VII THE PRIVATE RESPONSE

The Harrison Act initiated a comprehensive "official" public response to what had previously been a private institutional concern. Institutions, such as the medical profession which had previously been involved, abandoned the field ; others never became involved at all. In part, this was due to the vigor with which public agencies assumed their tasks, not only enforcing policy, but shaping and promoting it as well. The government seemed content to have the private sector play only a secondary role, a role which consisted largely of repeating information disseminated by enforcement agencies rather than addressing the substantive issues of drug-using behavior.
For their part, private institutions showed little reluctance to leave the problem to public agencies. The popular attitude towards drug users had changed from compassion to contempt, and someone dependent on prohibited substances was generally personna non grata to the rest of the community. The dominance of the official response is also illustrated by the other side of drug policy. After the repeal of Prohibition, availability of alcohol became an accepted feature of American life. And most formal private institutions failed to exert any significant influence on alcohol-using behavior.
Neglect of the drug area by private, institutions has had two serious consequences. First, the sudden increase in illegal drug use in the 1960's found law enforcement agencies able to rely only on the raw threat of arrest and imprisonment to turn the tide. Other than echoing this threat, families, churches, businessmen and schools were unequipped to render coherent moral and social support for the existing policy. Because of the harshness of the legal response, many private institutions were unwilling even to support the legal threat against drug use. The law began to lose its practical deterrent value.
The second consequence of the lack of a private response was that society tended to view the problem exactly as the law defined it. Thus, the country reacted strongly to reports of 300,000 or more opiate-dependent persons and ignored the much more extensive problem of alcohol dependence; it showed great concern for the tragedy of several thousand heroin overdose deaths each year, yet remained apparently unaware that many more people die from legally prescribed barbiturates. Private institutions mirrored the legal distinction among various drugs and for the most part failed to develop their own perspectives on use.
With the most recent drug crisis, private institutions have finally begun to assume an obligation long ignored. So far, however, the private response, though greatly increased, has been no more effective than the government response. In the private as well as in the public sector a rational approach requires careful definition of the problem and thoughtful allocation of roles and responsibilities.
The Commission strongly counsels the private institutions against continuing to rely upon the government to organize their response for them. At the same time, we realize that for the time being public agencies will necessarily retain their preeminence in the area, and that private institutions in part will have to shape their activity so that it complements the governmental response. In our opinion, this means that the private response must evolve in two stages. In the first phase, private institutions must initiate programs of prevention, counseling, treatment, and rehabilitation to supplement those established by the government. In many cases, privately developed programs will serve as the means through which governmental policy is implemented. At the same time, private institutions must begin to deal directly with the role of the psychoactive drugs in contemporary society and the nature of responsible use behavior. Their concern must extend to drugs which are now legal, as well as those which are illegal, and must attend to use within, as well as without, the medical system.
Over the long term, private institutions must have primary responsibility for controlling the consumption of psychoactive substances and reclaiming the casualties of irresponsible use. The day should come when an individual involved with drugs can approach his family, church, physician, or job counsellor and find the support and attention he needs. The day should pass when anyone experiencing a drug problem is sent only to the police, a public clinic or a social worker.
Since the first responsibility of this Commission was to provide the government with information and recommendations, most of our attention has been devoted to improving the official response. This should not mask the fact that ultimately the greatest potential for effective action lies within the private sector. In the following pages, we offer specific recommendations to several private institutions.

THE HEALTH PROFESSIONS

The medical profession largely abandoned its previously dominant role in the treatment of opiate-dependent persons after the passage of the Harrison Act. Yet, it was not only the law which prompted the exodus of private health personnel from the area of drug dependence. This illness had not responded to devices the traditional medical treatment models, and it had become identified with social deviance and criminality, attributes not particularly attractive to the health professions. The frustration health professionals experienced in attempting to treat drug dependence led many of them to believe that the problem was more a vice than a disease and that they should not waste effort on people too impoverished in will to change their behavior (Morrell, 1973).
With the increase in drug use in the 1960's, influential members of the health professions recognized the need to develop an effective medical response to drug use (Prettyman, 1963) . They also recognized that the health system to a great extent was unprepared to respond effectively, either in terms of treatment techniques or in its attitudes toward the problem. Since then, health professionals have become increasingly involved in treating drug users and drug-dependent persons, and both techniques and attitudes have substantially improved.
Despite this progress, barriers to private participation remain. Even when therapy is available, users may still be reluctant to seek assistance for fear that their drug use will be disclosed to others.
Disclosure, in turn, may result in any number of severe consequences; loss of job, expulsion from school, social stigmatization, even criminal prosecution. Professional ethics, of course, obligate doctors and other health professionals to respect the confidentiality of patient information. Some state laws, however, require those treating a drug user or drug-dependent person to report this fact to a government health or law enforcement agency. In a number of other states, a court may compel disclosure of information received in the course of treatment."
Confidentiality is essential to an effective treatment relationship with the drug patient. The Commission recommends that every state have confidentiality-of-treatment laws, modeled after the provision in the draft Uniform Drug Dependence Treatment and Rehabilitation Act currently before the National Conference of Commissioners on Uniform State Laws. The professional societies representing the health professions should urge enactment of such laws and ensure that their own ethical codes stress the need for confidentiality in these cases.
With drug-dependent minors, it may sometimes be necessary to have means whereby they can obtain treatment without parental knowledge. This is a difficult issue given the present incapacity of some parents to deal rationally with drug use among their children. Requiring parental consent may pose a deterrent to initiation of treatment in some instances. To meet this problem, some states, for example Connecticut and Massachusetts, have adopted laws permitting treatment without such consent. The health professions themselves must also devote attention to how treatment can best be provided under these circumstances.
In addition to removing barriers to treatment, members of the health professions must acquire the knowledge and skills needed to provide effective guidance and therapy. Much of the burden will fall upon those now studying or planning a career in health. They will have to bring both new ideas and new perspectives to the problem.
At present, however, professional schools in medicine and other health services either completely ignore the treatment of drug problems or give the matter only incidental notice in the curriculum. Unless the schools show more concern for the health problems attending drug-using behavior, many of their graduates will be unprepared, and therefore unwilling. to deal with drug-dependent patients in practice.
Accordingly, the Commission recommends that schools of medicine, pharmacy, nursing, and public health include in their curricula a block of instruction dealing with the social and medical aspects of drug use. This instruction should be designed so that health professionals are adequately informed of the problems and possibilities of treating drug use and dependence and understand as well the wider social implications of both licit and illicit drug use.
It is especially important that all physicians recognize the dangers inherent in use of ethical psychoactive drugs. Too often, damaging patterns of repeated use begin or continue with drugs prescribed by doctors. In an earlier Chapter, we pointed out the greatest potential for reducing misuse of barbiturates and tranquilizers lies with the medical profession itself. The problem there is not the unscrupulous doctors who sell drugs for profit, but the well-intentioned physician who, insufficiently aware of the risks, prescribes and represcribes where use of the drug is not indicated. Sloppy prescription practices unfortunately develop easily. Overworked and pressured by patients, the doctor may too often renew the prescription over the telephone, with no opportunity to confirm its continued need.
In addition to professional guidelines for use of barbiturates, recommended above, the Commission strongly recommends that the medical profession prepare criteria for use of all psychoactive drugs in medical practice. These guidelines should stress restraint in use of such drugs, emphasizing that they are not a treatment of first resort and that when prescribed, they should be given in the smallest dosage units and doses possible. Medical societies should see that the guidelines are widely distributed among health professionals and, in simplified form, made available to patients themselves. Professional organizations should also conduct continuing education courses in the uses and dangers of psychoactive substances. Both doctors and pharmacists should expressly warn patients of the risks of dependence, overdose, and use in conjunction with similar drugs such as alcohol.
Finally, the health professions have the responsibility to develop a general ethic for therapeutic use of psychoactive drugs. Such an ethic would govern not only prescription practices by physicians, but also the way in which all members of the health system and the public approach medical use of these drugs. It would apply not only to ethical. or prescription drugs, but also to the over-the-counter, proprietary drugs such as aspirin and other analgesics, tonics, and innumerable other preparations. The ethic would emphasize the dangers in repeated and heavy use of any drug, the risk in allowing self-medication to delay resort to professional health services, and the undesirability of resorting to drugs to cope with minimal anxiety, stress and depression. Because of the public trust in the knowledge and skill of the medical profession with respect to the drugs, the profession must not only take care in its own practices, but also assume the task of educating society in the proper and responsible use of drugs.

PHARMACEUTICAL INDUSTRY

Since World War II, the American pharmaceutical industry has discovered or created thousands of new drugs, including most of the broad-spectrum antibiotics and non-barbiturate-sedative drugs currently in use. These developments have revolutionized the practice of medicine. Comparisons in volume of sales at the manufacturing level not only mark industry growth but also suggest the profound impact on health services. In 1932, sales of prescription drugs were estimated at only $140 million (Rorem and Fischelis, 1932) ; by 1971, they had reached approximately $4.4 billion (Griffenhagen, 1973).
A significant part of this increase, particularly in the last decade, has been in the area of psychoactive substances. In 1964, retail pharmacies filled approximately 149 million prescriptions (including refills) for psychoactive drugs. By 1970, this figure had reached 214 million, representing 20% of all. prescriptions and refills (Brecher, 1972; Griffenhagen, 1973).
Most important for the Commission's purposes, particularly with regard to circumstantial drug-using behavior, is the astounding increase in medical use of the so-called minor tranquilizers. In 1946, these drugs were virtually. unknown, even to research. By 1970, prescriptions for minor tranquilizers numbered approximately 83 million, 38.8% of all psychoactive drug prescriptions. By comparison, the stronger depressant drugs accounted for 28.6% and the stimulants and anti-depressants accounted for 22.4% (Brecher, 1972).
With its remarkable post-war expansion in size and research effort, the pharmaceutical industry has also adopted more aggressive marketing practices. Research required investment of increasingly large sums, which companies were anxious to recoup before the patents on the new discovery expired. Since consumption choices in the ethical drug industry are made not by the user himself but by his physician, drug companies focused promotion efforts on the nation's 200,000 practicing physicians.
The immense number of pharmaceutical products available assured that the manufacturer's informational materials would find a receptive audience. In 1967, for example, there were an estimated 4,000 kinds of dosage forms, 1,200 single drug entities, and 6,000 combinations. Ten thousand differentiated products overwhelm the capacity of almost any practitioner to make independent judgments about their use (Task Force on Prescription Drugs, 1969).
Physicians obtain information on ethical drugs in a variety of ways. Their primary sources include journal articles, colleagues, detailmen, advertising, the Physicians' Desk Reference, and pharmacists. Still, the manufacturer is the primary source of information behind almost all these sources. The Physicians' Desk Referee e, for example, consists of reprints of the "Product Package Insert," which in turn emerges from a long negotiating process between the manufacturer and the hood and Drug Administration, sometimes resulting in language compromises regarding use indications and side effects. In their advertising, manufacturers naturally tend to point up the advantages of using their drug and tend to play down the disadvantages, particularly those identified as minimal risks or isolated reports of major risks.
The problem of advertising and information is particularly acute with respect to psychoactive substances. Pharmaceutical companies promote the use of these drugs to deal with stress complaints identified by the patient as tension and anxiety. Patients often know about the substances and ask that they be prescribed. Because stress-related complaints are now so common and tranquilizing drugs often seem the only quick way to provide relief, physicians find it difficult to resist either the blandishments of the manufacturer or the demands of his clients.
Much of the time the physician may not consider alternative therapies.
Notwithstanding its immediate economic interest, the pharmaceutical industry itself must take the lead in discouraging overuse of such drugs. Failure to do so will ultimately result in stricter legal controls on production and distribution, and even greater economic detriment. The Commission recommends that manufacturers of psychoactive substances undertake a major campaign to educate both health professionals and the public about the appropriate role of these drugs in treatment of conditions of anxiety, tension, and depression. Information and advertising aimed at physicians should emphasize the need for restraint in use of these drugs, particularly the more powerful ones; point out alternative therapies and plainly disclose harmful side-effects, risks in prolonged use, and dangers in combining use with that of other drugs, including alcohol. In non-technical language, a series of public service advertisements should carry the same message to the lay public.
The Commission also recommends that drug companies end the practice of sending doctors unsolicited samples of psychoactive drugs. Having free drugs on hand may encourage physicians to administer them too readily. The controlled substances laws already prohibit sample distribution of controlled drugs except upon specific written request from the doctor. Manufacturers should voluntarily extend this practice to non-controlled psychoactive products.
Finally, the Commission recommends that manufacturers contribute a significant part of their considerable research capacity to exploring the technical side of the drug use problem: the nature of drug dependence, the development of less harmful substitutes for those substances most often associated with disruptive use patterns, and the search for "anti-drugs"—chemicaI correctives to dependent and chronic use of psychoactive substances. In particular, the industry should continue to pool its knowledge and resources in the search for effective opiate antagonists.
The pharmaceutical industry does not consist exclusively of manufacturing firms, of course. It also includes an extensive distribution network comprised of drug wholesalers, community pharmacies, hospital pharmacies, and mail order pharmacies. The drug wholesaler buys in large quantities from producers and then distributes smaller quantities to retail pharmacies, though the large drugstore chains often combine the wholesaling and retailing functions. The pharmacies, in turn, sell to the consumer, usually on the written or oral order of a physician.
Wholesalers as well as manufacturers must ensure that companies purchasing psychoactive drugs in bulk are lawful and reputable distributors and that the quantities ordered are reasonable. Too often, a reporter or investigator has been able to demonstrate the porous nature of the drug distribution system by successfully ordering substantial quantities of drugs over the phone or on a dummy letterhead. To avoid this, all companies should monitor their sales to ensure that the product remains within legitimate channels of distribution.
At the retail level, the Commission recommends that pharmacists verify the identity of persons seeking prescription psychoactive drugs. They must also vigorously enforce the regulations which apply to over-the-counter cough preparations containing codeine. Pharmacies should keep their inventories of psychoactive drugs as low as practicable, in order to eliminate diversion through pilferage and thefts.
Pharmacists can take a positive role in dealing with drug consumption, as well as with availability. Recent developments in the industry have circumscribed the functions of the druggist, denying both him and his customer the full exercise of his knowledge and skills. For many years, small, independently owned neighborhood pharmacies dominated retail distribution of drugs ; the pharmacist knew his customers personally, and often advised them on their use of medicines. Today, chain-owned drug stores and outpatient dispensaries claim much of the market; most dosage units are preformulated by manufacturers; and doctors' prescriptions leave the pharmacist little, if any, room to exercise his professional judgment. As a result, society forfeits many sevices which the profession most learned in the properties of drugs could render.
The Commission recommends that steps be taken to reinvolve the community pharmacist in the consumption decision, particularly with respect to psychoactive substances. At the very least, pharmacists should be prepared and encouraged to make their customers fully aware of the risks in use of these drugs, and they should advise the prescribing physician when his choice of drug is questionable. Pharmacists should also counsel customers on use of proprietary psychoactive substances, taking the precaution of having those products available only at the prescription counter.

ALCOHOL INDUSTRY

The manufacture and sale of alcoholic beverages is a major industry in the United States. In 1971, it had over 100 million customers and retail sales totaling $23.8 billion. This meant that Americans over 15 years of age averaged an annual per capita consumption of 2.62 gallons 'of spirits, 2.08 gallons of wine and 25.9 gallons of beer. Taxes from sales of alcoholic beverages totaled $3.2 billion at state and local level and $5.05 billion at the federal level (Deering. 1972).
The massive economic growth of the alcoholic beverage industry since the end of Prohibition leaves little doubt that alcohol is the drug of choice in America. Present regulation of the industry is largely a revenue control function, though state laws do prohibit distribution to minors and generally impose some restrictions on times and places of sale. Nonetheless, alcohol is freely available to adults almost everywhere. This widespread availability is not without serious -costs. According to current estimates of the National Institute of Alcohol Abuse and Alcoholism, there are at least nine million alcohol-dependent persons in the T "sited States ( Brodie, 191-3) .
The Cosueission believes that the alcohol industry has an obligation to spearhead the private institutional response to that part of the drug problem with which it is directly involved. Specifically, the Commission recommends that the industry take the lead in funding research into the nature of compulsive alcohol-using behavior and the relation between alcohol use and traffic accidents, violent crimes, and domestic difficulties. We further urge manufacturers and distributors of alcoholic beverages to inform the public that compulsive use of alcohol is the most widespread and destructive drug-use pattern in this nation. Advertising should emphasize moderate, responsible use and point out the dangers of excessive consumption.
The Commission also recommends that the industry reorient its advertising to avoid making alcohol use attractive to populations especially susceptible to irresponsible use, particularly young people. By general agreement within the industry, hard liquor commercials do not appear on the broadcast media. The Commission urges the industry to pay special attention to the impact of advertising in the print media as well.
In addition, the Commission notes with approval that broadcasters and the industry have agreed voluntarily not to advertise beer and wine on television and radio programs whose probable audience are under 18. We further urge that the wine and beer industry consider eliminating their broadcast advertising altogether. While such action by governmental fiat would be inappropriate, the alcohol industry itself should revise its marketing methods to comport with an overall discouragement policy.

LEGAL PROFESSION

As long as this society designates possession and use of psychoactive substances outside channels of legal availability as crimes, the legal profession will play a special role in the response to the drug use. As a profession, lawyers must assure that those charged with drug offenses receive an adequate defense. The vast increase in drug arrests, now estimated at 500,000 a year, requires a commensurate increase in the number of defense attorneys qualified to handle this kind of case. Too often general practitioners or specialists in areas other than criminal law, and sometimes criminal lawyers as well, do not possess the special knowledge of drugs and drug-using behavior necessary for effective representation.
In particular, attorneys representing clients in drug cases must familiarize themselves with treatment alternatives to prosecution and punishment. When the client is actually drug dependent, advising and arranging treatment may be the most important service the attorney can perform. Accordingly, the Commission recommends that bar associations conduct seminars and courses on handling drug cases. We also recommend that law schools develop courses dealing with drug use and behavior as a part of the wider socio-legal problems confronting the legal profession.
Another important responsibility of the legal profession is to inform the public of the limitations of the criminal law in dealing with the drug problem and the consequences of our present over-reliance on it as a means of social control. The Commission recommends that lawyers, operating both individually and through bar associations, point out the need for alternatives to the legal response and the urgency of involving other social institutions in the effort to control drug-using behavior. By the same token, the bar has an equally important obligation to discourage any violations of the law.

INDUSTRY

Significantly increased employee drug use, other than drinking, seems a relatively recent phenomenon, which a large segment of business management continues to ignore. This is not surprising, since industry began to address the problem of alcoholism in the work force no more than 20 years ago, even though alcohol has been available and misused for centuries (Cloud and Seixas, 1971) .- Nor until the 1970's did industry begin to acknowledge that a significant proportion of employees might be using or under the influence of drugs other than alcohol while on the job.
In response to this problem, some companies have developed specific policies regarding use and established programs to assist drug-dependent employees, or at least to refer them to outside agencies for
• treatment. Unfortunately, many companies have formulated their programs on the basis of insufficient information. Most companies simply have no program; they respond to detected drug use by firing the employee, while disregarding drug use which does not come directly to their attention.
Fortunately, there are signs that attitudes and policies are changing. Within the past two years, representatives of major American companies have conducted conferences throughout the United States to discuss drug use and drug dependence within their respective industries. They have concluded that drug use is becoming, if it is not already, a serious employee problem. Unions have also held meetings on the problem of drug use in the work force.
A 1970 study of 220 companies ranging in size from 250 to 250,000 employees indicates that most companies have either experienced employee drug use or believe they soon will. More than half of the companies surveyed planned in-house programs to counteract drug use. Firms in large urban centers reported the highest incidence of drug use, though neither geographical location nor company size seemed to make much difference. Heroin use was thought to be relatively uncommon, but use of other powerful drugs, such as amphetamines, was often reported.
Approximately one-third of the companies indicated that they provided treatment or counselling to drug users, while 22% terminated the individual's employment and approximately 4% notified company security officers or local police. Another 3% indicated that they were not concerned about employee drug use, provided that job performance was unaffected. Overall, the response to employee drug use seemed to be sterner than the response to problem use of alcohol. Interestingly, only a small minority of firms surveyed had published formal drug policies, though others had issued guidelines to supervisors on detection of users and treatment referral procedures (Rush and Brown, 1971) .
In the Commission's own 1972 survey of 45 companies," two-thirds reported no apparent drug use problems, and less than one-half indicated that they had adopted, or intended to adopt, a formal policy concerning their employees' drug use and the drug-related behavior. The majority of those with formal policy statements responded to possession, use, sale or distribution by terminating the individual's employment. A minority considered each case on an individual basis, yet few companies had resources available for counseling, treatment or rehabilitation (Urban, 1973) .
As one means of preventing employee drug use, a wide range of companies have instituted pre-employment screening procedures. This practice reflects the fear that recent college and high school graduates are much more likely to use drugs than older workers. With the increased acceptance of drug-taking among all age groups and social and economic levels, however, companies are finding that such behavior use is not confined to the young or to minorities (Kurtis, 1971; Chambers and Heckman, 1972).
The problem of employee drug use and drug dependence is not limited to private business enterprise. Federal, state and local governments also face the problem. As an employer, the federal government regards alcoholism as an illness, fully protecting the afflicted employee's job rights if his rehabilitation is successful. Most federal agencies are training supervisors to detect problem drinkers and to initiate contact with them. To date, only the armed services have adopted a similar policy with respect to other drugs.
The first prerequisite of an effective, well-planned response to the problem of employee drug use is, of course, an accurate description of the problem itself. Intelligent policies will be impossible until industry thoroughly analyzes employee-drug-taking behavior .and evaluates its impact on output, individual productivity, damage to plant facilities and equipment, and injuries and accidents to fellow employees. The Commission recommends that management and unions, supported by the Departments of Labor and Commerce, cooperatively undertake a comprehensive study of employee drug use and related behavior.
Since drug use or dependence may cause absenteeism or impairment of employee productivity, management must sometimes intervene to protect the company's economic position. Supervisors should not simply deal with job performance impaired by drug use on an ad hoc basis, however ; companies must develop definite guidelines indicating when drug use warrants intervention and what types of intervention are appropriate.
The Commission recommends that industry consider alternatives to termination of employment for employees involved with drugs. Where the nature of the business allows, employees should be referred to company-run or other public and private rehabilitation or counseling programs.
Supervisors should be trained to detect troubled employees, including drug users and drug-dependent persons, though the supervisor's involvement need not go beyond identifying troubled employees and referring them to counsellors, medical personnel or other professionals for assistance. Smaller companies probably should not try to operate their own treatment programs, but rely on outside agencies instead. All companies, however, should be sensitive to the problems of the drug-using employee, so that they can detect early signs of trouble and make appropriate referrals.
The Commission recommends that the business community consider adopting employee programs patterned after the "troubled employee" or "employee assistance" concept. This program consists of a management control system based on impaired job performance, determined by minimum company standards. It seeks to determine and treat the underlying causes of poor performance, whatever they may be, rather than limit itself to the standard responses.
The Commission further recommends that the treatment and rehabilitation be kept confidential to encourage employees to accept counseling and other assistance. No record of the employee's drug problem should be carried in any file which is open to routine inspection. If treatment requires a temporary absence, the company should attempt to keep the employee's job open for that person.
Although some companies have adopted intelligent, precise hiring policies with regard to former drug users and drug-dependent persons, the majority have not. In most industries and for most jobs, the Commission believes that refusal to hire an applicant solely because of past drug use or dependence serves no real business purpose and frustrates policies favoring rehabilitation and social integration of problem drug users. The Commission recommends that the business community not reject an applicant solely on the basis of prior drug use or dependence, unless the nature of the business compels doing so.
In some instances, businesses will have to implement screening procedures to detect a job applicant's drug use. This may be particularly important in industries such as transportation, where the safety of others is directly involved. When pre-employment screening is necessary, the Commission recommends that companies establish appropriate screening procedures, including physical examination, for job applicants, and keep the results confidential.

COLLEGES AND UNIVERSITIES

In an earlier section, the Commission has discussed the role of secondary and elementary schools in responding to and preventing drug use. Because a significant percentage of the youthful use occurs among college and university students, institutions of higher education must also assume special responsibilities in dealing with this problem. First, of course, educators must inform themselves of the type of drugs and patterns of use within their particular student body. Using such information as a base, they should then develop coherent and comprehensive policies.
A Commission-sponsored survey of selected universities and colleges revealed that only 46% of the sample had a written policy dealing exclusively with drugs, although 86% had a written policy with some relevance to drug use. The overwhelming majority of institutions surveyed made no distinction in their policies or rules between possession, sale or transfer of drugs. Over one-half of the schools had policies which covered only on-campus violations and over one-third did not clearly differentiate between use of alcohol and of illegal drugs. Less than half of the sample had secured student assistance in formulating drug policies. Most striking, about 30/0 of the colleges and universities sampled routinely informed their students of federal, state and local drug laws (Robinson et al., 1973) .
Educational institutions tend to deal candidly with alcohol use problems and many institutions have written policies on drinking; but alcohol is socially acceptable and drinking is generally expected on college and university campuses. Because use of other psychoactive drugs is taboo, educators may prefer a more inconspicuous response to such behavior. An explicit policy is an admission that the problem exists, and this in turn requires that it be confronted. Whatever the reason, there is an obviously strong tendency among university administrators to hide campus drug problems from public view.
In dealing with violators of campus drug policy, student handbooks and other similar publications may spell out penalties and sanctions for illicit use, but there is a great deal of unevenness in how sanctions and penalties are applied. The administrator usually has broad latitude. His options may range from reprimand to counseling to expulsion. When the drug use attracts public attention, however, the situation alters. Violators of campus drug policy are referred to counseling in 43% of the instances in which campus personnel detected the offense. By comparison, students arrested for or convicted of violating the drug laws were referred to counseling only 26% of the time (Robinson et al., 1973) .
When violations of drug policy occur within the confines of the campus, many colleges and universities take strong precautions to protect their students. Ninety-one percent of the respondents provide counselling and 89% always treat such counselling as confidential. A majority of those institutions have a stated policy on confidentiality. In addition, most of these institutions respect the privacy of student records and do not provide information to external sources without student consent (Robinson, et al., 1973) .
In formulating drug use policy, colleges and universities should try to develop techniques for intervening informally in the experimental or recreational drug use patterns of students, in order to prevent escalation to intensified or compulsive, use. The most effective response is one that encourages voluntary participation. For this reason alone, the Commission recommends that counseling, treatment and rehabilitation programs on campus ensure confidentiality to their student clients. Specific rules should be set up indicating to whom confidentiality will be extended and under what circumstances.
The Commission recommends that colleges and universities make their policies and practices regarding drug use, including alcohol, explicit, unambiguous, and readily available to all students. Policies should clearly state the anticipated institutional response to drug use on the campus, as well as probable disciplinary action for students apprehended for violation of federal, state or local law. University faculties should recognize and correct attitudes of "benign neglect" toward drug use among their own members, as well as among students. To students, such diffidence suggests that law-breaking is acceptable whenever they consider the law inappropriate or unreasonable.
Emphasis on counselling as a response to individual student drug problems, reflecting an increasing perception of these problems as a manifestation of difficulty in personal adjustment, now seems to be predominant in colleges and universities. Accordingly, schools must find means to strengthen the counselling effort. Counsellors should receive more professional training, particularly in the special characteristics of the troubled drug user. Where necessary, campus programs should hire additional personnel. The Commission recommends that even those colleges and universities which strongly disapprove of student drug-use behavior expand their counselling services, rather than rely upon disciplinary measures alone.

MASS MEDIA

Mass communications—printing, television and radio—have become the universal source of public acculturation; they provide the means of selecting, recording, and disseminating societal notions of what is important, what is right, and what is relevant. Drug use is a subject which the popular media has treated extensively and sometimes sensationalized. They have carried messages which to a considerable degree have structured the public's sense of priorities, values and causes with respect to the drug problem.
As we noted earlier, the relationship between drug use and the media of mass communications has stirred great interest and considerable debate, especially with respect to advertising of proprietary pharmaceuticals. Medical experts, representatives of the pharmaceutical industry, government agencies, and public interest groups have all addressed themselves to the complex issues raised by the advertising of mood-altering drugs through mass media (Kramer, 1973).
A number of observers argue that the repeated advertising of mood-altering, over-the-counter preparations indirectly encourages use of prohibited substances (Penna, 1972; Johnson, 1972; Berger, 1972, Barces, et al.. 1973) . According to this theory, children spend a great deal of time watching television and are especially receptive to the advertiser's suggestion that mood-altering drugs are effective means of relief for a number of problems (Mathis, 1970). Some also maintain that frequent repetition of a commercial can create in children a feeling of familiarity with the product and thus remove their fear of it.
Until recently, in-depth studies of the possible relation between advertising of proprietary psychoactive drugs and problem drug use were lacking. Now, at least preliminary research is under way. One recent effort indicated that advertising alone apparently has relatively little influence on students, especially when compared to the stronger influences of family and friends. The researcher concluded that as a single factor, it could not be considered responsible for youthful attitudes toward drugs. Nonetheless, many of the study's subjects felt that advertising had a potential impact, particularly on younger members of their peer group (Kanter, 1970) .
It seems reasonable to hypothesize that mood drug advertising at least reinforces certain drug attitudes among the young. The recipient may often get the message better and more accurately than the sender realizes. The finding that users of illegal drugs tend to be more receptive to pharmaceutical advertisements than non-users (Kanter, 1970) further suggests that advertising may serve to reduce internal conflicts by implying to users that everyone turns on in his own way.
Although the Commission strongly urges against Governmental intervention, we do recommend that the media, on their own initiative, reexamine the impact of informational messages on • youthful interest in psychoactive drugs. They should look not only at advertising but also at anti-drug public service announcements, at program content, and at news coverage of "drug stories."
The Commission also recommends that in conjunction with their self-appraisal, the media sponsor and support long-term, longitudinal research into effects of various communications on behavior. Guided by the findings of these studies, the industry should take whatever corrective action is appropriate.
With respect to proprietary, mood-altering drugs, the Commission recommends elimination from their advertising of suggestions that the substance can result in pleasurable mood alteration or deal with malaise caused by stress or anxiety. The "feel better fast" pitch may encourage patterns of repeated use which, though begun with fairly harmless substances, may condition in the user a chronic drug-taking response to his or her problems.
At the same time, the Commission cautions against a reaction which denies the necessity for self-medication. Dr. Charles C. Edwards, Commissioner of Food and Drug Administration, has stated in reference to home medications, "The consumer demands it; the law provides for it ; and it is, in fact, a vital part of our nation's health-care system" (Edwards, 1972). The Commission agrees: without home medications, this nation's health-care delivery system could not survive.
Of course, safe and effective use of home-medications requires that proprietary drug advertising not mislead the consumer. Self-regulation of advertising, accordingly, benefits the industry as well as the public. The Commission recommends that proprietary drug producers develop clearly defined advertising standards, which reflect correct use of home-medications, and establish a procedure for insuring industry-wide compliance with these standards. At a minimum, the procedure should contain the following elements:
(1) an independent mechanism to review any advertisement for compliance with the advertising standards,
(2) opportunity for any member of the public to submit an advertisement for review and,
(3) specific sanctions to be imposed on advertisers who do not abide by decisions of the review board.
In theory, the Advertising Code of the National Association of Broadcasters, if applied consistently and firmly would eliminate most undesirable proprietary drug advertising practices. In practice, though, the Code has not achieved this result.64

THE RELIGIOUS COMMUNITY

Religious participation in the social response to drug use has followed an interesting path. Following the Civil War, religious forces, for the most. part Protestant, launched a major crusade for legislation prohibiting the manufacture, sale, distribution and use of alcoholic beverages. The Anti-Saloon League, formed in the late 19th Century, was the political organization through which many churchmen worked for national prohibition. In 1871, churchwomen organized the Women's Christian 'Temperance Union, a militant temperance group still in existence.
In the push for prohibition, these same churchmen and women tended to identify The Temperance Movement and its strong abstinence policy with Christianity itself. In this moral context, alcohol was regarded as evil and drinking as a sin. Such moralism led many churchmen to reject both the drinking and the drinker.
Against this background it is necessary to recall that not all religious communities aligned themselves with these attitudes and policies. The Roman Catholic and Jewish Communities never officially advocated Prohibition, nor was the sentiment universal among Protestant Churches. Many raised voices of protest and restraint, and some actively sought to meet the needs of alcoholics and their families. During the saine period, however, all religious bodies virtually ignored the problems of other drug use and dependence, except to support anti-narcotics legislation with the same fervor characterizing their demands for alcohol prohibition.
Following repeal in 1933, many Protestant Church bodies were immobilized by the "wet-dry controversy," a running debate between religious groups which considered drinking morally permissible and those which did not. The net effect of this polarization and exaggeration was that "dry" churches lost much of their constituency, as a new interest in alcohol problems developed in the religious community. Churchmen began evolving an alternative strategy to abstinence and prohibition, involving direct ministry by the church to the problems of the alcoholic.
In 1958, the National Council of Churches published its pronouncement "The Churches and Alcohol." This statement called for a fourfold approach to alcohol problems: a ministry to the victims of alcoholism and their families; alcohol education in the churches; alcohol education for the public ; and careful legal control of alcoholic beverages. The body agreed to disagree on the question of drinking.
Mainline Protestant denominations were changing as well. The United Methodist Church, one of the principal leaders in the drive for Prohibition and a committed "dry" church, voted in 1968 to remove all internal restrictions on the use of alcohol by members, officials and clergy. (It still advises abstinence on a voluntary basis.) Only churches in the strongly conservative, evangelical tradition continue to require abstinence as a condition of membership. Even many of these churches now sponsor missions for alcoholics.
This emerging consensus within the religious community regarding alcohol policy may have been the catalyst for reconsideration of the response to drug use in general. Following public concern for drug use in the late 1960's, individual clergy and churches at the local level became increasingly involved in drug programs. At the national level, though, activity by the religious community has been largely educational in nature and largely directed at young people.
To the present time, the national religious community has failed to address its most important task ; the elaboration of values upon which individual choice could rest. The decline of moral certitude regarding consumption has left, a void. The moral issues surrounding drug use for self-defined purposes have not yet been closely examined by the institutions which should be most concerned with them.
In the Commission's view, the religious community has a major responsibility to confront the, profound philosophical, moral and spiritual questions raised by the drug problem. On the one hand, it must deal with the many value-laden issues of social policy; on the other, with the fundamental questions of private moral choice which lie outside the realm of social policy.
Religious bodies must enter public discussion of such policy issues as the role of the criminal sanction in the area of drug consumption, the ethical questions surrounding methadone and other forms of chemical therapy, and the objectives of drug education programs. As with other social institutions, we would expect religious groups to differ widely on these issues. Still we believe that open, rational debate of the moral and ethical implications of particular policy issues will always enhance the decision-making process.
A more basic and specific role for the religious community, however, lies in dealing directly with the issues of private moral choice. The Commission noted in our first Report that "What we need, below and above all our deliberations, is the growth and development of an ethical system." In the collective task of determining the ethics of drug use, the religious community can make its most significant contribution. The Commission has identified four important issues in the realm of private moral choice on which the religious community needs to focus its expertise and insight.
First are the moral issues surrounding risk-taking behavior of all kinds. Clearly, neither society nor religious doctrine considers all risk-taking behavior morally wrong. Underground mining and the construction of skyscrapers are high risk occupations, but not immoral ones; accepted recreations, like skiing and sky-diving also involve risks. On most behavior, the risk-benefit ratio is weighed and a judgment made about whether it is "worth the risk."
Drug use, too, is a form of risk-taking behavior, the degree of risk depending on the drug, dosage, circumstances and individual characteristics. On what basis is the individual to decide whether the risk is an acceptable one and whether the benefits he perceives are appropriate? Is there a line on the continuum where it is appropriate for other institutions to intervene to stop the behavior, or should the individual be completely free to choose? To answer these questions requires coming to terms with fundamental questions of the purpose and meaning of life. In this sphere of discourse, the moral counsel of the religious community is indispensable.
Another important issue is the role of drug use in the pursuit of personal happiness. Drugs are used for recreational as well as self-medication purposes. With the exception of alcohol and tobacco, society has formally condemned the use of drugs for personal pleasure ; yet many individuals take other drugs recreationally without apparent harm to themselves or others. On what moral grounds, then, do we condemn this behavior?
Public discussion has only recently begun on the question of guidelines for the appropriate and inappropriate use of alcohol. The scope of this discussion should be expanded to include other drugs as well. The participation of the religious community will aid in resolving the moral ambiguities involved.
There are also moral questions surrounding the exploration of consciousness. `Western culture has stressed rational analysis and synthesis as the most valid form of experience and denigrated other forms of consciousness, such as the drug-induced "high." Yet the heritage of all the world's major religions is rich with the experiences of prophets, seers, saints and mystics. The religious community thus has a strong interest, as well as the moral basis, for exploring altered states of consciousness and evaluating the perceptions and insights which result.
The religious community must address the nature of the inner-directed spiritual experience. Users of hallucinogenic drugs have reported religious or mystical experiences. These experiences cannot be dismissed simply by dogmatic refusal to examine the evidence; instead, both theologians and scientists must look at them closely. The mystical tradition of the religious community should offer valuable insight and guidance on the nature and value of such experiences.
These four issues in the realm of private moral choice clearly indicate that the religious community must reassert its counseling role regarding behavior with moral overtones. Equally important is religion's role in promoting non-drug alternatives in coping behavior. Non-medical drug use in any form is not essential to living. The religious community's understanding of self and community, of freedom and responsibility, of love and hope offer positive guidance to individuals in their quest for values and for a meaningful life style which enables them to cope without use of drugs.
Finally, the Commission notes that the institutional network of religious bodies can serve as part of the preventive early warning system which the Commission is stressing. Local congregations have the most direct access to families of any of our social institutions. With appropriate training, clergy and lay religious leaders can work with parents and children with drug-use problems. Some congregations are doing this now, and the work should be greatly expanded.

THE FAMILY

The private institution with the greatest potential for positive impact on youthful drug use is the family. Yet, society's preference for formal intervention has long minimized the role of the family as a force. We believe that any future policies regarding drug use and drug dependence must include the family as an integral part of the response.
In order to equip the family for its future role, society must understand the family's current impact and find ways to maintain and, in many cases, redirect that impact.

In a variety of ways, the drug problem is grounded in family experience, even the experience of stable and intact middle class families. Attitudes which lead to drug-using behavior may begin with values which parents intend to teach their children : an interest in new experience, a desire for pleasant and relaxing forms of leisure, a certain degree of independence in ideas and actions. In addition to these healthy attitudes, however, adults also expose children to inconsistent and arbitrary rules about the use of psychoactive substances. Too often, parents and other adults disapprove use of tobacco, alcohol and pills only in words. They assume either that children do not experience their own stress, excitement, and depression or that childhood experience of these feelings does not merit pharmacological intervention. Finally, adult society bombards children with incomplete or inadequate information about which drugs are safe or dangerous, helpful or harmful, good or bad.
The family will continue to shape both attitudes and behavior about drug use. The issue, then, is how. Family responses to drug use need redirection toward honesty, consistency, and sensitivity. Just as the bearing and raising of children must not be left to chance, neither should parental influence concerning drug use.
Among the guiding principles of parental conduct, the first should be recognition that their patterns of drug use (or non-use) serve as a model for their children. Repeated studies have indicated a strong correlation between the degree of responsibility exercised by the parents in using drugs and that exercised by the children (Louria, 1971).
The second principle is that curiosity and the search for experience is a normal aspect of the adolescent growth process. Experimentation with drugs is properly disapproved, but parents should understand that youthful curiosity is generally a desirable motivation, which they should fashion and encourage.
Third, parents must concentrate on discouraging initial drug use; too often, parental concern is generated only after use has begun. Moreover, the family's preventive functions is not limited to forestalling drug use. It should also include attempts to deal with the entire spectrum of adolescent needs.
Finally, parents must assume primary responsibility for the detection of and response to drug use by their child. Too often parents have abdicated their responsibility to institutions, such as schools. These institutions, in turn, tend to act in loco parentis and try to remedy the child's difficulties, including drug use and drug-related behavior, without involving the family. When this happens, any problems in family structure are only aggravated. Parents must serve as the treatment agency of first resort, and if they decide that referral to professional services is necessary, they must participate actively with the program or person which provides these services.
In order to provide a basis for open discussions and interchanges between parent and child regarding use of psychoactive substances, á climate of honesty, mutual respect and love must be fostered within the family. Since rational discussion about drugs is impossible without informed attitudes and perceptions, parents must learn to discuss drugs, their effects, and drug-related behavior without hysteric emotion. Parents should share information with their children, in order to provide a common factual basis.
Although such discussions may not always lead to a resolution satisfactory to both parent and child, they should continue nonetheless in order to avoid a breakdown in communications. At the minimum, the discussion can lead to mutual self-respect and prevent the kinds of misunderstanding which only further cloud the central issues.

°; From written questionnaires sent to researchers in a study conducted for the Committee for Effective Drug Abuse Legislation (Unpublished, 1972) .

'See Appendix, Marihuana: A signal of Misunderstanding (First Report of the National Commission on Marihuana and Drug Abuse), Volume I, pp.,589-599.

°' Selected to provide a range of geographical locations, size, and types of industry. The sample, however, was not intended to represent all American businesses or management.

" On February 22, 1973, both the Proprietary Association and Television Code Review Board of the National Association of Broadcasters adopted new sets of rules regulating the advertising on television of all non-prescription medications. Both sets of rules become effective September 1, 1973. Implementation procedures have not been developed as of this writing.