentially harmful effects of illicit drugs and then to study the personality disorders resulting from use of these substances—disorders which, ironically, were considered responsible for the drug use in the first place.
    Even before the 1960S, however, it had been known that in order to understand how control of a substance taken into the body could be developed, maintained, or lost, different patterns of consumption had to be compared. This principle had long been applied to the comparative study of patterns of alcohol use: alcoholism as opposed to social or moderate drinking. Not until after 1970 was the same research strategy rigorously applied to the study of illicit drug use, and only since the mid-1970s have the existence and importance of a still wider range of using patterns been recognized by the scientific community.

The New Perspective on Control

    The new interest in the comparative study of patterns of drug use and abuse is attributable to at least two factors. The first is that in spite of the enormous growth of marihuana consumption, most of the old concerns about health hazards have proved to be unfounded. Also, most marihuana use has been found to be occasional and moderate rather than intensive and chronic (Josephson 1974; National Institute on Drug Abuse 1977; Marijuana and Health 1982). It has been estimated, for example, that 63% of all Americans using marihuana in 1981 were only occasional users (Miller & Associates 1983). These developments have spurred public and professional recognition of the possibility that illicit substances can be used in moderation and that the question of how control operates at various levels of consumption deserves much more research. A second factor responsible for the new research perspective is the pioneering work of a few scientists who have been more impressed by the logic of their own results than by the mainstream view of illicit drug use. The most influential work has been that of Lee N. Robins, whose research on drug use among Vietnam veterans (discussed in appendix C) indicates that consumption of heroin (the "most dangerous" illicit drug) did not always lead to addiction or dysfunctional use, and that even when addiction occurred it was far more reversible than had been believed (Robins 1973, 1974; Robins et al. 1979).
    As the belief lessened that illicit drugs were in a class by themselves, they began to be compared with licit drugs and other substances. At the same time an inverse shift in attitude was taking place toward licit substances. Research indicated that a wide assortment of these substances—tobacco, caffeine, sugar, and various food additives—were potentially hazardous to health (Pekkanen & Falco 1975; Marcovitz 1969). Other research demonstrated that prescribed drugs, if not used in the way the physician intended, could also be hazardous and might constitute a major public health problem. Thus the public became increasingly aware that even with the advice of a physician, "good" drugs used for "good" reasons could be difficult to control. It seemed that just as the mythology that illicit drugs were altogether harmful was losing ground, so too was the mythology that most licit substances were altogether benign. The result has been a new interest in discovering ways of controlling the use of a wide variety of substances, both licit and illicit.
    I came to appreciate these changes in perspective largely through my own research. In 1973, when The Drug Abuse Council gave its support to my study of controlled drug users, the conventional attitude of research agencies was that ways should be sought to prevent drug abuse, which at that time meant preventing all drug use (Zinberg, Harding & Apsler 1978). Since in 1973 marihuana, psychedelics, and opiates were causing the greatest concern, these were the drugs I chose to study. The year 1973 was crucial for several reasons. It just preceded the marked rise of cocaine use, as well as the enormous publicity given to PCP, although the use of PCP (under the pseudonyms of angel dust and THC) had long been fairly widespread. It just followed the year in which the National Organization for the Reform of Marihuana Laws (NORML) began formal efforts to decriminalize the private use of marihuana. It was also the last year in which psychedelic drug use increased at a great rate (131%, according to the National Commission on Marihuana and Drug Abuse, 1973). And finally, it marked the decline of overwhelming concern about a heroin "epidemic."
    The two related hypotheses underlying this project were far more controversial in 1973 than they would be today, although they are still not generally accepted. I contended, first, that in order to understand what impels someone to use an illicit drug and how that drug affects the user, three determinants must be considered: drug (the pharmacologic action of the substance itself), set (the attitude of the person at the time of use, including his personality structure), and setting (the influence of the physical and social setting within which the use occurs) (Weil 1972; Zinberg & Robertson 1972; Zinberg, Harding & Winkeller 1981). Of these three determinants, setting had received the least attention and recognition; therefore, it was made the focus of the investigation (Zinberg & DeLong 1974; Zinberg & Jacobson 1975). Thus the second hypothesis, a derivative of the first, was that it is the social setting, through the development of sanctions and rituals, that brings the use of illicit drugs under control.
    The use of any drug involves both values and rules of conduct (which I have called social sanctions) and patterns of behavior (which I have called social rituals); these two together are known as informal social controls. Social sanctions define whether and how a particular drug should be used. They may be informal and shared by a group, as in the common maxims associated with alcohol use, "Know your limit" and "Don't drive when you're drunk"; or they may be formal, as in the various laws and policies aimed at regulating drug use (Zinberg, Harding & Winkeller, 1981; Maloffet al. 1982). Social rituals are the stylized, prescribed behavior patterns surrounding the use of a drug. They have to do with the methods of procuring and administering the drug, the selection of the physical and social setting for use, the activities undertaken after the drug has been administered, and the ways of preventing untoward drug effects. Rituals thus serve to buttress, reinforce, and symbolize the sanctions. In the case of alcohol, for example, the common invitation "Let's have a drink" automatically exerts some degree of control by using the singular term "a drink." By contrast "Let's get drunk" implies that all restraints will be abandoned.
    Social controls (rituals and sanctions together) apply to the use of all drugs, not just alcohol, and operate in a variety of social settings, ranging all the way from very large social groups, representative of the culture as a whole, down to small, discrete groups (Harding & Zinberg 1977). Certain types of special occasion use involving large groups of people—beer at ball games, marihuana at rock concerts, wine with meals, cocktails at six—despite their cultural diversity, have become so generally accepted that few if any legal strictures are applied even if such uses technically break the law. For example, a policeman may tell young people drinking beer at an open-air concert to "knock it off, " but he will rarely arrest them; and in many states the police reaction would be similar even if the drug were marihuana (Newmeyer & Johnson 1982). If the culture as a whole fully adopts a widespread social ritual, it may eventually be written into law, just as the socially developed mechanism of the morning coffee break has been legally incorporated into union contracts. The T. G. I. F. (Thank God It's Friday) drink may not be far from acquiring a similar status. But small-group sanctions and rituals tend to be more diverse and more closely related to circumstances. Nonetheless, some caveats may be just as firmly upheld: "Never smoke marihuana until after the children are asleep," "Only drink on weekends," "Don't shoot up until the last person has arrived and the doors are locked."
    The existence of social sanctions and rituals does not necessarily mean that they will be effective, nor does it mean that all sanctions or rituals were devised as mechanisms to aid control. "Booting" (the drawing of blood into and out of a syringe) by heroin addicts seemingly lends enchantment to the use of the needle and therefore opposes control. But it may once have served as a control mechanism that gradually became perverted or debased. Some old-time users, at least, have claimed that booting originated in the (erroneous) belief that by drawing blood in and out of the syringe, the user could gauge the strength of the drug that was being injected.
    More important than the question of whether the sanction or ritual was originally intended as a control mechanism is the way in which the user handles conflicts between sanctions. With illicit drugs the most obvious conflict is between formal and informal social controls—that is, between the law against use and the social group's approval of use. The teenager attending a rock concert is often pressured into trying marihuana by his peers, who may insist that smoking is acceptable at that particular time and place and will enhance his musical enjoyment. The push to use may also include a control device, such as "since Joey won't smoke because he has a cold, he can drive, " thereby honoring the "don't drive after smoking" sanction. Nevertheless, the decision to use, so rationally presented, conflicts with the law and so may cause the user anxiety. Such anxiety interferes with control. In order to deal with the conflict the user may display more bravado, exhibitionism, paranoia, or antisocial feeling than would have been the case if he or she had patronized one of the little bars near the concert hall. It is this kind of personal and social conflict that makes controlled use of illicit drugs more complex and more difficult to achieve than the controlled use of licit drugs.
    Of course, the application of social controls, particularly in the case of illicit drugs, does not always lead to moderate use. And yet it is the reigning cultural belief that drug use should always be moderate and that behavior should always be socially acceptable. Such an expectation, which does not take into account variations in use or the experimentation that is inevitable in learning about control, is the chief reason that the power of the social setting to regulate intoxicant use has not been more fully recognized and exploited. This cultural expectation of decorum stems from the moralistic attitudes that pervade our culture and are almost as marked in the case of licit as in that of illicit drugs. Only on special occasions, such as a wedding celebration or an adolescent's first experiment with drunkenness, is less decorous behavior culturally acceptable. Although such incidents do not necessarily signify a breakdown of overall control, they have led the abstinence-minded to believe that when it comes to drug use, there are only two alternatives—total abstinence or unchecked excess leading to addiction. Despite massive evidence to the contrary, many people remain unshaken in this conviction.
    This stolid attitude inhibits the development of a rational understanding of controlled use and ignores the fact that even the most severely affected alcoholics and addicts, who may be grouped at one end of the spectrum of drug use, exhibit some control in that they actually use less of the intoxicating substance than they could. Moreover, as our interviews with ordinary citizens have shown, the highly controlled users and even the abstainers at the other end of the spectrum express much more interest in the use of intoxicants than is generally acknowledged. Whether to use, when, with whom, how much, how to explain why one does not use—these concerns occupy an important place in the emotional life of almost every citizen. Yet, hidden in the American culture lies a deep-seated aversion to acknowledging this preoccupation. As a result, our culture plays down the importance of the many social mores—sanctions and rituals—that enhance our capacity to control use. Both the existence of a modicum of control on the part of the most compulsive users and the general preoccupation with drug use on the part of the most controlled users are ignored. Hence our society is left longing for that utopia in which no one would ever want drugs either for their pleasant or their unpleasant effects, for relaxation and good fellowship, or for escape and oblivion.
    The cultural insistence on extreme decorum overemphasizes the determinants of drug and set by implying that social standards are broken because of the power of the drug or some personality disorder of the user. This way of thinking, which ignores the social setting, requires considerable psychological legerdemain, for few users of intoxicants can consistently maintain such self-discipline. Intoxicant use tends to vary with one's time of life, status, and even geographical location. Many who have made heavy use of intoxicants as adolescents slow down as they reach adulthood and change their social setting (their friends and circumstances), while some adults, as they become more successful, may increase their use. For instance, a man born and bred in a dry part of Kansas may change his habits significantly after moving to New York City. The effects of such variations in social circumstances are readily perceived, but they have not been incorporated into a public understanding of how the social setting influences the use and control of intoxicants.
    Enormous variations from one historical epoch to another can also be found in the social use of intoxicants, especially alcohol, in various countries. From the perspective of alcohol use, American history can be divided into three major epochs, differing in the power of the mores to moderate the use of alcohol. In considering these epochs it is useful to bear in mind the following social prescriptions for control, summarized from cross-cultural studies of alcohol use (Lolli et al. 1958; Chafetz & Demone 1962; Lolli 1970; Wilkinson 1973; Zinberg & Fraser 1979).
  1. Group drinking is clearly differentiated from drunkenness and is associated with ritualistic or religious celebrations.
  2. Drinking is associated with eating or ritualistic feasting.
  3. Both sexes and all generations are included in the drinking situation, whether they drink or not.
  4. Drinking is divorced from the individual effort to escape personal anxiety or difficult (even intolerable) social situations. Moreover, alcohol is not considered medicinally valuable.
  5. Inappropriate behavior when drinking (violence, aggression, overt sexuality) is absolutely disapproved, and protection against such behavior is exercised by the sober or the less intoxicated. This general acceptance of a concept of restraint usually indicates that drinking is only one of many activities and thus carries a low level of emotionalism.

    During the first period of American history, from the 1600s to the 1770s, the colonies, though veritably steeped in alcohol, strongly and effectively prohibited drunkenness. Families ate and drank together in taverns, and drinking was associated with celebrations and rituals. Tavern-keepers had social status; preserving the peace and preventing excesses stemming from drunkenness were grave duties. Manliness and strength were not measured by the extent of consumption or by violent acts resulting from it. This pre-Revolutionary society did not, however, abide by all the prescriptions for control: "groaning beer," for example, was regarded as medicine and consumed in large quantities by pregnant and lactating women.
    The second period, from the 1770s to about 1890, which included the Revolutionary War, the Industrial Revolution, and the expansion of the frontier, was marked by alcoholic excess. Men were separated from their families and in consequence began to drink together and with prostitutes. Alcohol was served without food, its consumption was not limited to special occasions, and violence resulting from drunkenness became much more common. In the face of increasing drunkenness and alcoholism, people began to believe (as is the case with regard to some illicit drugs today) that the powerful, harmful pharmaceutical properties of the intoxicant itself made controlled use remote or impossible.
    Although by the beginning of the third period, which extended from 1890 to the present time, moderation in the use of alcohol had begun to increase, this trend was suddenly interrupted in the early 1900s by the Volstead Act, which ushered in another era of excess. American society has not yet fully recovered from the speakeasy ambience of Prohibition in which men again drank together and with prostitutes, food was replaced by alcohol, and the drinking experience was colored by illicitness and potential violence. Although the repeal of the prohibition act provided relief from excessive and unpopular legal control, it left society without an inherited set of clear social sanctions and rituals to control use.

Social Sanctions Internalized

    Today this vacuum is gradually being filled. In most sectors of our society informal alcohol education is readily available. Few children grow up without an awareness of the wide range of behaviors associated with alcohol use, learned from that most pervasive of all the media, television. They see cocktail parties, wine at meals, beer at ball games, homes broken by drink, drunks whose lives are wrecked, along with all the advertisements that present alcohol as lending glamour to every occasion.
    Buttressed by movies, the print media, observation of families and family friends, and often by a sip or watered-down taste of the grown-ups' potion, young people gain an early familiarity with alcohol. When, in a peer group, they begin to drink and even, as a rite of passage, to overdo it, they know what the relevant sanctions are. The process of finding a limit is a direct expression of "know your limit." Once that sanction has been internalized—and our culture provides mores of greater latitude for adolescents than for adults—youngsters can move on to such sanctions as "it is unseemly to be drunk" and "it's OK to have a drink at the end of the day or a few beers on the way home from work or in front of TV, but don't drink on the job" (Zinberg, Harding & Winkeller 1981).
    This general description of the learning or internalization of social sanctions has not taken into account the variations from individual to individual that result from differences in personality, cultural background, and group affinity. Specific sanctions and rituals are developed and integrated in varying degrees by different groups (Edwards 1974). Some ethnic groups, such as the Irish, lack strong sanctions against drunkenness and have a correspondingly higher rate of alcoholism. In any ethnic group, alcohol socialization within the family may break down as a result of divorce, death, or some other disruptive event. Certainly a New York child from a rich, sophisticated home, accustomed to having Saturday lunch with a divorced parent at The 21 Club, will have a different attitude toward drinking from that of the small-town child who vividly remembers accompanying a parent to a sporting event where alcohol intake acted as fuel for the excitement of unambivalent partisanship. Yet one common denominator shared by young people from these very different backgrounds is the sense that alcohol is used at special events and in special places.
    This kind of education about drug use is social learning, absorbed inchoately and unconsciously in daily life (Zinberg 1974). The learning process is impelled by an unstated and often unconscious recognition by young people that drug use is an area of emotional importance in American society and that knowledge about it may be quite important to their personal and social development. Attempts made in the late 1960s and early 1970s to translate this informal process into formal drug education courses, chiefly intended to discourage use, have failed (Boris, Zinberg & Boris 1978). Such formal drug education, paradoxically, by focusing on drug use has stimulated such use on the part of many young people who were previously uncommitted, and while acting to confirm the fears of many who were already excessively concerned. Is it possible for formal education to codify social sanctions and rituals in a reasonable way for those who have been bypassed by the informal process, or does the reigning cultural moralism preclude the possibility of discussing reasonable informal social controls that may condone use? This question will remain unanswered until our culture has accepted the use not only of alcohol but of other intoxicants so that teachers will be able to explain how these drugs can be used safely and well. Teaching safe use is not intended to encourage use. Its main purpose is the prevention of abuse, just as the primary purpose of the few good sex education courses in existence today is to teach the avoidance of unwanted pregnancy and venereal disease rather than the desirability of having or avoiding sexual activity.
    Whatever may happen to formal education in these areas, the natural process of social learning will inevitably go on for better or for worse. The power of this process is illustrated by two recent and extremely important social events: the use of psychedelics in the United States in the 1960s and the use of heroin during the Vietnam War.
    Shortly after Timothy Leary's advice to "tune in, turn on, and drop out" was adopted as a counterculture slogan in 1963, the use of psychedelics became a subject of national hysteria. The "drug revolution" was seen as a major threat to the dominant cultural values of hard work, family, and loyalty to country. Drugs, known then as psychotomimetic (imitators of psychosis), were widely believed to lead to psychosis, suicide, or even murder (Mogar & Savage 1954; Robbins, Frosch & Stern 1967). Equally well publicized was the contention that they could bring about spiritual rebirth and mystical oneness with the universe (Huxley 1954; Weil 1972). Certainly there were numerous cases of not merely transient but prolonged psychoses following the use of psychedelics. In the mid-l960s psychiatric hospitals like the Massachusetts Mental Health Center and New York City's Bellevue Hospital reported that as many as one-third of their admissions resulted from the ingestion of these drugs (Robbins, Frosch & Stern 1967). By the late 1960s, however, the rate of such admissions had dropped dramatically. At first, many observers concluded that psychedelic use had declined in response to the use of "fear tactics"—the dire warnings about the various health hazards, the chromosome breaks and birth defects, that were reported in the newspapers. This explanation proved false, for although the dysfunctional sequelae had radically declined, psychedelic use continued until 1973 to be the fastest growing drug use in America (National Commission on Marihuana and Drug Abuse 1973). What then had changed?
    It has been found that neither the drugs themselves nor the personalities of the users were the most prominent factors in those painful cases of the 1960s. Although responses to the drugs varied widely, before the early 1960s, they included none of the horrible, highly publicized consequences of the mid-1960s (McGlothlin & Arnold 1971). Another book, entitled LSD: Personality and Experience (Barr et al. 1972), describes a study made before the drug revolution of the influence of personality on psychedelic drug experience. It found typologies of response to the drugs but did not discover a one-to-one relationship between untoward reaction and emotional disturbance. In 1967 sociologist Howard S. Becker, in a prophetic article, compared the current anxiety about psychedelics to anxiety about marihuana in the late 1920s, when several psychoses had been reported. Becker hypothesized that the psychoses came not from the drug reactions themselves but from the secondary anxiety generated by unfamiliarity with the drug's effects and ballooned by media publicity. He suggested that the unpleasant reactions had ceased to appear after the true effects of marihuana had become more widely known, and he correctly predicted that the same thing would happen in the case of the psychedelics.
    The power of social learning also brought about a change in the reactions of those who expected to gain insight and enlightenment from the use of psychedelics. Interviews (ours and others') have shown that the user of the early 1960s, with his great hopes of heaven or fears of hell and his lack of any sense of what to expect, had a far more extreme experience than the user of the 1970s, who had been exposed to a decade of interest in psychedelic colors, music, and sensations. The later user, who might remark, "Oh, so that is what a psychedelic color looks like," had been thoroughly prepared, albeit unconsciously, for the experience and thus could respond in a more restrained way.
    The second example of the enormous influence of the social setting and of social learning on drug use comes from Vietnam. Current estimates indicate that at least 35% of enlisted men (EMs) tried heroin while in Vietnam and that 54% of these became addicted to it (Robins et al. 1979). Although the success of the major treatment modalities available when these veterans became addicted (therapeutic communities and civil commitment programs) cannot be precisely determined, evaluations showed that relapse to addiction within a year was a more common outcome than abstinence, and recidivism rates as high as 90% were reported (DeLong 1972). Once the extent of the use of heroin in Vietnam became apparent, the great fear of Army and government officials was that the maxim, "Once an addict, always an addict," would operate; and most of the experts agreed that this fear was entirely justified. Treatment and rehabilitation centers were set up in Vietnam, and the Army's slogan that heroin addiction stopped "at the shore of the South China Sea" was heard everywhere. As virtually all observers agree, however, those programs were total failures. Often servicemen used more heroin in the rehabilitation programs than when on active duty (Zinberg 1972).
    Nevertheless, as Lee N. Robins and her colleagues have shown (1979), most addiction did indeed stop at the South China Sea. For addicts who left Vietnam, recidivism to addiction three years after they got back to the United States was approximately 12%—virtually the reverse of previous reports (DeLong 1972). Apparently it was the abhorrent social setting of Vietnam that led men who ordinarily would not have considered using heroin to use it and often to become addicted to it. Still, they evidently associated its use with Vietnam, much as certain hospital patients who are receiving large amounts of opiates for a painful medical condition associate the drug with the condition. The returnees were very much like those patients, who usually do not crave the drug after the condition has been alleviated and they have left the hospital.
    For some individuals dependence on almost any available intoxicating substance is likely. But even the most generous estimate of the number of such individuals is not large enough to explain the extraordinarily high rate of heroin use in Vietnam. The number of addiction-prone personalities might even have been lower than that in a normal population because the military had screened out the worst psychological problems at enlistment. Robins found that heroin use in Vietnam correlated well with a youthful liability scale. This scale included some items that are related to set—that is, to emotional difficulties (truancy, dropout or expulsion from school, fighting, arrests). But it also included many items related to the social setting, such as race or living in the inner city, and even then it accounted for only a portion of the variance in youthful heroin use.
    A better explanation for the high rate of heroin use and addiction in Vietnam than the determinant of set or personality might be the drug and its extraordinary availability. Robins noted that 85% of veterans had been offered heroin in Vietnam, and that it was remarkably inexpensive (Robins et al. 1979). Another drug variable, the method of administration, must also have contributed to widespread use in Vietnam. Heroin was so potent and inexpensive that smoking was an effective and economical method to use, and this no doubt made it more attractive than if injection had been the primary mode of administration. These two drug variables also help to explain the decrease in heroin use and addiction among veterans following their return to the United States. The decreased availability of heroin in the United States (reflected in its high price) and its decreased potency (which made smoking wholly impractical) made it difficult for the returning veterans to continue use.
    Although the drug variable may carry more explanatory power in the case of Vietnam than the various set variables, it also has limits. Ready availability of heroin seems to account for the high prevalence of use, but it alone does not explain why some individuals became addicted and others did not, any more than the availability of alcohol is sufficient to explain the difference between the alcoholic and the social drinker. Availability is always intertwined with the social and psychological factors that create demand for an intoxicant. Once a reasonably large number of users decide that a substance is attractive and desirable, it is surprising how quickly that substance becomes plentiful. For instance, when the morale of U. S. troops in Germany declined in 1972, large quantities of various drugs, including heroin, became readily available, even though Germany is far from opium-growing areas. In the early 1980s cocaine is the best example of drug availability.
    In the case of both heroin use in Vietnam and psychedelic use in the 1960s, the setting determinant, including social sanctions and rituals, is needed for a full explanation of the appearance, magnitude, and eventual waning of drug use.
    Control over the use of psychedelics was not established until the counterculture developed social sanctions and rituals like those surrounding alcohol use in the society at large. The sanction "The first time use only with a guru" told neophytes to try the drug with an experienced user who could reduce their secondary anxiety about what was happening by interpreting it as a drug effect. "Use only at a good time, in a good place, with good people" gave sound advice to those taking the kind of drug that would make them highly sensitive to their inner and outer surroundings. In addition, it conveyed the message that the drug experience could be a pleasant consciousness change instead of either heaven or hell. The specific rituals that developed to express these sanctions—just when it was best to take the drug, how it should be used, with whom, what was the best way to come down, and so on—varied from group to group, though some rituals spread between groups.
    It is harder to document the development of social sanctions and rituals in Vietnam. Most of the early evidence indicated that the drug was used heavily in order to obscure the actualities of the war, with little thought of control. Yet later studies showed that many EMs used heroin in Vietnam without becoming addicted (Robins, Davis & Goodwin 1974; Robins, Helzer & Davis 1975). Although about half of the men who had been addicted in Vietnam used heroin after their return to the United States, only 12% became readdicted to it (Robins et al 1979).
    Some rudimentary rituals do seem to have been followed by the men who used heroin in Vietnam. The act of gently rolling the tobacco out of an ordinary cigarette, tamping the fine white powder into the opening, and then replacing a little tobacco to hold the powder in before lighting up the OJ (opium joint) seemed to be followed all over the country even though units in the North and the Highlands had no direct contact with those in the Delta (Zinberg 1972). To what extent this ritual aided control is impossible to determine, but having observed it many times, I know that it was almost always done in a group and that it formed part of the social experience of heroin use. While one person was performing the ritual, the others sat quietly and watched in anticipation. Thus the degree of socialization achieved through this ritual could have had important implications for control.
    My continuing study of various patterns of heroin use, including controlled use, in the United States confirmed the lessons taught by the history of alcohol use in America, the use of psychedelics in the 1960s, and the use of heroin during the Vietnam War. The social setting, with its formal and informal controls, its capacity to develop new informal social sanctions and rituals, and its transmission of information in numerous informal ways, is a crucial factor in the controlled use of any intoxicant. This does not mean that the pharmaceutical properties of the drug or the attitudes and personality of the user count for little or nothing. All three variables—drug, set, and setting—must be included in any valid theory of drug use. It is necessary to understand in every case how the specific characteristics of the drug and the personality of the user interact and are modified by the social setting and its controls.

Illicit Drugs and Social Learning

    Our culture does not yet fully recognize, much less support, controlled use of most illicit drugs. Users are declared "deviant" and a threat to society, or "sick" and in need of help, or "criminal" and deserving of punishment. Family-centered socialization for use is not available . Parents, even if they are willing to help, are unable to provide guidance either by example (as with alcohol) or in a factual, nonmoralistic manner.
    If parents tell their sons or daughters not to use drugs because they are harmful, the youngsters disregard that advice because their own experiences have told them otherwise. Their using group and the drug culture reinforce their own discovery that drug use in and of itself is not bad or evil and that the warnings coming from the adult world are unrealistic. If parents try a different tack and tell young people that some drugs are all right but others have a high risk component and should be avoided, their position again is vulnerable. "They were wrong about marihuana; why should I believe what they say about cocaine?" think the youngsters (Kaplan 1970). Moreover, by counseling their children that some illicit drugs are "more all right" than others, parents are placed in the position of having to approve an illegal activity. Thus their role as conveyors of the public morality becomes glaringly inconsistent.
    The interviews conducted by my research team have indicated that if parents try to obtain first-hand knowledge of the drug experience by smoking marihuana, taking a psychedelic, or shooting heroin, similar difficulties occur. At the very least, they not only are condoning but are themselves engaging in a deviant act. This problem pales, however, before those that arise when the parents try to find out where to get the drug and then how to interpret the high. If they ask their children to get the drug for them or to be with them while they are experiencing the high, the traditional roles of instructor and pupil are reversed. While the youngsters may enjoy this novel authority, it places them in an extremely difficult caretaking role. Above all, such a situation creates enormous anxiety for the parents. Many parents interviewed by my team had never achieved a high because of the dynamics of the social situation, and others had experienced a major panic reaction that convinced them the drug was bad and their children were indeed on the road to destruction (Jacobson & Zinberg 1975). Parents could avoid this pitfall by obtaining the drug in question from their own peers, but even then they would be placed in the position of participating in an illegal activity. In short, illicit drug use is a no-win situation for everyone, even for those trying to plan and teach useful drug education courses .
    In the case of the mass media, most of the information provided is dramatically opposed to drug use and to the possibility of controlled use. Heroin consumption is viewed as a plague, a social disease. Stories about bad psychedelic trips resulting in psychosis or suicide have served for years as media staples, and more recently there has been a new spate of marihuana horror programs. In the early 1980s, when extreme care is being taken not to offend any ethnic group, it seems that drug users and peddlers, along with hopeless psychotics, are the only villains left to be featured in the innumerable "cops and robbers" serials and movies shown on television.
    When parents, schools, and the media are all unable to inform neophytes about the controlled use of illicit drugs, that task falls squarely on the new user's peer group—an inadequate substitute for cross-generation, long-term socialization. Since illicit drug use is a covert activity, newcomers are not presented with an array of using groups from which to choose, and association with controlled users is largely a matter of chance. Early in their using careers, many of our research subjects became involved either with groups whose members were not well schooled in controlled use or with groups in which compulsive use and risk-taking were the rules. Such subjects went through periods when drug use interfered with their ability to function, and they frequently experienced untoward drug effects. Eventually these subjects became controlled users, but only after they had realigned themselves with new companions—a difficult and uncertain process. Unfortunately, many adolescent users never make this transition.
    Cultural opposition complicates the development of controlled use in still another way: by inadvertently creating a black market in which the drugs being sold are of uncertain quality. With marihuana, variations in the content do not present a significant problem because dosage can be titrated and harmful adulterants are extremely rare; the most common negative effect of the black-market economy is that the neophyte marihuana user pays more than he should for a poor product. For the other drugs there are wide variations in strength and purity that make the task of controlling dosage and effect more difficult.. Psychedelics are sometimes misrepresented: LSD, PCP, or the amphetamines may be sold as mescaline. With heroin, the potency of a buy is unknown and the risk of an overdose is thus increased. If adulterants are present, the risk of infection may be heightened when the drug is injected.
    The present policy of prohibition of drug use by legal means would be justifiable if it persuaded some people never to use drugs and led others to abandon them. Undoubtedly prohibition discourages excessive use, a goal with which I sympathize. But no one knows whether the number of users would be increased if prohibition were to be suspended. Would many people who had not tried illicit drugs choose to use them? Would many who had tried them go on to become compulsive users?
    Aside from its questionable effect on the number of drug users, the prohibition policy actively contributes to the prevailing dichotomy between abstinence and compulsive use. It makes it extremely difficult for anyone who wishes to use drugs to select a moderate using pattern. This outcome may have been acceptable before the 1960s, when there were few potential drug experimenters, but it could prove catastrophic in the 1980s when adolescent experimentation approaches statistically normal behavior. Since 1976 more than 50% of high-school seniors report having tried marihuana or hashish at some time in the past, and over 44% have tried within the past two years (Johnston, Bachman & O'Malley 1982).
    Although the opportunities for learning how to control illicit drug consumption are extremely limited, rituals and social sanctions that promote control do exist within subcultures of drug users. Our interviews have shown that these controlling rituals and sanctions function in four basic and overlapping ways.
    First, sanctions define moderate use and condemn compulsive use. Controlled opiate users, for example, have sanctions limiting frequency of use to levels far below that required for addiction. Many have special sanctions, such as "don't use every day." One ritual complementing that sanction restricts the use of an opiate to weekends.
    Second, sanctions limit use to physical and social settings that are conducive to a positive or "safe" drug experience. The maxim for psychedelics is, "Use in a good place at a good time with good people." Two rituals consonant with such sanctions are the selection of a pleasant rural setting for psychedelic use and the timing of use to avoid driving while "tripping."
    Third, sanctions identify potentially untoward drug effects. Rituals embody the precautions to be taken before and during use. Opiate users may minimize the risk of overdose by using only a portion of the drug and waiting to gauge its effect before using more. Marihuana users similarly titrate their dosage to avoid becoming too high (dysphoric).
    Fourth, sanctions and rituals operate to compartmentalize drug use and support the users' non-drug-related obligations and relationships. For example, users may budget the amount of money they spend on drugs, as they do for entertainment; or they may use drugs only in the evenings and on weekends to avoid interfering with work performance.
    The process by which controlling rituals and sanctions are acquired varies from subject to subject. Most individuals come by them gradually during the course of their drug-using careers. Without doubt the most important source of precepts and practices for control is the peer using group. Virtually all of our subjects had been assisted by other noncompulsive users in constructing appropriate rituals and sanctions out of the folklore and practices circulating in their drug-using subculture. The peer group provided instruction in and reinforced proper use; and despite the popular image of peer pressure as a corrupting force pushing weak individuals toward drug misuse, our interviews showed that many segments of the drug subculture have taken a firm stand against drug abuse.

Footnote

    1. For a survey of previous research on drug addiction, abuse, and controlled use, see appendix C.
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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 Panel1978):
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.

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