Drug Abuse

Chapter One - Defining the Issues

The need to solve the "drug problem" has been a recurrent theme of political and social commentary in the United States for most of the past decade. The apparent increase in drug use - itself defined as the problem - has precipitated a serious inquiry into its causes, a massive investment of social efforts to contain it, and a mobilization of medical and para-medical resources to treat its victims.

The Commission does not deny that a "drug problem" exists. We share the public's concern that an apparent rise in crime and other anti-social behavior may be related in part to drug-using or drug-seeking behavior. Likewise, we share the public alarm over the attraction to drug use by large portions of this nation's youth, particularly when such use is indiscriminate and apparently oblivious to its risks. The lives and futures of our young people can only be hurt by such behavior. We share, too, the frustration which comes from knowing that drug use spreads by example, and that a continuing growth in the using population augurs no better for tomorrow.

While recognizing that a drug problem exists, we cannot allow our distress to interfere with the performance of our mandate. We were appointed not to fan public anxiety, but to convert it into meaningful activity with constructive proposals. This can be done only 'by refusing to accept at face value many of the common assumptions about drugs and the drug problem. We must examine the reasons behind the fears, conducting the inquiry without passion and with candor. Confident social action comes from an understanding of the problem and from an impartial assessment of the impact of alternative strategies. We have sought to define the problem and to provide at least an initial assessment of the possible responses to it.

The Commission has carefully surveyed the social response to the contemporary drug problem, and has been struck by a persisting uneasiness which seems to color the entire effort. On the street and in the councils of government, increasing numbers of drug abuse "experts" wonder whether their commitment and efforts have had any actual imp-act on the problem. Many of them assume optimistic positions in public, while suspecting privately that no solution will be found. The Commission understands the reasons for this malaise. We are convinced that public policy, as presently designed, is premised on incorrect assumptions, is aimed at the wrong targets, and is too often unresponsive to human needs and aspirations.

In this Chapter, the Commission seeks to bring the issue of drug use into focus. First, we will explore the way our society thinks about drugs by analyzing both the vocabulary of the drug problem and the historical roots of contemporary attitudes. After considering the way in which the drug problem is presently defined, we will redefine it, first by broadening the scope to cover the entire range of drug use in America and then by narrowing it to that drug-using behavior which properly should arouse social concern.

After the problem has been carefully defined, the policy-making task begins. In this sense, this Chapter, and the two which follow, are designed primarily to create a climate for the formulation of new policy concepts. Chapter Four details the policy-making process and sets forth specific recommendations for immediate implementation by governmental and private institutions. Chapter Five will then provide a broad perspective on the development of a long-term social response to drug-using behavior.

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DEFINITIONAL CONFUSION: WHAT IS DRUG ABUSE?

The use of psychoactive drugs is commonplace in American life. Distribution of these drugs is an integral part of the social and economic order. In 1970, 214 million prescriptions for psychoactive drugs were issued, representing annual retail sales of approximately $1 billion (Balter and Levine, 1971). The alcohol industry produced over one billion gallons of spirits, wine and beer for which 100 million consumers paid about $24 billion.

What is the pertinence of this information for a Commission mandated to report to the American people on drug "abuse?" Can such familiar American behavior include drug abuse, even though that term is generally thought to refer only to the consumption of psychoactive substances obtained illicitly from a market with an estimated annual volume of $2 billion?

The Commission concluded early in its deliberations that the focus of inquiry should not be determined by general impressions or facile labels. Instead, formulation of a coherent social policy requires a consideration of the entire range of psychoactive drug consumption, and a determination as to whether and under what circumstances drug-using behavior becomes a matter of social concern. For example, does youthful experimentation with alcohol involve different social policy considerations than experimentation with marihuana? Do alcoholism and heroin dependence present similar or dissimilar social policy questions? Do the social policy implications of repeated use of barbiturates or minor tranquilizers depend solely on whether a physician has prescribed the drug or on the motivations for such use? In order to deal coherently with such questions, it is necessary to examine how this society thinks about drugs and their use.

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Drugs-The All-Purpose Concept

The meaning of the word drug often varies with the context in which it is used. From a strictly scientific point of view, a drug is any substance other than food which by its chemical nature affects the structure or function of the living organism. From this perspective, the term includes some agricultural and industrial chemicals. The physician might define a drug as any substance used as a medicine in the treatment of physical or mental disease; when treatment of illness is the referent, the lay public may use the word in the same sense. However, when used in the context of drug "abuse" or the drug "problem," the meaning of "drug" becomes social rather than scientific.

In its social sense, drug is not a neutral term. This point is best illustrated by the fact that "drug problem" is frequently used not as a descriptive phrase, but a substitute for the word drug. In our visits to communities throughout this country and other nations, we have noted that local leaders often feel compelled to report not simply that drugs are available or that they are used, but that there is a "drug problem."

This value component of the word drug is reflected in the selective application of this term by the general public. Table T-1, drawn from a Commission-sponsored National Survey (Abelson et al, 1973) * illustrates that the public tends uniformly to regard heroin as a drug, as well as other substances associated with the drug problem, such as marihuana, cocaine, the amphetamines and the barbiturates. Some psychoactive substances, such as alcohol and tobacco, are generally not regarded as drugs at all. In neither public law nor public discussion is alcohol regarded as a drug. It may be called a beverage, -a food, a social lubricant or a relaxant, but rarely is it called a drug.

*The survey, conducted by Response Analysis, involved face-to-face interviews with a random sample of 2,411 adults and 880 young persons age 12-17 in the contiguous -states. Findings from the Survey are reported and discussed throughout this Report. The reader should note that surveys which employ probability samples may be generalized to the population as a whole within known limits. it should also be noted that the Survey data presented here involve unweighted bases with percentages calculated on weighted bases.

Depending on the context in which the term "drug" is used, statements about what a given drug does are liable to differ. If the therapeutic meaning is employed, for example, the characterization is likely to involve the reasons for using the drug, the dose, the frequency of use and an evaluation of its effects in terms of medical benefits. It might be asked whether the drug made an individual feel better, cured his illness, or made him less anxious or depressed. If the social meaning is being used, however, the analysis generally focuses on toxicity, lethality, dependence liability, possible genetic defects, psychosis and effects of high doses; that is, on drug effects in terms of their risks.

The imprecision of the term "drug" has had serious social consequences. Because alcohol is excluded, the public is conditioned to regard a martini as something fundamentally different from a marihuana cigarette, a barbiturate capsule or a bag of heroin. Similarly, because the referents of the word "drug" differ so widely in the therapeutic and social contexts, the public is conditioned to believe that "street" drugs act according to entirely different principles than "medical" drugs. The result is that the risks of the former are exaggerated and the risks of the latter are overlooked.

This confusion must be dispelled. Alcohol is a drug. All drugs act according to the same general principles. Their effects vary with dose. For each drug there is an effective dose (in terms of the desired effect), a toxic dose and a lethal dose. All drugs have multiple effects. The lower the dose, the more important non-drug factors become in determining drug effect. At high dose levels, and for some individuals at much lower dose levels, all drugs may be dangerous. The individual and social consequences of drug use escalate with frequency and duration of use. American drug policy will never be coherent until it is founded on uniform principles such as these, which apply to all drugs.

'Unless otherwise noted, the word drug is Intended to encompass only "psychoactive drugs," or those which have the capacity to influence behavior by altering feeling, mood, perception or other mental states.

Drug Abuse: Synonym for Social Disapproval

Drug abuse is another way of saying drug problem. Now immortalized in the titles of federal and state governmental agencies (and we might add, in our own), this term has the virtue of rallying all parties to a common cause: no one could possibly be for abuse of drugs any more than they could be for abuse of minorities, power or children. By the same token, the term also obscures the fact that "abuse" is undefined where drugs are concerned. Neither the public, its policy makers nor the expert community share a common understanding of its meaning or of the nature of the phenomenon to which it refers.

The Commission has noted over the last two years that the public and press often employ drug abuse interchangeably with drug use. Indeed, m . any "drug abuse experts," including government officials, do so as well.

The Commission was curious about whether the public had any more precise conception of the meaning of drug abuse than the experts. In our second National Survey, public attitudes on this issue were probed. The public was requested to give a free-response explanation of what drug abuse meant. (See Table I-2.)

In this multiple-response question, the public was divided between perceptions related to the purpose or motivation of drug taking (the first three responses) on the one hand, and to the consequences of use on the other (the remaining responses). Roughly 30% of both youth and adult populations associate drug abuse with the use of drugs for other than medical purposes, including any use of those substances which have been prohibited because they have no medical uses. In contrast, large numbers of both adults and youth relate the term to the consequences of drug taking. Excessive doses (27% and 16%), dependence (17% and 15%) and danger to health (11% and lWc) are the most common examples. Also of interest were those respondents who indicated that they didn't know what drug abuse meant (13% and 20%).

In another part of the Survey, the respondents were asked whether they regarded ten specific drug-using behaviors as drug abuse. These data illustrate that drug abuse is an entirely subjective concept. It is any drug use the respondent frowns upon. Most respondents disapprove of the use of medically-distributed pills for other than medical purposes (those sanctioned by a physician), any use of heroin, and any use which suggests that the user is dependent or seeking pleasure.

Significantly fewer respondents seem to disapprove of daily use of alcohol, weekly use of marihuana and experimentation with legitimate pills not obtained through a physician. (See Table 1-3.)

As the National Survey data demonstrate, drug abuse may refer to any type of drug or chemical without regard to its pharmacologic actions. It is an eclectic concept having only one uniform connotation: societal disapproval.

The Commission believes that the term drug abuse must be deleted from official pronouncements and public policy dialogue. The term has no functional utility and has become no more than an arbitrary codeword for that drug use which is presently considered wrong. Continued use of this term , with its emotional overtones, will serve only to perpetuate confused public attitudes about drug-using behavior.

Drug abuse, or any similar term, creates an impression that all drug-using behavior falls in one of two clear-cut spheres: drug use which is good, safe, beneficial and without social consequence; and drug "abuse" which is bad, harmful, without benefit and carrying high social cost. From either a descriptive or an evaluative standpoint, the matter is much too complex to be handled in such a polarized fashion. The Commission urges that the public and its policy makers avoid such labels and focus instead on the relative risks and social consequences of various patterns of drug-taking behavior.

The Roots of a "Problem"

We have focused our initial attention on vocabulary for an important reason. The linguistic symbols which our society attaches to certain drugs and drug-related conduct illustrate the extent to which present attitudes and social responses are rooted in the past. "Drug abuse" is only the most recent in a long line of such symbols which this society has applied to disapproved drug-taking behavior or to disapproved substances. In fact, the history of drug vocabulary is also a history of the changing perception of the drug "problem" in the United States.

Current social policy is largely an accumulation of ad hoc policy responses to the use of particular substances. "Street" use of a previously unknown substance at a time of social tension tends to generate a set of untested assumptions about the drug, often including a presumed consequence of undesirable behavior, and to result in a restrictive legal policy, all of which become imbedded in public attitude.

Drug policy as we know it today is a creature of the 20th Century. Until the last third of the 19th Century, America's total legal policy regarding drugs was limited to regulation of alcohol distribution (and the periodic regional attempts to prohibit its use altogether), localized restrictions on tobacco smoking, and the laws of the various states regulating pharmacies and restricting the distribution of "poisons." Nineteenth century statutory vocabulary was simple and direct: arsenic, tobacco, alcohol, morphine and other opium alkaloids were all "poisons." Until the Civil War, distribution of opium and morphine, which were widely used as therapeutic agents, was substantially unregulated. Gradually, however, official reliance was placed on the health professions to police distribution of these drugs; Pennsylvania enacted what may have been the first prescription law in 1860, and most other states followed suit over the next three decades. Medical lexicons classified opium and morphine as "narcotics," along with most other psychoactive substances then in use, including alcohol; however, that term was not employed in most of these laws or in common parlance.

As early as the 18th Century, the medical profession was aware that the oral use of opium could result in the development of an "appetite" or "habit," a phenomenon which was generally classed in the same category as the "alcohol habit." This awareness was not of sufficient consequence to suggest the need for caution when morphine was discovered in 1803 and when the hypodermic syringe was introduced in the middle of the century. As the hypodermic use of morphine became common in the United States, the syringes were left with patients for their own use to remedy practically every painful condition.

The drug was used indiscriminately during the Civil War for the wholesale relief of pain and, most significantly, to treat common gastrointestinal ailments. After the War, morphine was widely used in medical practice and was easily available outside the medical system in proprietary medicines. Within a few years, "morphinomania" (or the "army" disease) became a recognizable medical entity. Nonetheless, use of the drug was only minimally restricted either from outside the medical profession or within it, as Terry and Pellens noted in their classic work:

Meanwhile the ease with which pain could be relieved through the hypodermic administration of the drug, the time it saved the physician in his busy rounds, the contentment it brought the patient, and above all, the all too common inclination to relieve symptoms rather than cause, contributed to increase the practice. Consequently throughout the period of the earlier warnings of its dangers, the employment of this mode of administration was increasing by leaps and bounds wherever medicine was practiced. (Terry and Pellens, 1928)

This phenomenon of medically-based opiate use was largely invisible and was not a matter of major concern outside the medical profession for several decades.

Meanwhile, a public response was triggered by use of these same drugs and cocaine in another social context. Beginning with increased Chinese immigration after the Civil War, the practice of smoking opium took root on the West Coast and spread rapidly across the country to most urban areas. Although the practice was confined mainly to the Chinese, it also appeared to attract "sporty characters" and the underworld figures in the cities.

In 1875, San Francisco enacted an ordinance prohibiting the smoking or possession of opium, the possession of opium pipes and the maintenance of "opium dens." As the practice spread, it generated a succession of similar state laws and local, ordinances. Despite a growing problem of opiate dependence arising from unrestrained distribution of these drugs within the medical system in the United States, it was the "street" use of the opiates and cocaine which accelerated professional and public interest in their habit-forming properties.

By the turn of the century, the nation had become aware of a large opiate-dependent population in its midst. Although contemporary estimates of its size varied as widely as current figures do, most researchers have concluded that the total never exceeded a quarter of a million, divided evenly between "medical" and "street" dependence. As a result of increased awareness, the medical profession and state legislatures intensified their efforts to control availability of these substances, primarily by tightening the restrictions on medical distribution and prohibiting non-medical distribution. In 1906, the Congress passed the Pure Food and Drug Act, the first major federal drug legislation, which required labelling of all preparations containing "habit-forming" drugs, and proprietaries containing significant quantities of opiates soon disappeared.

By 1900, then, policy makers and the medical profession were attuned to the dangers of chronic drug use, and some commentators have suggested that the availability of more accurate information within the profession and improved methods of medical education would have retarded the medically-based opiate-dependence problem had it not been for the introduction of heroin in 1898 (Terry and Pellens, 1928). This new cough suppressant was promoted on the theory that it possessed many of the virtues and few of the dangers of morphine; some even suggested that it would be useful in the treatment of morphinism itself. From the time of its introduction, however, there were conflicting claims regarding its capacity for producing dependence. Regardless of these claims, the drug was available for the next decade in proprietary medicines and throughout medical practice.

By 1910, the medical profession had become seriously concerned about the habit-forming characteristics of heroin. The publicity attending its pleas for legislative controls on the availability of this drug, together with a crusade being waged by law enforcement officials against the street use of opiates and cocaine, aroused public anxiety about a "narcotics problem" of major proportions. Although almost every state had regulatory laws of some kind, most observers contended that the states could not control the problem. Federal legislation was also said to be necessary to implement international treaties. In addition, the movement for national alcohol prohibition began gathering steam in 1913, sensitizing the public to the possibility of national drug prohibitions. All these factors culminated in passage of the Harrison Narcotic Act in 1914 (.Musto, 1973).

The Harrison Act crystallized a national policy of curtailing the availability of "habit-forming" substances. The previous failure to appreciate the habit-forming properties of new substances had now resulted in professional and legislative preoccupation with this issue. Whereas the term narcotics formerly referred to those substances which produced stupefication and sleep ("narcosis"), including alcohol, the term now assumed a new meaning, one defined by the public policy bearing its name. The term was now associated with any unfamiliar drug which appeared on the streets among those populations which were associated with the opiates and cocaine. The acute effects of the various specific drugs became blurred. Because physicians and policy makers had now become exceedingly cautious about the dependence issue, any new drug was carefully scrutinized for habit-forming properties; if the drug was used on the streets it was often presumed "habit forming" and therefore classified as a "narcotic."

Within the next three decades, peyote and marihuana were inserted in the "narcotics" laws of many states; chloral hydrate, which had been covered by earlier drug laws, was also included in the definition of "narcotics" in the new legislation. It should be noted that legal classification of a drug as a "narcotic" tended to malign its therapeutic utility. For example, heroin, and later marihuana, were purged from the pharrnacopoeia altogether. In sum, the word "narcotics" had been purged of its scientific meaning and became, instead, a symbol of socially disapproved drugs.

Other substances were introduced into the practice of medicine, notably the barbiturates and amphetamines, but they were regulated under general pharmacy laws rather than under the "narcotics" laws. Although amphetamines were introduced in 1929 and the short-acting barbiturates appeared a few years later, they did not enter the illicit marketplace on a massive scale in the United States until the 1960's and consequently were not associated with the narcotics until then.

During the last decade, succeeding waves of hallucinogens, amphetamines and barbiturates escaped from the laboratories, pharmacies and medicine chests and found they way into the streets. Together with marihuana, which moved from one socio-economic "street" to another, use of these drugs defined a new phenomenon and became associated with a new kind of drug user. To a substantial degree, the narcotics policy had from the beginning been identified with underprivileged minorities, criminals and social outsiders in general, although a common feature of each periodic drug scare, including cocaine at the turn of the century, heroin in the 1920's, marihuana in the 1930's and heroin again in the 1950's, was the fear that drug use would spread to youth. However, the drug problem of the 1960's was clearly identified with the children of the middle and upper classes. Drug use was now associated with unfamiliar life styles, youthful defiance of the established order, the emergence of a visible street culture, campus unrest, communal living, protest politics and even political radicalism.

The drug taking of this youth population coincided with pervasive social anxieties regarding social disorder in general and youthful behavior specifically. To many, youthful drug use, offered a convenient explanation for these problems, and, as the Commission noted in its first Report, marihuana in particular came to symbolize the entire spectrum of social concern. Existing legislative controls and vocabulary were closely tied to the old stereotypes, and society responded to this new drug-using behavior through separate legislative action (the Drug Abuse Control Amendments of 1965) and a new linguistic symbol. "Dangerous drugs" emerged as the statutory label for the nonnarcotic drugs, such as hallucinogens, amphetamines and barbiturates, whose non-medical use was socially disapproved.

The single-mindedness of American drug policy is illustrated clearly by the reorganization of the federal drug bureaucracy which took place in 1968. For technical reasons stemming from the revenue structure of the Harrison Act, narcotics enforcement had always been lodged in the Treasury Department. When the, "dangerous drugs" were brought under regulatory control in 1965, enforcement responsibility was assigned to a new bureau in the Department of Health, Education, and Welfare. Then in 1968, the responsibilities of the two agencies were merged in a new agency established in the Department of Justice: the Bureau of Narcotics and Dangerous Drugs. Public policy had the appearance of coherence once again.

But this was not enough. Marihuana use continued to increase throughout the decade, and the public was caught up in a highly emotional debate. For the first time since the inception of the American "narcotics" policy, public opinion focused on some of the fundamental assumptions. Not surprisingly, debate on the marihuana issue was often couched in terms of the statutory vocabulary which has come to symbolize drug policy. For example, the scientifically indefensible classification of marihuana as a "narcotic" immediately provoked an erosion of the symbolic coherence which had previously characterized drug policy. Similarly, the inevitable comparison between alcohol and marihuana called into question the substantive separation between narcotics and dangerous drug policies on the one hand and alcohol policy on the other.2 After all, alcohol can legitimately be classified as a "narcotic" in a very specific sense of that term, and it is surely a "dangerous drug" as well.

2 During most of the period of national alcohol prohibition, the Bureau of Prohibition was responsible for enforcement of the Harrison Act as well as the Volstead Act; but passage of these two laws had parallel rather than shared histories, a point clearly demonstrated by subsequent events.

Until the close of the 1960's, official defenses of marihuana policy continued to be premised on the implications of the statutory vocabulary. Although the narcotic ideology was quickly abandoned, many official pronouncements continued to link marihuana with the opiates because of their association in the law and to insist that marihuana was a "dangerous drug" even if it was not a "narcotic." An historical understanding apprises us that these classifications are reflections of, rather than reasons for social disapproval.

It became clear by the end of the decade that "narcotics" and "dangerous drugs" were no longer adequate symbols of social policy; consequently "drug abuse" was adopted as a replacement symbol. However, the need to distinguish marihuana use from other forms of "drug abuse" resulted in yet another distinction: marihuana was classified as a "soft" drug as opposed to the "hard" drugs, suggesting the same kind of distinction drawn between "hard liquor" and other alcoholic beverages. But, as has been the case with all drug vocabulary, this distinction serves a social rather than a scientific purpose. This terminology generally indicates an attempt to distinguish marihuana from heroin and cocaine, the stereotypical "hard" drugs. However, there is no consensus whatsoever as to which other substances, if any, are considered to be "hard." If hard drugs is a narrow category, referring only to the opiates and cocaine, it is simply another way of saying "narcotics;" on the other hand, if it is taken to mean everything other than marihuana, it is simply an expedient way of disassociating marihuana from other disapproved drugs.

Like "drug abuse," the hard-soft terminology reflects a nascent effort to reestablish a sphere of "bad" drug use. Within the official community as well as the general public, attempts are being made to grade drugs according to their potential hazards, particularly their capacity for inducing physical dependence. To the extent that this is true, the new linguistic symbols suggest that public concern has in some ways returned full circle to where it began almost a century ago.

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THE SOCIAL RESPONSE: FALSE PREMISES AND THE PERPETUATION OF A PROBLEM

As this brief historical summary illustrates, American drug policy is almost seven decades old, and not once during this period have the underlying assumptions been systematically evaluated and a broad, coherent foundation for policy making established. As a result, each new occurrence in drug development and each new use pattern have been viewed as unfamiliar, with the unfamiliarity breeding a sense of crisis, and the crisis precipitating ad hoe policy responses.

The Commission feels strongly that the present institutional response, despite sincere efforts to move it in the right direction, continues to be rooted in the mistakes of the past, and, indirectly, tends to perpetuate the "problem." Accordingly, it is useful to scrutinize the goals toward which the policy is directed and the premises which support it, as well as to describe briefly some of the present governmental responses which are guided by these assumptions. Finally, as a prelude to the remainder of the Report, the concluding sections of this Chapter will attempt to "wipe the slate clean" and to sketch a general frame-work for defining the problem and formulating a coherent social policy.

The Assumptions and Premises of Present Policy

Elimination of Non-Medical Drug Use

American drug policy has been predicated on one fundamental or the societal objective is to eliminate "non-medical" drug use. Inquiry has rarely been addressed to whether this goal is desirable or possible. Failure to address such questions is abetted by the exclusion of certain drugs and certain types of drug taking from the realm of social distress. For example, the non-medical use of alcohol and tobacco would be inconsistent with the declared goal; thus, statutory vocabulary and social folklore have established the fiction that they are not drugs at all. Although use of these substances may arouse concern, they are not viewed in the wider context of drug use.

Another area excluded from public discussion is drug use sanctioned by medical judgment. While most medically-approved consumption of psychoactive drugs is substantially different from the situation where the individual chooses to use the drug himself, this is not always true. The absence of the intervening judgment of a third party does not mean that the individual's motivation is "non-medical," or hedonistic. Nor does the intervention of medical judgment assure that the drug will be used for medically-intended purposes.3

3 The third party judgment may intervene directly, as is the case with prescription drugs, or indirectly, as is the case with over-the-counter preparations previously approved for this purpose by the Food and Drug Administration.

Drug policy makers cannot truthfully assert that this society aims to eliminate non-medical drug use. No semantic fiction will alter the fundamental composition of alcohol and tobacco. Further, even if the objective is amended to exclude these drugs, human history discounts the notion that drug-using behavior can be so tightly confined as a self-medication in pharmacy, where their prescription drugs with them, the proliferation of over-the-counter preparations, the advertising of mood-altering drugs, and the popularity of minor tranquilizers are all manifestations of an important contemporary trend.

The medical/non-medical distinction has become increasingly blurred as emotional ailments increase. Many individuals tend today to assess their own needs and define the purposes for which they use a drug. For this reason, generalized societal proclamations regarding the need to eliminate non-medical drug use raise an important question that must be honestly answered: how does the daily use of a prescribed barbiturate to bring a person "down" from the day differ from the similar use of a self-prescribed minor tranquilizer or, for that matter, a martini?

Deferring for the moment our own view as to what society's objective in this area ought to be, we do know that it is not as clear cut as official pronouncements imply. In determining the appropriate objective, a task that we will undertake in Chapter Four, policy makers must recognize the scope and complexity of drug-using behavior and develop rational distinctions between that which should be disapproved and that which should be tolerated, or even approved. Within the area of disapproval, policy makers should not consider all disapproved drug use to be of equal importance; priorities must be assigned on the basis of actual and potential social consequence, and not just on the basis of numbers of users.

Risk-Taking and Health

Often cited in support of societal disapproval of non-medical drug use is the proposition that individuals should not risk their health by using drugs. Without regard to the philosophical propriety of this premise as a guide for social policy, this view appears to be somewhat at odds with the facts about drug use and with prevailing social attitudes toward risk-taking in other areas.

Much emphasis has been placed on whether or not a drug is a dangerous drug; and analogies have been drawn between "street" drugs and such substances as cyclamates. These examples illustrate how closely public discussion of drug abuse has become tied to matters of individual health. In supporting present social policy, spokesmen often list those drug effects which are potentially harmful to individual health rather than focusing on the social consequences of drug-using behavior.

The Commission believes that persons who take this approach have misconstrued the nature of the drug issue. The assumption that all psychoactive drug use is a high-risk behavior presumes a progression from irregular use of low doses to continuous use of high doses, thereby ignoring pharmacological variations among drugs and the importance of frequency of use, method of administration, dose, and non-drug factors as determinants of risk. In fact, injury to health is associated primarily with chronic heavy use and at times with the acute effects of high doses.

Further, there is no correlation whatsoever between the capacity of psychoactive drugs to induce behavioral disorders and their capacity to induce organic or somatic toxicity or pathology. Of the drugs which are most commonly associated with dependence or drug-induced behavior, alcohol produces the most clearly established and reproducible brain pathology. Cocaine, amphetamines and other stimulants, heroin and morphine-like drugs, and cannabis do not appear to have this effect. On the other hand, very heavy use of phenacitin, which has no significant behavioral impact at all, may produce renal damage, and heavy tobacco smoking is associated with greatly increased risk of lung cancer. If the standard for social policy were potential injury to individual health, barbiturates, alcohol, and tobacco would present the clearest cases for prohibition. Yet, the latter two are available for self-defined purposes, and the former is widely used in the practice of medicine.

Nonetheless, the approach often applied to "drugs of abuse" is the same as that applied to non-psychoactive substances: risks to individual health will be tolerated only if the medical needs for the substance justify the risks. But individuals would not choose to use psychoactive drugs if they did not perceive some advantage to themselves. So the fundamental question arises: Who is to weigh the perceived advantages of drug use against the risk, the individual or the society?

To deal with this question, we must examine the pattern of social response to risk-taking behavior in general. For example, we urge our youth -to be curious and to explore. Until recent years, Americans tended to place a premium on high-powered automobiles. We tolerate the private ownership of firearms. We tend to applaud the courageous mountain climber or other adventurer who ignores the risks in the effort to establish human dominion over nature. In short, risk-taking behavior is -permitted and often encouraged by many of our social institutions, which defer to individual judgment the weighing of often intangible benefits against the quite tangible risks.

Society has long been aware of the individual and social risks of alcohol use. Even with the effort now being made to inform the public of the risks of tobacco use, society still permits this drug to be widely available. In both cases, society clearly subordinates the risks inherent in such behavior, deferring instead to individual judgment.

The Commission is not suggesting that health risks are irrelevant to the formulation of drug policy. However, whatever appropriate weight is given to health considerations, it is a peripheral, rather than focal, concern. Drug policy must be based on the social consequences of drug use, and on the social impact of drug-induced behavior.

Motivation for Mood Alteration

Subsumed within the societal goal of eliminating non-medical drug use is the value judgment that use of drugs for the explicit purpose of mood alteration is per se undesirable. To harmonize this judgment with approved conduct, we avoid analyzing the motivations of similar behaviors.

As noted earlier, we do not verbalize the motivation f or alcohol use in terms of pleasure but rather in terms of the drug's function as a relaxant, as a social lubricant, and as a beverage. We do not think about the alcohol experience as an altered state of consciousness but rather as a means to some other end, such as promoting conviviality or stimulating conversation.

Within the medical setting, the individual is increasingly making the decision to use medically approved drugs and selecting them according to their capacity to alter his mood. The National Survey shows that 157o of the adult population reported that they "take a pill to calm down or cheer up" when they feel "out of sorts . . . not really sick, but nervous, or depressed or under stress." Eighteen percent of the public reported that they used alcohol for similar purposes. The use of a variety of new mood altering drugs to cope with stress is undoubtedly a, significant social development, particularly among women. This option to employ drugs for what is essentially an individual diagnosis of felt needs has, to a large extent, changed public perception concerning the role of the drugs as mood alterants in our society.

Whatever the biological and psychological foundations for the common human desire to alter consciousness, policy makers must recognize that drugs have always been used for this purpose. Most societies have institutionalized at least one form of drug-induced mood alteration; only the drugs differ, not the essential purpose. Instead of assuming that mood alteration through some drugs is inherently objectionable, while similar use of others is not, the public and its leaders must focus directly on the appropriate role of drug induced mood alteration. It is no longer satisfactory to defend social disapproval of use of a particular drug on the ground that it is a "mind-altering drug" or a "means of escape." For so are they all.

Drugs and Individual Responsibility

Implicit in present policy is the concern that many individuals cannot be trusted to make prudent or responsible decisions regarding drug-taking. Certain drugs are thought to possess even greater powers than they have, including the capacity to overbear individual will. Most people are not accustomed to thinking about drug effects in terms of probabilities and uncertainties, of dose-response curves, of multiple effects (some desirable and some undesirable), of reactions which vary from individual to individual and from time to time in the same individual.

A deep-seated popular belief that some drugs diminish or destroy the individual's capacity to control his behavior is reflected in hypotheses such as "drugs cause crime" or "drugs cause dropping out" or "drugs cause mental illness." Any perceived correlation between use of the drug and the unwanted consequence is attributed to the drug, removing the individual from any and all responsibility. Similarly, while it is true that certain drugs offer more intense psychological rewards than others, seduction characteristics are attributed to all psychoactive drugs, suggesting a chain of progression from light to heavy use, from weak to stronger drugs, all without the intervention of individual choice.

A drug has no effect until it interacts with an organism. The effects of any drug, psychoactive drugs included, are mainly dose related. At low or moderate doses they are determined mainly by non-drug factors, such as the psychological characteristics of the individual, the reasons why he uses the drug, what he expects the effects will be, the physical and social setting in which he uses it, and how he perceives its use or non-use in relation to self-defined goals. Further, how his friends, his sub-culture, and his society define and respond to his drug use are equally important f actors. These psychological and social criteria not only influence the reaction to a specific drug but they are key factors in determining use or non-use, selection of substance, and the pattern and circumstances of use.

An Overview of the Present Response

Because of this confusion about objectives, the formal institutional response to the drug problem has been more reflexive than rational, more situation-oriented than strategic. The ad hoc responses to use of specific psychoactive drugs have interfered with examination of the fundamental questions relating to behavior patterns and the appropriate means of social control.

Research has provided us with an almost endless stream of psychoactive substances. The tendency is to identify a new substance, determine its potential hazards as a chemical and then to insert it into the existing system. This procedure tends to perpetuate the public focus on the drugs rather than on the prevention of behavior about which society is concerned. When the drug appears in the streets, as it inevitably does, social institutions respond as if the behavior was unanticipated, and because they are ill-prepared to deal with the situation, an atmosphere of crisis is generated.

Because the focus has always been on the elimination of prohibited substances altogether and on the elimination of the street use of therapeutically useful drugs, social institutions have directed primary attention to the problem of use of specific drugs. Patterns of drug-using behavior have been ignored except as an afterthought of intervention. When increases in prohibited drug use continue to escalate, policy makers respond, not by reassessing the problem from different perspectives, but rather by pressing for ever-more costly mechanisms of control; costly both in terms of resources and important social values. Drug policy can be, thus summed up: increased use of disapproved drugs precipitates more spending, more programs, more arrests and more penalties, all with little positive effect in reducing use of these drugs.

Details of the present institutional response share the confusion of purpose which characterizes the, entire social response. We will sketch a few of the key features here although these matters will be considered in some depth in Chapter Four.

Throughout this Report, consumption-related offenses will refer to offenses such as use, possession for personal use, presence in a place where prohibited drugs are being used. Unless stated otherwise, "possession" means possession for personal use.

Risk-Education

An important operating assumption of the present response is that if people are educated about the risks of drug taking, they will not use drugs. It is presumed that presentation of information regarding dangers and risks can quiet curiosity and the desire for anticipated pleasant psychological sensations, the factors which account for most individual drug experiences.

Society's experience in attempting to discourage use of substances not labeled as drugs is instructive. Campaigns have been mounted in the past, both through the mass media and the schools, about the dangers of alcohol use and cigarette smoking. Facts have been marshaled, scientific opinion has been mobilized, and the adverse consequences of use of these drugs have been amply demonstrated by the number of alcoholics within the United States and the number of persons dying yearly from heart disease, lung cancer and other respiratory ailments. Still the consumption of alcohol continues and the number of persons smoking cigarettes increases.

This same kind of educational effort has been directed at the illicit drugs with no apparent impact on behavior. Little insight has been gained as to why this approach has not worked with alcohol and cigarettes, or as to whether risk-oriented curricula may actually arouse interest rather than dampen it. Further, assuming that such programs might be useful, little thought has been given to how to transmit the information, the assumption again being that the facts speak for themselves. This vast expenditure of time, money and effort has apparently paid few measurable social dividends, and those that have claimed success have done so not on the basis of scientific proof, but on the basis of impressions and anecdote.

Coercion

If information about risks and moral suasion is insufficient to convince many people not to use drugs, it is assumed that the threat of a criminal sanction will do so. While a criminal proscription does function as a deterrent to some degree for all behavior, the strength of this factor varies according to the nature of the offense, the, characteristics of the actor, the probability of detection and the certainty of punishment. With regard to drug consumption, all of these factors diminish the utility of the criminal sanction. Drug consumption is an expressive conduct which normally occurs in private among groups which are least influenced by legal condensation. In addition, the consumption-related offenses are no longer supported by the strong social consensus which once existed, and the emerging ambivalence is reflected in the dispositional decisions of police, prosecutors and courts.

We note that drug consumption offenses have not been remarkably successful in curtailing use in general. However, it is important here, as elsewhere, to distinguish between different patterns of drug taking behavior. On the one hand, the law may deter indiscrete use and continued use of a prohibited drug. On the other hand, experimental behavior, particularly by youth, is unlikely to be deterred by the law alone. For those who are dependent upon prohibited drugs, such as the heroin-dependent person, the deterrence concept is functionally inapplicable.

Sickness

Anyone choosing to use drugs, despite the enumerated risks, moral suasion and threat of criminalization, is often considered abnormal, emotionally ill and weak of character. The last decade has seen the pendulum of legislative opinion swing toward the belief that drug dependence and even drug use is a "medical" problem, that it can be "treated," and that the user can be "rehabilitated." Like many ideas which aim to correct those previously in vogue, the medical approach has itself become a runaway concept. Policy makers have adopted policy guidewords such as "treatment," "rehabilitation," "contagion," and "epidemic," without regard to their utility in the present context.

The "sickness" label has been attached to all users of prohibited drugs without regard to their patterns of drug-taking behavior. While very few question that persons compulsively using drugs are in need of some form of therapeutic assistance, the same is rarely true for the experimental and recreational user. To label drug users in general as mentally ill is to place a large segment of American society in need of formal medical assistance.

With regard to drug dependence in particular, the public has been led to believe that this condition is as definable and treatable as ordinary illnesses of the body. In reality, there is not, at the present time, any generally applicable cure for drug-dependent persons let alone non-dependent users of drugs. "Success" in treatment programs has been difficult to define, reflecting the complex relationship between drug use, social functioning and mental health. Even when measured against their own criteria for evaluation, most treatment programs can demonstrate only limited "success."

Public policy is committed to the treatment and rehabilitation of all drug-dependent persons. While thousands of persons have been aided by treatment efforts in recent years, social objectives continue to outstrip professional understanding of the condition and official capacity to deliver the necessary services.

Perpetuating the Problem

Because of the intensity of the public concern and the emotionalism surrounding the topic of drugs, all levels of government have been pressured into action with little time for planning. The political pressures involved in this governmental effort have resulted in a concentration of public energy on the most immediate aspects of drug use and a reaction along the paths of least political resistance. The recent result has been the creation of ever larger bureaucracies, ever increasing expenditures of monies, and an outpouring of publicity so that the public will know that "something" is being done.

Perhaps the major consequence of this ad hoc policy planning hag been the creation, at the federal, state and community levels, of a vested interest in the perpetuation of the problem among those dispensing and receiving funds. Infrastructures are created, job descriptions are standardized, "experts" are created and ways of doing business routinized and established along bureaucratic channels. During the last several years, drug programming has become a multi-billion dollar industry, one administering to its own needs as well as to those of its drug-using clientele. In the course of well-meaning efforts to do something about drug use, this society may have inadvertently institutionalized it as a never-ending project.

All of these responses stem from one fundamental flaw in present drug policy: the problem is defined incorrectly. The uneasiness which the Commission has encountered among thoughtful observers and officials arises largely from their own perceptions that the present response, although massive, has so far been relatively ineffective. Yet, any challenge to the basic premises of policy may be viewed by some as a disavowal of the entire social response. The Commission does not believe the present policy should be abandoned out of hand. Instead, we hope that policy can be made more coherent and more flexible. In order to do so, we must put aside preconceived notions, setting out afresh to redefine the problem.

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DEFINING THE PROBLEM

The Meaning of Drug Use

Throughout history man has used available psychoactive substances to seek relief from cold, hunger, deprivation, anxiety, pain and boredom. He also has used such substances to receive pleasure or to achieve new experiences. Various cultures have sought out and used naturally occurring plants for their psychoactive ingredients, discovering their effects by trial and error. Modern man has consciously created new chemical substances and institutionalized their availability for similar uses.

Drugs have effects other than those which are sought; and all drug effects vary with amount and frequency of use, the characteristics of the user, and the set and setting in which they are used. Consequently, different cultures have applied different values to the presumed consequences of drug use, whether beneficial or deleterious. Each society has decided which needs are legitimate, which effects are valuable and which risks are tolerable. These judgments are based on prevailing values concerning specific drugs, their effects, the reasons for which they are used, and the people who use them.

Man does not ordinarily continue to do something that does not fulfill some real or imagined need. To persist, behavior must be reinforced. To the extent that it does fulfill a need, it will recur, often at some risk, unless it interferes with some more important need. The need for a drug may be closely related to its real or imagined effects or it may be grounded in social rather than chemical elements. Use of specific substances may determine group membership, or status within a group, or among groups. It may function as either a symbol or symptom of rebellion, alienation, independence or sophistication.

To better understand current self-defined drug use and to determine the scope of social concern, one must go beyond the cataloguing of substances (pharmacologically defined where possible), the listing of effects, and the counting of users and non-users of drugs. The inquiry must shift from drugs to people, from pharmacological effects to the meaning and function of drug use.

The Incidence of Drug Use

The nature and scope of society's drug problem at any given time are generally perceived in terms of the incidence of non-medical use of legal and illegal substances. Tables 1-4 and 1-5 present data, of this kind obtained in the Commission-sponsored National Survey.

Such statistics may be useful for assessing in general terms the relative success or failure of institutional efforts to channel drug taking behavior into prescribed channels. However, these figures, and similar ones, are often used to arouse public concern, and do not explain either the meaning of such drug use or the nature and scope of the social problem which it poses.

As an example, Table 1-5 illustrates that regular use of alcohol is extremely widespread among Americans 18 years of age and older (53%), and that large numbers of the nation's youth (12-17) consume alcohol despite official blandishments (24%). Do the respective legitimacy and illegitimacy of these behaviors tell us anything about the nature of social concern about alcohol use?

In comparison, Table 1-4 indicates that 16% of the adult population and 14% of the youth have used marihuana despite the legal proscriptions, and that 8 % of the adults and 7 % of the youth continue to use the drug. Smaller percentages of the populace have also violated the law by trying hallucinogens such as LSD, cocaine or heroin. Does the illegitimacy and relative incidence of such behavior bear directly on the dimensions of social concern? Is marihuana use more or less of a social problem than heroin use? Than alcohol use?

The data in Table 1-5 illustrate that over-the-counter preparations are sometimes consumed for non-therapeutic reasons. Does the permissibility of this behavior suggest that it is without social consequence? Does the motivation for use make a public policy difference?

Scientifically acceptable incidence data, together with demographic analysis, can tell us who uses various drugs and bow they are used in terms of frequency and duration. Such information cannot, however, answer the crucial social policy questions: why and so what?

Drug-using Behavior

The initial step in understanding the meaning of drug use and its impact on the social order is to regard this phenomenon as we would any other human behavior. In Chapter Two of the Report, the Commission will place these incidence figures in perspective, elaborating on the patterns of drug-using behavior and the individual and social factors which seem to influence individual decisions to initiate, continue or terminate the use of drugs. In short, we will try to answer the why of drug use. Because drug-using behavior is not a unitary phenomenon, the social consequences of this behavior are tied directly to the individual's reason for the drug use and in turn to the frequency, duration, intensity, dose, set and setting of use. The Commission has divided the entire spectrum of drug-using behavior into five patterns reflecting essentially distinct meanings for the individual users.

The most common type of drug-using behavior can be classified as experimental: a short-term, non-patterned trial of one or more drugs, motivated primarily by curiosity or a desire to experience an altered mood state. Experimental use most often occurs among young persons in the company of one or more drug-experimenting friends or acquaintances.

Most non-experimental drug-using behavior can be classified as recreational, which occurs in social settings among friends or acquaintances who desire to share an experience which they define as both acceptable and pleasurable. Generally, recreational use is both voluntary and patterned and tends not to escalate to more frequent or intense use patterns. This type of behavior is not sustained by virtue of the dependence of the user on the drug in any meaningful sense of that term. Reinforcement for continued use is strengthened by non-drug factors.

A pattern of drug-using behavior which has grown significantly during the last decade is circumstantial drug use. This behavior is generally motivated by the user's perceived need or desire to achieve a new and anticipated effect in order to cope with a specific problem, situation or condition of a personal or vocational nature. This classification would include students who utilize stimulants during preparation for exams, long-distance truckers who rely on similar substances to provide extended endurance and alertness, military personnel who use drugs to cope with stress in combat situations, athletes who attempt to improve their performance and housewives who seek to relieve tension, anxiety, boredom or other stresses through the use of sedatives or stimulants.

A much smaller group of drug users may be regarded as having escalated from recreational or circumstantial use patterns into intensified drug-using behavior. Although this is the most amorphous of the behavioral categories, the Commission refers in general to drug use which occurs at least daily and is motivated by an individual's perceived need to achieve relief from a persistent problem or stressful situation, or his desire to maintain a certain self-prescribed level of performance. This category includes persons generally referred to as "problem drinkers" or "heavy social drinkers," housewives who regularly consume barbiturates or other sedatives and business executives who regularly consume tranquilizers. A very different group of intensified users are those youths who have turned to drugs as sources of excitement or meaning in otherwise unsatisfying existences. The salient feature of this class of behavior is that the individual still remains integrated within the larger social and economic structure; however, the regular use of one or more drugs may constitute dependence in a broad sense and may threaten to impair individual or social functioning.

The most disturbing pattern of drug-using behavior, encompassing the smallest number of drug users, is compulsive use which consists of a patterned behavior at a high frequency and high level of intensity, characterized by a high degree of psychological dependence and perhaps physical dependence as well. The distinguishing feature of this behavior is that drug use dominates the individual's existence, and preoccupation with drug taking precludes other social functioning. Under current social and legal conditions, compulsive drug use is most easily recognized as occurring among chronic alcoholics and heroin-dependent persons, although the incidence of compulsive barbiturate use is probably significantly higher than the essentially episodic nature of street use would suggest.

Drug-Related Risk

An understanding of the different types of drug-using behavior is the starting point for problem definition. In these behavioral classifications, the key element is the meaning of drug use to the individual; the specific drug being used is subsumed within this framework. In reaching the next step in the problem definition process, we must focus on the individual and social risks attending drug use and those factors which distinguish drug-using behavior from other forms of experimental and recreational activities and other forms of coping behavior. As an aid to understanding, basic psychopharmacological principles concerning drug-related risk must be kept in mind.

Drug-related risk, both individual and social, escalates with increasing dose and higher frequency of administration.

Drug-related risk varies with the mode of drug administration, generally being highest for intravenous administration and lowest for oral ingestion.

Drug-related risk varies according to the setting in which use occurs, particularly when low doses are used.

Drug-related risk varies according to the user's capacity to control intake and detoxify the drug. The greatest risk occurs when the rate of administration exceeds the capacity of the body to detoxify the drug and in consequence the brain is never drug free.

Drug-related risk varies according to the "set" of the user, including the expected and desired outcome of the drug experience, the user's personality, his ability to compensate for drug effects on the basis of prior experience, and his ability to limit intake according to a predetermined capacity.

Drug-related risk often increases significantly if more than one drug is used concomitantly.

Further, many risks associated with drug use are a function of social policy rather than of the drugs themselves. Unintentional drug overdoses, whatever their precise pharmacological characteristics, occur most often among those who have secured drugs outside the legitimate channels which control quality and potency. For example, the incidence of alcohol-induced blindness was significantly higher during alcohol prohibition than it is today mainly because users resorted to methyl alcohol. In addition, the unsupervised intravenous use of illicitly obtained substances increases the likelihood of pulmonary and circulatory disorders and diseases which may result from use of unsterilized equipment or from injection of insoluble material used on the street to increase the bulk of the drug. Finally, much drug-related crime, particularly that associated with dependence on opiates such as heroin, is a function of a prohibitory social policy toward availability rather than of the drugs themselves.

The above propositions apply to all drugs. However, an additional axiom is crucial to formulation of social policy: specific drugs are qualitatively different in terms of individual and social risk. Drug using behavior is not a unitary phenomenon; nor are all drugs the same. At lower levels of use, when non-drug factors predominate in determining drug effect, the differences among drugs in terms of relative risk may be relatively unimportant. At other levels of use, particularly in large doses or high frequencies, the characteristics of the drug may become most important in determining risk.

With these psychopharmacological postulates in mind, we now turn to an analysis of the type of risks which engender social concern. The Commission has categorized drug-related risks into those affecting individual health, those involving drug-induced behavior as an acute consequence of the drug experience, and those associated with the behavioral aspects of chronic use or dependence.

Risks to individual health

The health risks arising from the acute effects of a drug experience are related primarily to dose and the set and setting of use. When drugs are consumed in small doses orally or by sniffing, acute risks to health are usually slight; when they are administered intravenously, however, even in small doses, the acute health risks are multiplied, and fatalities have occurred, often for obscure reasons. High doses, individual predispositions, including those related to age, and uncertain expectations increase the risk of overdoses and of physical and psychological injury. Since the lethality and psychological effects of individual drugs differ widely, the drug used is an important determinant of health-related risks.

The major concern from the standpoint of individual health is the effect of repeated administration of the drug over a long term, rather than the acute effect of the drug experience. The possibilities of organ damage as well as impairment of psychological function increase with the frequency and intensity of use; also, chronic use of tolerance producing drugs increases the risk of overdose as well as the likelihood of physical or psychological damage. Individual drugs vary widely in toxicity, in tolerance and in psychological effect.

As we noted earlier, the special public policy considerations posed by psychoactive drug use arise not from risks to individual health per se but rather from the capacity of these drugs to affect behavior. There is no correlation between the capacity of a psychoactive drug to induce behavioral disorders and its capacity to induce either brain or other somatic pathology.

Drug-Induced Behavior

Whether a person under the influence of a drug will become aggressive or passive, will have impaired psychomotor capacity or will exhibit otherwise disordered behavior depends on the entire range of variables determining drug effect. Set and setting play a most important role, particularly when low doses are consumed. However, drugs are qualitatively different in this connection and can be compared. A regular user of psychoactive substances is generally able to compensate for some of the acute behavioral effects. Over the long term, however, additional risks may be encountered; as a result of chronic use, a person may become significantly more aggressive or passive, may become significantly less adept at muscular control, or may deteriorate mentally, becoming incapable of engaging in voluntary learning efforts. Most important, the likelihood of adverse long term effects on behavior is increased substantially if the person becomes dependent upon the substance. It is for this reason that we have isolated the dependence liability of various substances as a separate risk factor.

Dependence Liability

Whether a person who continues to use a psychoactive substance will become dependent on the substance, escalating from recreational or circumstantial patterns to intensified or compulsive patterns, is an issue where the characteristics of the drug and the individual play equally important roles. As we will discuss in Chapter Three, drugs are qualitatively different in terms of their potential for reinforcement. For example, marihuana is significantly less reinforcing than heroin or cocaine. The behavioral consequences of chronic use also differ among drugs, as does the potential for behavioral disruption when the dependent person's drug-taking is interrupted. From these perspectives, chronic use of dependence-producing doses of barbiturates pose significantly different problems from chronic use of cocaine.

Because the health and behavioral risks of drug use increase with frequency, intensity and duration of use, the likelihood of dependence is a crucial determinant of social concern.

Evaluating the Social Consequences of Drug Use

In order to translate the analyses of drug-using behavior and risk potential of specific drugs into a meaningful framework for policy making, a description and evaluation of the social consequences which flow from drug-induced behavior or drug dependence is necessary. Although these issues will be addressed in Chapter Three, some general observations regarding the social impact of various patterns of drug-using behavior and of the use of individual drugs is useful so that a definition of the drug problem as it is understood to exist in American society today can be undertaken.

As we wrote in our first Report on marihuana, the social impact of the use of a particular drug or of a specific pattern of drug-using behavior involves three distinct considerations. First is the impact on public safety of drug-induced behavior or drug dependence. The major concerns from the standpoint of drug-induced behavior are increased aggressiveness or violent behavior, loss of psychomotor control or alteration of judgment and perception which might result in dangerous conduct. With regard to drug dependence, the public safety may be threatened by persons who are dependent upon a drug which is not legitimately available and who may commit crimes to finance purchases in the illicit market.

The second general area of social consequence is the impact on the public health and public welfare arising from drug use. This is a quantitative concept pertaining to the health resources and social services necessary to prevent, treat and compensate for the adverse effects of drug use as well as the social loss, in terms of productivity and social contribution, which occurs whenever drug use interferes with normal social and economic functioning. For example, unemployment, absenteeism, decreased social performance levels and family disruption may all stem from intensified or compulsive drug use, resulting in a measurable social loss.

When drug use is approached from the public health and welfare standpoint, it must be viewed as part of the larger health and welfare system which deals with many related problems. This system generally focuses on populations at risk, organizing the necessary range of medical, human and social services for delivery of services to the appropriate population. In the drug area, health resources must be allocated and available to deal with acute reactions, overdoses and diseases, such as hepatitis, among predictable proportions of drug-using populations. This may require a shift of limited medical services from one health area to another. More important, medical and social services must be organized for delivery to persons whose intensified or compulsive drug use is correlated with impairment of social functioning (treatment and rehabilitation), as well as to populations who might develop these patterns of use (prevention).

Finally, an understanding of the social impact of drug use must also include the impact on the normative social order. Although this concept is entirely qualitative, dealing with the prevailing social values, it has always determined the manner in which the drug problem has been defined and the nature of the social response. In terms of establishing policy predicates, the Commission believes strongly that considerations of morality do influence the formulation of appropriate policy objectives. However, the Commission believes that such considerations often have been overemphasized in the process of defining the problem. Only when the impact of drug use on the normative social order is placed in proper perspective can we hope to dispel the climate of crisis in which drug policy is now made.

Defining America's Drug Problem

Theoretically, social concern about use of a particular substance relative to another should correlate with the verified social costs attending the use of each drug in that society. As the incidence of intensified and compulsive use increases, so too should the public's concern with the problem. However, the current problem definition in the United States bears little relationship to actual social cost. The intense public concern regarding use of most drugs in large measure reflects anxiety for the future rather than empirical considerations rooted in the present. The result has been an overestimation of the nature of the problem attending use of some drugs, such as marihuana, and an underestimation of the problem attending use of other drugs, such as barbiturates and alcohol.

In the Commission's view, problem definition should take into account the relationship between the maximum potential social cost of use of a particular drug under given conditions of availability, compared with the verified social costs at a particular point in time. In this context, the most serious concern in contemporary America should attach to the use of alcohol and heroin. Moderate social concern should attach to the use of amphetamines, barbiturates, hallucinogens, methaqualone and cocaine, the use of which is relatively well-controlled within the present social policy framework. The use of marihuana and the so-called minor tranquilizers appears to require relatively minimum social concern at the present time. Present trends do suggest, however, that the incidence of use of and dependence on barbiturates and cocaine may be increasing and may demand increased social attention. It is in this context that we turn to a general overview of the means by which social control should be achieved.

The Limits of Social Control

The Commission believes that the contemporary American drug problem has emerged in part from our institutional response to drug use. Since we have failed to appreciate the diverse nature of drug using behavior, we have failed to weave policy into the fabric of social institutions. Instead, policy has been imposed from the top, often without regard to possible impact on the institutional fabric itself, much less on drug use. It is worthwhile, then, to consider the general requirements of social control and the general guidelines upon which policy making should be based.

Responsible observers agree that society has an interest in controlling the individual's drug-taking behavior. The potentially disruptive behavioral effects of the drug experience and the potentially adverse social consequences of the chronic use of most psychoactive drugs are matters of appropriate concern. The policy maker's task in this area is not to choose between social control or social disinterest; rather, it is to determine if and when informal mechanisms of social control must be supplemented with formal ones.

Drug use, in one form or another, has been a common feature of most cultures throughout history. To the Commission's knowledge, no society has successfully eliminated drug use altogether, although all have attempted to set limits, and most heterogeneous societies have contained distinct subgroups opposing all drug use among their own members. The alcohol prohibition experience in this country is best viewed as an attempt by one social group to impose its abstentionist doctrine on the entire culture. Social control generally stops short of elimination.

In its most basic sense, drug taking is socially controlled when it is routinized, ritualized and structured in ways which reduce to a minimum the occurrence of drug-induced behavior which the culture considers undesirable. In small, primitive societies, the social control over drug use tends to be most successful since it is fully integrated with the overall institutional control structure, generally dominated by kinship and religious institutions. The well-controlled, ritualized use of hallucinogenic substances by a number of tribal cultures, such as the Indians in Central and North America and the aborigines of Australia, has been amply demonstrated (deRios 1973).

In contemporary mass societies, however, responsibility for social control over increasing spheres of human conduct has tended to pass from the family and church to educational, economic and governmental institutions. This reliance on formal institutions, coupled with the impersonality and complexity of industrial and post-industrial societies, has made the task of social control of drug-taking behavior all the more difficult. For this reason, together with the proliferation of available substances, the problem appears far more pervasive in these societies, especially when they are heterogeneous and individualistic.

Western societies have routinely utilized their public institutions, particularly the legal ones, in an effort to contain undesirable drug use within tolerable limits.

The success of social control through law is always difficult to measure. First, "tolerable limits" is a relative concept. Many societies in the early stages of industrialization have large populations of chronic drug users, but the importance of enforcement of legal controls on drug taking behavior pales beside the more pressing social needs of food, shelter, clothing and national survival. In this sense, the United States is comparatively fortunate to be able to be concerned about its drug problem, and to have a surplus of national resources to devote to its resolution.

A second factor which complicates heavy reliance on social control through law are the values different societies place on the rights of individuals. Application of criminal law must conform to well-established limitations in the United States and Great Britain, for example, and certain proscriptions thought necessary to minimize a given drug using behavior may be more intolerable to the general social fabric than the behavior itself. But this is not true in all societies. Japan, which is a more authoritarian society, was able to stem a large and growing amphetamine problem during the mid 1950's and an incipient heroin problem during the early 1960's by mobilizing a broadly based social response centered on effective use of the criminal law and an educational effort based in large measure on national pride. It is doubtful that similar exhortations and enforcement techniques could be as readily employed in this country.

These cross-cultural observations provide the backdrop against which we must consider the current American response to its drug problem. First, reliance on law is unlikely to be effective in American society unless it is joined consciously and directly with use of other institutions of social control. Second, drug policy should not be made in a vacuum. A proposed policy must be analyzed both in terms of its likely impact on drug-taking behavior as well as its likely impact on other social values and institutions. Third, the problems to which the society directs its formal response must be those which exceed the level of socially tolerable limits. For example, most drug use, even of disapproved substances, is socially controlled to some degree by informal institutions such as peer groups and families. Formal social efforts should be directed to those behaviors which are not adequately controlled by informal mechanisms of social control, aiming primarily to support the informal control mechanisms and intervening directly only as a last resort.

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THE COMMISSION'S ROLE

The Commission believes that the first step toward resolving the drug problem is to reconsider the present diagnosis of the ailment. The social response is presently a large part of the problem, one which is compounded with each unanticipated crisis. To break this cycle, it is necessary to refocus our attention on that behavior which carries the most serious social consequence. Preoccupation with the drugs themselves must be replaced by an understanding of the behavioral impact of drug use. We must deal directly with the ambivalence of our attitudes with respect to drugs, conforming our beliefs to reality and our conduct to our ideals. Only then will a coherent policy emerge, one which can withstand legitimate criticism, and one which will have a beneficial impact on the problem.

Promises which cannot be kept must not be made. The public must be apprised that disapproved drug use is part of a larger social pattern, and that all the money and effort that the American society can muster will never be able to deal effectively with this behavior if the problem continues to be defined as it is now. Drug policy making must take into account a wide range of social phenomena of which drug use is a small part, and institutional responses must be framed in the context of broader social roles. Unless present policy is redirected, we will perpetuate the same problems, tolerate the same social costs, and find ourselves as we do now, no further along the road to a more rational legal and social approach than we were in 1914.

The Commission has not attempted to devise utopian policy recommendations. Instead we have attempted primarily to formulate a policy-making process, one which includes all of the important variables and which separates various crucial issues. We have applied this process in order to provide a plan of action to be implemented immediately. But we would be remiss if we were only to propose recommendations for the present. The Commission feels that a coherent social policy requires a fundamental alteration of social attitudes toward drug use, and a willingness to embark on new courses when previous actions have failed.