Who are the drug educators in the United States and other countries around the world? They are not just those of us in schools, police departments, government agencies, and other community agencies officially designated as formal drug educators. In reality, they are practically everyone.
Drug educators in the broadest sense include parents, siblings, peers, neighbors, physicians, legislators, journalists, radio announcers, TV and movie writers, advertisers, anti-drug crusaders, and users and abusers of any legal or illegal drug. In other words, most people at one time or another send messages about drugs, by word or by deed. Sometimes the messages are intended to inform or influence others. At other times, the messages are sent without such an intent but may have a stronger effect.
For example, I say to my neighbor one Sunday morning, within hearing of my children, "We had a great time at the party last night, the booze was really flowing — nobody felt any pain." Whether I know it or not, at that moment I am a drug educator. While acting informally, I may be much more influential than my children's drug educator at school.
My point is that we are all drug educators, for better or for worse, and that the words we use about drugs and the ideas and emotions we convey have the potential for informing or misinforming others. The words and concepts we choose, or uncritically mouth, are more powerful than we may realize.
Defining Drugs As Illegal Substances Is Part of the Problem
Each society has its own cultural history of reactions to the use of the wide variety of substances which either science or the general public defines as "drugs."
This country's history is one of controlling drugs which are unpopular with the majority of its citizens or with a vocal minority (as was the case with Prohibition) by making their sale and/or possession illegal. Popular drugs, on the other hand, even if subject to serious abuse, have generally been protected from harsh controls. This history has helped mold popular definitions of what a drug is. Defining drugs on the basis of their legality, while partly based on the relative risks of addiction and of other physical and psychological effects of the drugs, has been heavily influenced by dominant cultural biases, powerful economic interests and substantial misinformation.
The term "drug" itself means different things to different groups. Police, illegal drug sellers, alcohol and tobacco salesmen and often the public refer only to illegal drugs as drugs. In contrast, pharmacologists, doctors, pharmacists and others with a more objective view, like some drug educators, include as drugs both medicines and recreational drugs, regardless of whether or not they are currently classified as legal or illegal.
A typical pharmacological definition of drugs states that all chemical substances which modify the function of living tissues, resulting in physiologic or behavioral change, are drugs. This scientific definition is broad enough to include drugs which physicians or patients may use as medicines to prevent or treat illness and drugs which may be used non-medically to achieve certain effects or lifestyles.
In its popular meaning, however, "drugs" generally refers only to illegal drugs. This alternative to a simple scientific definition leads to two major types of problems of miseducation: the use of other definitions and terms to perpetuate misconceptions about drugs; and the use of emotion-laden words and street-wise expressions which deter clear thinking. I will discuss each of these problems separately and conclude by suggesting that we help popularize a language about drugs based on knowledge and objectivity, to replace that which reflects misconceptions and emotionality.
Our Drug Language Perpetuates Misconceptions
Foremost among examples of the first type of problem is the popular definition of "drug abuse" as any use of illegal drugs but not the abuse of legal drugs. A related example is the common use of the terms "hard drugs" and "soft drugs." While efforts may occasionally be made to base such a distinction on objective criteria, the primary basis for classifying drugs as "hard" or "soft" is usually their legal status, regardless of other negative consequences to the individual, to others in the community and to society.
By any scientific measure of its effects on the morbidity and mortality of users as well as non-users exposed to the drug, tobacco (i.e., nicotine) would certainly warrant classification as a "hard" drug. This common sense classification, however, does not fit the popular stereotype of what a "hard" drug is. As popularly conceived, "hard drugs" are substances which are addictive, unpopular, dangerous to your health and illegal. Only the cultural criteria of unpopularity and illegality preclude another familiar and often addictive and dangerous drug, namely alcohol, from popular classification as a "hard" drug.
Some thirty years ago, Joel Fort classified drugs, on the basis of objective criteria of harm to the individual, into three categories of "hardness." The first and most dangerous category of hardness included alcohol, barbiturates, amphetamines, nicotine and, "probably," cocaine. In the second category were opiates and hallucinogens, while the third category of hardness included caffeine, aspirin and marijuana.
Even when hazards to society as well as to the individual are taken into account as Samuel Irwin has done, alcohol ranks higher than opiates as a drug of abuse. If alcohol and tobacco are defined as non-drugs or, at worst, "soft" drugs, then drug education is built on a basic hypocrisy. To paraphrase a self-serving saying: "His drugs are 'hard,' your drugs are 'soft' and my drugs are not drugs."
It is true that there is increasing acceptance in the media as well as in the literature that alcohol and tobacco are drugs and their abuse should properly be considered drug abuse. In fact, the term "substance abuse" has been used in recent years to connote misuse ofboth legal and illegal drugs. But reports, studies and other publications from government and non-government sources have been inconsistent in how they define substances. Sometimes they include alcohol and tobacco and sometimes they do not.
Around the early 1970s, there were posters proclaiming that "Alcohol is a drug." While such lip service has long been given to this idea, most articles, reports, and educational materials have continued to use the term "alcohol and drugs." This has reinforced the belief that alcohol, since it is legal, is not a drug.
Recently, however, there has been progress in this regard.
The Phrase "Alcohol and Drugs" Mistakenly Proclaims Alcohol Is Not A Drug
The words "alcohol and drugs" have been juxtaposed incorrectly for many years and still today in spoken and written references to various forms of drug problems. This phrase reinforces the popular belief that since alcohol is legal, it is not a drug. This belief has been buttressed, until recently, by the entire bureaucratic structure of the Department of Health and Human Services (HHS) with its monolithic nomenclature.
A few examples will suffice: the major division of HHS dealing with drugs is entitled the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA); a major source of federal funds is the Alcohol and Drug Abuse Treatment and Rehabilitation (ADTR) block grant; The National Clearinghouse for Alcohol and Drug Information is the name of HHS unit for distributing information on drugs.
Accompanying the official bureaucratic nomenclature was the pervasive practice in both spoken and written references to use the expressions "alcohol and drugs" and "alcohol and drug abuse." Since descriptions of available grants for research, treatment or prevention used the inaccurate term "alcohol and drugs," proposals for such grants as well as the reports and publications flowing from them, repeated the error, thus reinforcing the misconception. Recently, however, there has been progress in this regard.
"Alcohol and Other Drugs": A Major Conceptual Breakthrough
A high point of official acceptance of alcohol as a drug came in 1987 when Secretary Otis R. Bowen of the Department of Health and Human Services (HHS) sent a clarifying letter to all divisions in his Department. Dr. Bowen, a physician, wrote about the official use of the term "substance abuse" as follows:
Alcohol is the most widely abused drug in the United States. Unfortunately, the increasingly frequent use of the term "substance abuse" fails to communicate this critical fact, and often obscures the nature and implications of the problems the De- partment is trying to address. Additionally, we as a Department, also tend to equate this term with the abuse of illicit drugs in activities and reports and other documents which concern substance abuse. He then added, acting as the Government's chief drug educator, the following strong and significant statement:
Consequently, I am directing that, effective immediately, the term "alcohol and other drug abuse" be used wherever appropriate in all our documents and publications, except where the term "substance abuse" is explicitly required by statute. I am also directing that activities and reports and other documents which describe or relate to our Department's substance abuse activities include activities designed to combat alcohol abuse and alcoholism.
Leaving aside for the moment the now obvious omission of tobacco, the second most widely abused drug in the United States, the Secretary's statement represents a strong attack on the official misuse of terminology. His underlying message was that alcohol, even though legal under most circumstances, is a drug and subject to abuse along with other drugs, whether legal or illegal.
The results of Dr. Bowen's directive appear to be limited but encouraging. A quick sampling of bureaucratic nomenclature and language used in materials, studies and reports issued by the U.S. government or its contractors suggests that "alcohol and drugs" remains the phrase of choice. Yet, in a small but growing number of in stances the term "alcohol and other drugs" is appearing. The National Clearinghouse for Alcohol and Drug Information, for example, now publishes Prevention Pipeline: An Alcohol and Other DrugAwareness Service.
In its 1990 Prevention Monograph 6, the Office of Substance Abuse Prevention of HHS's Public Health Service departed strikingly from past practice. It consistently used the term "alcohol and other drugs" and even employed a new acronym, AOD, to stand for alcohol and other drugs used or abused, whether legal or illegal.
A good measure of the impact of Dr. Bowen's directive now and in the future is the degree to which the term "alcohol or other drugs" appears outside as well as inside the Public Health Service and outside HHS. On one day last June, for example, I picked up a pamphlet from the University of Maryland Health Clinic and was pleased to read the term "alcohol and other drugs." But an hour later, I passed under a sign on a bridge outside Baltimore with a more familiar phraseology, "Alcohol, Drugs and Driving Don't Mix." While slow, there are indications that progress is being made.
There has reportedly even been discussion among some federal drug officials about using the acronym ATOD to refer specifically to alcohol, tobacco and other drugs. This would constitute a further step forward since it would single out tobacco along with alcohol as the two most abused drugs in this country.
The Term "Drug-Free" Is Conceptually Unsound
The traditional term "alcohol and drugs" may seem an innocuous reflection of custom with no real educational impact. Yet, the Secretary did not think so. And when this basic misuse of words is combined with a series of other misuses, the cumulative impact cannot be easily overestimated. "Drug-free" is another common phrase with which is conceptually unsound. It helps us mislead ourselves into thinking that drug problems primarily involve illegal drugs.
Derived from the misuse of the word "drugs," the term "drug-free" has been increasingly used in recent years as an adjective as in "drug-free therapeutic community," "drug-free America," and "drug-free workplace," and "drug-free schools." Not only is the adjective used improperly in all these instances to exclude medicines but it usually refers, once again, to only certain non-medical or lifestyle drugs, namely those currently illegal. Thus, it has usually been acceptable to smoke in so-called drug-free therapeutic communities on the false premise that tobacco is not a drug and that a cigarette smoking patient in treatment for dependence on an illegal drug is "drug-free."
Likewise, a "drug-free America" is one in which residents can smoke two packs a day and drink a six pack of beer every evening and still be "drug-free." With all the patients who legitimately take prescription and non-prescription drugs in this and other countries, it would be unthinkable to want to become drug-free. Of course, the retort is, that is not what we mean by drug-free. And that is exactly the problem. What is narrowly meant is "illegal drug-free" or "opi ate drug-free." But we often use the shorter version, "drug-free," not because it is more convenient as much as because we "buy into" the popular definition of drugs as referring to illegal drugs.
It is only by maintaining the fiction that drugs do not include medicines, alcohol, tobacco and caffeine that we can continue to support the goal ofbeing "drug-free."
In 1986, the federal government added its prestige to the popular practice of equating drug-free with illegal-drug-free. In September of that year, the President signed Executive Order 12564, "A Drug-Free Federal Workplace." It stated that federal employees are required to refrain from the use of illegal drugs, whether on or off duty. It described such use as contrary to the efficiency of the service and as unsuitable for federal employment. Under that Executive Order, a government office in which a quarter of the employees smoked cigarettes at work or more than half drank beverages containing caffeine would have been inaccurately considered "drug-free."
Also in 1986, however, the federal government took steps to limit cigarette smoking in its work environment. The General Services Administration, following the Surgeon General's report on the health risks ofpassive smoking, established regulations which allowed agency heads to declare which areas in their buildings, if any, were to be smoking areas. Since the use of alcohol was previously banned from federal buildings, we are approaching a situation in which the goal could reasonably be described as "free of drugs of abuse."
In the case of "drug-free schools," we are also beginning to approximate a partially accurate use of the term. More and more schools have policies banning the use of tobacco as well as alcohol by students and even by faculty and staff. All legal as well as illegal drugs which can produce dependency, except perhaps for caffeine, should be included in the term "drug-free schools." This would be a major advance towards using drug language based on scientific concepts rather than on stereotypical misconceptions.
The final step would be to properly include medicines which some children and faculty take for their medical conditions as drugs. But that would point up the reality that we do not want schools, workplaces or the country to be "drug-free" in the pharmacological sense of the term. One solution, of course, would be to specify the kinds of drugs we want to be free of. For example, we want all these locales to be "free of drugs of abuse" or more accurately "free of drug abuse." Such semantic purity, however, would be inconvenient and at first confusing. Given the number of "Drug-Free School Zone" signs in use, it would also be costly.
The inconvenience, costs and confusion which would result from instituting proper terminology and correct but unpopular language points up the deep seated nature of the problem. Once incorrect concepts and terms have been established by common usage as part of our dominant cultural beliefs, it is difficult at best to gain acceptance for more accurate alternatives. Those with the power to influence the language we use would have to be convinced it is worth doing and then, by whatever authority given, issue directives or guidelines for establishing new policies and practices. Finally, through monitoring and positive and negative incentives, they would need to conduct a campaign of educational reinforcement with the cooperation of other committed organizations.
The beginnings of such a campaign by HHS have already begun. The ground-breaking directive of Secretary Bowen has been described above and some of its effects have been noted. And recently, the Office of Substance Abuse Prevention issued its OSAP Editorial Style Guidelines. Its recommendations include:
• "Alcohol and other drugs" is the suggested expression when writing about drugs, including alcohol. The use of this expression emphasizes the too-often overlooked fact that alcohol is a drug... • AOD is an abbreviation that may be used in place of 'alcohol and other drugs'... • Avoid using the terms 'hard' and 'soft' drugs because these terms imply that some drugs, such as marijuana, are virtually harmless.
Although the reason OSAP gives for avoiding the terms "hard" and "soft" drugs assumes that marijuana will be classified as "soft," it does not go far enough in pointing out that tobacco is almost always and alcohol is usually included among the so-called "soft" drugs. As noted above, the misclassification of these two legal drugs of abuse as "soft" is especially misleading.
Emotional Words About Drugs Deter Clear Thinking
A second major problem is the use of emotion-laden words and street-wise slang. When drugs refer only to illegal substances and potential users or abusers are to be warned against using them, then negative and emotional language is likely to emerge. Often the warnings have been designed to scare potential users about the real or sometimes exaggerated dangers of illegal drugs. Such scare tactics, while generally viewed as ineffective, die slowly.
Early examples like "Marijuana leads to insanity" and "Speed Kills" have been replaced by such messages as those suggested by the poster of a fried egg in a pan with the caption, "This is your brain on drugs." The poster sends two messages. The first is that all drugs have the same effect which, of course, is not true even of all illegal drugs. The second is that all (illegal) drugs to the same degree damage the brain physically and/or "mess-up" the brain psychologically. That also is not true.
While such scary messages may be effective in deterring some viewers from trying illegal drugs, they are potentially counterproductive. By communicating information which is inaccurate, the communicator may lose credibility when, later, the receiver realizes the message, while "cool," was not truthful. Also, these messages usually serve to detract attention from hazardous drugs which happen to be legal. It is only when we unwisely see illegal drugs as the main enemy, that we employ emotional words like "the war on drugs," and the "drug menace" to engage the emotions. We do not talk about the "menace of alcohol" or the "war on tobacco."
Recognizing the mixed reactions which such negative appeals to emotions may receive, OSAP's recent Editorial Style Guidelines advises:
War and military metaphors, while widely used and often very meaningful to many people, are sometimes not well understood by others. In some cases, they may even be resented. Although military and war metaphors permeate our language, when writing prevention materials be particularly judicious in order to try and produce a message that will communicate with most and offend none... Prevention messages would promote strengths, capabilities, and skills...
The term "cancer sticks" for cigarettes is one of the few instances in which emotional language is used to refer to a legal drug of abuse. In most cases, we save our words of anger or denigration for illegal drugs and illegal drug users.
Again, however, OSAP in its Guidelines promotes a less emotional use of words. It urges developers of messages about generic drug problems to: Avoid using derogatory terms such as "drunks," "pothead," "dope fiends," or "drug addicts." These expressions show a lack of respect for individuals with alcohol and other drug problems and may alienate the very people toward whom prevention efforts are aimed.
Slang Can Increase the Appeal of Drugs of Abuse
A whole host of street-wise expressions are often used by both official and unofficial drug educators in communicating about drugs. Such slang words are frequently included in drug education materials to show familiarity with the illegal drug culture. Examples include "angel dust," "speed," "uppers" and "downers," "acid," and "pot." In using the vocabulary of an insider, the communicator is often inadvertently reinforcing the positive emotional appeals which such words have for some current and potential users of these drugs. Such usage can add to the glamour of these drugs as "forbidden fruit."
Other phrases like "King Heroin," "pure heroin," and "the white lady," also have negative effects. By using emotional words which emphasize the powerful effects or purity of drugs, their riskiness, or "badness," we make it harder to discuss drugs calmly and objectively." And for some, we make these drugs more attractive as symbols of alienation or rebellion. The distributors of L and M cigarettes knew what they were doing some years back when they advertised their product as "super bad."
Slang for alcohol can have similar effects. The common term "booze," like the older term "hooch," add an emotional layer to references to alcohol. Innocent sounding as the word "booze" is, it tends to connote for many, albeit subliminally, a less than normal and legitimate use of a drug. The responsible use of alcohol for relaxation and fun, like the responsible use of sex, should not require words which may connote something abnormal, suspect or illicit. When the opening quote in this paper which contained the phrase "the booze was really flowing" is followed by another like "nobody felt any pain," the miseducation is compounded.
In a similar vein, slang for having too much to drink, like "sloshed" or "toasted," adds an element of titillation and comic relief which conveys an attitude of acceptance if not outright admiration for alcohol abusers. The values of the alcohol-abusing subculture are thus given support by the commonplace slang of popular culture.
On this point, OSAP's Guidelines agree and extend their advice to both legal and illegal drugs. The Guidelines say to: "Avoid such phrases as 'getting high,' tripping out,' or 'hooked.' These slang expressions trivialize the effects of alcohol and other drug use."
Finally, drug professionals, as well as popular writers, often use these and similar terms to capture the attention of publishers and readers, to sell books, and to appear savvy. The titles of many drug publications, newsletters and organizations are "catchy but counterproductive." Examples include "Road to H," "Dope," "Capsule," and "Stash." While such terms facilitate communication by being easily understood, they are depending on the language of emotion and drug slang to get a positive response. While such terminology catches our attention, it tends to miseducate, either by signaling a tolerance for abuse of legal drugs or by "upping the ante" of the attractiveness as well as the risk for illegal drugs.
Conclusion
In this paper, I have suggested that the language we use for substances which pharmacologists call drugs is often conceptually inaccurate and creates serious problems for drug education. Much of our current language makes difficult a rational, comprehensive discussion of all drugs. Our unscientific definitions and usage of terms, and use of emotional words and slang, have the effect of focusing on illegal drugs as if they were the primary drug problems we face. The equal, if not greater seriousness, of the legal drug problems of alcohol and tobacco are thus spared equal scrutiny and comparable preventive efforts. This unequal treatment is understandable in terms of the importance of these two drug industries to this country's economy.
While separate efforts to curtail abuse of these legal drugs are increasing, the traditional separation of efforts to control illegal drug abuse from efforts to control legal drug abuse has created two profound problems for generic drug education. The separation has led to hypocrisy on the one hand and subtle encouragement to abuse drugs, both legal and illegal, on the other hand. In effect, we have been preaching against any use of illegal drugs while holding a drink of alcohol in one hand and a cigarette in the other. We have lost credibility over the years with young people sensitive to such hypocrisy.
One effect of this hypocritical stance, sometimes abetted by exaggerated claims of illegal drug effects, has been to increase the lure of some illegal drugs like marijuana or more dangerous drugs. Another effect, perhaps more common, is the subtle, or not so subtle, encouragement by parents and others for children to choose tobacco and alcohol as drugs of choice. They are seen as preferable alternatives to using illegal drugs with their criminal stigma.
Ideally, we need an accurate and non-emotional language with which to teach and communicate about all drugs, whether currently legal or illegal. No small task in the face of powerful legal drug industries, we need to make progress one step at a time. The OSAP "Guidelines" are one official beginning. Since we are all "drug educators," we all have an important role to play. Those of us in the drug field have a special responsibility.
The view expressed in this paper are those of the author and in no way represent those of the U.S. Department of Health and Human Services.
Alan S. Meyer, Ph.D., works within the Office of the Inspector General at the New York Department of Health and Human Services.
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