Drug Abuse

7 THE USE AND MISUSE OF INTOXICANTS

Factors in the Development of Controlled Use

Norman E. Zinberg

INTRODUCTION

Careful interviewing has revealed that controlled users—regular oc-casional users of intoxicants whose use is unquestionably under con-trol—and even abstainers express much more interest in and preoccupation with the use of intoxicants than is generally acknowl-edged. Whether to use, when, with whom, how much, how to ex-plain why one does not use—these questions are of concern to a great many citizens. Within the American culture lies a deep-seated aver-sion 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 the use of intoxicants. Thus the whole issue becomes muddy. The existence of some control on the part of even the most compulsive users, and the interest in drugs and the quality of drug use (the question of with whom, when, and how much to use) on the part of most controlled users, are ig-nored. We are left with longings for the utopian society where no one would want drugs either for their pleasant or unpleasant effects, or for relaxation and good fellowship, or for escape and torpor.

Since such abstinence is impossible, however, the reigning cul-ture's model of extreme decorum overemphasizes the pharmaceutical powers of the drug or the personality of the user. It inculcates the view that only a disordered person would not live up to the culture's standards or that the power of the drug is so great that the standards cannot be upheld. To consider only the drug itself or the personality of the user tends to ignore the power of the social setting in which the drug use takes place. This oversight requires considerable psy-chological legerdemain, for as in most areas of living, people in com-plex social situations can rarely remain indefinitely on an extremely decorous course. Intoxicant use tends to vary with one's time of life, status, and even geographical location. Most adolescents who have used intoxicants heavily slow down appreciably as they reach adult-hood and change their social setting (friends and circumstances); there are some adults who, as they become more successful, may increase intoxicant use. A man born and bred in the dry part of Kansas may change his use significantly after moving to New York City. The effects on intoxicant use of such variations in social cir-cumstances have certainly been perceived, but they are usually not incorporated into a sound theoretical understanding of how the so-cial setting influences the use and control of intoxicants.'

In this chapter I will consider first some background on historical variations of controlled use before looking at how the reactions to the drugs themselves, the personalities of the users, and the social setting lead to the development of social sanctions and rituals that are the bases for controlled intoxicant use. A section on the powerful influence of social learning on such use is followed by a discussion of the problems for researchers in the field of intoxicant use at a time when there is so much controversy about social policy.

HISTORICAL BACKGROUND

The history of the use of alcohol in America provides a striking example of the variability of intoxicant use and its contro1.2 First, it illustrates the social prescriptions that define the social concept of control, and second, it shows that the time span of these control variations can be decades.

Five social prescriptions that define controlled or moderate use of alcohol—and these may apply to other intoxicants as well—have been derived from a study of alcohol use in many different cultures. All five of these conditions encourage moderation and discourage excess.'3

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, as well as different generations, are included in the drinking situation, whether they drink or not.

4. Drinking is divorced from the individual effort to escape per-sonal anxiety or difficult (even intolerable) social situations. Furthermore, 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 by the con-trolled intoxicant user usually indicates that drinking is only one of many activities and thus susceptible to reasonable levels of constraints on behavior. It also shows that drinking is not asso-ciated with a male or female "rite of passage" or sense of superiority.

The enormous variations in alcohol use that have taken place dur-ing three major periods of American history (the 1600s to the 1770s, the 1770s to about 1890, and 1890 to today) illustrate the importance of these social prescriptions in controlling the use of alcohol.4

During the first period, the American colonies, although veritably steeped in alcohol, strongly and effectively prohibited drunkenness. Families drank and ate together in taverns, and drinking was associated with celebrations and rituals. Tavern keepers were people of status; keeping the peace and preventing excesses stemming from drunkenness were grave duties. Manliness or strength was measured neither by the extent of consumption nor by violent acts resulting from it. Prerevolutionary society, however, did not abide by all the prescriptions, for certain alcoholic beverages were viewed as medi-cines: "Groaning beer," for example, was consumed in large quan-tities by pregnant and lactating women.

The second period, which included the Revolutionary War, the Industrial Revolution, and the expansion of the frontier, was marked by excess. Men were separated from their families and began to drink together and with prostitutes. Alcohol was served without food and was not limited to special occasions, and violence resulting from drunkenness grew. In the face of increasing drunkenness and alco-holism, people began to believe (as is the case with some illicit drugs today) that it was the powerful, harmful pharmaceutical properties of the intoxicant itself that made controlled use remote or impossible.

Although by the beginning of the third period moderation in the use of alcohol had begun to increase, this trend was suddenly inter-rupted in 1920 by the Volstead Act, which ushered in another era of excess. We are still recovering from the speakeasy ambience of Pro-hibition in which men again drank together and with prostitutes, food was replaced by alcohol, and the drinking experience was colored with illicitness and potential violence. Although repeal provided re-lief from excessive and unpopular legal control, the society was left floundering without an inherited set of social sanctions and rituals to control use.

THE BASIS FOR CONTROLLED INTOXICANT USE

In order to understand how sanctions and rituals that help differ-entiate use from misuse of intoxicants develop, one must think in terms of how three factors or variables interact to affect an individ-ual's decision to use an intoxicant, the degree of effect it has on him, and the ongoing social and psychological reactions to use. These variables are (1) the pharmaceutical properties of the intoxicant, (2) the attitude and personality of the user (the set), and (3) the physical and social setting in which use takes place. Despite apparent accep-tance of this theoretical position, which stresses the importance of all three variables (as mentioned in the Introduction), the influence of setting on intoxicant use and the user, and the way in which setting interacts with the other two variables have been little understood.5

Even those who make use of this threefold theoretical construct in analyzing the patterns of drug use and treating users fail to realize the exact role played by the setting (including both physical and so-cial setting) as an independent variable in determining the impact of use. When a drug is administered in a hospital setting, for example, the effect is very different from that experienced by a few people sitting around in a living room listening to records. Not only is there a vast difference between the actual physical locations, but different social attitudes are involved. In the hospital the administration of opiates subsumes the concept of the institutional structure of therapy and licitness. In the living room there is a flavor of dangerous ad-venture, antisocial activity, and illicit pleasure, as well as the con-siderable anxiety that accompanies all three. It is not surprising that few patients in hospital settings continue to take drugs on their own after the necessity for therapy has passed,6 whereas many living room users express an intense and continuing interest in the drug experience.

When intoxicant use is considered, it is remarkable how often peo-ple attempt to deny the existence of a widespread preoccupation with drugs. In particular, when the "drug revolution" began in the 1960s, public and professionals alike tended to think of any use of sub-stances not only as misuse but as something that was difficult to understand. The question that comes up again and again is, "Why do they use it?"

The obvious reply, "Because they like it," is misleading. First, the question of what constitutes pleasure is extremely hard to answer, and even in a general sense the notion of personal gratification is misunderstood. Such a reply is often used pejoratively to indicate a dangerous relationship with a substance that could lead to depen-dency or addiction. By implication, this view suggests that controlled users of intoxicants do not get personal satisfaction from ingesting their drugs. Although there unquestionably are people who use a small amount of a substance merely to be sociable, like the guest who nurses one drink throughout a cocktail party, most users find their use gratifying. In fact, even those who obviously are in careful control of their use respond "yes" to the question, "Would you like to use more than you do?" Besides citing their fear that they might get addicted—a fear expressed most strongly, of course, by those with the least to fear—people who use drugs moderately apparently do so to preserve the pleasure obtained from the substance.

The issue, therefore, is not one of obtaining gratification from substance use, for most users do. The issue is the degree to which an individual can balance and hence control those wishes for sub-stance gratification with other factors, such as moral revulsion, the desire to enhance gratification in the long run, automatic acceptance of peer group standards, or unconscious utilization of available so-cial sanctions and rituals. In other words, the gratification aspect of drug use may not be very different from that aspect of the con-sumption of everyday things, such as food. Some people who gratify themselves thoroughly and overeat one evening find that the next day food does not appeal to them. Others after a debauch can ex-ercise a balancing control by keeping busy, getting distraught by seeing the numbers on the scale, beginning a careful regimen of ex-ercise, or consciously being where the food is less appetizing or is low in calories. Still others try these same mechanisms but they suc-ceed only intermittently or partially. They gain weight or, in psy-chodynamic terms, suffer from inhibitions against control. But the difficulty, in the case of both food and intoxicants, lies not in the pleasure factor but in the inhibition of existing controls. And it can be seen easily, if only by watching old movies, how the cultural norm of what an attractive body is, i.e., the social setting, influences the extent of the control exercised.

As to how one fixes on a substance that is pleasurable, I am not sure that the analogy with food altogether holds. With drugs there is far less choice, and that choice is determined by what is socially available. Today respectable, middle-class professionals can easily find marijuana as well as alcohol, but they probably would have to go to some unacceptable lengths to obtain heroin.

Much has been made of the possibility of drug specificity, the view that an individual is so enamored of a particular drug that the pleas-ure from it overwhelms all other substances and nothing else would have the same appeal.'7 Every once in a while a story emerges, usually from a patient under drug treatment, that tells of multiple and dys-functional drug use until the user discovered the drug, which makes giving up all else easy, and despite its own problems is an overall stabilizing experience. In my clinical experience the drug has always been heroin. But this kind of story goes beyond the question of ex-tent of pleasure. One patient, for example, had been using "ups" (usually amphetamines), "downs" (usually barbiturates or diazepam [Valiump, some alcohol, and some marijuana. The combination kept her in a state of chaos, socially, psychologically, and physiologically. Periods of little sleep, food, personal interaction, or euphoria alter-nated, in no particular sequence, with periods of being constantly on the nod, gregarious, or high. When she finally found a drug with a strong, consistent, regular, and flexible action, it was a great relief. It is strange to think of heroin as being an integrating drug, but in this case it seemed to be just that.

If the idea of a particular drug for a particular person is less gen-erally true than the popular myth implies, then could the reverse of that myth be true? Will any drug do as long as it gets one high? Probably not. There is no doubt that some people like one drug or some drugs better than others. And the converse is even more likely to be the case. Some who very much like to get high are quite neg-ative about one drug or another. Although the split of the 1960s between heads and juicers has long since faded out, there still are regular marijuana users who express a distaste for alcohol, and few heroin users show much appreciation for marijuana. If they use it at all, they use it so heavily that it acts more as a "down" than as an experience enhancer.

Studies suggest that there are two large classes of drugs.8 One class, for want of a better term, may be called "bread-and-butter" drugs. Within it alcohol, cannabis, and the opiates can be depended upon to give a consistent but relatively flexible effect that can thus be adapted to the situation as desired. A small number of respondents would also include the minor tranquilizers in this class, but so far most clinical experience has not borne this out. The pleasurable ef-fect of the bread-and-butter drugs can generally be depended upon, although alcohol, cannabis, and the opiates have quite different sub-jective qualities and, as already noted, liking one does not necessarily mean liking the others. Despite books with titles such as /es So Good, Don't Even Try It Once,9 I would guess that many people find the opiates dysphoric.

The other class of drugs I call the "exotics." People try them either because they are pleasurable or because they are faddish. The fad factor is of great importance. Since the drug revolution of the 1960s, many people have discovered that they like to get high. If they hear that something new—remember the banana skin craze of 1967—will get them high, a mini drug explosion may occur. But among the ex-otics, even the pleasurable drugs have a limited application. The psy-chedelics, for example, are long lasting and have an extremely high impact. Although the content of trips may range widely from eu-phoria to depression to chaos, and even to an indication of a higher sensibility, the changed state of consciousness in any particular per-son is invariant and repetitious.1° Despite the frequent reports of immense delight and discovery upon initial use, the interviewed sub-jects usually got bored with the experience after a time. This controlled-use study, sponsored by the Drug Abuse Council, con-firmed reports from the Haight Ashbury Free Medical Clinic that not one user continued to use psychedelics frequently after a year or two.11

Generally the amphetamines belong in the exotic class, as far as their pleasure-seeking use is concerned. Again the initial sense of enormous stimulation from these high-impact, disorganizing drugs seems extremely pleasurable to some, but after a period of regular use the disorganizing qualities become uppermost, and the difficulty of maintaining interpersonal relationships either creates serious trou-bles for the user or makes him (or her) give up the drug. In the late 1960s when there was a faddish outbreak of amphetamine use all over the country, even the most prodrug underground newspapers ran headlines reading, "Speed Kills."12 Obviously, drug users of either exotics or bread-and-butter drugs can find that their use and interest in use can change over time, particularly after a period of heavy use.

The dependency-inducing potential of the amphetamines (and the barbiturates) can create a serious problem for another sort of user. Many a woman, and not a few men, who have been given a low dose of amphetamines for mild depression or as a diet aid have later found that they could not get through the day without them. When there was a general crackdown on the overprescribing of amphetamines, many of these people became desperate and protested strongly that they were not taking the drugs for fun. In the words of one woman, "I have four children and a house to clean. I can't get through the day without Dexedrine."" To their knowledge, these people never got high from the drug and did not want to. Much of the heavy use of a variety of tranquilizers may fall into the same category rather than into that of pleasure seeking. It is often argued, of course, that this is to some extent true of all chronic substance use, but the re-search interviews of my control studies support the contention of McAuliffe and Gordon that even the most chronic users continue to report a pleasurable response.'14

The difficulty of defining pleasure makes it very hard to discuss two other exotic drugs, phencyclidine (PCP) and amyl nitrate. There is no doubt that PCP, which has been readily available on the street for more than ten years, produces some sort of high state.'5 Never-theless, interviews with many users rarely specify particularly plea-surable experiences. As is the case with any other drug, users learn how to use it so as to avoid the most dysphoric effects; these subjects have reported little of the violence and few of the toxic symptoms that have been emphasized in the recent flurry of frightening reports about PCP.16 They do, however, report considerable psychological and physiological disorientation as well as the heavy feelings in the limbs and body that are characteristic of this drug. Almost without exception they have understood why PCP, which can be sniffed, smoked, or eaten but is, in itself, not usually experienced as plea-surably as the other intoxicants, generally is passed off as another substance, such as delta-9-tetrahydrocannabinol (THC), mescaline, psilocybin, or even LSD. Users of amyl nitrate, too, although men-tioning the excitement of the "pop" in the head that comes with ingestion and repeating the traditional story of popping at orgasm, do not sound so interested in or pleased with the drug experience as when they are discussing the bread-and-butter drugs.

In the current climate it is possible for any of the exotic drugs to catch on for a time, but it is hard to imagine them in continuous usage for pleasure. Great media attention, if fueled by the "scare" reports from professional sources that always make a drug sound much more attractive than it actually is to those hungry for a high, can push usage beyond that which the drug would warrant on a sim-ple pleasure scale. Even the constant discovery of one more drug menace probably cannot ensure continued popularity of a substance that is not intrinsically pleasurable (whatever that means), except among a relatively small group with highly specialized and possibly peculiar tastes.

The existence of a small group whose interest in a substance ex-perience may be perverse raises again the familiar question of the set or personality variable. Set and personality are not identical; set sub-sumes personality but in a basic sense goes beyond personality. For example, as attitudes toward marijuana have changed, many people who had been negative or fearful about it, and whose personality did not polarize toward either adventurousness or righteousness, now find it easy to accept marijuana use or to try it themselves. Here, set has been affected by the interaction with the social setting, while personality has remained constant. In fact, there is increasing evi-dence that many who did try marijuana under the social conditions of the 1960s and 1970s find that they like it little in the eighties and have stopped using it.'7

At no point should it be assumed that the social setting is the only active factor at work. Just as the actions of the small group men-tioned above—and of other groups who find some special attraction in an otherwise not pleasant experience—are dominated by personality factors, there are those whose antipathy on personality grounds to specific intoxicants or intoxicants in general is so great that they would not use them under most circumstances.

In the majority of instances, even the very extreme, it is the in-teraction of the three variables (drug, set, and setting) that is crucial. This can vary at different times, of course, and the powerful influ-ence of one variable may even obscure the effect of another. The example of heroin use in Vietnam, which will be discussed later to illustrate the power of the social setting, also shows how easy it is to miss the influence of one of the other variables. Because so many servicemen used heroin in Vietnam, the social-setting variable seemed predominant. But what of the group that continued to use the drug after returning to the United States? According to follow-up studies of Vietnam veterans, they are fewer than 8 percent, and the same studies raise the suspicion that their problems with drugs ante-dated Vietnam and may well have sprung predominantly from personality.18

The existence of this group, however, poses serious questions about the nature of addiction and the interaction of the three vari-ables. Did these men really have the sort of addictive personality structure that would have led them to some sort of addiction whether or not they had gone to Vietnam? Perhaps in the United States they might have become alcoholics. But might not some of them have functioned adequately in a more regular social situation where her-oin was not so easily available? And might they not, therefore, have avoided addiction, even though they would have had other psycho-logical problems? Unfortunately, it is not possible to devise con-trolled experiments that can easily answer these questions.

The Vietnam experience, however, teaches us a great many things. The fact that most of those soldiers who became addicted to heroin in Vietnam but did not become readdicted in the United States dem-onstrates clearly the inhibition exercised by controls under certain social circumstances.'9 That those who became readdicted in the United States chose not to exercise the available controls, which must have existed inasmuch as they had not been addicts before going to Vietnam, is not necessarily evidence of inherent personality defects.

The use of any drug involves values and rules of conduct, norms, if you will, which in this essay are called "social sanctions," and patterns of behavior, called "social rituals," which together are known as "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 maxims applied to alcohol use, "Know your limit" and "Don't drive when you're drunk"; or they may be for-mal—as in laws and policies aimed at regulating drug use.2° Social rituals are the stylized, prescribed behavior patterns surrounding the use of a drug and may apply to the methods of procuring and ad-ministering the drug; the selection of the physical and social setting for use; the activities undertaken after the drug has been adminis-tered; 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 statement, "Let's have a drink," au-tomatically exerts control by using the singular term "a drink."

Social controls (rituals and sanctions) apply to all drugs, not just to alcohol, and operate in a variety of social contexts, ranging all the way from very large social groups, representative of the culture as a whole, down to small, discrete groups.2' Certain types of special-occasion use involving widely disparate, culturally diverse groups of people—beer at ball games, drugs at rock concerts, wine with meals, cocktails at 6:00—have become so generally accepted that few if any legal strictures are applied even if such uses techni-cally break the law. For example, a policeman will usually tell young people with beer cans at an open-air concert to "knock it off," but he will rarely arrest them; and in many states the police reaction would be the same even if the drug were marijuana.22 If the culture as a whole thoroughly inculcates a widespread social ritual, it may eventually be written into law, just as the socially developed mech-anism of the morning coffee break has been legally incorporated into union contracts. 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, for example, "Never smoke marijuana 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 or 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 seem-ingly lends enchantment to the use of the needle and, therefore, op-poses 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 tell the strength of the drug that was being injected.

More important than the question of whether the sanction or rit-ual 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 that between formal and informal social controls, that is, between the law against use and the social group's condoning of use. The teenager attending a rock concert is often pressured into trying marijuana by his peers, who insist that smoking is acceptable at that particular time and place and will enhance his musical enjoyment. The push to use may 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 may make the user anxious as to whether the police will be benign in this instance. Such anxiety interferes with control. In order to deal with the conflict, the user will probably come forth with more bravado, exhibitionism, paranoia, or antisocial feeling than would be the case if he or she had patronized one of the little bars set up alongside the concert hall for the selling of alcohol during intermission. Perhaps with some drugs such as marijuana, it is this kind of mental conflict, even more than their illegality, that makes control of illicit drugs more complex and difficult than the control of licit drugs.

The existence and application of social controls, particularly in the case of illicit drugs, does not always lead to moderate, decorous use, and yet it is the reigning cultural belief that controlled use is or should be always moderate and decorous. This requirement of de-corum is perhaps the chief reason why the power of the social setting to regulate intoxicant use has not been more fully recognized and exploited. The cultural view that the users of intoxicants should al-ways behave properly stems from the moralistic attitudes toward such behavior that pervade our culture, attitudes that are almost as marked in the case of licit drugs as in the case of illicit drugs. Yet on some occasions—at a wedding celebration or during an adoles-cent's first experiment with drunkenness—less decorous behavior is culturally acceptable. Although we should never condone the exces-sive use of any intoxicant, it has to be recognized that when such boundary-breaking occurs, it does not necessarily signify a breakdown of overall control. Unfortunately, these occasions of impropriety, particularly after the use of illicit drugs, are often taken by the ad-vocates of abstinence to prove what they see as the ultimate truth: that in the area of drug use there are only two possible types of be-havior—abstinence or unchecked excess leading to addiction. De-spite massive evidence to the contrary, many people remain unshaken in this belief.

Such a stolid stance inhibits the development of rational under-standing of controlled use. As mentioned earlier, the fact is over-looked that the most severe alcoholics and addicts who cluster at one end of the spectrum of drug use exhibit some control in not using as much of the intoxicating substance as they could. Next, and of great importance, at the other end of the spectrum of drug use, as the careful interviewing of ordinary citizens has shown, highly con-trolled users and even abstainers, as noted earlier, express much more interest in and preoccupation with the use of intoxicants than is gen-erally acknowledged.

In most sectors of our society, informal alcohol education, which conveys the culture's informally developed sanctions and rituals, is readily available. Few children grow up without an awareness of a wide range of behaviors associated with the use of alcohol, learned from that most pervasive medium, television. They see cocktail par-ties, 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 al-cohol. When, in a peer group, they begin to drink and even, as a rite of passage, to overdo it, they know what they are about and what the sanctions are. Finding a "limit" is the direct implementa-tion of the injunction, "Know your limit." Once that sanction has been experientially internalized—and our culture provides mores of greater latitude for adolescents than for adults—they can move on to such sanctions as "it's not nice to be drunk" and "it's O.K. to have a drink at the end of the day, or a few beers on the way home from work or in front of the television, but don't drink on the job."23

This general description of the learning or internalization of social sanctions, although neat and precise, does not take account of 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 with different groups.24 Certainly a New York child from a rich, so-phisticated family, brought up on a 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 accom-panying a parent to a sporting event where alcohol intake acted as fuel for the excitement of unambivalent partisanship. Yet one com-mon denominator shared by young people from these very different social backgrounds is the sense that alcohol is used at special events and belongs to special places.

This kind of education about drug use is social learning, absorbed inchoately and unconsciously as part of the living experience.25 The learning process is impelled by an unstated and often unconscious recognition by young people that this is an area of emotional importance in American society and, therefore, knowledge about it may be quite important in future social and personal development. Attempts made in the late 1960s and early 1970s to translate this in-formal process into formal drug education courses, chiefly intended to discourage any use, have failed.26 Formal drug education, para-doxically, has stimulated drug use on the part of many young people who were previously undecided, and at the same time has confirmed the fears of those who were already excessively concerned. Is it pos-sible, one might ask, for formal education to codify social sanctions and rituals in a reasonable way for those who have somehow been bypassed by the informal process? Or does the reigning cultural mor-alism, which has pervaded all such courses, preclude the possibility of discussing reasonable informal social controls that may, of course, condone use? So far, these questions remain unanswered. It will be impossible even to guess at the answers until our culture has accepted the use not only of alcohol but of other intoxicants sufficiently to allow teachers to explain how they can be used safely and well. A course in the safe use of alcohol is not intended to encourage use: Its main focus is the prevention of abuse. Similarly, the primary pur-pose of the few good sex education courses in existence today is to teach the avoidance of unwanted pregnancy and sexually transmitted disease, not to encourage or discourage sexual activity.

Whatever happens 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.

Following the Timothy Leary "Tune In, Turn On, and Drop Out" slogan of 1963, the use of psychedelics became a subject of national hysteria—the "drug revolution." These drugs, known then as psy-chotomimetics (imitators of psychosis), were widely believed to lead to psychosis, suicide, or even murder.27 Equally well publicized were the contentions that they could bring about spiritual rebirth, mystical oneness with the universe, and the like.28 Certainly there were nunierous cases of not merely transient but prolonged psychoses after the use of psychedelics. In the mid-1960s psychiatric hospitals like the Massachusetts Mental Health Center and Bellevue were reporting that as many as one-third of their admissions resulted from the inges-tion of these drugs.29 By the late 1960s, however, the rate of such admissions had declined dramatically. At first, many observers con-cluded that this decline was due to fear tactics—the warnings about the various health hazards, the chromosome breaks and birth de-fects, which were reported in the media (and which were later proved to be false). In time, although psychedelic use continued to be the fastest growing drug use in America through 1973, the dysfunctional sequelae virtually disappeared.3° What then had changed?

It has been found that neither the drugs themselves nor the per-sonalities of the users were the most prominent factors in those pain-ful cases of the 1960s. The retrospective McGlothlin and Arnold study of the use of such drugs before the early 1960s has revealed that although responses to the drugs varied widely, they included none of the horrible, highly publicized consequences of the mid-1960s.31 Another book, LSD: Personality and Experience, describes a study, made before the drug revolution, of the influence of per-sonality on psychedelic drug experience." It found typologies of re-sponse to the drugs but no one-to-one relationship between untoward reaction and emotional disturbance. And Howard S. Becker, in his prophetic article of 1967, compared the then current anxiety about psychedelics to anxiety about marijuana in the late 1920s, when sev-eral psychoses were reported." Becker hypothesized that the psy-choses 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 such unpleasant reactions had disappeared when the effects of marijuana became more widely known, and he correctly predicted that the same thing would happen with 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 have shown that the user of the early 1960s, with his great hopes or fears of heaven or hell and his lack of any realistic sense of what to expect, had a far more ex-treme 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 uncon-sciously, for the experience, and responded accordingly, within a middle range.

The second example of the enormous influence of the social set-ting and of social learning in determining the consequences of drug use comes from Vietnam. Current estimates indicate that at least 35 percent of enlisted men used heroin, and 54 percent of these became addicted to it." Statistics from the U.S. Public Health Service hos-pitals active in detoxifying and treating addicts showed a recidivism rate of 97 percent, and some observers thought it was even higher. 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 people in the rehabilitation programs used more heroin than when they were on active duty."
Nevertheless, as the study by Robins et al., cited earlier, has shown, most addiction did indeed stop at the South China Sea." For addicts who left Vietnam, recidivism was approximately 10 percent after they got home to the United States—virtually the reverse of the previous U.S. Public Health Service figures. Apparently the abhor-rent social setting of Vietnam led men who ordinarily would not have considered using heroin to use, and often become addicted to, the drug. But evidently they associated its use with Vietnam, much as hospital patients who are receiving large amounts of opiates for a painful medical condition associated the drug with the condition. The returnees were like those patients who, having taken opiates to relieve a physiological disturbance, usually do not crave the drug after the condition has been alleviated and they have left the hospital.

Returning to the first example—psychedelic drug use in the 1960s—it is my contention that control over use of drugs was estab-lished by the development in the counterculture of social sanctions and rituals very like those surrounding alcohol use in the culture at large. "Only use the first time with a guru" was a sanction or rule that told neophytes to use the drug the first time with an experienced user who could reduce their secondary anxiety about what was hap-pening by interpreting it as a drug effect. "Only use at a good time, in a good place, with good people" was a sanction that gave sound advice to those taking a drug that would sensitize them intensely to their inner and outer surroundings. In addition, it conveyed the mes-sage that the drug experience could be simply a pleasant conscious-ness change, a good experience, 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, with whom, the best way to come down, and so on—varied from group to group, though some rituals spread from one group to another.

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 enlisted men used heroin in Vietnam without becoming addicted.37 More im-portant, although 95 percent of heroin-addicted Vietnam returnees did not become readdicted in the United States, 88 percent did take heroin occasionally, indicating that they had developed some capac-ity to use the drug in a controlled way.38 Some rudimentary rituals, however, do seem to have been followed by the men who used heroin in Vietnam. 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 0.J. (opium joint) seemed the ritual followed all over the country, even though the units in the north and in the highlands had no direct contact with those in the delta." To what extent this ritual aided control is, of course, impossible to determine. Having observed it many times, however, I can say that it was almost always done in a group and thus formed part of the social experience of heroin use. While one person was performing the ritual, the others sat quietly and watched in anticipation. It would be my guess that the degree of socialization achieved through this ritual could have had impor-tant implications for control.

Still, the development of social sanctions and rituals probably occurs more slowly in the secretive world of illicit drug use than with the use of a licit drug like alcohol. The furtiveness, the suspi-cion, the fears of legal reprisal, as well as the myths and misconcep-tions that surround illicit drug use, all make the exchange of information that leads to the development of constraining social sanctions and rituals more difficult. It is particularly hard to imagine that any coherent social development occurred in the incredible pres-sure cooker of Vietnam. Today the whole experience has receded so far into history that it is impossible to nail down what specific social learning might have taken place. But certainly Vietnam illustrates the power of the social setting to induce large numbers of apparently or-dinary people to engage in drug activity that was viewed as extremely deviant and to limit the activity to that setting. Vietnam also showed that heroin, despite its tremendous pharmaceutically addictive po-tential, cannot in any sense be regarded as universally or inevitably addictive.

Further study of various patterns of heroin use, including con-trolled use, in the United States confirms 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 legal and institutional formal controls and its infor-mal social controls, its capacity to develop new informal social sanc-tions and rituals, and its transmission of information in numerous informal ways, is a crucial factor in the controlled use of any intox-icant. This does not mean, however, that the pharmaceutical prop-erties of the drug or the attitudes and personality of the user count for little or nothing. As I stated early in this chapter, all three vari-ables—drug, set, and setting—must be included in any valid theoryof drug use. In every case of use it is necessary to understand how the specific characteristics of the drug and the personality of the user interact and are modified by the social setting and its controls.

THE POWER OF SOCIAL LEARNING

It may be that society is facing not only the powerful impact of wide-spread drug use on individual behavior but also a striking change in the influence of social learning itself. Technological change is one of the most important elements affecting society today. Philosophers of science point out that the rate of growth of knowledge has in-creased exponentially, as judged by rates of publication, patents, and other measurements. Before 1945, it took more than a hundred years for the sum of knowledge to double; then, amazingly, it doubled between 1945 and 1960, and again between 1960 and 1970.4° What is more, as of the early 1980s, the totality of human knowledge is expected to double every twelve years.

This rapid change means, for one thing, that parents have a dif-ferent social environment from that of their children. Parents born in the 1920s or 1930s often find computers and their accessories strange and forbidding. When first confronted with computers, they found it difficult to restrain themselves from disobeying the injunc-tion not to "fold, spindle, or mutilate." By contrast, people born in the 1960s or later regard the computer, whether pocket, desk-top, or any other model, as just one more familiar article they have learned about and used in school.

The splendid works of Thomas Hardy describe a society in which most learning took place vertically from one generation to the next. In Hardy's Wessex, children learned from their parents about work, relationships, and customs, and they followed the family pattern. Leaving one's village was a major step. When Jude left home to live in far-off Oxfordshire, he broke away from the family pattern, and his life broke up in consequence.'" For most people in such a society, social learning hardly went on outside the family or the close social group.

Today much learning and perhaps most social learning is horizontal, that is, intragenerational. The peer group is largely responsible for spreading information about work, relationships, and customs. Certainly most information about drug use, including par-ticularly sanctions and rituals, is transferred through peer groups, although the specific informational content may vary enormously from one group to another. It seems likely that this growing famil-iarity will permit future generations to make distinctions among drugs and forms of use that are not being made today by either par-ents or policy makers. It is also possible that social learning relating to drug use will in the future be transmitted within the family, as is the case with alcohol use now, and that the role of the peer group will be less important. A change in that direction seems to be tak-ing place already in relation to certain illicit drugs, in particular marijuana.

The first generation of illicit drug users in the general society is always regarded as deviant. They have strong personal motives for seeking out such a drug as marijuana, and they use it with great anxiety. Gradually, as the deviant activity catches on (as marijuana use did in the mid-1960s), knowledge increases, misconceptions are corrected, and the users become more confident and tend to stop thinking of themselves as deviants.

The second generation of users tries the illicit drug not primarily because it wants to rebel against the straight society (the larger social setting) but out of curiosity or because they are interested in its ef-fects. When the second generation supports the arguments of the first generation and opposes the cultural stereotypes about mari-juana use and users, it is more likely to be heard: There are more of them; they are more diverse in background; and their motives, which seem less personal and less antagonistic to the reigning culture, are more acceptable to society.

By this time even the straight society has moved away from its formerly rigid position toward marijuana and has become mainly confused. Such confusion encourages others in the larger social set-ting who are not primarily motivated by either drug hunger or social rebellion to experiment with the drug. Their reports have an even greater effect on the larger society; and in addition, the new diversity of the using population makes it possible to develop various styles of use that work better and cause less trouble.

Although advances in drug technology have enormously increased the availability and use of both licit and illicit substances, they have at the same time inhibited the development of rituals and sanctions like those that accompany the social use of many natural drugs. Be-fore the American Indians use peyote, they all take part in the ritual of preparing the drug. This ritual puts them into the right frame of mind for use, gives them a knowledge of the drug, and emphasizes the quality of use, thus providing social learning and social control of the drug. But when, as in our culture, drug preparation is trans-ferred to the technical expert or manufacturer, the natural social method of control is lost. The first-time user can suddenly be con-fronted with a substance he does not understand, one for which rit-uals, sanctions, and other social controls have not been developed or disseminated.

In addition to providing society with new, more powerful drugs that lack built-in social controls, technology has supplied the means of publicizing the worst effects of these new drugs. In the 1960s, at the beginning of the drug revolution, the reading and viewing public suddenly learned from widely disseminated media reports, princi-pally on television, about the disastrous results of a psychedelic trip. The discovery of this new experience, experimentation by a few in-dividuals who had a variety of reactions, and further experimenta-tion by others were all kaleidoscoped into a few searing media presentations. These presentations gave the impression, accepted by most of the public, that such disastrous effects were the normal re-sponse to psychedelic drug use. Those whose personal experiences or observations had shown them otherwise were forced into a sharply opposing position, as has often happened in the field of illicit drugs. Neither of these positions allowed room for reasonable social learn-ing about the range of responses to the drug and how best to cope with them or for the development of social sanctions and rituals that might prevent many of the dysfunctional reactions.

Personality Theory and Social Integration

Most proponents of strictly psychological theories, such as the orig-inal Freudian instinct theory, do not deny that technological change brings about social change, but they do question the view that social change contributes to continued personality development. They say instead that the two dominant drives, sex and aggression, are aroused in all individuals and that society works out ways for those impulses to achieve a degree of discharge under acceptable circumstances. For example, when an individual uses alcohol to remove his inhibitions, society accepts his flirtatiousness and his argumentativeness within limits that are subtly but differently defined by various ethnic groups and social classes. But why do such Freudian theorists not apply the same reasoning to the individual who uses marijuana in a controlled way in order to focus attention on a particular event or to reduce the boundary between himself and his sensations? Both the alcohol user and the marijuana user find reassurance in being able to express or gratify their feelings in a socially acceptable, albeit somewhat primitive, way.

Unlike those, including Andrew Wei1,42 who believe that the search for intoxication and consciousness change is instinctual, I believe that much interest in intoxicants is an integral function of the more struc-tured part of the personality, the ego. The ego has the potential to achieve discharge of primitive affects and fantasies in various ways, including that of consciousness change. Thus, in this and many other societies, the use of intoxicants, which may well be closely linked with impulse discharge, is integrated so as to be under ego control. The group ceremonies and other elaborate social mechanisms de-veloped by primitive societies not only define these discharges as ac-ceptable but also structure and regulate them, often under conditions of religious exemption. Those South American Indian societies that use psychedelic drugs on special occasions have for centuries man-aged to control their use in this fashion. It is interesting to note, however, that such societies have not been able to cope with a new, technologically advanced intoxicant—distilled alcohol.

No society can hold back technological and social change. New substances, along with ideas about their use, are continually being introduced, and it takes time for society to find out which of them affect personality development and personal relationships. Not only the drug and the personal needs of the user but also the subtleties of history and social circumstances must be taken into account. No one has understood this more clearly than Griffith Edwards, director of the intoxicant research center at the Maudsley Hospital in Eng-land. He once remarked, in pointing out the fallacy of trying to sep-arate the specific incident of drug taking from its social matrix, "One could not hope to understand the English country gentleman's fox-hunting simply by exploring his attitude toward the fox."43

The view that intoxicant use depends only on the drug or on a disturbed personality may seem attractive to those who accept the moral condemnation that society has visited upon illicit drug use. But for experts to use psychoanalytic theory to further such a view would be to belittle their own clinical and theoretical aims as well as the capacity of personality theory to incorporate social structural variables and the social learning process.

THE PROBLEM FOR RESEARCH IN AN ARENA OF SOCIAL CONTROVERSY

Doing research on intoxicants, particularly illicit drugs, invariably raises the question as to whether the findings will act to increase use. As our current formal social policy is aimed unabashedly at attempt-ing to decrease use of illicit substances," the question also arises whether research efforts, if they are to be judged ethical, must ad-here to this social policy. Then, if research is so judged, and there is little doubt that to a large extent it is, what effect does that have on which research projects get 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 engaged in drug research would agree that it is extremely difficult in this field to have one's work perceived as ob-jective and relatively neutral. Not only do the popular radio and tele-vision shows try to "balance" their presentations by including someone considered "antidrug" on a program that negates the spe-cific harmfulness of drug use, but scientific programs have often felt obliged to follow a similar procedure. In this climate almost any work or worker is quickly classified as for or against use, and halfway positions are not acknowledged. It is virtually equivalent to the po-litical litmus test of the Communist Party. To a diehard advocate of the National Organization for the Reform of Marijuana Laws (NORML), any indication that marijuana can be disruptive is dis-puted, just as any claim that Communists were inhumane was dis-puted in the 1930s. When it was suggested at a recent scientific meeting that marijuana users should not drive when intoxicated, floor discussants were quick to point out that some experienced users claim to drive better while intoxicated. Conversely, at the same meet-ing the statement that there had been no deaths attributed to mari-juana during the last fifteen years, when over 51 million people had used the drug, was greeted by a retort from the floor that marijuana was not water-soluble and, therefore, was retained in the body. This non sequitur was not intended to counter the original statement but merely to show that no one could get away with saying something about marijuana that did not stress its dangers.

Although it is easy to ridicule the extremes of this litmus testing, the ethical issues themselves are serious, and the implications of pub-licizing and exploiting drug effects so as to make drug use glamor-ous, as in Timothy Leary's case, have given rise to grave concerns. There is little doubt that the explosion of LSD use in the 1960s was propelled by the wide publicity given such use. It certainly could be argued that this explosion around Timothy Leary was not principally the result of the presentation of actual drug research. But the drug hysteria aroused by that drug use very quickly spread to research, so that one previously objective inquirer apparently saw little wrong in stating that he was setting out to prove the drug's potential for harm.45 With the appearance and widespread acceptance of this at-titude by, among others, the National Institute on Drug Abuse,46 the official research-funding body, every researcher has had to concern himself with whether his work would meet a standard based more on discouraging the use of drugs than with uncovering the truth.

In a basic sense, it is doubtful if anyone in the field, no matter how misguided he might be considered, has set out to falsify the facts. Rather, within a certain frame of values—say, the outlook that any illicit drug is so bad that efforts to prove it so are legitimate and for the greater good—the search for truth can become deductive rather than inductive. And, indeed, because to a certain extent all scientific inquiry begins with an operating hypothesis, what we are worrying about in relation to the aims of research is hardly a 100- percent-or-nothing matter. The issue is rather the subtle one of feel-ing sufficiently righteous about the culture's current policy or value of reducing illicit drug use to allow that to outweigh objectivity. Re-searchers who treasure objectivity and neutrality and present the data, whatever they are, may end up carrying on work that con-travenes dearly held cultural beliefs. These beliefs are not only dearly held in their own right but are believed to be sacrosanct in that they help to prevent a bad thing, that is, more illicit drug use.

In 1968, when Andrew Weil and I began the first controlled ex-periments in giving marijuana to naive subjects in order to study the effects of acute intoxication, we were much criticized.' If marijuana proved to be as dangerous as many people thought at that time, we ran the risk of addicting or otherwise damaging our innocent vol-unteer subjects. If it should prove that marijuana was not so deadly as was assumed, then, we were told by many, our findings could be morally damaging to the country by removing the barrier of fear that was assumed to prevent drug use. It is, of course, impossible to say whether these experiments and others that replicated the findings were significant in increasing the popularity of drug use. Even by 1968 it was becoming clear that marijuana was not the devil drug of "Reefer Madness." During that period of criticism, I believed, and continue to believe, that supplying credible, responsible, and objec-tive information about the drug was essential.

Because the issue is so polarized, however, withholding or dis-torting information in order to support the current social policy of reducing use runs a great risk of causing possible users, whose in-formation about the substance in question is different and more ex-periential, to disbelieve any reports of potential harmfulness.48 This situation makes it extremely difficult to separate use from misuse and to help people avoid the destructive and dysfunctional conse-quences of misuse. On the other hand, in this same climate the presenting of information indicating that all use need not be misuse, thus contravening formal social policy, runs the equally grave risk that the 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 you free" in some mys-tical sense. Of course, neither can one believe that hiding facts, hiding the truth, will make everything come out all right. And what makes it considerably harder when thinking about research on pow-erful intoxicating substances is that general principles about truth and objectivity are not all that is involved; human lives are at stake. It was relatively easy to bear the criticism of marijuana research. The growing popularity of the drug was evident; there were no fatalities reported from its use; the need for more precise information about its effects in order to distinguish myth from fact was pressing. For example, at that time police officers and doctors believed that mar-ijuana dilated the pupils. This misconception, which affected both arrests and medical treatment, needed to be cleared up. But when it became evident that understanding controlled use required looking at drugs whose physical properties, unlike those of marijuana, de-manded control, the researcher's ethical problem became more se-rious. Studying heroin meant studying a powerful addicting drug whose potential to kill through a misjudgment on dosage is very great. Disabusing the professional community and the public (by way of the omnipresent media, which seize on anything in the drug area as good copy) of the belief that any use is inevitably addicting and destructive ran the risk of reducing the barrier of fear that might have kept someone from using opiates, and this possibility has been and is a tormenting concern. Whatever the devotion to research and the importance of knowledge may be, the work cannot be counte-nanced if the subjects are not protected from the harm caused by the research, either directly or by withholding information, as, for example, in the unfortunate U.S. Public Health Service research on syphilis that held back a treatment long after it had been proved effective .49

Nevertheless, even my preliminary investigations of heroin and other opiate use confirmed what had been found in every investi-gation of drug use. The reality was far more complex than the simple pharmacological presentation that I had received in medical school. Certainly, heroin is a powerfully addicting drug with great potential for deadly overdose. But there were those who managed to use it in a controlled way, and even those who got into trouble with the drug displayed various patterns of response very different from that of the stereotypical junkie. And, because the truth, although it will not set you free, will usually come out, other investigators such as Leon Hunt and Peter Bourne were beginning to report similar phenom-ena.5° Once it became clear that these phenomena were extensive and significant, it was also clear that any attempt to remove from the sci-entific purview such behavior patterns, because they were morally reprehensible or disapproved of, would reduce the credibility of all scientific enterprise. In addition, in the process of controlling their use, these users might have developed a system of control that could be extremely valuable as a possible method of treatment for addiction.5'

That research may have a positive application beyond its purely informational value is not a requirement of scientific investigation. Basic research needs no defense here. But as I pointed out earlier, the way the work is received and treated, particularly by the media, can raise extremely serious problems. To what extent researchers who report findings have a responsibility for what is done with them pub-licly is a moot point. In a basic sense, although these researchers are as accurate and careful in their statements as possible, they cannot control what others say or do with the work. But in the present cli-mate of emotionalism about drug research, they would be naive in-deed if they did not realize that certain findings might be picked up by the press. Unfortunately, in order to herald their findings, several researchers have called prepublication press conferences in which they have speculated about far-reaching implications of the work—implications that go beyond the actual published data.52

Thus, it is not enough to avoid carelessness in one's actual work and the reporting of it. A researcher must also consider carefully whether the work might cause some people who would not otherwise use drugs to do so. In this context, the potentially positive applica-tion of the work as a therapeutic aid may help shift attention away from the overwhelming preoccupation with illicit use. Although discussing the work from the viewpoint of possible therapeutic applications can lend itself to another brand of sensationalism and overstatement, this danger may be easier to avoid.

The difficulty of knowing what objectivity is and the problem of questioning the ethics of doing certain research and imparting its results are by no means confined to research on illicit drugs. Few people today, in this era of recognition of the overwhelming number of choices faced by each individual, are able to preserve the image of the disinterested scientist burdened by few, if any, values except dedication to the purity of science. A searching article by a promi-nent jurist in Science points out that even when scientists have been able to agree on what is scientific fact—for example, that a certain amount of saccharine can give white mice cancer—they could not, because of the different value-systems influencing their interpreta-tion of those facts, agree on whether this risk was low or moderate for humans.53

In his article David L. Bazelon goes on to comment upon matters pertinent to this discussion of illicit drug use, although he did not have that particular subject in mind.

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 con-sider not disclosing risks which in their view are significant, 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 dis-cussion. More important, it leads to the suppression of information that may be critical to developing new knowledge about risks or even to de-veloping ways of avoiding those risks.

Who today is willing to assume the risk of deciding to limit our knowledge? The consequences of such limitation are awesome. I do not mean to equate the social issues of opening areas of research on heroin use with the potentially catastrophic consequences of failing to disclose problems with nuclear reactors, but the principles are sim-ilar. It is understandable that government agencies, already over-whelmed by the number of factors that must be considered before reaching a decision and buttressed by a sense of righteousness that what they are trying to do is for the public good, would want to minimize the confusion and uncertainty that might result from pre-senting the public with more controversial and conflicting infor-mation. Such bureaucracies, in principle, want all the information possible; but, once they are settled on a course or a value position that they can unabashedly support, they believe that anything which raises further doubts will raise greater risks. Also, as our cultural belief in the disinterested scientist wanes and as our disillusionment with the efficacy of the judicial system as a means of righting wrongs grows, we are increasingly tempted to surrender to the ostensible be-nevolence and wisdom of bureaucrats.

Bazelon makes another point that supports my argument and those of John Kaplan and other researchers.54 Regulations that attempt to limit risks have their own social cost. This does not mean that we should not have regulations. Of course we should, but even at the price of increasing the uncertainty, the choices, and the number of factors to be considered, there must be a keen assessment of the risk cost of the regulations themselves. In few areas is this as true as it is in the drug area. Certainly much of the damage now resulting from marijuana and heroin use occurs because of the illicit status of these drugs and not from their pharmacology. Whether this would con-tinue to be true under a different regulatory situation, no one knows. Reasoning from the basis of historical precedents and from psycho-logical and social attitudes as well as pharmacology, I believe that the use of drugs such as alcohol, marijuana, and heroin might well be regulated in different ways. But in each case we should not as-sume, as we now assume automatically, that the regulations will not be socially, psychologically, and clinically costly.

The research on controlled use of illicit drugs has one basic policy implication. If, as this work suggests, the problem is not the simple use of these drugs but rather how they are used—when, with whom, under what conditions, and how much—then a formal social policy is needed that separates use from misuse." It is obvious that misuse, like pregnancy, is avoided under conditions of total abstinence, but with both drugs and sex it is doubtful whether total abstinence is possible. As it now stands, in the case of illicit drugs anyone who is not abstinent is considered a criminal and a social deviant. Under these conditions it is extremely difficult to develop viable nonlegal sanctions and rituals that will prevent the dysfunctional conse-quences of use. Even when such controls are developed by small so-cial groups, it is not easy for knowledge about them to be transmitted through social learning.

The framers of current formal social policy, by attempting to re-strict drug supplies and punish any use whatever, hope to reduce the number of users, arguing that if there are fewer users there will au-tomatically be fewer cases of dysfunctional use.56 This argument im-plies a straight-line arithmetical relationship between use and misuse. If there are 1,000 users, for example, and 10 percent of them get into trouble, there will be 100 cases of misuse; with 10,000 users there will be 1,000 cases of misuse, and so on. To pursue this type of ar-gument and policy in relation to alcohol use leads to the highly de-batable decision to raise prices in order to discourage use.

But what if current social policy is discouraging only those who use drugs moderately? Certainly regular users, to whom the sub-stance is more vital, would be less easily discouraged. Then, inas-much as the socially derived sanctions and rituals that help maintain control are developed and embodied most definitively by moderate, occasional users, the conditions conducive to controlled use would gradually give way to conditions conducive to dysfunctional use. Thus, the formal social policy whose goal it is to minimize the num-ber of dysfunctional users may actually be making more and more users dysfunctional.

By following the same simplistic mathematical argument, advo-cates of current social policy claim that preventing any use is crucial because of the high percentage of users who are indeed misusing. This circular reasoning leads to the view that what is needed is not a reassessment of policy but more of the same policy, that is, better law enforcement and stricter penalties on trafficking and using. My research on controlled use suggests that greater attention should be paid to conditions of use than to the prevention of use. What are the conditions under which dysfunctional use occurs, and how can these be modified? Conversely, what conditions maintain control in the nonmisusers, and how can they be promulgated?

Firm advocates of current policy fear that use will increase if at-tention is shifted from the fact of use to the conditions of use. That is an understandable fear if one gives credence to the circular ar-gument. But if that argument is challenged, then, on the basis of my research and the theory underlying it, what is needed is a reassess-ment of current social policy, with a new focus on preventing the dysfunctional problems of use rather than use itself. This new focus does not mean that all substances should be treated alike. Careful studies of the use of different substances and of the varying condi-tions of use may well result in a call for different policy strategies. Clearly, this question cannot be settled until drug use is separated from misuse. By means of competent psychosocial research, the myths inherent in the emotionally laden subject of illicit drug use must be exposed, the realities of such use brought to light, and a theoretical framework constructed through which the research re-sults may be understood and perhaps even employed to prevent or treat addiction.

 

1. N. E. Zinberg, Drug, Set, and Setting: The Basis for Controlled Intoxicant Use (New Haven and London: Yale University Press, 1984).

2. G. Ade, The Old-Time Saloon: Not Wet—Not Dry, Just His1ory (Detroit: Gale Re-search Corporation, 1931); S. Bacon, "Introduction," in D. Cahalan, 1. H. Cisin, and H. M. Crossley, eds., American Drinking Practices: A National Survey of Behavior and Attitudes, Rutgers Center for Alcohol Studies, No. 6 (New Brunswick, N.J.: Rutgers University Press, 1969).

3. N. E. Zinberg and K. M. Fraser, "The Role of the Social Setting in the Prevention and Treatment of Alcoholism," in J. H. Mendelson and N. K. Mello, eds., The Diagnosis and Treatment of Alcoholism, 2d ed. (New York: McGraw-Hill, 1985), pp. 457-83.

4. Ibid.

5. N. E. Zinberg, "Addiction and Ego Function," Psychoanalytic Study of the Child 30 (1975): 567-78; N. E. Zinberg and W. M. Harding, "Introduction," in N. E. Zinberg and W. M. Harding, eds., Control over Intoxicant Use: Pharmacological, Psychological, and So-cial Considerations (New York: Human Sciences Press, 1982), pp. 13-35.

6. C. O'Brien, Personal Communication (1978); N. E. Zinberg, "The Search for Rational Approaches to Heroin Use," in P. G. Bourne, ed., Addiction: A Comprehensive Treatise (New York: Academic Press, 1974).

7. H. Milkman and W. A. Frosch, "The Drug of Choice," Journal of Psychedelic Drugs 9 (1977): 11-20.

8. Zinberg, Drug, Set, and Setting.

9. D. E. Smith and G. R. Gay, eds., /t's So Good, Don't Even Try It Once: Heroin in Perspective (Englewood Cliffs, N.J.: Prentice-Hall, 1972).

10. N. E. Zinberg, "High" States: A Beginning Study, Drug Abuse Council Publication No. SS-3 (Washington, D.C.: Drug Abuse Council, 1974).

11. Zinberg, Drug, Set, and Setting; Zinberg, "High" States; N. E. Zinberg et al., Controlled Nonmedical Drug Use (Washington, D.C.: Drug Abuse Council, 1976); D. E. Smith, Personal Communication, 1975.

12. Avatar, August 1%8, p. 3.

13. N. E. Zinberg and J. A. Robertson, Drugs and the Public (New York: Simon and Schuster, 1972).

14. W. E. McAuliffe and R. A. Gordon, "A Test of Lindesmith's Theory of Addiction: The Frequency of Euphoria among Long-term Addicts," American Journal of Sociology 79 (1971): 795-840.

15. A. Stickgold, "The Metamorphosis of PCP," Grassroots 1, October Supplement (1977).

16. R. C. Petersen and R. C. Stillman, eds., Phencyclidine (PCP) Abuse: An Appraisal, National Institute on Drug Abuse (NIDA), Research Monograph 21 (Washington, D.C.: Gov-ernment Printing Office, 1978).

17. NIDA, Marihuana and Health, Ninth Annual Report to the Congress from the Sec-retary of Health and Human Services (Washington, D.C.: Government Printing Office, 1982).

18. L. N. Robins, D. H. Davis, and D. W. Goodwin, "Drug Use in U.S. Army—Enlisted Men in Vietnam: A Follow-up on Their Return Home," American Journal of Epidemiology 99 (1974): 235-49.

19. Ibid.; L. N. Robins, J. E. Helzer, and D. H. Davis, "Narcotic Use in Southeast Asia and Afterwards," Archives of General Psychiatry 32 (1975): 955-61; L. N. Robins et al., "Vietnam Veterans Three Years after Vietnam," in L. Brill and C. Winick, eds., Yearbook of Substance Abuse (New York: Human Sciences Press, 1979).

20. D. Maloff et al., "Informal Social Controls and Their Influence on Substance Use," in Zinberg and Harding, eds., Control over Intoxicant Use, pp. 53-76; N. E. Zinberg, W. M. Harding, and M. Winkeller, "A Study of Social Regulatory Mechanisms in Controlled Illicit Drug Users," in H. Shaffer and M. E. Burglass, eds., Classic Contributions in the Addictions (New York: Brunner/Mazel, 1984), pp. 277-300.

21. W. M. Harding and N. E. Zinberg, "The Effectiveness of the Subculture in Developing Rituals and Social Sanctions for Controlled Drug Use," in B. du Toit, ed., Drugs, Rituals, and Altered States of Consciousness (Rotterdam, Neth.: Balkema, 1977), pp. 111-33.

22. J. Newmeyer and G. Johnson, "Drug Emergencies in Crowds: An Analysis of 'Rock Medicine,' " in Zinberg and Harding, eds., Control over Intoxicant Use, pp. 127-37.

23. Zinberg, Harding, and Winkeller, "A Study of Social Regulatory Mechanisms in Controlled Illicit Drug Users."

24. G. F. Edwards, "Drugs, Drug Dependence, and the Concept of Plasticity," Quarterly Journal of Studies on Alcohol 35 (1974): 176-95.

25. Zinberg, "High" States.

26. H. N. Boris, N. E. Zinberg, and M. Boris, "Social Education for Adolescents," Psy-chiatric Opinion 15 (1978): 32-37.

27. R. E. Mogar and C. Savage, "Personality Change Associated with Psychedelic (LSD) Therapy: A Preliminary Report," Psychotherapy: Theory, Research and Practice 1 (1954): 154-62; E. S. Robbins, W. A. Frosch, and M. Stern, "Further Observations on Untoward Reactions to LSD," American Journal of Psychiatry 124 (1967): 393-95.

28. A. Huxley, The Doors of Perception (New York: Harper and Row, 1954); A. T. Weil, The Natural Mind (Boston: Houghton Mifflin, 1972).

29. Robbins, Frosch, and Stern, "Further Observations on Untoward Reactions to LSD."

30. National Commission on Marihuana and Drug Abuse, Drug Use in America: Problem in Perspective (Washington, D.C.: Government Printing Office, 1976).

31. W. H. McGlothlin and D. O. Arnold, "LSD Revisited: A Ten-Year Follow-Up of Med-ical LSD Use," Archives of General Psychiatry 24 (1971): 35-49.

32. H. L. Barr et al., LSD: Personality and Experience (New York: Wiley-Interscience, 1972).

33. H. S. Becker, "History, Culture, and Subjective Experience: An Exploration of the Social Bases of Drug-induced Experiences," Journal of Health and Social Behavior 8 (1%7): 163-76.

34. Robins et al., "Vietnam Veterans Three Years after Vietnam."

35. N. E. Zinberg, "Heroin Use in Vietnam and the United States: A Contrast and a Critique," Archives of General Psychiatry 26 (1972): 486-88.

36. Robins et al., "Vietnam Veterans Three Years after Vietnam."

37. Robins, Davis, and Goodwin, "Drug Use in U.S. Army—Enlisted Men in Vietnam."

38. Robins et al., "Vietnam Veterans Three Years after Vietnam."

39. N. E. Zinberg, "GIs and 0Js in Vietnam," New York Times Sunday Magazine, 5 December 1973.

40. T. S. Kuhn, The Structure of Scientific Revolutions, 2d ed. (Chicago: University of Chicago Press, 1970).

41. T. Hardy (1895), Jude the Obscure (New York: W. W. Norton, 1978).

42. Weil, The Natural Mind.

43. G. F. Edwards, "Drugs, Drug Dependence, and the Concept of Plasticity."

44. M. H. Moore, "Limiting Supplies of Drugs to Illicit Markets," in Zinberg and Hard-ing, eds., Control over Intoxicant Use, pp. 183-200.

45. M. M. Cohen, M. Marinello, and N. Bach, "Chromosomal Damage in Human Leu-kocytes Induced by Lysergic Acid Diethylamide," Science 155 (1967): 1417-19.

46. See the following NIDA publications, all available from the Government Printing Of-fice (Washington, D.C.) and dated 1977, 1977, and 1978, respectively: Cocaine-1977, Re-search Monograph 13; The Epidemiology of Heroin and Other Narcotics, Research Monograph 16; Drug Use in Industry.

47. A. T. Weil, N. E. Zinberg, and J. Nelsen, "Clinical and Psychological Effects of Ma-rihuana in Man," Science 162 (1969): 1234-42.

48. Zinberg and Robertson, Drugs and the Public; J. Kaplan, Marijuana: The New Pro-hibition (New York: World, 1970).

49. N. Hersey and R. D. Miller, Human Experimentation and the Law (Germantown, Md.: Aspen Systems Corp., 1976).

50. Abt Associates, Drug Use in the State of Ohio: A Study Based upon the Ohio Drug Survey (Cambridge, Mass.: Abt Associates, 1975); P. G. Bourne, L. G. Hunt, and J. Vogt, A Study of Heroin Use in the State of Wyoming (Washington, D.C.: Foundation for Inter-national Resources, 1975); L. G. Hunt and C. D. Chambers, The Heroin Epidemics: A Study of Heroin Use in the United States, 1965-1975 (New York: Spectrum, 1976).

51. N. E. Zinberg et al., Processes of Control among Different Heroin-using Styles (Wash-ington, D.C.: NIDA, 1980).

52. New York Times, 4 February 1974 and 9 April 1974, interviews with G. G. Nahas and R. C. Kolodny, respectively.

53. D. L. Bazelon, "Risk and Regulation," Science 205 (1979): 277-80.

54. Kaplan, Marijuana: The New Prohibition; Robins, Helzer, and Davis, "Narcotic Use in Southeast Asia and Afterwards"; C. P. Herman and L. T. Kozlowski, "Indulgence, Excess, and Restraint: Perspectives on Consummatory Behavior in Everyday Life," in Zinberg and Harding, eds., Control over Intoxicant Use, pp. 77-88; D. Waldorf and P. Biernacki, "Na-tional Recovery from Heroin Addiction: A Review of the Incidence Literature," in Zinberg and Harding, eds., Control over Intoxicant Use, pp. 173-82.

55. President's Commission on Mental Health, "Report of the Liaison Task Panel on Psychoactive Drug Use/Misuse," in Volume IV, Appendix: Task Panel Reports Submitted to The President's Commission on Mental Health (Washington, D.C.: Government Printing Of-fice, 1978).

56. Moore, "Limiting Supplies of Drugs to Illicit Markets."

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