Section III The Causes of Non-Medical Drug Use

Our terms of reference require us to inquire into the "motivation underlying the non-medical use of drugs" and the "social, economic, educational and philosophical factors" relating to such use. In the Interim Report we attempted to touch on some of the dominant themes concerning the causes of non-medical drug use that had emerged from the public hearings and other sources of interpretation available to us during our first year. At that time our attention was attracted chiefly to the motivation and other related factors associated with drug use by young people—in particular, the use of cannabis, the strong hallucinogens and the amphetamines. It was an attempt to place the new upsurge of non-medical drug use in some social perspective, particularly in relation to the basic concerns underlying youthful dissatisfaction and protest. It did not purport to be a comprehensive discussion on the subject. It emphasized the extent to which curiosity and the simple desire for pleasure were primary motivations for the use of cannabis, it touched on the apparent association between youthful drug use and the search for a new meaning and approach to life, and it referred to the personality problems underlying some of the more dangerous forms of drug use, such as the intravenous use of amphetamines. Among the themes which this discussion touched on were pleasure, curiosity, the desire to experiment, the sense of adventure, the search for self-knowledge and self-integration and for spiritual meanings, the collapse of religious values, the division of life into work and play, role rejection, the search for authenticity, alienation and anomie, the loss of faith in reason, the emphasis on feeling and immediate experience, the relief of stress and tension, the bombardment of the nervous system by stimuli of all kinds, depression, the feeling of powerlessness, and a lack of belief in the future. Reference was also made to pathological causes of drug use, although the Commission expressed the view that the majority of non-medical drug users were not suffering from mental illness.

Since the Interim Report we have attempted to develop a more comprehensive discussion of motivation and other factors related to non-medical drug use referred to in our terms of reference. Our purpose here is not to sum up the detailed discussion of motivation in Appendix D or the discussion in other appendices of related factors, but to state the conclusions which may be drawn from these discussions for the purpose of developing social policy with respect to non-medical drug use.

As we have seen, there are many theories about the causes of nonmedical drug use and no overall explanation. In fact, we cannot be sure that we know the causes or predisposing factors in any particular case. What this means is that it is extremely difficult to identify the populations at risk to non-medical drug use or to predict whether any individual is likely to become a user of drugs, and if so, one whose drug use will lead to harm. The extent to which individuals engage in non-medical drug use is very much a reflection of opportunity. Opportunity is presented by availability and by someone who gives the individual the necessary invitation, encouragement or assistance which he may need to make the first attempt. Initial drug use may reflect nothing more in the personality or environment of the user than the fact that he has associates who bring him into contact with the opportunity for use. The extent to which a person becomes involved in regular-heavy drug use, or in patterns of use that may engender harm to himself or others, may depend in some measure on particular factors in his personality and social environment. The effects of the drug itself, if pleasurable, play an important role in influencing a person to continue use, but the fact that certain persons will seek such pleasure or relief despite obvious risk of harm is probably due in part to the particular makeup of the personality, although this has not, as yet, been adequately ascertained. In many cases, it can be hypothesized that persons will seek such gratification despite the risks because they have a low tolerance for discomfort, a poor self-image or a self-destructive impulse. In other cases, the physical or mental anguish of an individual is such that recourse to drugs can be viewed as a form of self-medication.

Although it is impossible to generalize about the motivation behind non-medical drug use, certain dominant themes keep recurring. One of these themes is that many excessive users suffer from a lack of self-acceptance. They do not like themselves, and they seek escape from this pain in the oblivion of intoxication. We could reduce the vulnerability to harmful drug use very greatly if we could remove the conditions that contribute to this lack of self-acceptance. People in the treatment field attest over and over to the fact that persons who make an excessive use of drugs have this sense of failure or personal inadequacy.

Another theme that recurs is the desire to escape from an intolerable bombardment of the nervous system by environmental stimuli. There is here both a sense of discomfort and a sense of personal inadequacy. The human being feels overwhelmed by the demands upon him. He seeks, by the effect of drugs, to insulate his nervous system against the shower of stimuli from the environment. A very prevalent condition which accounts for much drug use is stress produced by the nervous strain of modern living. Much adult non-medical drug use has the relief of stress as its main objective, particularly in the case of depressant substances, such as alcohol or barbiturates and tranquilizers.

The continued use of stimulants, in particular the amphetamines, seems to appeal in particular to those who feel depressed, incompetent, impotent or suffer from low self-esteem. Such people may seek relief from a painful consciousness of self in sedation or they may seek escape in an increased sense of energy or power. These are simply two different ways of trying to dispel the painful awareness of personal inadequacy.

An explanation that has frequently been offered for non-medical drug use, particularly by young people, is the notion of alienation. It is said that there is a widespread feeling of estrangement from established institutions and values. They no longer convey a sense of relevance. There is an inability to identify with them. The notion of alienation is used in many different senses to characterize prevailing attitudes or reactions. It is used very often to convey the dissatisfaction which young people feel with the existing educational system.

Closely akin to alienation as a feeling or condition that can lead to drug use is boredom. Many people fail to be adequately stimulated by their environment and consequently are involved in a restless search for pleasure and for new experiences. Boredom is simply one form of mental discomfort that persons can seek relief from through the use of drugs.

It is incorrect to assume that all drug use has some underlying psychopathology, but it is equally incorrect to assume that some people are not more prone to excessive use than others. It is necessary to distinguish between the occasion of initial use, for which nothing more may be necessary than the opportunity and curiosity, and the persistence which leads to excessive use and excessive involvement in a pattern of life oriented around use. For the latter transition to occur there is probably some combination of individual and social factors which explain the continued and in some cases even obsessive use of a drug.

To a person who can relax and find peace of mind by other means a sedative obviously does not represent as strong an attraction as it does to one who cannot. The peculiar quality of psychotropic drugs resides precisely in the change of mental state which they can produce. If one can produce these desired states by other means then there is less likely to be a compulsion to resort to mind-altering drugs. We all have to cope with the problems for which drug use may appear to offer some relief. The difference in degree to which we become dependent on drug use lies, to some extent, in our access to viable alternatives and our ability and willingness to make effective use of them. All must cope at some point with stress, pain, overwhelming demands, self-doubt, anxiety, and boredom. Some are able to use conventional and sanctioned resources to cope with these states; others do not have the ability to deal with inner conflicts or have access to the means of resolving these conflicts.

While it is necessary for purposes of analysis to concentrate on the motivations for specific kinds of drug use, the single motivation which is of most concern is that of the chronic multi-drug user—the person who engages in indiscriminate and reckless drug use. Obviously, there must be motivations common to a number of drugs to explain the behaviour of such individuals. The chronic multi-drug user would seem to be driven in some cases by a strong impulse towards self-destruction. He appears bent upon oblivion, often as a result of a profound dissatisfaction with self.

Some recent studies have suggested that family influences can have an important bearing on drug use.* It is said of white middle-class families that the high risk family (i.e., a family in which the children have higher chances of becoming drug users) is one in which the parents are uncertain of their roles, both as parents and husband and wife; in which the mother tends to be dominant and the father lacking in leadership in the family; in which the parents are permissive, hesitant to convey their values, and indeed unsure of their values, except the belief that children should be given freedom to develop their personalities; in which there is not a proper balance of affection and discipline; in which emotions are not expressed with freedom and confidence but problems tend rather to be intellectualized; in which the relations between husband and wife do not inspire a sense of security in the children; in which there is poor communication between the parents and children; in which there is fairly heavy reliance by the parents on drugs of various kinds; in which there is a lack of religious belief, a hostility towards authority, and a progressive leaning on political and social issues. The low-risk families, by contrast, exhibit a very strong, warm, well-integrated pattern of family life, with a good combination of affection and discipline; there are warm and happy relations between the parents who accept their role as parents and as husband and wife, with leadership from the father that is authoritative but not autocratic—gentle but firm and tempered with humour; the parents are confident they know how to bring up their children and are clear as to the values which they want to transmit, with emphasis on faith in God, respect for parents, self-control, tolerance and respect for one another. Within this framework of standards and discipline children are in fact given considerable scope for freedom and personal responsibility. Because they know what their parents expect they appear to be much more confident in their judgments. The children of the low-risk family are found to be resistant to peer group pressure. Because of the direction and support they receive in the families they do not seem to be as dependent on the approval or guidance of others. It is noteworthy that the parents and children of low-risk families are much more forgiving of themselves and each other. They like themselves and each other. They do not expect too much of each other. Blum's conclusion that a certain quality of family relationships provides the necessary conditions for self-restraint and the capability to resist group pressure and resolve personal conflicts without resorting to drug use is certainly an interesting hypothesis which warrants further attempts at empirical verification.

There is no doubt that children are influenced by the importance which their parents attach to drugs and by the example of drug use which their parents give. Parents convey more by their conduct than by their words. If parents show that they rely on drugs to relieve discomfort and to change their mood, how can they expect their children not to follow their example? No doubt there are exceptional cases where children may become so disgusted by the effect of drug use on their parents that they are turned off it for good, but studies show that the children of alcoholics are more likely to become alcoholics themselves, and that the children of parents who make extensive use of prescription and other drugs are at greater risk to drug use than the children of parents who do not.

From the public point of view most concern focusses on the question of what leads people to experiment with heroin, and having experimented, to go on to the regular use which leads to dependence. There have been a great many theories, psychological and sociological, to explain opiate narcotic use and dependence, but there seems to be little in the way of a general consensus which is firmly supported by empirical evidence. There are, however, a number of hypotheses which are attractive because of their plausibility. They fit at least some part of what we intuitively feel must occur; in each case there must be some combination of psychological and environmental factors, although the circumstances vary so much that it is virtually impossible to generalize. The following factors appear to be worthy of particular consideration: the factors which produce the opportunity of first use and the willingness to accept this opportunity or invitation; the role played by the personality, the effects of the drug, and personal associations and pattern of life, in the continuing use which develops into dependence; and the factors which make for the tenacious hold of dependence and the difficulty of remaining abstinent without relapse.

It would appear that sociological or environmental factors are far more important than psychological ones in the opportunity and willingness to use an opiate narcotic like heroin for the first time. The crucial factor in initial use is availability or access to the drug, and for the non-user this almost always means coming into contact with a user. The user may also be a dealer but this initial contact is usually of a casual, friendly nature, and does not ordinarily arise out of a dealer forcing himself upon a prospective user. If an individual decides to use heroin it is generally because his curiosity has been aroused by what he has heard or observed in his contact with another user. Why some persons who are exposed to this opportunity for use take advantage of it and why some do not is a matter of pure speculation. Obviously the initial or experimental user does not have such reservations about heroin use that he is unable to overcome them. Some studies have suggested that those who decline the invitation have more negative knowledge or attitudes about heroin than those who accept it. An increasingly important factor influencing response at this point must be the now wide-spread knowledge that one does not become instantaneously dependent on heroin but that it takes some time to develop dependence. The person who is prepared to experiment with heroin will almost always have a background of multi-drug use (although this was not necessarily true prior to the mid-1960s, and there are still important exceptions) and must be favourably disposed to drug experimentation. Today, it will generally be involvement in the multi-drug use pattern of life that will have brought the individual into contact with a user of heroin in the first place.

The personality background and makeup of this multi-drug user who is prepared to experiment with heroin is difficult to characterize. Obviously, he must be someone who has become sufficiently involved in a pattern of multi-drug use to be able to overcome any inhibitions about the use of the hypodermic needle. Consequently, those who are most at risk to heroin use and dependence are undoubtedly the intravenous users of amphetamines or 'speed'. They are already familiar with the use of the needle, and heroin offers them relief from the strain of amphetamine use. There seems to be agreement that the 'speed freak' generally suffers from serious personality problems. He frequently comes from a disturbed family background and, according to some authorities, often shows feelings of sexual inadequacy as a result of slow maturation. These characteristics have also been noted in heroin dependents. Indeed, there is a marked similarity in the background of these two types of drug users.

For those who have not used 'speed' intravenously, something more is required to permit this critical step in drug use than simply the kind of curiosity that may lead to the initial use of cannabis or even to one of the strong hallucinogens. Certainly, curiosity is there in many cases, but there is probably also a background of multi-drug use and risk-taking. Nevertheless, one must not forget that opiates are the most powerful of analgesic drugs, and therefore, they may be sought in cases of very severe physical or mental pain.

The factors which lead to repeated use and finally to the increasingly regular and frequent use which ends in dependence include the reinforcing effects of the drug and the attraction of a certain pattern of life and assotions. The gratification afforded by the drug is obviously a major factor in causing an individual to repeat his use of the drug until he becomes dependent. There is both gratification in the form of a pleasurable sensation and gratification in the form of relief of distress or discomfort of some kind. The discomfort in a great many cases may be a strong sense of personal inadequacy. This feeling of personal inadequacy may proceed from a failure to perform satisfactorily in the educational system or to find and hold satisfactory employment. A high proportion of heroin users drop out of the educational system before the end of high school, despite the fact that they are quite often above average in intelligence. Most of them have a poor record of employment in their background before heroin use. A high proportion also have a record of delinquency or antisocial behaviour of various kinds which pre-dates their use of heroin. There is also often a background of unstable family life without a strong father figure. For males, this may result in a weak masculine self-image and fears of sexual inadequacy. These observations by clinicians and others who have had the opportunity of examining heroin addicts may not have all the empirical foundation which might be considered desirable, but they are recurring themes which have to be treated as serious hypotheses. The truth about the motivation to heroin use does not seem to lie in an exclusive emphasis on factors in the pre-use personality of the user, nor on factors in the personal and social environment of the user before he took up use, nor again in the reinforcing effects of the drug and the pattern of life and associations developed after use, but rather in a combination of all of these factors. Although it is impossible to predict with any degree of assurance what types of persons are likely to come into contact with the opportunity for heroin use, likely to take advantage of the opportunity, and likely to continue use until they become dependent, there are certain generalizations that we can make of importance to the development of social policy.

Important factors in connection with heroin use are the early family influences which may produce a vulnerable personality; the existence of a multi-drug-using subculture which allows for a bridging of the traditional gap between drugs such as cannabis and the hallucinogens, on the one hand, and methamphetamine and heroin, on the other; and the pattern of life and associations which the heroin user acquires once he becomes dependent. The key factor is undoubtedly availability which turns on contact with a heroin user. Many persons of vulnerable personality are never exposed to an opportunity for heroin use. Many who are exposed do not take advantage of the opportunity. Others do not pass beyond the stage of experimentation. Still others do not pass beyond occasional, non-dependent use. What seems to be of chief importance is the formation of a close relationship with a heroin user. It is a combination of a person being psychologically or socially vulnerable to heroin use, and receiving encouragement or persuasion from another person on whom one feels somewhat dependent, that explains becoming a heroin dependent.

In the United States social conditions in the depressed urban core of large metropolitan centres have created the desperation and extreme vulnerability which is particularly fertile ground for heroin use, especially because heroin is so readily available in these same areas. We have not had similar conditions on the same scale in Canada, particularly the plight of underprivileged racial minorities. There has been some evidence, however, that among Canada's newer heroin dependents, there are many first generation Canadians whose traditional parental values conflict with the dominant normative system.

It is necessary to place the role played by multi-drug use and so-called `contagion' or 'infection' in some reasonable perspective. Obviously, there are not clearly defined causal relationships between the various kinds of drug use, but there are associations between them of a predisposing nature. For example, there is the association between the smoking of tobacco and the smoking of cannabis, the use of cannabis and the use of LSD, and the intravenous use of the amphetamines and heroin. Alcohol figures in the background of most multi-drug users. There is a strong correlation between it and the use of other drugs. Multi-drug use exercises an overall influence which makes it more likely that persons who have used certain drugs will use other drugs. It increases interest in drugs and drug experimentation. The more heavily involved a person is in multi-drug use the more likely he is to move on to new drug experiences. This increases the chance of the progression to heroin use, although it does not necessarily predict heroin dependence. Involvement in multi-drug use brings the users into contact with persons using a variety of drugs and is more likely to expose them to the opportunity for use of potentially more dangerous drugs.

The 'contagion' or 'infection' theory holds that drug use spreads mainly through contact with users. It is a use of the term contagion or infection by way of analogy. Obviously, the process is not strictly like that of the spread of infectious disease since in drug use the 'victim' is not infected without an intervening act of volition on his part. However, the opportunity to use heroin depends on contact with other users and, in many cases, his curiosity or interest in the use of the substance would not be sufficiently aroused without the influence of others. Nor indeed would he in many cases learn the particular procedure or practice required for effective use. In these senses, then, contact with another user is generally necessary for the spread of drug use. Controversy about the contagion or infection theory seems to be of a semantic nature. To this extent it is much like the controversy about progression. No doubt there are many factors which account for drug use in a particular case, but previous experience with drugs and contact with the users of other drugs which have yet to be tried must certainly be significant factors. Experience with other drugs whets the appetite for drug experiences, and contact with users creates the essential condition of availability. The real question is how much relative importance is to be attached to these factors and what, if anything, we can or should do about them as a matter of social policy.

Qne cause of drug use which has been much emphasized is peer group influence. The source of such influence is the desire of young people to be accepted by a group of their contemporaries on the street, at school or in a university. Such acceptance is necessary for the formation of friendships, the opportunity for participation in social and recreational activity, and generally for the sense of well-being and identity which derives from belonging to a group. It seems to be a necessary form of recognition for the building of youthful self-confidence. Children who have difficulty gaining such acceptance experience considerable mental pain. Since there will be many such groups in practice into which one may gain access there will be considerable range in the choice of possible companions. But the need to win the acceptance of some group, however small, makes a child particularly vulnerable to influences which indicate the kinds of behaviour required for acceptance. Sometimes a child may overestimate the degree of compliance or conformity which is required or the extent to which a refusal to conform on some point will keep him out of the group, but the anxiety not to be considered so odd or different as to risk exclusion is a very understandable one. There is reason to believe, nevertheless, that a strong, supportive family can be an effective counter-balance to deleterious peer group influence.

The influence of the media on drug use is a subject about which there is much controversy, and it is probably impossible to evaluate the full extent of its impact. The influence of the media is no doubt not the most important factor, but it is probably one which has a significant bearing on use. Surveys have suggested that contact with users has been more important in initiation to drug use than the media—and this is what one would expect—but this does not exclude some influence for the media. It is one of many factors contributing to a general climate of awareness and the formation of attitudes about drug use. The advertising media cannot have it both ways: the vast expenditures on modern advertising are based on the assumption that advertising can influence behaviour, and the advertisers claim credit for their clients' increase in sales; they cannot now disavow any effect on drug use as a result of their efforts to make it as attractive as possible. Of course, the advertisers are only concerned with legal use, but we may assume that not only does their advertising encourage legal use but that the extent of legal use has a bearing and influence on the extent of illegal use. It is legal use in the form of tobacco, alcohol, sedatives, stimulants, analgesics and a host of over-the-counter remedies that creates the general climate of reliance on drugs to change our mood and relieve discomfort. It is this general climate that propagates the notion, overtly and subliminally, that such reliance is not only acceptable but the intelligent course of action when one is troubled by physical or mental discomfort of some kind.

Apart from advertising, the media have certainly had an influence on attitudes toward drug use. In many ways they have played a constructive role, helping to point up the issues and to spread useful information. In other ways they have tended to exploit the sensationalism in illicit drug use and to arouse unhealthy and voyeuristic interest. For example, some 'rock' lyrics and the pronouncements of several youth-oriented radio stations have probably contributed to the development of a climate of drug acceptance among many Canadian adolescents. Similarly, it is difficult to see the constructive purpose served by a graphic television portrayal of how to use certain drugs as this is bound to arouse interest in those who are vulnerable to such experimentation. The 'how-to-do-it' approach of the media on occasion has probably been their gravest fault in their exploitation of popular interest in non-medical drug use. They have also tended to excite emotional concern and to emphasize and exacerbate the polarization of opinion in the country. The media feed on controversy, and they may also on occasion try to stimulate it. The gradual decline of the media's interest in the subject of non-medical drug use has probably been a good thing on the whole for the country.

The sensationalization of drug use can only lead to adverse results. It tends to obscure the real issues, it encourages emotional over-reaction, and it stimulates unhealthy interest. It interferes with the dissemination of accurate information and prevents the development of a balanced perspective. This, however, is a negative aspect of the influence of the media. By and large, the contribution of the media to the better understanding of the phenomenon of non-medical drug use has been a constructive one. They have made the complexity of the issues and the range of opinion more accessible to Canadians. The media, then, can be a force for good and a force for harm. It is certainly an impressive form of power, and like all forms of power it must be used with discrimination and self-restraint, and an overriding sense of public responsibility.

Now, to attempt to sum up about motivation and related factors of a social, economic, educational and philosophic nature as they bear on social policy:

1. We cannot begin to think and act effectively in the field of prevention unless we can come to some consensus about motivation and other related factors which influence the cause of non-medical drug use.
2. In the absence of some sound understanding about motivation, all that prevention can fall back on is fear—fear of the criminal law and fear of the dangerous effects of drug use.
3. Although it is likely that fear has some deterrent effect, reliance on fear has not been able to prevent a steady increase in non-medical drug use. This is partly a reflection of the extreme difficulties of law enforcement in this field, but it is also a reflection of a readiness to take risks, particularly if they are the price of present pleasure, and also in some cases of a general scepticism about the alleged dangers of certain kinds of drug use.
4. There has to be a more varied strategy than fear in order to compete with pleasure and the desire for experience. It is not enough simply to say "No". We cannot take away the drugs without putting something in their place. There has to be much more emphasis on viable substitutes and alternatives.
5. Habit plays a very large part in drug use. Breaking up habit patterns is an important aspect of stopping excessive drug use. Persons can be diverted from certain habits by involvement in other activities which fill up the space occupied by habits that are thought to be harmful.
6. While it is true that many of the theories about the causes of nonmedical drug use have little empirical basis, they nevertheless represent working hypotheses, some of which can be tested empirically. We have little to lose by testing the more plausible explanations of drug use by making such explanations the basis of attempts at prevention and treatment. This is the way experimental effort has to proceed in other areas, on the basis of testing reasonable assumptions. If we take reasonable precautions, the individuals concerned will not be the worse off for our acting on plausible assumptions.
7. Several authorities have contended that there is a drug-dependent or dependence-prone type of personality. While critics of this theory have pointed out that there is little empirical evidence to support it, the notion that some people, given sufficient opportunity for drug use, are more prone to excessive use than others has strong intuitive appeal. It appears that certain personality characteristics are likely to have an influence on the decision to use or not use drugs, initially or on a continuing basis.
8. Among these psychological factors which may be presumed to have a bearing on drug use, one of the most important is the opinion which the individual holds of himself We see much non-medical use as having its origins in a poor self-image or a lack of self-acceptance. We believe that anything that seriously undermines the individual's sense of personal adequacy is likely to render him or her more vulnerable to involvement in excessive reliance on drug use. Conversely, we feel that any influence that strengthens the individual's acceptance of self is likely to play a prophylactic role in relation to drug use.
9. Other factors of a personal nature that increase vulnerability to excessive involvement in non-medical drug use are inability to accept one's natural emotional cycle and swings of mood without recourse to drugs, a low level of tolerance for frustration or boredom, and an inability to cope with tension and anxiety by exercising self-control.
10. Both the family and the school have an important role to play in laying the foundation for self-acceptance and self-esteem and for helping the individual to develop the resources and skills for coping with mental discomfort without reliance on drugs.
11. Availability—that is, the opportunity for use and access to a supply of the drug—remains a primary matter of social concern. Without availability the vulnerability which is created by certain factors of a psychological and social nature would never be tested. Thus availability remains one of the most important causal factors. So also does contact with users. The two go closely together. It is a user who generally serves as a source of supply. The prevention of contact with users must therefore be an important consideration, especially when persons are young, inexperienced and perhaps less able to make prudent choices.
12. One of the most compelling factors in the use of illicit, dependence-producing drugs is the pattern of life and associations which the drug user develops. He generally breaks or loses his contacts with conventional society and living. He may no longer have a legal means of livelihood, he lacks the support of individuals in the "straight" world, and he lacks a variety of normal social and recreational activities which could fill the place of his preoccupation with drugs. He becomes involved in a pattern of delinquency and crime, and he becomes dependent on his associations in the drug subculture. This dependence is almost as strong as the dependence on the drug itself; indeed, it may be stronger, or at least an important aspect or component of the drug dependence as a whole. The obsessive character of the dependence of someone who relies upon a legal drug is no less involving, but the licit nature of his drug does not compel him to divorce himself from conventional society or engage in criminal enterprise.
It is very difficult to win the chronic drug user away from this pattern of life and supportive relationships. An adequate understanding of the role played by the life style and pattern of relationships in reinforcing the hold of drug dependence and precipitating relapse is fundamental if treatment and rehabilitative efforts are to be successful.
13. In speaking of motivation we must be careful to distinguish between experimental or occasional drug use of a relatively harmless nature which is prompted mainly by curiosity, and persistence in chronic, multi-drug use which carries a high risk of harm. The motivation for the latter kind of drug use passes well beyond mere curiosity and generally involves serious social and psychological problems. At the same time, there are no clean-cut lines of demarcation between the various stages of drug use, and one stage tends to slip fairly easily and imperceptibly into another. The general climate and extent of non-medical drug use also contributes to the extent of harmful drug use. Thus it is not realistic to attempt to deal with any one form of drug use, as if it can be separated or isolated from the others, nor to attempt to base a general strategy of prevention on distinctions between harmful and non-harmful use. We have to be concerned with drug use which has a potential for harm as a whole.
14. There are certain conditions in modern life which are conducive to non-medical drug use. Among them is the bombardment of the nervous system by stimuli of all kinds. This leads to a desire to seek relief by withdrawal or insulation of some kind.
15. Influences of various kinds toward conformity in order to achieve acceptance within the adolescent peer group or the adult social group also play their part in encouraging non-medical drug use as a means of facilitating social relations and winning social acceptance.
16. Modern advertising reinforces the impression that there is a chemical relief for all states of physical and mental discomfort. It fosters a general climate of acceptance of drug use by its promotion of tobacco and alcohol. It conveys the message that these substances facilitate social relations and serve to change one's mood for the better. The impression that is created is that one cannot get along effectively without them. It is not the particular substance that is important but the idea of mood-modifying substances as a necessary aid to effective living.
17. As we have seen, the massive extent of adult drug use and the ease with which adults resort to pharmaceutical and alcoholic substances are major influences on illegal and non-medical drug use by adolescents.
18. Non-medical drug use, particularly among young people, has been seen as expressive of a general dissatisfaction with the conditions of modern life, in particular the dehumanizing conditions of urban living and employment. It is thought to reflect the sense of alienation or estrangement from modem institutions and values which many young people feel. In this sense, non-medical drug use is seen as an aspect of a general protest against or retreat from modern conditions. While its symbolic significance seems to have declined somewhat in recent years, and there is much less ideological connotation to non-medical drug use than there was a few years ago, there is still in our opinion a close association between non-medical drug use by the young and a general feeling of dissatisfaction and pessimism about the prospects for a satisfying and self-fulfilling life. This is related to the rapid rate of change, doubts about the continuing relevance and utility of knowledge acquired in the formal educational system, doubts about the ability to find appropriate employment after a long period of formal education, and concern about the future of the human community arising from such problems as over-population, pollution, racial tension, economic instability and the threat of global war. These conditions give rise to a certain degree of depression for which relief is sought in non-medical drug use.

In summary, there are factors in the personality or psychological makeup of the prospective user, in his close personal relations and environment in the family, school, and the peer group, in social and economic conditions, and in the general attitude of the society towards drug use, as reflected by advertising, the media and the practices of the adult population, which predispose and encourage the individual to engage in non-medical drug use. The drugs themselves, as a means of relieving discomfort and affording pleasure, exercise a powerful attraction for people who have been conditioned more and more to seek comfort and pleasure. Modern advertising encourages the notion that there is no reason to put up with discomfort. A whole consumer industry turns on keeping people in pursuit of pleasure. While such a philosophy has its uses, it conveys a hedonistic approach to life which makes it increasingly difficult for people to tolerate the dissatisfactions of everyday living.

* R. H. Blum, & Associates, Horatio Alger's Children (San Francisco: Jossey-Bass, 1972).