Drug Abuse

2. Addiction, Abuse, and Controlled Drug Use: Some Definitions

THE USE OF ILLICIT DRUGS HAS BEEN A TOPIC OF ENDLESS DISCUSSION IN both professional and lay circles. Most discussions have centered on specific aspects of "drug abuse," such as damage to the user's health and his consequent inability to function effectively. While such effects are undoubtedly felt by some users, it is equally true that many others are able to use drugs moderately rather than destructively. Yet the term "drug abuse" continues to be applied to all styles of drug use, and little or no effort has been made to distinguish abuse from use. In addition, scientific writers as well as the mass media use the term "drug abuse" without defining it explicitly, and even when concerned and informed professionals attempt to formulate precise definitions, their attempts reflect the prevailing cultural values and do not clearly differentiate use from abuse. Many people use "drug abuse" rather than "addiction" because drug abuse is a loose term meant to convey whatever the person using the term thinks is bad. Addiction is a more specific term used to define physiological dependence and, although sometimes used loosely, has a strictly defined meaning.

Users or Abusers? Three Cases

Not surprisingly, the greatest problem I faced in studying controlled users of illicit drugs was that of differentiating between drug use and drug abuse. This difference was fairly evident at the extremes of behavior, but it was by no means so obvious in the gray area where the majority of cases in my study fell. At one extreme were those who used no drugs except marihuana and used that only once a week, along with those who used psychedelics only three or four times a year. All these subjects were so clearly responsible in their drug use that it would not have been rational to define them as drug abusers. At the other extreme were several compulsive users who were included in the research only because my staff and I failed to screen them out during the initial telephone contact. These obvious drug abusers proved useful in helping us to understand how wide the range of using patterns was. Finally, many of our subjects fell into the gray area of more or less controlled use. The case histories of three such subjects-Michael, Jim and Dawn-illustrate that some individuals can keep their drug use under control, avoiding the excessive use and destructive effects that characterize the drug abuser. Michael and Jim's cases have been condensed. Dawn's story is told more fully because it shows the value of approaching the use-abuse problem longitudinally (over time) rather than only crosssectionally (at a particular point in time).

Michael is a thirty-one-year-old, single, white male social worker, the third of nine children born to a strict, lower-middle-class Catholic family. He has always done well in school (A.B. in Philosophy and M.A. in Social Work) and has a regular and exemplary work history. The members of his immediate family have no history of alcoholism or other serious involvement with drugs, including prescription drugs, but his father uses tobacco heavily. Both of his parents are light drinkers, and from the age of nine or ten Michael was allowed to taste wine on such formal occasions as weddings, baptisms, and birthdays. He began to drink occasionally with his friends at age fourteen or fifteen and after getting sick two or three times reverted to an occasional drink about twice a week and occasional wine or beer with certain meals: "Much less often than my friends." This pattern has continued to the present time. He smoked surreptitiously until age sixteen, when his parents grudgingly gave him permission to continue openly, and he now averages one pack a day. He did not use marihuana until age twenty-seven when, after two or three unsatisfactory experiences, he began to find it pleasurable. Now he uses the drug socially once or twice every other week.

Michael enjoys his job and also takes pleasure in woodworking and handicrafts, and he is renovating his apartment. He has two separate groups of friends, one from work and the other whom he met through tennis, skiing, and craft work. He has had two moderately serious relationships with women, each lasting about a year, as well as several short-term affairs. He has been sexually active in all his adult relationships, including the one with his current girlfriend, whom he has known for three months. He finds that marihuana use "makes sex more pleasurable, more spontaneous, but not easier." After acknowledging his marihuana use in the course of family discussions, Michael was persuaded by two of his brothers, a sister, and a sister-in-law to "turn them on" also.

With characteristic conservatism Michael says of marihuana and alcohol,

"In the use of both I have a take-it-or-leave-it attitude although I like what I do." He regards the dangers of drug use as greatly exaggerated and the drug laws as archaic and unworkable. His friends experiment with psychedelics and this has intrigued him, but Michael does not plan to use other drugs: "I'm afraid of physical or psychological damage, and I don't want to risk it." He does plan to continue his current pattern of marihuana use, however.

Jim, a twenty-four-year-old black male, has always lived with some member of his family. His father, who was a habitual alcoholic until twelve years ago, spent little time at home. His mother worked in the evenings as a maid. Jim and his two brothers were left unsupervised and "went to the streets" in early adolescence.

Jim was first arrested at age eleven for purse-snatching. Each year further arrests followed, for armed robbery, attempted murder, possession of heroin with intent to distribute, and assault and battery on a police officer. During his school years, his criminal activities took precedence over studies and he quit in the tenth grade, although he felt he was capable of doing well academically. At age eighteen he was incarcerated for nine months on a drug charge.

By age thirteen Jim was a daily tobacco user; on weekends, at dances, and on other special occasions he was drinking to get drunk; and he was also using amphetamines five or six times on weekends. By age sixteen he was using marihuana several times a day and had tried heroin. He began by snorting but in a few months was injecting and within nine months had experienced the first of his five "habits" (periods of physiological addiction). His longest heroin habit coincided with participation in a methadone maintenance program at about age nineteen, and it lasted almost two years. His last habit started some six months later and lasted three or four months. At the time he was pimping, and his earnings enabled him to use at least $100 worth of heroin a day. Then he decided to quit using because of the size of his habit and the increasing risk; as he said, "I felt myself going to jail." After withdrawing without anyone's helpan unpleasant but less dramatic experience, he reported, than is often portrayed on television-he started "chipping." He began use at the rate of three times a week, but more than two years ago he cut down to his present level of "twice a week, and sometimes only once a week."

Jim is especially particular about keeping his "works" clean and will not share them with friends. Hence he prefers to use alone, often at his brother's apartment, and then go out and meet friends. The day after using he invariably exercises because he believes this activity helps cleanse his system of heroin. Jim's use of other drugs has also fallen off. He uses beer and wine occasionally ("Me and alcohol don't get along"), marihuana twice a day or less, cocaine once or twice a week, and Valium and Quaaludes erratically.

Jim has had many "temporary jobs here and there" but is ordinarily unemployed. His chief activities and means of support are dealing heroin and hustling of various sorts-usually breaking and entering. He lives either with a brother or with a girlfriend whom he has known for five years. His drug use is important to him but less important than the criminal activity he takes pride in: "I put my business first before I use a drug, and there's got to be extra money to buy some stuff with."

Jim has indicated some interest in obtaining a high school equivalency degree and eventually attending college and becoming a physical education instructor. He plans to continue heroin use, but would like to reduce it to once or twice a month.

Dawn is a twenty-seven-year-old, single, white female employed by the court to work with juveniles to avoid criminal sentencing if possible. She was brought up in New York City, the only child of middle-class, achievementoriented parents. She has always been on much better terms with her father than with her mother. Her parents are moderate social drinkers. There is no history of alcoholism or of the heavy use of other drugs, illicit or prescribed, in her immediate family.

Dawn was exposed to marihuana when she went out with a young man who was a regular user, but she did not begin to use it herself until she had stopped seeing him. She tried it first at age sixteen with her friend Susan, and the two girls then began to smoke in school and on the school bus, apparently quite provocatively. This came to the attention of their parents and the school administrators, who regarded Dawn and Susan as a pair of "rebellious kids." About five months after she had begun smoking marihuana Dawn started experimenting with psychedelics, which she liked. She continued to use both drugspsychedelics only occasionally-throughout her school and college years.

Dawn went through the only period of regular drinking in her life during the summer of her eighteenth year, consuming about two six-packs of beer a week. She and her parents were much at odds that summer and have never been close since; but they had little objection to her alcohol use. If anything, they expressed surprise when she later gave it up.

She first used heroin at age eighteen, shortly after arriving at a college in Boston. She and a friend, Lois, were exploring what was then Boston's "hippie" section, looking for "downs" (Seconal). They were unable to make any drug connections except with a young man who offered them "junk." They declined and went back to the dorm. Then, as Dawn put it, "I felt depressed and lonely and none of my roommates were home. And I wanted to get high, and so I said to myself, `Well, the hell with this. I'll go back there and I'll ask him one more time and I'll just buy something to get high on and I don't care what it is.' ' She went back alone. The dealer sold her a bag of heroin at a very low price but warned her not to "ever get into it" or come back again. She immediately went into a bathroom in her dorm and snorted some of it. "I felt great, I was high, and I felt really good." Later she went to the room of "some sophisticated girls" who had previously intimidated her, felt quite comfortable, and snorted the rest with them. When she told Lois what had happened after they parted, Lois became very upset and begged her not to do it again. Because this made her feel that "somebody really cared," Dawn stayed away from heroin use for the next two years.

During those two years she spent the summers in a communal living situation with her boyfriend, Paul, and a large group of other people. Paul and the others were using heroin regularly: "People were constantly coming over and getting off that year and the next year, and I just never tried it. I was repulsed by the whole thing and I wouldn't do it. " She did try methadone in this house, however, two years after her first heroin use. She recognized and enjoyed the opiate high and felt safe in drinking rather than shooting it.

A year later., at age twenty-one, Dawn again tried heroin when Susan, her old school friend, came to visit and told Dawn she had been shooting heroin once a week. "I was like in a really depressed, really angry, really rebellious sort of mood . . . so when Susan said, `Oh, let's get some,' I said, `Great.' ' This was the first time Dawn had injected a drug. She next used heroin a month later, after dropping out of college and moving to the West Coast. She left Paul behind, as he was now "getting strung out." Once in the West she called George, a good friend of Paul's, "to come over and hit me up." They began to live together. George had unlimited access to heroin: "For a couple of months it was like all you want, any time you want, you've got it, it's yours. So I was doing just thousands of dollars, for free." She used heroin several times a day. "I'd do a shot and my head would be between my knees and he'd say, 'Did you get high enough?' and I'd say, `No, I need another shot' . . . I was drowning myself in dope." After three months, when George went away for the weekend and Dawn contracted what she thought was the flu, she realized she was addicted. "It freaked me out because I thought it couldn't happen to me ... After that I started feeling like I was really going down the tubes real fast ... going to hell on a sled. And so what I did was buy a plane ticket back to the East Coast, because I knew that the only thing there [in the West] for me was just to be in the mire of dope, and I was just caught in it." She resolved it would never happen to her again.

She returned to Boston and worked as a secretary for the next year and a half, laying plans for graduate school and "chipping" heroin on a once-a-week basis. She had contacted all of her old "dope crowd" friends and so had easy access, but her funds were limited. She established a Friday night using pattern to "reward" herself for having worked all week.

In early 1974 she began another heavy using period when she went to the West Coast for a visit and met her old boyfriend Paul, who was now on the West Coast, and several other friends who had become heroin addicts. She used the drug with them daily for one month but then had to make a choice between staying with Paul and returning East to complete her graduate school plans: "I knew that if I were back there [in the West] I would just get strung out ... there was no motivation to stop using drugs, it was there, it was too easy." So she returned to enter graduate school in New York, where she stayed for two years. During this time she used hardly any drugs, and no opiates at all, even though she had "coincidentally" met a dope dealer.

In 1976, after completing graduate work, she returned to Boston and began a sporadic "chipping" pattern: heroin three times in January; Demerol ten times during the course of the summer; heroin again twice in the fall and about once a month after that.

Now Dawn is experiencing some conflict in regard to future opiate use. She still "loves the high," but she sees use as a tremendous risk to her new career. She feels strongly that heroin should be legalized in order to eliminate the risk and because, as she says, "you can function when you're high on heroin, you can do your job ... I would not hesitate to drive, for instance, if I was stoned on heroin ... as long as I wasn't too stoned."

Only three of Dawn's associates know of her opiate use, and all of them are also occasional users. She never gets high at home; her usual pattern is to go to someone else's house. She does not own her own works and never self-injects but is meticulous about cleaning the needles she shares. She will not buy more heroin than she can easily afford and is never high around "straight friends" or at work. She finds that the high state usually lasts for six hours, and she spends that time indoors talking and playing music. "You just talk a whole lot and you ... fantasize a lot. You feel as though your dreams come true, and you start to think about them and little things don't bother you so much."

During the entire period of family conflict and heavy drug use, Dawn did extremely well scholastically and at work. She regards herself now as ambitious and potentially successful.

All three of these drug histories-Michael's, Jim's, and Dawn's-show a complex interrelationship between personality factors and social factors as determinants of the extent and quality of drug use.

It is clear that Michael, judged on personality grounds alone, is an unusually controlled person whose drug use would not be considered a problem if it were not for our current drug policy. It is also quite clear that without the influence of a peer group that approved of illicit marihuana use, provided reasonable assurance of its safety, and offered standards and procedures of appropriateness, Michael would not have used marihuana at all.

The other two cases, which are more complex, illustrate how hard it is to decide when an individual's drug use has crossed the line separating use from abuse and whether the change in either direction is going to be permanent. Both Jim and Dawn are committed to "high" life-styles and do not plan to give them up. Both have been physiologically addicted to heroin, which is generally considered the same thing as being in serious trouble: Yet at the time of our first interview Jim had been a controlled user for more than two years and on reinterview a year later seemed even more controlled than before. Dawn, whose last period of heavy use, once a day for a month on the West Coast, is more recent, will need a long-term follow-up before we can be sure that she has achieved genuine control.

Drug Abuse and Addiction

Though the terms "drug abuse" and "addiction" are used nearly interchangeably by some today, historically the narrower concept of addiction has not always been regarded as drug abuse. Even "drug abuse" did not emerge as a problem until early in the twentieth century, when the nonmedical use of certain intoxicants began to evoke moral indignation and public concern and led to legal regulation.

The term "drug abuse" seems to have been applied first to the use of cocaine by Southern blacks, but as David F. Musto (1973) and John Helmer (1975) have pointed out, it originally reflected race and class prejudice against the black users rather than concern about the dangerous effects of cocaine. A little later the term was extended to the smoking of opium by Chinese Americans, and again it expressed fear of a despised minority. In this case, however, the importation of opium for smoking purposes was banned (a909), though its use in patent medicines continued to be permitted.

Not until the passage of the Harrison Narcotic Act in 1914 was the use of two more drugs-heroin and morphine-subsumed under the term "drug abuse." This act and the series of regulations and Supreme Court decisions interpreting it transformed the use of all unprescribed opiates from a bad habit into a criminal activity. Even physicians lost their right to prescribe opiates at will, and attempts to supply addicts legally with opium through medical clinics, which had begun in 19i9, were all abandoned by 1924 (Musto 1973; Waldorf, Orlick & Reinarman 1974). Rural addicts who were unable to give up the drug moved to the coastal cities, where black markets sprang up and public animosity toward addiction developed.

Also in the early years of the twentieth century the meaning of the term "addiction" changed markedly. It had been used traditionally, at least since the Civil War, to mean "a habit, good or bad . . . more often the former" (Szasz 1975). Following the medical use of the opiates (particularly morphine) during the Civil War, addiction resulting from the nonmedical use of morphine became widespread. Popularly known as "the soldier's illness," addiction was regarded then either as a nonspecific illness or as evidence of character weakness, not as a form of degeneracy. Later, in the final years of the nineteenth century and the first decade of the twentieth, the use of patent medicines containing large amounts of opiates led to an even higher rate of addiction among the general population (higher than the rate in the late 197 0s) (Lindesmith 1965). Yet the opiates were viewed as "God's own medicine," and although addiction was disapproved of, it was tolerated. "Morphinists," like the mother in Eugene O'Neill's autobiographical "Long Day's journey into Night" (1956)-predominantly rural white women who in spite of their addiction managed to function in society-were viewed with pity rather than contempt (Brecher 1972). Nevertheless, their plight contributed to the passage of the Pure Food and Drug Act of 1906, which, though not excluding opiates from patent medicines, required that these drugs be identified on the label.

Between igio and 192o the word "addiction" began to be applied to the culturally disapproved use of certain drugs, just as the term "drug abuse" is used today (National Commission on Marihuana and Drug Abuse 1973). Gradually, too, the word was given a more specific meaning. In 1912 Charles B. Towns described what he called the "addictive triad": increased craving, growing tolerance, and a withdrawal syndrome when the drug was withheld (Musto 1973). Today addiction is generally accepted as a scientific term that describes the inevitable physiological dependence that follows the continued and heavy use of substances (such as the opiates, barbiturates, or alcohol) that have certain pharmacological properties. Nevertheless, it is clear that the concept of addiction, like the concept of drug abuse, has long been approached in an unscientific or pseudoscientific way.

It is obvious, for example, that the original definition of the "addictive triad" rests on moral as well as medical opinion. Two of its three elements do not stand up to scientific analysis. First, it is impossible to define "increased craving" precisely, or to limit those notions to drug abuse. The very choice of the term "craving" indicates the subtle biases behind the definition: craving connotes weakness and a sense of desperation that may lead to antisocial and even criminal behavior. Second, for many years the concept of "growing tolerance" was accepted as a direct arithmetic progression: after someone had used a drug a certain number of times he or she would need a correspondingly greater amount of it to get the same effect. As a matter of fact, although all users definitely do experience an increasing physiological accommodation to the substance they use individuals differ so markedly in their capacity to deal with different amounts of substances without developing tolerance that it is difficult to understand how the complexity of this phenomenon has escaped detection by the scientific community. Have the observers perhaps been so carried away by their own moral convictions that they have not studied drug use objectively?

One reason for the prevalence of definitions of drug abuse that are neither logical nor scientific is the strength of Puritan moralism in American culture, which frowns on the pleasure and recreation provided by intoxicants. A recent editorial on drug abuse in the American Journal of Psychiatry epitomizes this cultural position. It calls for "an active effort to teach the individual and society how to enjoy and endure [life] without euphorants and escapants" (Cohen 1968). As Herbert Marcuse (1955) has pointed out, there is probably a rationale for this position-the generally accepted view that pleasure-seeking behavior, particularly if it threatens the cultural norm, must be rationed and controlled in an industrial society. Nevertheless, this view overlooks the fact that all known societies (with the possible exception of earlier Eskimo cultures) have used intoxicants for recreational purposes (Weil 1972) and that, certainly in our society, intoxicants offer many individuals the benefits of relaxation and greater social ease.

It is ironic indeed that this society set up a firm double standard of behavior in which the use of alcohol as a pleasure-producing, psychotropic drug is accepted while the use of any other intoxicant for that purpose is regarded as abusive. The fact that alcohol is psychotropic is easy to dismiss because more than ioo million social drinkers know from experience that an alcohol "high" can be controlled; abusive use, or alcoholism, is viewed as a disease that is caught by only the susceptible few. This illogical social attitude means that a single use of LSD or heroin is far more likely to be construed as drug abuse than is the heavy ingestion of alcohol (Jaffe 1975).

Our Puritan heritage is so deeply ingrained that even drinking is attended by a deep-seated ambivalence. In a study of the social setting in which drinking takes place, Rupert Wilkinson (197o) has given three examples of this ambivalence: the temperance movement, Prohibition, and the American adult's tendency to mention his drinking as though it were "naughty." Arthur Hellman, too, has called attention to the crazy-quilt pattern of American laws that regulate the dispensing and sale of alcoholic beverages, arguing that although they are unsupported by any principle of jurisprudence, they are condoned because they serve as a moral sop to the public belief that the "drinking evil" needs special handling (Hellman 1975). The idea that pleasure, or at least the kind of pleasure that leads to escape and euphoria, is potentially dangerous and must be rationed is imprinted in the American consciousness.

This Puritan attitude pervades the use of illicit intoxicants to an even greater degree, as shown by the ambivalence of many users of illicit drugs. On the one hand, most users of marihuana and the psychedelics contend that their drug use is acceptable and pleasurable and are defiant of society's definition of them as deviant (Gusfield 1-979). But rather than repent of their deviance, as others might have done forty or even twenty years ago, they attack first the laws and then society itself. On the other hand as my study has revealed, even very moderate drug users also reflect Puritan attitudes and values by feeling guilty about their use. Some of my subjects claimed that they had used psychedelics such as LSD solely for "serious" purposes-that is, in order to gain personal or religious insight-and they expressed disdain for, and even labeled as abusers, their pleasure-seeking counterparts who wanted only to get "high" and enjoy their psychedelic experiences in a sensual way (Harding & Zinberg 1-977). This attitude mirrored the disdain shown by society toward all drug users and toward pleasure-seeking behavior in general.

The superimposition of Puritan morality on scientific attempts to define drug abuse is also apparent in a recent disagreement in the scientific literature over the nature of addiction-specifically, the experience of acknowledged heroin addicts. From 1-947 until recently, the accepted position was that taken by Alfred Lindesmith, who contended that during the initial phase of heroin use the user was totally infatuated with the drug's effects but that this pleasure phase usually passed after the onset of physiological addiction, when the addict became preoccupied with his struggle to stave off the dreaded symptoms of withdrawal (Lindesmith 1-947). Lindesmith claimed that heroin users experienced little pleasure in the years of actual addiction and called for a recognition of addicts as socially and psychologically troubled or "sick."

In 1-975 William E. McAuliffe and Robert A. Gordon disputed Lindesmith's conclusions in an article summarizing their survey findings. This article, which abounds with such words as "euphoria," "high," and "pleasure," and even compares the effect of the drug to a sexual orgasm, reports that longterm addicts actually get continuing pleasure from using heroin.

My findings, based on information gathered from many compulsive subjects, disagree sharply with both Lindesmith's and McAuliffe and Gordon's conclusions, as do those of Stanton Peele (1-975). After prolonged heroin use my subjects did experience a "desirable" consciousness change characterized by increased emotional distance from both external stimuli and internal response, but it fell far short of euphoria. Soine subjects described it as follows: "It is as if my skin is very thick but permeable"; and "It is like being wrapped in warm cotton batting." Many of them recognized that their preference for this consciousness change had little to do with warding off withdrawal sickness, although they were well aware of their excessive fear of withdrawal. Neither did their preference stem from a wish to feel "normal," because they knew that the ordinary self-aware state was an uncomfortable one for them. They tended to describe themselves in heaven-or-hell terms, not because that is what they felt but because they were incapable of explaining to a "straight" interviewer their complex relationships to the treasured drug.

The WHO Definitions of Drug Abuse

Researchers in the field of drug use tended initially to look at all styles of drugtaking behavior as drug abuse, that is, as physiologically addictive. Later, when it became apparent that not all substances were physically addictive, they turned to a new concept, that of psychological habituation. In 1957 the World Health Organization (WHO), through its Expert Committee on Addiction Producing Drugs, formulated official and detailed definitions of both physiological addiction and psychological habituation. By 1964, however, these two concepts had been found to be unsatisfactory, and a new WHO committee turned to a descriptive approach to abuse based on the type of "dependence" supposedly engendered by the various drugs. This approach, too, proved unsatisfactory. As Robert Apsler pointed out, "One cannot create precise definitions by relying on amorphous concepts for specifying the definitions. Often the definitions essentially state that something is bad without clarifying what the something is, without specifying the criteria on which the negative judgment is based, and without stating the assumptions from which the value is derived" (1975). Other investigators also criticized the attempts of the WHO committees, calling them ambiguous, confusing, and culture-bound (Fort 1969; Christie & Braun 1969; Freedman 1970; Young 1971; Goode 1972; National Commission on Marihuana and Drug Abuse 1973; Smart 1974). Unfortunately, because these definitions were formulated by the prestigious World Health Organization, they have continued to dominate the field.

Drug Addiction and Habituation, 1957. The 1957 WHO Committee de fined addiction and habituation as follows:

Drug addiction is a state of periodic or chronic intoxication produced by the repeated consumption of a drug (natural or synthetic). Its characteristics include: (i) an overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means; (ii) a tendency to increase the dose; (iii) a psychic (psychological) and generally a physical dependence on the effects of the drug; and (iv) detrimental effects on the individual and on society.

Drug habituation (habit) is a condition resulting from the repeated consumption of a drug. Its characteristics include: (i) a desire (but not a compulsion) to continue taking the drug for the sense of improved well-being which it engenders; (ii) little or no tendency to increase the dose; (iii) some degree of psychic dependence on the effect of the drug, but absence of physical dependence and hence of an abstinence syndrome [withdrawal]; and (iv) detrimental effects, if any, primarily on the individual.

Both of these definitions make use of the same four basic characteristics: desire, increase in dosage (development of tolerance), dependence, and detrimental effect. Habituation is presented as a less severe state than addiction, free of compulsive desire or craving, of increase in dosage, of physical dependence (and hence the withdrawal syndrome), and of detriment to society. But these four key terms cannot be accepted at face value. They need to be examined carefully and objectively.

Since the first characteristic, desire (related to habituation) or compulsion (related to addiction), is very difficult to separate from the third characteristic, psychic or physical dependence, they will be analyzed together. How can either physical or psychic dependence exist without a desire or compulsion? And conversely, is not the reason for a desire or compulsion the existence of psychic or physical dependence? This confusion in itself constitutes a major flaw in the WHO definitions.

While the concept of dependence seems to be more definite and therefore a better analytic tool than the concept of desire, it is very difficult to separate physical from psychic dependence. The presence of physical symptoms alone does not distinguish between these two types of dependence. Although, according to Fred Leavitt ( 1974), "physical dependence is defined as a state characterized by the appearance of physical symptoms when administration of a drug is suspended," psychiatrists and psychologists know that physical symptoms may also appear following the withdrawal of loved ones and other psychologically precious objects. Except at the furthest extreme it is virtually impossible to measure the degree to which psychological factors determine or interpret physical symptoms.

Moreover, "physical dependence" has proved to be a much less helpful concept than many experts on drug use originally expected. Its main advantage is that it is a physiological entity that can serve as a straightforward measure of addiction. It does not necessarily define drug abuse from a social and cultural standpoint, however. Obviously, the members of the WHO committee, who omitted any mention of alcohol, caffeine, and nicotine as drugs of dependence, were not thinking of the everyday beer or cocktail drinker, cigarette smoker, or coffee drinker, who more than likely is physically addicted, or of those individuals with hypertension who find their craving for salt irresistible, or of the ice cream "addicts" vividly described by John Pekkanen and Mathea Falco (1975) . Nevertheless, a definition utilizing physical dependence as a measure of abuse could apply to substances and behaviors that lie far beyond the realm of illicit drugs.

The committee evidently assumed that physiological addiction was more overpowering than psychological habituation, although each member could have supplied many clinical examples showing the opposite. In their eyes, habituation was less inevitable and more susceptible to the elements of set and setting than addiction. Addiction was compulsive while habituation was the result of simple desire.

It is undoubtedly true that physiological addiction to an unavailable substance results in a painful syndrome, but it is debatable whether this is more painful than the suffering from an unfulfilled longing that involves no physiological attachment at all. Take, for example, the possibly tongue-in-cheek reference by John Kaplan (1970) to the numbers of people who are psychologically habituated to reading the Sunday New York Times. They have a habit that they enjoy; they look forward to reading the newspaper each week; they are disappointed and sometimes very upset if they cannot obtain it; they will put themselves and sometimes others to considerable inconvenience and expense in order to get it. For these habitués it is not the physiological but the psychological state that may eventually lead to desperation.

As for the power of drugs, the notion that the pharmacological properties of a drug, irrespective of set and setting, are the sole determinants of disturbed or violent behavior dies hard. There is considerable evidence to the contrary, however. The profound effect of set and setting was evident in the play, "The Concept," put on in 1967 by the residents of Daytop Village, a residential treatment center for hard-core addicts on Staten Island, New York. The play, based on real-life experiences, showed what could happen when an addict was cut off from his supply. At first, when he was in jail, he went through all the hell of the withdrawal syndrome: he screamed, begged, and suffered a variety of painful, overpowering physical symptoms. After being released and sent to Daytop for treatment he again received no drugs. When he began to complain about symptoms, he was simply handed a broom and told to shut up and go to work. And he did! The drug was the same in both situations, but because the settings differed, the experiences of withdrawal differed. The influence of set and setting on the withdrawal syndrome of heroin users was also demonstrated in Vietnam. Initially the enlisted men who were heavy users were given extensive hospital treatment for withdrawal, but later many of them were transferred to the outpatient department and simply given a little Compazine for stomach cramps.

The second characteristic cited in the WHO definitions, development of tolerance, which the committee members described in terms of "tendency to increase the dose," is even more ambiguous than the concepts of desire and dependence. This term implies that one must continue to use more of the substance in order to get the same effect and that without a period of abstinence the development of tolerance is irreversible. The concept of "getting the same effect" is very difficult to define or measure. Consider, for example, a heroin addict who has developed the habit of using his drug four or five times a day. He acquires a bit of cash, makes a good buy, and suddenly becomes a dealer. His habit increases rapidly, and in two weeks he is shooting up ten or twelve times a day. But soon he uses up his capital and loses his dealership. He is then back on the street copping, down to using the drug four or five times a day. Is he now getting the same effect he got before his period of heavy use? He doesn't know, nor does anyone else.

Had the WHO definition of tolerance been more solidly based on the pharmacological phenomenon of biological accommodation to drugs, it would have been a more useful measure of dependence. Such tolerance does, of course, develop in relation to doses of the opiates, alcohol, and the barbiturates. It is a very handy diagnostic sign of a drug habit and is used in the induction protocol of programs for methadone maintenance and drug detoxification (Blachly 1 973; Gay, Senay & Newmeyer 1974). But tolerance should not be defined as a "tendency to increase the dose" when it really means the biological ability to withstand increased dosage. Some addicts enter treatment programs solely in the hope of bringing down their tolerances to manageable levels.

The question of tolerance also varies from one drug to another. Many people find that the first few times they try marihuana they can consume enormous quantities and experience little or no effect (Becker 1963; Zinberg & Weil 1970). Once they learn how to get high, however, they stabilize at a dose level that varies little from one individual to another. At some point, though, regular users complain that while they can get high just as readily, the high does not last as long as it once did. They also say that they must change their dope fairly often in order to continue to get high. These complaints sound like evidences of tolerance; since different strains of marihuana contain different combinations of cannabinoids and cannabinols, the user is probably not accustomed to the new strain. But that fact, if true, would indicate a very low level of cross-tolerance to a very similar drug, in itself a remarkable finding.

Regular users of marihuana develop control over their high and so can shorten its time span if they wish (Becker 1963; Zinberg, Jacobson & Harding 1975). But does this reduced time span result from a change in tolerance to the drug or from a change in the individual's psychological reaction to the drug effect? Certainly regular users experience their highs differently. The "giggles," for example, are almost exclusively part of the early use of the drug, when the incongruity between what Andrew Weil calls straight and stoned thinking seems uproariously funny (1972). Even the "munchies" (increased appetite following marihuana use) can be experienced differently by regular users. My study data, which agree with the findings of other researchers, show that once a user reaches a dose level that suits him, he tends to stick to it. None of our marihuana subjects evidenced an increase in use after a long period of regular consumption; on the contrary, several showed a decrease.

Neither did our users of psychedelics reveal a tendency toward increased dosage. After the first few pleasurable experiences, some users, especially those who had begun to use between 1963 and 1968, went through a period in which they took the drug several times a week for a year or two. But it is my impression that many users of psychedelics become so rapidly acclimated to the high-impact, consciousness-changing aspect of the experience that they begin to show still greater interest in the underlying speedy (amphetamine-like) effect of the drug. Today psychedelics tend to be used only occasionally-rarely more than six times a year. Like Dr. David E. Smith and the group at the Haight-Ashbury Free Medical Clinic, my staff and I did not find a single longterm heavy user of psychedelics (Smith 1975a). Our subjects, rather than showing a tendency to increase their dose, expressed a wish to continue use on a reduced or very occasional basis.

Users of barbiturates and other depressants do need larger and larger doses in order to get the desired effect, but only up to a certain point; for even if they develop tolerance to the high or sedative dose, they do not develop tolerance to the lethal dose, and continued increases will eventually produce a fatal overdose. As for the amphetamines, continued high doses eventually disrupt metabolic functioning so much that they too must be reduced. In fact, it is impossible for users of any of the drugs ordinarily associated with abuse to continue to increase their doses and get what they want from the drug or, indeed, survive. Clearly the phrase "tendency to increase the dose" is not a consistent or easily applicable mark of drug abuse.

The fourth characteristic listed in the WHO definitions-the concept of "detrimental effect" on the individual or on both the individual and society-is also inadequate. The specific definition of a detrimental effect must always be culturally determined. As John Clausen (1968) says, "A particular drug (e.g., marihuana) may be accepted as an appropriate adjunct to sociability in one society, used as an invaluable ingredient in religious contemplation in another, and banned by law as dangerous in a third." Even would-be scientific attempts to arrange certain drugs according to their goodness (benignness) or badness (harmfulness) are not free of this cultural determinism. Evaluations of current drug research that shows a specific illicit drug to be harmful have usually found that the drug is associated with detrimental effect rather than the cause of it.. Claims have been made, for example, that marihuana causes brain damage, psychosis, the amotivational syndrome, birth defects, chromosome damage reduction of sexual functioning, and/or interference with DNA metabolism an( immune response. But according to a survey of research published in Psychol ogy Today (Zinberg 1976) and a conference of experts sponsored by The Drug Abuse Council (Tinklenberg 1975), none of these charges has been prove( (Marijuana and Health 1982).

This is not to say that some illicit drugs cannot and do not cause harm andeven death. Indeed they do, but so do the licit drugs that are freely available for nonmedical use. Nicotine and alcohol are the most obvious examples; alcohol;'' in fact, is more likely than marihuana to produce the harmful effects of drug use usually ascribed to marihuana. Harm and death can also result from a response to nature or to the therapeutic use of drugs with or without a doctor's prescription, as in the case of allergic responses to animal bites or to an antibiotic. Nor in the abuse of illicit drugs described in the WHO definitions necessarily any more detrimental than the use of sugar or food additives.

Hearings sponsored by the FDA in 1977 on the efficacy and safety of over the-counter medicinal preparations revealed that recommended dosages of many cold remedies, sleeping aids, and mood elevators were patently ineffective, but that larger doses, which did produce the desired effects, often had harmful side effects bordering on toxicity. Yet these drugs, some of then[ containing atropine, scopolamine, ephedrine, or potent antihistamines, remain on the druggists' shelves, a clear threat to the unwary consumer who believes the advertising he reads and has implicit faith in the government's watch-dog agencies (American Pharmaceutical Association 1967; Inglefinger 1 977).

And finally, even in cases where a drug, licit or illicit, can be shown to be harmful to the individual, that harm is always related to a host of variables, such as dosage, chronicity of use, and health of the user. One of these variables, which is seldom recognized, is the psychological effect of the legal definition of abuse and of the socially accepted view of abuse. When most Americans hear the word "heroin," for example, they picture the typical junkie, but they are unaware that some of his symptoms are related to the illegality of his use (Young 1971; Goode 1973; Zinberg 1975). The WHO definition takes no account of the effect of these legal and social stigmas on the user.

The idea of a detrimental effect on society is even harder to elucidate. In sharp contrast to the WHO committee's view, one social theory holds that deviants perform a useful and necessary social function by defining . the boundaries of social acceptability (Erikson 1964; 1966). Thus their behavior points the way to social change because the boundaries of acceptability gradually adjust to changing times and values; what is not accepted at one historical moment may be accepted at another. Smoking marihuana at an academic party would have been lunacy in the late 1960s, but ten years later it was hardly noticed. It is essential, however, to differentiate between the kind of value change that can be integrated into the social mores and the kind that cannot be so integrated. It is not realistic or constructive to label all currently illicit drug use (and no currently licit drug use) detrimental to society without first determining whether certain of these drugs or certain patterns of use can be successfully integrated into our social mores.

Drug Dependence, 1964. In 1964 a new committee of the World Health Organization made the concept of dependence the basis of its definition of drug abuse. After specifying dependence as "a state of psychic dependence or physical dependence, or both, on a drug, arising in a person following administration of that drug on a periodic or continued basis" (Eddy et al. 1965), the members wrote:

The characteristics of such a state will vary with the agent involved, and these characteristics must always be made clear by designating the particular type of drug dependence in each specific case.... All of these drugs have one effect in common: they are capable of creating, in certain individuals; a particular state of mind that is termed "psychic dependence." In this situation, there is a feeling of satisfaction and psychic drive that requires periodic or continuous administration of the drug to produce pleasure or to avoid discomfort.

Unfortunately, this definition relies on the ambiguous concepts of psychic dependence and physical dependence that had been used in the earlier formulation. It also hints at the notion of desire or need in referring to the administration of the drug on a periodic or continuous basis. And in a later section of the definition (not quoted here), where some of the types of dependence are designated, the concept of harm or detriment to the individual and society reappears.

The old notion that dependence must result from the periodic administration of a drug has been utterly negated by my research study. Many of our users who had at one time used a drug regularly developed the capacity to keep the same drug on the shelf for weeks-and in the case of a psychedelic, for months or years-before they used it. They would have liked to use it, of course, but their ability to postpone use contradicted the assumption of dependent behavior.

And again, the inference that the use of illicit drugs is more addictive than the use of certain socially accepted substances is incorrect. The users of sugar and salt, caffeine, nicotine, and alcohol are no less controlled by their need for these substances than are the users of marihuana, LSD, and cocaine. The WHO committee, by ascribing the term "dependence" to the use of illicit substances considered pleasurable, was attaching a pejorative label to such use simply because it was illicit, not because these substances were unique in causing dependent behavior.

Further, the implication that greater problems arise from periodic or repeated use of intoxicants than from initial or nondependent use is not correct. The new or infrequent drinker of alcohol or user of barbiturates may have an automobile accident or engage in a brawl while under the influence of booze or drugs. If he cannot learn to use a substance adaptively, he is no less a problem because he is not dependent. In fact, most of the substances considered drugs of abuse (with the exception of alcohol and the barbiturates) are used with far greater control by regular, experienced users than by neophytes.

Finally, and worst of all, the 1964 WHO definition of drug abuse employs circular reasoning in an even more confusing way than the earlier definition. To quote Robert Apsler (1975), again "The definition of drug dependence ... was developed in order to describe a particular form or pattern of drug use. Yet, when the question is asked, `Why are they using drugs all the time?' a common answer is, `Because they are dependent on drugs.' In other words, the term drug dependence has become a cause; it is now often seen as an explanation of the pattern of drug use for which it was proposed as a definition."

Further Analysis of Drug Definitions, 1957 and 1964. The two WHO definitions (addiction and habituation, and then drug dependence), which sprang from the moralistic cultural concept of drug abuse, are not precise, objective, or medically supportable. This judgment, given after more than a decade of the so-called drug revolution-and after a great deal of study of the drug issue from every vantage point, including that of pharmacology, medicine, ethnology, sociology, and psychology-seems obvious. But the faults in the definitions could not have been so clear in 1956 and 1963, when the two WHO committees were at work. At that time drug users were a tiny group of repentant deviants; heroin addicts and even the marihuana-using "Bohemians" and musicians accepted the cultural view that they were doing something wrong. In that historical context, when little was known about most of the drugs and when myth and misconception were rampant, the committees' efforts to define a slippery topic in an objective way seemed reasonable both to their learned members and to the scientific community that was seeking guidance.

Nevertheless, from the perspective of the early 1980s, the WHO definitions as well as many other supposedly scientific expositions on drug abuse and dependence contain two disturbing flaws. First, instead of describing the harmful consequences of the psychoactive drugs the writers have dealt only with the causes or motivations behind drug use. Second, they tended to attack the users rather than the use of these drugs.

The first fault is clear in the description of amphetamine use given by the WHO committee in 1964: "The abuse of this class of drugs originates in and is perpetuated by the psychic drive to attain maximum euphoria: no physical dependence is created." Evidently the committee members, unable to point to physical dependence as an ill effect, decided to refer pejoratively to the reward of a socially proscribed "psychic drive"-that of achieving maximum euphoria.

When psychological motivation becomes the basis for judging the abuse potential of a substance, double standards can be set up and socioeconomic differences can be emphasized in a most specious fashion, as in a paper distributed by the American Medical Association (Gottlieb 1970):

Drugs can represent both an attempt at personal adjustment, or a personal reaction to maladjustment. The dilettante-ish experimentation with druginduced experience of the middle class, though fraught with dangers, still represents groping for meaningful personal adjustment. Having already experienced the impact of socialization through family, school, and peer groups, most will "return to the fold." In contrast, the urban poor resort to drugs more as an adaptation to maladjustment. This maladjustment stems from disturbed family relationships, poor school adjustment, and deprived if not hostile interactions with the dominant society.

Those concerned with motivational distinctions also refer to the crosscultural use of drugs. The religious use of peyote by the Native American (Indian) Church, which is protected by statute, is the best known example. The same plant product-peyote "buttons"-is illegal for all but Indian users, and its principal active ingredient-mescaline-is illegal for all users. In this instance the user's motivation is employed to distinguish use from abuse: as long as pleasure or euphoria is not the sole object, limited use is approved. According to Richard E. Schultes (1972), "Aboriginal utilization of hallucinogens has a discrete, constructive, necessary purpose. It is religious. It is not frivolous or casual. Hallucinogens are not taken for the pleasure that they can afford-in fact, some afford no pleasurable sensations but are most definitely a trial to take" (see also De Rios & Smith 1976).

The second flaw in the WHO definitions and other scientific writings, that of attacking the user rather than the use of the psychoactive drugs, is more subtle but also more prevalent. According to the WHO committee, the frequent intravenous injection of cocaine "appeals to persons with psychopathic tendencies, which are often unmasked by the drug." Similarly, the hallucinogens "possess a particular attraction for certain psychologically and socially maladjusted persons who have difficulty in conforming to usual social norms. These include `arty" people such as struggling writers, painters, and musicians; frustrated nonconformists; and curious, thrill-seeking adolescents and young adults" (Eddy et al. 1965). One gets the impression that if these drugs were not being used by these types of people, they would not be labeled drugs of abuse. Surely such personal denigrations of the users of drugs fall short of scientific judgment.

It must be remembered that each of the people attempting to describe addiction-dependency was trying to clarify the confusion introduced by previous definitions. Lindesmith's pioneering efforts to show the important psychological factors brought him considerable criticism at that time as an apologist for drug users, who were, of course, morally bad. The WHO efforts which I dissect so minutely represented the hard work of distinguished committees trying to introduce more order into a chaotic field of study. While in retrospect it seems possible to see the biases of previous workers in the field, I am sure that my own biases at this moment will be equally clear to scholars in the near future. Thus later in this'chapter and in chapter 7 I warn against too broad definitions of these conditions and call for careful case histories that describe what is happening with as few labels as possible.

Medical and Legal Definitions of Abuse

WHO was probably the first medical organization to define the good use of drugs as medically prescribed use, and bad use, or abuse, as use that had not been medically prescribed. The WHO Bulletin of 1965 stated that "there is scarcely any agent which can be taken into the body to which some individuals will not get a reaction satisfactory or pleasurable to them, persuading them to continue its use even to the point of abuse-that is, to excessive or persistent use beyond medical need" (Eddy et al. 1965, emphasis added).

The following year the American Medical Association, through its Committee on Alcoholism and Addiction, also equated abuse with nonmedical use in a characteristic statement on the use of amphetamines:

In this communication "use" refers to the proper place of stimulants in medical practice; "misuse" applies to the physician's role in initiating a potentially dangerous course of therapy; and "abuse" refers to self-admin istration of these drugs without medical supervision and particularly in large doses, that may lead to psychological dependency, tolerance and abnormal behavior (emphasis added).

In 19-72 the American Psychiatric Association presented its definition of drug abuse, again based on the nonmedical nature of use:

... as a general rule, we reserve the term drug abuse to apply to the illegal, nonmedical use of a limited number of substances, most of them drugs, which have properties of altering the mental state in ways that are considered by social norms and defined by statute to be inappropriate, undesirable, harmful, threatening, or, at minimum, culture-alien (Glass cote et al. 1972, emphasis added).

And later in 1972 Edwin Lipinski reiterated the basic theme of all these definitions: "For the sake of clarity and at the risk of simplification, misuse [abuse] will be viewed as a nonmedical use of psychoactive drugs."

The term "nonmedical use" is complex; it has three possible connotations. First, it may refer to the use of a drug that has no recognized medical value. The expression "recognized medical value" is in itself a shifting and elusive concept. Before 1950 marihuana was listed in all the pharmacopoeias, was reputed to have many useful therapeutic properties, and was widely prescribed (Grinspoon 1971). For the next twenty-five years it was considered medically useless, but in the late 1970s it again seemed to be regaining recognition as an antiemetic and a reducer of ocular pressure (Sallan, Zinberg & Frei 1975; Hepler & Frank 1971). Second, the term "nonmedical use" may refer to the use for a nonmedical purpose of a drug having recognized medical value, such as the use of codeine to get "high" rather than as an analgesic or cough medicine. And third, "nonmedical use " may refer to the use of a drug without the supervision of a doctor or in contravention of a doctor's instructions. Reginald Smart (1974) bas observed that according to this principle, drug abuse would include "all use of alcohol, tobacco, aspirin, etc. unless under `professional advice.' This is so ridiculous it hardly requires comment." This third connotation has also prompted Thomas Szasz and others to remark that defining nonmedical use as drug abuse serves the economic and political interests of organized medicine (Szasz 1975).

The chief fault of the medical definition of drug abuse is that it claims to interpret completely and finally a type of behavior that lies outside the realm of medicine. At issue, of course, is the medical claim of hegemony over the use of most psychoactive substances, accompanied by a denial of this culture's natural interest in intoxication. Such a claim need not be challenged too strongly in relation to drugs with well-defined medical uses-stimulants, depressants, tranquilizers, and narcotics -even if these are also used for intoxication; but in relation to the psychedelics and marihuana, which have substantial social and personal significance as recreational agents but only questionable medical impact, the medical and scientific community is on shaky ground. Under current social policy, which encourages health professionals to bolster society's claim to the right to proscribe "hedonistic" behavior, a frantic "scientific" search is going on to discover any and all deleterious effects of the hallucinogens and marihuana. The result is that premature reports of unsubstantiated findings have reduced medical credibility with the very population under consideration-the drug users themselves. The restrictive concept that any nonmedical use of psychoactive substances is abusive has not only done much to sap users' faith in medical authority in this field but also raised grave doubts about the medical definition of abuse.

The legal definition of drug abuse-any recreational use of an illicit drugis even less satisfactory than the medical definition. Whenever a defendant has challenged the drug laws in court, the prosecution has presented lengthy briefs supposedly proving the harm caused by the drugs and their potential for abuse. These contentions, however, rest on a number of misconceptions, chief among them the belief that the occasional use of certain drugs, such as heroin, without becoming addicted is impossible (National Commission on Marihuana and Drug Abuse 1973).

A long-standing problem has been the reluctance of legislators to seek scientific guidance during the formulation of drug legislation. For this reason cocaine, which is not a narcotic but a central nervous system stimulant, was defined as a "narcotic" by the 1914 Harrison Narcotic Act and has therefore been included in legislative efforts to stamp out recreational use of the opiates. During the 1937 hearings on the proposed Marihuana Tax Act only one medical witness was summoned, and he opposed the legislation (Grinspoon 1971). It looks as though medical and scientific testimony has been called for only when it has promised to support the contentions and fit the purposes of the politicians who draft the laws and of those who enforce them. But the legislative and judicial branches have not alone been at fault. Even before President Nixon's National Commission on Marihuana and Drug Abuse (the Shafer Commission) published its findings and recommended the decriminalization of the personal possession and nonprofit transfer of marihuana, Nixon stated that he would not accept these findings or allow the Attorney General to implement this recommendation.

Users' Definitions

Oddly enough, asking users what constitutes drug abuse sheds little light on the question. The alcoholic's denial of the problems caused by his habit is notorious: he either refuses or is unable to acknowledge that his drinking interferes with his health, personal relations, and ability to function. Similarly, many heavy users of drugs, particularly those in the depressant class, practice denial. Clinical reports describe individuals who stagger so badly that they can hardly walk and evidence marked nystagmus and slurred speech and yet insist that they do not use barbiturates excessively.

Denying or minimizing excessive use is not the only distortion practiced by users. Some nonaddicts claim to be addicted in order to get treatment at methadone clinics. Since these clinics are naturally reluctant to addict to methadone anyone who is not already physiologically dependent on an opiate, they must screen all applicants carefully. It is difficult to understand why certain individuals choose to pose as addicts, but the wish to join a deviant group and adopt its negative identity may be one reason (Gay, Senay & Newmeyer 1974). Again, some young users who wish to impress their peers and others may make exaggerated claims about their drug use and cling to these claims through intensive questioning. Some of these youngsters may even begin to believe their own stories despite the contrary evidence of laboratory tests or observers' reports.

As long as current social policy takes drug abuse and dependence as its point of departure, it will keep drug users on the defensive, forcing them not only to account for their use but to prove themselves nondependent. Those who wish to rationalize periods of compulsive use will continue to account for their dependence in. terms of the drug rather than try to understand their own behavior (Zinberg 1975). Emphasizing the inevitability of dependence instead of recognizing it as a possible result of prolonged use always makes communication with users difficult because it suggests to them that they will not be understood. When the professional employs the concept of psychic dependence, the user must either respond with denial or accept the "abuser" label and become repentant. Those who give in to guilt and self-condemnation become incapable of making an objective assessment of the extent of their use or of its destructive results.

Guilt is not the only factor leading to such distortions. Other personality and cultural dispositions affect the accuracy of users' reports. A young man who is committed to the importance of the inner life and who finds himself yearning for one more joint may indulge in self-examination and even give an exaggerated report of his difficulties. Another young man who has a similar yearning but has been brought up to shun self-examination may plunge into troublesome behavior and resent having it called to his attention.

Of course, such tendencies to deny, minimize, exaggerate, or otherwise distort use are not confined to users of drugs; they may characterize those who engage in many other types of repetitious habitual behavior. Nevertheless, it is these tendencies that make the drug user's efforts to define drug abuse of little value.

"Use," Not "Abuse"

Drug abuse cannot be defined in the abstract; it must be determined on a caseby-case basis. This is the basis from which my staff and I proceeded in selecting and classifying subjects for our research on the controlled use of illicit drugs. In judging each case we had at our disposal two standards of measurement: quantity of use and quality of use. Quantity of use refers to the size and frequency of the dosage. Quality concerns how the drug is used or the conditions of use, which include the using pattern and the social setting (how much, when, where, and with whom the drug is used).

Quantity of consumption would seem to be the most useful measure of drug abuse, for any drug consumed to excess can cause serious problems. A drinker absorbing more than a quart of hard liquor a day can rarely function at work, keep up coherent social and personal relationships, or maintain health. Even here, however, there are exceptions-Winston Churchill, perhaps. Alcoholics Anonymous (A.A.), in its twelve-question pamphlet on drinking habits entitled Is A.A. for You?, asks such questions as, "Have you taken a morning drink during the past year?" "Have you missed time from work because of drinking?" and it defines four or more "yes" answers as evidence of a drinking problem (Alcoholics Anonymous 1954). Thus the symptoms of a user who passes (or flunks) this test must be related to quality as well as quantity of consumption. This is also true of the twenty-six-question checklist prepared by the National Council on Alcoholism (1975).

At extraordinary dose levels, quantity of use is generally a foolproof standard for differentiating use from abuse. A barbiturate user who has taken so much of his drug that he staggers sleepily, an amphetamine user so speedy that he never stops talking or moving, and a heroin user sticking the twelfth spike of the day into his body are all contravening the standards of acceptable behavior and must be classified as drug abusers. But once the extreme examples have been exhausted, sheer quantity may not be a comprehensive or practical measure of drug abuse. Further, the standard of quantity is not equally applicable to all types of drugs. What level of marihuana use should be defined as abusive? There is virtually no toxic dose, nor is marihuana physically addictive. In 1975 the New England Journal of Medicine described the case of a four-year-old girl who, after eating 1.5 g of hashish containing 15o mg of delta-g-tetrahydrocannabinol, became comatose, but recovered within twenty-four hours (Bro and Schou 1975). Heavy users of marihuana experience great difficulty in giving up the drug. Once they do give it up, however, they experience no great discomfort or psychic dependency and relatively little functional incapacity. Their relation to that drug appears to be more like that of the person who habitually takes a sleeping pill at night long after its sedative capacity is effective. The fear of sleeplessness and the symbolic nature of the pill-taking make it extremely hard to renounce. In attempting to classify our marihuana subjects, my research team and I had to consider carefully whether those who used the drug more than once a day, even though they gave no indication of compulsion, could be considered controlled. To be rigorous, we eliminated those who used the drug several times a day. But that did not help us classify those who used only once a day. Here we were forced to consider in addition each subject's quality of use in order to decide whether use or abuse was going on.

Quantity (including frequency) of use was a less difficult standard to apply to the low end of the scale than to the high end. When we had to determine the minimum quantity that would distinguish between occasional users and mere tasters or experimenters, we finally agreed on a frequency of more than once a month. But it was more difficult to decide on acceptable maximum use, as distinct from abuse, in terms of quantity alone. There we were obliged to adopt an admittedly subjective procedure-making the quality of use the major criterion.

A convincing example of the need to measure quality as well as quantity is the case of Dr. C., whose history was published in the January 1-976 issue of the American Journal of Psychiatry. Dr. C. used four shots of morphine a day, five days a week, ten months of the year (Zinberg & Jacobson 1976). He abstained every weekend and also during his two months' vacation. His case had been presented earlier (1-964) in the New England Journal of Medicine (Zinberg & Lewis 1-964) and had been followed up continuously since then, including documented periods of hospitalization during which the subject received no drug and showed no withdrawal symptoms. From 1-964 to 1-975 Dr. C. had not developed tolerance or increased his dose. Yet when the later article had originally been submitted to Science, a referee of that distinguished arm of the American Association for the Advancement of Science had rejected it because "the title of the paper ["The Natural History of Chipping"] does not properly portray its addicted ... [He is] an addict who `maintains."' This referee did not realize that in some cases of excess use, the quality of use may make for control.

Whenever my study team came across users who showed signs of physical dependency with impending withdrawal symptoms (unlike Dr. C.) or of very frequent and repetitive use, they classified such users as compulsive rather than controlled. Even these decisions, however, turned out to be far more complex than we had expected and required the application of the standard of quality as well as that of quantity. We found heroin users who exhibited some withdrawal symptoms and were not so controlled as Dr. C. but who nevertheless were extremely cautious about increasing their dose and took health-care measures. They were certainly not occasional users, but equally certainly they maintained certain controls successfully and were not interested in giving up heroin. We stuck to our rule and did not classify them as controlled users, but in that process we learned that compulsive use also encompasses many gradations.

Judgments about quality of use must take into account a complex set of factors. Here the social elements are often more important than the pharmacological. Making a regular practice of starting a long day of drinking early in the morning is quite different from occasionally ingesting a dose of LSD at the same time of day. The use of alcohol-a significant nervous system depressant-as a morning "eye-opener" is a clear indicator of trouble. This would also be true of LSD if its use were of the same compulsive nature; but if the morning dose of acid has been carefully planned and is to be followed by specific activities, usually carried out in a social framework, the quality of use will be radically different.

In the case of users of LSD and other psychedelics, drastic changes have occurred during the past decade in quality of use, changes that have made the experience less cataclysmic and thus have reduced the incidence of serious problems (see appendix C). By the early 1970s the admission of psychedelic users to mental health facilities for the treatment of acute or even long-term psychotic episodes following drug use, which had occurred frequently in the late 1960s and through 1970, had all but disappeared (Grinspoon 1974; McGlothlin 1974; Smith 1975). It is important to note that the quantity of psychedelic drug use did not decline until after 1973, according to the National Commission 0n Marihuana and Drug Abuse. In addition, since the established psychiatric resources were not always able to handle bad drug experiences successfully, the counterculture had begun to rely on its own experienced "personnel," ill-informed as they might be, to deal with bad trips. Many users, moreover, were willing simply to ride out a bad trip, knowing that the problem was a transient drug effect and not an indication of insanity. Even those among our subjects who had used the psychedelics heavily for some time did not usually show the interest in Eastern religious thought and a higher consciousness state that had been common a few years earlier. The new social setting, a qualitative element, seems to have been the predominant factor in that change.

Our finding that there is probably no long-term heavy use of psychedelics does not deny that users can react very badly to an acid trip, perhaps even to the point of having an acute upset. Nor does it deny that frequent acid trips over a short period of time can result in a changed outlook that may include intrinsic changes in personality. But there are subtle alterations-matters of conjecture or, more often, of values; for what a psychiatric or psychological examiner may call circumstantiality and ambivalence about reality testing may seem to the user to be an increased interest in abstraction and spirituality.

Another factor that makes it important to differentiate quality from quantity of use in the assessment of risk and the potential for harm is the vulnerability of inexperienced users. Certainly vulnerability to bad experiences from the drug is shown by the casualties among neophyte users of psychedelics in the 1960s. But, as noted earlier, neophyte users of alcohol, marihuana, barbiturates, and opiates may be more at risk for subjective deleterious responses, automobile accidents, damaging relationships, and generally making fools of themselves than more experienced users.

To summarize, drug abuse can be determined only on an individual basis. Only after examining each case and reporting in detail on a variety of factors relating to it can the investigator judge whether abuse has occurred. Therefore, instead of trying to formulate definitions of drug abuse, those working in the field would do well to make "drug use" their starting point and to report in detail whatever adverse effects of use they have observed. Then research could proceed in a more objective manner, and researchers, by comparing the case studies they have collected, would be able to determine whether they are talking about the same kind of drug use.

Dropping the term "drug abuse" is a necessary preliminary to understanding why and when people use drugs, how they use them, and above all, whether they can use them successfully-that is, in a controlled way. The descriptions of some users will clearly show their use to be excessive, but the histories of other users will reveal the same complexity that has characterized our own case studies. Getting rid of the ambiguity of one of the code words intended to indicate what society thinks is wrong about drug use will give investigators a chance to find and employ clear, precise, and realistic terms. With this clarity they can then study the whole range of phenomena included in the area of drug use and can undertake the task of developing and extending reasonable control over drug-taking behavior.

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