Drug Abuse

INTRODUCTION

CONTROL AND INTOXICANT USE:
A THEORETICAL AND PRACTICAL OVERVIEW

Norman E. Zinberg*
Wayne M. Harding*

This collection of articles on controlled use of drugs reflects the new research perspective that has emerged in the past few years. Formerly, research was strongly influenced by the reigning stereotypic and moralistic view that all illicit drug use is bad and inevitably harmful, "addictive," and that abstention is the only alternative (Zinberg et al., 1978b). Consequently, studies of drug consumption tended to equate use (any use) with abuse, and they seldom took occasional and moderate use into account as a viable pattern (Heller, 1972). If the possibility of nonabusive use was acknowledged, it was usually treated as a very brief transitional stage leading either to abstinence or more probably to compulsive use. The primary research emphasis was placed upon determining the potentially harmful effects of illicit drugs, which were frequently dramatized by describing the most extreme cases of misuse and overconsumption. Even then, however, it was well known that in order to understand how control of a substance taken into the body could be developed, maintained, or lost, different patterns of consumption had to be compared. But though this principle was applied to the comparative study of patterns of alcohol use--alcoholism versus social or moderate drinking only recently (since 1970) has it been rigorously applied to the use of illicit drugs such as marihuana, LSD, cocaine, and heroin, with the result that a wide range of using patterns is now recognized.

The New Perspective on Control

The new interest in the comparative study of drug use and abuse is attributable to two major factors. The first is the enormous and continuing growth of marihuana consumption. Although the number of users has vastly increased, widespread, debilitating health effects have not appeared. Also, most marihuana use has been occasional and moderate, rather than intensive and chronic (Josephson, 1974; National Institute on Drug Abuse, 1976). These developments have spurred public and professional recognition of the possibility that all illicit substances can be used in moderation and that the question of how control operates at various levels of consumption deserves research attention. The second factor contributing to the new research perspective is the pioneering work of a few researchers who have been more persuaded by the logic of their own results than by the mainstream view of illicit drug use. The most influential work has been that of Lee-Robins, whose research on drug use among Vietnam veterans (to be discussed in detail later) indicated that consumption of the illicit drug that the public considers the most dangerous, heroin, did not always lead to addiction or dysfunctional use, and that even when addiction occurred it was far more reversible than was popularly believed (Robinset al., 1977).

This collection of essays also reveals another slightly more recent shift in research interests to the comparative study of control ofdifferent substances, including some that are not drugs, such as sugar and other foods. As the view that illicit drugs were a special class of substances posing dangers moderated, they began to be compared with licit drugs and other substances. At the same time there was a parallel but inverse shift in attitude toward licit substances. Research findings showed that a wide assortment of these substances-tobacco, caffeine, sugar, and various food additives-are potentially hazardous to health. Other research demonstrated that the failure to use prescribed drugs in the way the physician intended can also be hazardous, and may constitute a major public health problem. Thus, even with the advice of a physician, "good" drugs used for "good" reasons can be difficult to control. It seemed that just as the mythology that illicit drugs are altogether harmful was giving way, so too was the mythology that many licit substances are altogether benign. The result has been a new interest in studying the commonalities in the ways of controlling a wide variety of substances, both licit and illicit.

We came to appreciate these changes in perspective in large part through our own research. In 1973 we began a study of moderate, occasional ("controlled") users of marihuana, psychedelics, and opiates with support from the Drug Abuse Council, Inc. By means of depth interviews conducted for several years with self-selected subjects we accumulated sufficient evidence to demonstrate that long-term, controlled use of these drugs was possible. In 1976, new funding was secured from NIDA to pursue a study of controlled users of opiates, particularly heroin, with the broader goal of identifying factors associated with this pattern of use. 1

While recruiting new subjects who met our strict criteria for controlled use, we unintentionally interviewed a small number of subjects with compulsive using patterns. Study of these users not only underscored how controlled our subjects were, but it also revealed that even compulsive users exercise some degree of control. Although it seems obvious now, we were struck then by the fact that compulsives did not use as much of the drug as they could have. Clearly they were using too much, but a variety of internal and external factors still kept use down. About the same time a substantial subgroup (42 percent) of controlled subjects were identified who had been previously addicted to opiates but whose use had since been controlled for two or more years. These findings suggested that it was necessary to consider the commonalities as well as the differences among various patterns of opiate use, and they also indicated the importance of understanding how one using pattern evolved into another (Zinberget al., 1978b). Accordingly, our research was redefined as a study of control across various using patterns rather than as a study of controlled users. The sample was reconstituted so as to include subjects ranging from controlled, that is, occasional and moderate users, at one extremity, through a middle group of "marginal" users, to compulsive users at the other extreme.

During the period from the beginning of the DAC study to the development of the present, ongoing NIDA-sponsored project (1973-1977), changes in the way our findings were received and in the number of similar projects being pursued by other researchers confirmed the importance of work on control. At the close of the DAC project there was still considerable resistance to accepting the existence of moderate users; today such resistance is rare in the scientific community. At the outset of the DAC study only one published study focused on occasional use of any illicit drug, while now there are a few dozen studies dealing substantively with this kind of use (Zinberg et al., 1978b).

More than a year ago it was suggested by Richard L. Rachin, editor of the Journal of Drug Issues, that a special issue be devoted to the topic of control over substance use. Convinced that this was an idea whose time had finally come, we agreed. After drawing up a-somewhat fanciful list of potential contributors, we found to our surprise that all were interested in the topic Of control. Those few who could not participate referred us to others who could. In fact, the problem became one of limiting the number of contributors. Many of the articles grew beyond the length we had anticipated. The sustained enthusiasm of the authors is reflected, we believe, in the quality of the collection.

The articles are at once diversified and unified. When Soliciting contributors we asked them to describe how substance control works, but we did not specify particular substances or a particular approach. The great range in substances discussed and in the approaches taken suggests that many aspects of current work in substance use and abuse are encompassed by the theme of control. The substances include: prescription drugs such as barbiturates, amphetamines, and methadone (Apsler; Dole and Singer; McKenna; Moore); licit recreational drugs such as alcohol, caffeine, and nicotine (Apsler; Newmeyer and Johnson; Hunt; Herman and Kozlowsky; Maloff et al.); illicit drugs such as marihuana, heroin, opium, the psychedelics, and PCP (Apsler; Hunt; Waldorf and Biernacki; Kramer; Bunce; Maloff et al.,Kaplan); and food (Apsler; Herman and Kozlowsky; Maloff et al.). The approaches used include a review of the research literature (Waldorf and Biernacki), analysis of historical documents (Kaplan), theoretical exposition (Herman and Kozlowski), survey research (Apsler), Policy analysis (Moore), epidemiological research (Newmeyer and Johnson), clinical research (McKenna), analysis of research methods (Hunt), and cross-cultural analysis (Maloffet al.). Despite this apparent diversity, all the articles incorporate one or both of the research themes that are beginning to compete with more traditional research interests: the need (1) to compare different patterns of substance use and (2) to compare control across different substances.

Because all the contributors were aware of our research on the topic of controlled use, and either explicitly or implicitly took it into account in their articles, our theoretical perspective on control will be outlined before the articles are discussed. Each of the articles will then be described briefly and assessed from the standpoint of our theory. Finally, the implications of this collection of articles for social policy and for future research will be considered.

The Social Setting and Control

In the last decade it has become increasingly commonplace for investigators to divide the variables that are presumed to influence drug-taking behavior into three groups: (1) drug variables (the pharmacological properties of the drug being used); (2) set variables (the attitudes and personality of the user); and (3) setting variables (the social and physical environment in which use occurs). Underlying this model-which corresponds to the public-health model of agent, host, and environment--isSo premise that at any one time variables from each of the three groups interact hi complex ways to determine who uses an intoxicant, how it is used, and what Its effects are.

Our primary theoretical and research interest has been the impact of setting variables on control. We will begin by defining the two aspects of setting with which we are most concerned, rituals and social sanctions. 2 Next, the importance of setting variables will be illustrated by considering how control over alcohol use has developed In American culture and how it operates today, and then by describing how today's social setting is influencing the development of control over illicit drug use. Finally, examples will be given of the interaction of the drug, set, and setting variables in shaping the use of illicit drugs.

Rituals and social sanctions. As used here, the term rituals refers to the stylized, prescribed behavior patterns surrounding the use of a drug. This behavior may include methods of procuring and administering the drug, selection of a physical and social setting for use, activities undertaken after the drug has been administered, and methods of preventing untoward drug effects. For example, two familiar alcohol-using rituals are having cocktails before dinner and drinking beer at ball games.

Social sanctions are the norms regarding whether and how a particular drug should be used. They include both the informal (and often unspoken) values and rules of conduct shared by a group and the formal laws and policies regulating drug use. Two of the informal sanctions or basic rules of conduct that regulate the use of alcohol are "Know your limit" and "Don't drive when you're drunk." Although laws and regulations are clearly social sanctions, we will emphasize informal social sanctions, which frequently are internalized and actually may exert greater Influence over use than do formal rules. For instance, most Americans avoid drunkenness more because they feel it is unseemly-and drunken driving more because they have learned it is unsafe-than because of the possible legal consequences (Zinberget al., 1977).

Rituals and social sanctions operate in different social contexts that range all the way from small discrete clusters of users (drinks at a weekly poker game with friends) through larger collections of people (cocktail parties, or drugs at rock concerts) to entire classes or segments of society (morning coffee, or wine with meals in Italian households). Different segments of society may develop complementary, or even opposing, rituals and social sanctions, and usually each segment is cognizant of the alternatives and to some degree is influenced by them. Rituals and social sanctions can operate either for or against control. Drinking muscatel from a bag-wrapped bottle while squatting in a doorway is not a controlling ritual nor is the soliciting of psychedelics from strangers on the street. According positive status to the ability to withstand extraordinarily high doses of LSD or to the sizableness of one's heroin habit is not a controlling sanction. We are chiefly concerned with the rituals and sanctions that promote moderate use, as exemplified by the evolution of control over alcohol consumption.

Social setting and alcohol use. The history of alcohol consumption in America reveals striking variations in patterns of use from one era to another. Sometimes a period of control, or lack of control, has coincided with a major historical epoch. The following five social prescriptions defining controlled or moderate use of alcohol, which have been derived from studies of use in many different cultures, will serve as a standard for assessing control in the major periods of American history: 3

(1) Group drinking is clearly differentiated from drunkenness and is associated with ritualistic or religious celebrations.

(2) Drinking is associated with eating or ritualistic feasting.

(3) Both sexes, as well as two or more generations, are included in the drinking situation, whether they drink or not.

(4) Drinking is divorced from the individual effort to escape personal anxiety or difficult (even intolerable) social situations. Further, alcohol is not considered medicinally valuable.

(5) Inappropriate behavior when drinking (violence, aggression, overt sexuality) is absolutely disapproved, and protection against such behavior is offered by the sober or the less intoxicated. This general acceptance of a concept of restraint usually indicates that drinking is only one of many activities and thus carries a low level of emotionalism. It also shows that drinking is not associated with a male or female rite de passage or sense of superiority.

The importance of these social prescriptions in controlling alcohol use is evident in the changing patterns of consumption through the colonial period, the Revolutionary War and nineteenth century, the Prohibition era, and the period that has followed repeal of the Volstead Act.

Pre- Revolutionary America- (1620-1775), though veritably steeped in alcohol, strongly and effectively prohibited drunkenness. Families drank and ate together in taverns, and drinking was associated with celebrations and rituals. Tavern-keepers were people of status; keeping the peace and preventing excesses stemming from drunkenness were grave duties. Manliness or strength was not measured by the extent of consumption or by violent acts resulting from it. Pre-Revolutionary society, however, did not abide by all the prescriptions, for certain alcoholic beverages were viewed as medicines. For example, "groaning beer," a very potent alcoholic beverage, was consumed in large quantities by pregnant and lactating women. Even though alcohol was viewed as medicinally valuable, alcohol-related problems remained at a low level, due in part to the strict standards that limited consumption and dictated deportment when drinking.

Beginning with the Revolutionary War and continuing with the Industrial Revolution and expansion of the frontier through the nineteenth century, an era of excess dawned. Men were separated from their families, which left them to drink together and with prostitutes. Alcohol was served without food and was not limited to special occasions. Violence resulting from drunkenness became more common. In the face of increasing drunkenness and alcoholism, people began to believe (as in the case with some illicit drugs today) that it was the powerful pharmacological properties of the intoxicant itself that made more controlled use difficult or impossible. By the latter part of the nineteenth century the West was won, and the family and personal disruptions brought on by the Industrial Revolution were moderated. In both the West and the East, families became more closely integrated. There was a change in the character of the neighborhood saloon or bar. Customers partook of free lunches with their beverages and tended once again to represent a mix of generations and sexes who frowned on violence, overt sexuality, and excessive consumption of alcoholic beverages. This moderation, however, was interrupted in the early twentieth century by the passage of the Volstead Act, which ushered in another era of excess. In the speakeasy ambience of the Prohibition era, men again drank together and with prostitutes, food was replaced by alcohol, and the drinking experience was colored with illicitness and potential violence.

Although Repeal provided relief from excessive and unpopular legal control, years passed before regular but moderate alcohol use emerged as normative behavior. Today, however, the vast majority of drinkers manage to control their use. Of an estimated 105 million drinkers fewer than eight million are alcoholics (Harding and Zinberg, 1977). While alcoholism is still a major public health problem, the extent of noncompulsive use of such a powerful, addictive, and easily available intoxicant is remarkable. This can only be fully understood in terms of the rituals and sanctions that pattern the way alcohol is used.

Alcohol-using rituals define appropriate use and limit consumption to specific occasions: a drink with a business luncheon, wine with dinner, or perhaps beer with the boys. Positive social sanctions permit and even encourage alcohol use, but there are also negative sanctions that condemn promiscuous use and drunkenness; for example , "Don't a* drinks," "Don't drink before sundown," and "Know your limit." Ibis is not to say that users never break these rules, but when they do they are aware of making a special exception. They know, for instance, that having a Bloody Mary with breakfast is acceptable behavior for an occasional Sunday brunch, but that drinking vodka with breakfast every morning would violate accepted social standards.

The internalization of rituals and social sanctions begins in early childhood. Children see their parents and other adults drink. They are exposed to acceptable and unacceptable models of alcohol use in magazines and movies and on television.

Some may sip their parent's drink or be served wine with meals or on religious occasions. So, by the time they reach adolescence they have already absorbed an enormous amount of information about how to drink. When the adolescent tests--as most do-the limits he has learned and gets drunk and nauseated, there is little need to fear that this excess will become habitual. As he matures the adolescent has numerous examples of adult use at hand and can easily find friends who share both his interest in drinking and his commitment to becoming a controlled drinker. Support for control continues throughout adult life.

Obviously the influence of social learning on the alcohol user is not always so straightforward. Social sanctions and rituals promoting control are not uniformly distributed throughout the culture. Some ethnic groups, such as the Irish, lack strong sanctions against drunkenness and have a correspondingly higher rate of alcoholism. Alcohol socialization within the family may break down as a result of divorce, death, or some other disruptive event. In some instances the influence of other variables-personality, genetic differences, as well as other setting variables may outweigh the influence of social learning. Nonetheless, controlling rituals and social sanctions exert a crucial and distinct influence on the way most Americans use alcohol (Harding and Zinberg, 1977).

Social setting and illicit drug use

In contrast to the situation with alcohol, the opportunities for learning how )to control illicit drug consumption, although changing, are still extremely limited. Neither the family nor the culture regularly provides long-term education or models of use. The worst propaganda of the 1960s against illicit drug use has faded, but the chief educational message from media and the schools is still that reasonable, controlled use of illicit drugs is impossible.

Certainly no official advice is given on to use these drugs safely. Compounding these disadvantages are the possible problems of variable dosage and purity of drugs on the black market, and the very real threat of arrest and incarceration. Ironically, the efforts to eliminate any and all use of illicit drugs work against the development of control by those who decide to use drugs anyway.

Despite these difficulties, our DAC and NIDA studies and the work of other investigators have shown that it is possible to attain a high level of control over illicit drugs. Furthermore, there is some indication that occasional rather than intensive patterns of consumption predominate in the use of most if not all illicit drugs. Our research comparing controlled and compulsive users of marihuana, psychedelics, and opiates suggests that rituals and social sanctions promote this control in four basic and overlapping ways:

(1) Sanctions define moderate use and condemn compulsive use. Controlled opiate users have sanctions limiting frequency of use to levels far below that required for addiction. Many have special sanctions, such as "Don't use every day." A complementary ritual would be to restrict the use of an opiate to weekends.

(2) Sanctions limit use to physical and social settings that are conducive to a positive or "safe" drug experience. 'Me maxim for psychedelics is "Use in a good place at a good time with good people." Rituals consonant with such sanctions are the selection of a pleasant rural setting for psychedelic use, or the timing of use to avoid driving while "tripping."

(3) Sanctions identify potentially untoward drug effects. Rituals embody the relevant precautions to be taken before and during use. Opiate users may minimize the risk of overdose by using only a portion of the drug and waiting to gauge its effect before using more. Marihuana users similarly titrate their dosage to avoid becoming too high (dysphoric).

(4) Sanctions and rituals operate to compartmentalize drug use and support the users' non-drug-related obligations and relationships. Users may budget the amount of money they spend on drugs, as they do for entertainment. Drugs may be used only in the evenings and on weekends to avoid interfering with work performance.

The process by which controlling rituals and sanctions are acquired varies from subject to subject. Most individuals come by them gradually during the course of their drug-using careers. But the most important source of precepts and practices for control seems to be peer using groups. Virtually all of our subjects required the assistance of other noncompulsive users to construct appropriate rituals and sanctions out of the folklore and practices circulating in the diverse drug-using subcultures. The peer group provides instruction in and reinforces proper use; despite the popular image of peer pressure as a corrupting force pushing weak individuals toward drug misuse, many segments of the drug subculture stand firmly against misuse of drugs.

Ibis does not imply that all illicit drug use, even among controlled users, is altogether safe or decorous. As with alcohol consumption, there are occasions when less than decorous behavior occurs. Obviously the only way to completely eliminate the attendant risks is to remain abstinent. We should never condone excessive use of any intoxicant, but we must recognize that if occasional lapses of control occur, they do not signify a breakdown of overall control. Drunkenness at a wedding reception is not a reliable indicator of alcoholism. Unfortunately, occasions of impropriety following the use of illicit drugs are likely to be taken (by abstainers, usually) as proof of the prevailing mythology that with these drugs the only possibilities are abstinence or compulsive use.

Despite occasional lapses by some subjects, the bulk of the controlled users we have studied demonstrate as much responsibility, caution, and control over their illicit drug use as does the average social drinker.

Interactions among drug, set, and setting.

As stated earlier, in order to understand drug use, drug, set, and setting variables must all be taken into account. The use of opiates during the Vietnam War and psychedelic use during the past decade and a half illustrate how these variables can interact and also how control of an illicit drug can evolve.

Recent estimates indicate that during the Vietnam War as many as 35 percent of enlisted men used heroin. Of these, 54 percent became addicted to it, and 73 percent of all those who used at least five times became addicted (Robins et al., 1977). When the extent of heroin use in Vietnam was first realized, officials of the armed forces and government assumed that the commonly believed maxim, "Once an addict always an addict," would operate, and that returning veterans would contribute to a major heroin epidemic in the United States. Treatment and rehabilitation centers were set up in Vietnam, and the Army's claim that heroin addiction stopped "at the shore of the Soath China Sea" was heard everywhere. As virtually all observers agreed, however, those programs were largely failures. Often people in the rehabilitation centers used more heroin than when they were on active duty, and recividism rates in Vietnam approached 90 percent (Zinberg, 1972).

Although pessimism was warranted at the time, most addiction did indeed stop at the South China Sea. As Lee Robins has shown, only 50 percent of the men who had been addicted in Vietnam used heroin at all after their return to the United States; and, what is more surprising, only 12 percent became readdicted (Robins et al., 1977). In order to account for the fact that so many veterans used heroin in Vietnam and that their rate of addiction dropped dramatically after they returned to the United States, set, drug and particularly setting variables must be considered.

Undoubtedly some personality configurations are such that dependence on almost any available intoxicating substance is likely. But even the most generous estimate of the number of such individuals is not large enough to explain the extraordinarily high rate of use in Vietnam. And since the military screens out the worst psychological problems at enlistment, the number of addiction-prone personalities might even have been lower than in a normal population. Robins found that a youthful liability scale correlated well with heroin use in Vietnam. The scale included some items that could be indicative of personality difficulties (truancy, dropout or expulsion from school, fighting, arrests, and so on), but it also included many non -personality-related items, such as race or living in the inner city. And it accounted for only a portion of the variance in heroin use.

It should be noted here that the bulk of research evidence linking personality with drug use has been riddled with serious methodological problems. Perhaps the most frequent problem in attempting to assess the importance of the user's personality is the difficulty of drawing sound conclusions when interviewing those who have become dependent on intoxicating substances. In the American cultural setting these users tend to sound and look like a group that is extremely vulnerable to dependence, and in a retrospective study it is easy to make a case for their original vulnerability. Until recently, studies of drug consumption have reinforced this tendency by centering on the most severe cases of misuse (Zinberg, 1975).

Another reasonable explanation for the high rate of heroin use and of addiction in Vietnam might be the availability of the drug. Robins notes that 85 percent of veterans had been offered heroin in Vietnam, and that it was remarkably inexpensive (Robins et al., 1977). Another drug variable, the route of administration, must also have contributed to widespread use in Vietnam. Heroin was so potent and inexpensive that smoking was an effective and economic method of use, and this no doubt made it more attractive than if injection had been the primary mode of administration. These two drug variables also seem to explain the decrease in heroin use and addiction among veterans following their return to the United States. The decreased availability of heroin in the United States (reflected in high price) and its decreased potency (which made smoking it wholly impractical) made it more difficult for the returning veterans to continue to use the drug as they had in Vietnam.

In the case of Vietnam, the drug variable may carry more explanatory power than the various personality variables, but like them it has limits. Ready availability of heroin seems to account for the high prevalence of use, but it alone does not explain why some individuals became addicted and others did not, any more than availability of alcohol is sufficient to explain the difference between the alcoholic and the social drinker. (Our current NIDA study, too, indicates that opiates are just as available to controlled users as to compulsive users.) Availability is inextricably intertwined with the social and psychological factors that create demand for an intoxicant. Once a reasonably large number of users decide that a substance is attractive and desirable, it is surprising how quickly that substance can become more plentiful. (Cocaine is a current example.) When the morale of U.S. troops in Germany declined in 1972, large quantities of various drugs, including heroin, became much more available than they had been before, even though Germany is much farther from opium growing areas than Vietnam.

The social setting of Vietnam was both alien and extremely stressful. This abhorrent environment must have been a significant factor, if not the primary factor, in leading men who ordinarily would not have considered using heroin to use it and sometimes to become addicted. Their low rate of addiction after returning home suggests that the veterans themselves associated heroin use with Vietnam, much as hospital patients who are receiving large amounts of opiates for a painful medical condition associate the drug with the condition and do not crave it after they have left the hospital.

The importance of the three variables--drug, set, and setting--becomes even clearer when we attempt to account for the changes in psychedelic use that have taken place during the last ten or fifteen years. Whereas the Vietnam data primarily illustrate how the prevalence of use is affected by these variables, psychedelic use illustrates how a more specific aspect of control--control over adverse effects--is influenced by drug, set, and setting.

About 1963 the use of psychedelics became a subject of national hysteria--the so-called "drug revolution "-epitomized by Timothy Leary's "Tune In, Turn On, and Drop Out" slogan. These drugs, known then as psych otomimetics (imitators of psychosis), -were widely believed to cause psychosis, suicide, and even murder. Equally well publicized were the contentions that they could bring about spiritual rebirth or a sense of mystical oneness with the universe. Certainly there were numerous cases of not merely transient but prolonged psychosis following the use of psychedelics. In the mid-1960s such psychiatric hospitals as the Massachusetts Mental Health Center and Bellevue were reporting that as many as one third of their emergency admissions resulted from the ingestion of these drugs. By the late 60s, however, the rate of admissions had dropped dramatically (Zinberg et al., 1977). Initially, many observers concluded that this drop was due to a decline in use brought about by fear tactics-the warnings about various health hazards, the chromosome breaks and birth defects, reported in the newspapers. In fact, although psychedelic use continued to be the fastest growing drug use in America through 1973, the dysfunctional sequelae virtually disappeared. What then had changed?

Neither the drugs themselves nor the personalities of the users were the major factor in cases of psychotic reactions to psychedelics. A retrospective study of the way such drugs had been used before the early 60s has revealed that although responses to the drugs varied widely, they included few of the horrible, highly publicized consequences of the mid-60s (McGlothlin and Arnold, 1971). In another study conducted before the drug revolution, typologies of response to the drugs were found, but not a one-to-one relationship between untoward reactions and emotional disturbance (Barr et al., 1972). It appears therefore that the hysteria and conflict over psychedelic use that characterized the mid-60s created a climate in which bad trips occurred more often than they had before. Becker in his prophetic article of 1967 compared the then current anxiety about psychedelics to anxiety about marihuana in the late 1920s when several psychoses had been reported (Becker, 1967). He hypothesized that the psychoses of the 1920s had come not from reactions to the drug itself but from the secondary anxiety generated by the media, which had exaggerated the drug's effects. Suggesting that such unpleasant reactions had disappeared later because the actual effects of marihuana use had become more widely known, he correctly predicted that the same thing would happen in relation to the psychedelics.

Social learning about psychedelics also brought a change in the reactions of those who had expected to gain insight and enlightenment from their use. Interviews have shown that the user of the early 1960s who hoped for heaven, feared hell, and was unfamiliar with drug effects had a far more extreme experience than the user of the 1970s, who had been exposed to a decade of publicity about psychedelic colors, music, and sensations (Zinberg, 1974). The later user had been thoroughly prepared, albeit largely unconsciously, for the experience, and therefore his response was far less extreme.

Increased control over the psychedelics seems to be attributable to the subcultural development of controlling sanctions and rituals very like those regarding alcohol use In the larger culture. The rule "Use the first time only with a guru" counseled neophytes to team up with experienced users who could reduce their secondary anxiety about what was happening by interpreting it as a drug effect. "Only use at a good time, in a good place, with good people" gave users sound advice about taking drugs that would make them intensely sensitive to their inner and outer surroundings. In addition, it conveyed the message that the drug experience could be merely a pleasant consciousness change rather than a visit to he extreme of heaven or hell. The specific rituals that developed to express these sanctions--as to just when it was best to take the drug, how it was best to come down, and so on-varied from group to group, though some that were particularly effective spread from one group to another. Today (1979), controlling rituals and sanctions are widely available to those who use psychedelics.

The psychedelics also provide a good example of the role that pharmacology plays with regard to control of use. Since they produce a long period of well-defined consciousness change, they are more easily controlled than other drugs. The length of intoxication and its intensity make the psychedelics special -occasion drugs, requiring users to set aside a considerable period of time in which to deal with drug effects. And the process of defining a special occasion brings in a variety of controlling factors, including the development of sanctions and rituals. Although at the height of the drug revolution some users took psychedelics several times a week, reports from the Haight Ashbury Free Medical Clinic and from our own study show that no case of such use lasted longer than a year or two at the most (Zinberg et al., 1977). While that was, of course, a long time in which to make frequent use of such powerful substances, and the resulting psychological damage cannot be assessed, it is still hard to imagine anyone becoming habituated to the psychedelics. So, though the social setting variable explains the reduction and virtual elimination of severe emotional reactions to psychedelic drugs, the drug variable is most important in accounting for the low rate of dependence.

These themes-informal social controls; the evolution of these controls; and the complex interactions of drug, set and setting-are addressed by many of the articles in this issue.

Comments on the Articles

The articles in this issue have been divided into three groups, arranged according to theme. The first four articles offer a broad theoretical perspective on control (Apsler; Maloffet al., Herman and Kozlowski; and McKenna). The second group of five articles deals with the problem of ascertaining the actual degree of control within a population (Dole and Singer; Bunce; Newmeyer and Johnson; Kramer; and Hunt). The last three articles (Kaplan; Waldorf and Biernacki; and Moore) share a common concern for the more formal aspects of control, represented by treatment and a policy of supply reduction.

Theoretical perspective on control.

Robert Apsler's article, which summarizes the results of his survey research, has a much broader perspective than most empirical reports and therefore fits well with the more purely theoretical pieces by MaIoffet al., Herman and Kozlowski, and McKenna. Apsler's findings deal with a variety of substances, including food, prescription drugs, and licit and illicit recreational drugs, and the data are organized around the fundamental theoretical issue of the nature of control.

The article argues that control is a valuable measure of substance-using behavior. Apsler distinguishes between controlling consumption in accordance with some internal standard of appropriate use, such as using until one is satisfied, and controlling it according to an external standard, such as the advice of friends as to how much should be consumed. This dimension, which he labels "style of control," varies systematically with the self-reported degree of dependence on a substance and with problems associated with its use. Thus, style of control is logically tied to other dimensions that we automatically associate with the concept of control. Moreover, Apsler shows that "the way individuals control their use of a substance is at least as important a dimension of substance use as is the actual amount of the substance ingested." Since style of control is a unique and separate element contributing to the consequences of substance use, Apsler argues that it and other dimensions of control should be used to supplement such well-worn quantitative measures as number of using occasions and number of days of use.

As Apsler's work suggests, control consists of or might be measured by a combination of different dimensions, including the way in which consumption is managed (style of use), amount consumed over time, short- and long-term effects on mental and physical health and on capacity to function socially, and degree of dependence (Zinberget al., 1978a). All of these elements define quality of consumption (that is, control); and many are represented in the papers that follow.

Maloffet al. deal with the external half of Apsler's external-internal dichotomy in style of use; that is, they are specifically concerned with how external social forces influence control. Acknowledging that psychological and biological variables and differences in the properties of substances determine the consequences of use, Maloff focuses specifically on the influence of sociocultural factors. She pursues this topic with respect to informal factors, excluding the formal rules created and enforced by the state and its agencies and subsidiaries. Her goal then is to describe "how participation in social groups enables people to know how much of a substance is 'enough' or 'too much' to be used."

Remarkably, after narrowing the focus, Maloff is able to show that what remains-namely, informal controls-is itself an extremely complex and powerful determinant of substance use. Dozens of cross-cultural examples are given to show how social factors--cultural recipes, social learning, sumptuary rules, sanctions, and "everyday social relations "~-in fluence every aspect of substance use including when, where, why, how, and with whom use occurs. Many of the carefully detailed aspects of social control which Malof 'I discusses and analogous to our concepts of rituals and social sanctions (Harding and Zinberg, 1977). Her catalogue of informal social controls is extremely comprehensive, indicating the richness of this area for future investigation.

Maloff's view concerning the relative importance of social variables is also very close to what we discussed earlier in our own work. An example is her discussion of the variations in how substances are used, which relates to our earlier comments about the limitations of drug variables. Using data from different cultures and subcultures she shows that the same substance can be used in many different ways. Alcohol, for example, can be used as a treatment for illness, as a recreational intoxicant, a sacramental substance in a religious context, a lubricant for socializing, a beverage with food, a sleeping potion, a symbol of celebration, and so on (also see Zinberg and Fraser, 1979). As Maloff states, this variability "suggests that the purposes and the outcomes of use are not dependent solely upon the pharmacological properties of the substance." And since these variations occur among the largest social groupings it is difficult to see how they could arise from set variables and, more specifically, from personality-unless, of course, it could be shown that each of the cultures and subcultures has specific personality characteristics which vary systematically. Thus, setting becomes the logical choice for explaining the variability in the consequences of drug use.

A further limitation on the influence of drug variables is put forth by Herman and Kozlowski. They point out that the pharmacological effect for a given substance may be very difficult to determine since it can be significantly altered by other substances. Coffee, for instance, which contains the stimulant, caffeine, can help counteract the fatigue associated with intoxication from the depressant, alcohol. Herman and Kozlowski indicate, however, that drug interactions are often more complex than a balancing of or a simple change in subjective effects. Discussing the effect of alcohol on the regulating threshold for nicotine they state: "Acute doses of alcohol can double or even triple smoking rate in ongoing smokers." Apsler too notes uncertainties with the drug variable, such as the impurities and variable potency of "street" drugs, which make if difficult to determine the dosage used. Thus, to the extent that drug variables do exert an important influence on use, this influence may be very difficult to measure and to study.

Herman and Kozlowski hypothesize that control depends upon individual thresholds for consumption, which are influenced in turn by a variety of constitutional and conditioned factors. Rejecting earlier theory that described the individual as attempting to regulate use at a single level, they advance the idea of a range in regulation between upper and lower bounds that signal excess and insufficiency. These bounds provide feedback as they are approached, but between them there is room for the substantial variation so commonly observed in the amount of a substance used. In the consumption of food, for example, there is wide variation between "starving to death" and "being stuffed."

Herman and Kozlowski also posit the existence of two interacting regulatory systems, short term and long-term, to explain complicated situations, such as that of the truly starved individual who after finally eating may be "simultaneously hungry (below the lower limit of long-term regulation) and sated (at or above the limit of short-term regulation)." They remind us that any theory of control must account for phenomena as diverse and inherently selfcontradictory as anorexia nervosa and obesity.

Again we find in Herman and Kozlowski's work the recognition that control depends on multiple "constitutional" and "conditioned" factors, including pharmacological, physiological, psychological, and situational variables. Furthermore they contend-we think correctly-that although all these factors are constantly interacting, then relative importance varies at different levels of consumption. Their specific formulation is that the effect of "pharmacological/ physiological forces will predominate outside the range of regulation, whereas psychological /situational factors will be more evident within the range of regulation."

This formulation works, but it should be kept in mind that Herman and Kozlowski are talking about an immediate rather than a chronic level of consumption. When the focus is shifted to a given long-term level, the relative importance of the variables may also shift (which presumably is allowed for in Herman and Kozlowski's theory). McKenna deals with a case in point, the long-term intensive use of a drug, which he argues is more closely related to psychological variables, or set, than to other factors. He defines the drug-dependent individual as one who often takes a substance to relieve a dysphoric psychological state. For such a person heroin may alleviate distress as well as or better than the tranquilizers or other licit drugs so frequently prescribed for similar purposes. The problem, of course, is that however legitimate the drug taker's need, heroin use is illegal, and associated with its illegality are the possibility of arrest, high cost, uncertainty as to strength and purity of the drug, and other risks. Thus the self-treatment with heroin may well prove more harmful than the original condition.

As McKenna's review of the literature reveals, the choice of psychological factors as an explanation for drug use has been favored for many years. Why, it has been asked, is an individual so foolish as to lose control or to enslave himself to a drug like heroin, unless he is crazy or the drug is chemically seductive? McKenna rejects such simplistic approaches, qualifies his viewpoint much more carefully than do most of the investigators who emphasize the psychological aspects of drug use, and clarifies the role of set in controlled use by spelling out when personality is important and when it is not. He cautions that (1) drug dependence must be understood in terms of pharmacological and environmental factors as well as psychological variables; (2) psychological factors may not be important for all drug users who are dependent, though they are clearly paramount for some; (3) drug dependence is associated with a variety of personality types and problems; and (4) it must not be assumed that the personality defects observed after abuse actually existed before the drug was used. In relation to the last point, it appears that McKenna is much more concerned with the immediate motives for use, for example, to relieve dysphoria, than with the personality factors which led to beginning use and on to abuse.

When we solicited an article on the influence of set variables on drug use, we expected that we would have to explain at length why we and perhaps the other contributors disagreed with the conventional psychological point of view (see Zinberg, 1975). But McKenna has divorced himself from the conventional view, has so clearly limited his discussion to drug dependence, and has qualified his viewpoint so carefully that there is no theoretical conflict between us (see Zinberg, 1975). Certainly he leaves room for the view that social setting plays an equal and at times a paramount role in shaping drug-using behavior, particularly with respect to nonabusive patterns of consumption.

Empirical assessment of substance control.

The first article on this theme, by Dole and Singer, is concerned with evaluating methadone maintenance. They assert that although an evaluation of a therapeutic agent may employ appropriate methodological safeguards-including random assignment to a treatment or control group, double blind administration of the drug, and objective measurement of outcomes--almost insurmountable problems remain that bias the results. For example, the number of variables, such as the demographic variables, that presumably affect response to a drug is much larger than can be controlled for in a study aimed at evaluating that drug. Researchers usually compromise by running trials on only a subgroup of the population of interest and then assume that the findings can be extrapolated to the entire population. Dole and Singer emphasize that evaluating drug treatment for chronic medical conditions raises even more difficult problems. If treatment lasts for months or years, the external conditions affecting it may vary uncontrollably, the treatment regimen itself may be difficult to hold constant, and subject attrition may increase beyond tolerable levels. Dole and Singer are discussing a restricted situation that, unlike a natural setting, gives the researcher opportunities to control at least some conditions. As a consequence, the research problems they emphasize are even more discouraging to the investigator of drug variables than are the uncertainties described by Herman and Kozlowski and by Apsler.

This paper is consistent with the positions taken by Dole and his frequent collaborator, Dr. Marie Nyswander, from the very beginning of their work. Their first published studies on methadone established the drug variable as a necessary but not sufficient factor to explain drug consumption. Methadone treatment was essentially an attempt to make use of the drug variable; heroin was replaced by another drug that was longer-acting, less intoxicating, could be used orally, and was legal. But apart from what they called "social rehabilitation," which encompassed both the psychology of the individual and the development of capacities that allowed him to be aware of and cope with the social setting, they found that changing the drug variable had only limited potential (Dole and Nyswander, 1967, 1976).

The next two articles, by Bunce and by Newmeyer and Johnson, discuss recent changes in one aspect of control-the rate of transient adverse reactions associated with recreational drug use.

Bunce's analysis of survey data indicates that from 1965 through 1975 there was a substantial decline in the rate of bad trips among American male psychedelic users, which he ties to changes in the cultural outlook toward psychedelics. He theorizes that the higher rate of bad trips in the mid-1960s was the result of sharp public controversy over psychedelic use, while the later decline in bad trips corresponded to a quieting of this controversy. Bunce disagrees with Howard Becker's view that adverse drug effects decline as the subculture of drug takers grows and develops more information about how to use the substance appropriately and as it provides increasing social support for use. But it should be noted that while Bunce fails to find statistical evidence for Becker's hypothesis, he has only limited data to examine, data that apparently were not collected originally for the purpose of testing either Becker's or Bunce's views. As our earlier discussion indicates, we believe both Bunce and Becker are correct; that is, both the broad cultural attitudes and the activities and values of the drug-using subculture have shaped the consequences of psychedelic use as well as other illicit drug use. As we see it, several levels of the social setting interact to influence drug experience, including the cultural (Bunce), subcultural (Becker), peer group, and parental levels.

Following Bunce's excellent documentation of an improvement in level of control over psychedelics, Newmeyer and Johnson offer evidence of change in the use of alcohol, marihuana, psychedelics, and other recreational drugs within the specific setting of rock concerts. Working with data gathered from emergency medical teams, they conclude that between 1973 and 1977 the type of drug associated with adverse reactions shifted from LSD to alcohol and PCP. Thus it appears that the improvement in control observed by Bunce does not extend to all drugs in all settings. The reasons for increased problems with alcohol and PCP need further study. It may be that, pharmacologically speaking, these substances are more likely than the psychedelics to generate short-term adverse effects; or perhaps, since their widespread use in this setting is relatively new, we can expect that
problems With them will decline as experience in L',cchc! is of course, an old drug, but its consumption by adolescents in a concert setting for the same general purposes as they would use marihuana, psychedelics, and other illicit drugs is relatively new.)

A striking feature of Newmeyer and Johnson's findings is that at rock concerts the overwhelming majority of users "either have a positive experience on the drug or are able to handle a negative experience without the assistance of the emergency care facilities." Contrary to the prevailing view that illicit drugs readily overwhelm the user, particularly the younger user, it appears that control over the high state is normative at least in the rock concert setting. It would be interesting to know whether the more widely accepted use of other intoxicants in other crowd environments-beer at ball games, for example-results in more or fewer adverse reactions.

John Kramer also upsets conventional beliefs about the dangers of certain "bad" drugs, in this case the history lesson that use of opium in nineteenth-century China resulted in widespread dysfunctional addiction. Careful. analysis of historical data on the production, import, and consumption of opium, combined with pharmacological evidence about the drug's potency and the development of addiction, leads him to conclude that intermittent and nonaddictive use was in fact the most common pattern of consumption. Further, he finds that even when addiction to opiates did occur, it was not always disabling. Since opium was easily available for decades in China, Kramer's conclusions also upset the conventional view that ready access to a pleasure-producing, addicting drug inevitably results in widespread addiction and dysfunctional use.

Kramer appeals to both "psychophysiological " and cultural factors to explain why most Chinese seem to have been moderate, controlled opium users. Although it has been widely assumed that drug users in general take as much of the drug as is available until they approach what they believe to be a dangerous amount, he notes that lower doses of opium may be preferred because higher doses may be more dysphoric than euphoric. Kramer states, however, that social values also led users to restrain use, and that such cultural variables were probably more important than psych ophysiol o gic al factors in moderating nineteenth century Chinese opium use, as they are today in other Asian countries. Again, setting variables are seen as the primary influence on control.

Leon Hunt discusses the relationship between an increase or decrease in the number of users of a drug and its level of misuse. Obviously, a policy attempting to eliminate all use of a drug may be unnecessary or unwise if the proportion of those who misuse it is very small and not likely to increase even if overall use should increase. Nonetheless, as Hunt says, the question of how the level of misuse changes "is seldom asked by policy rnakers and has never been answered satisfactorily for any substance."

Answering this question can be a complicated matter. For example, per capita consumption figures are relatively easy to obtain for licit substances such as tobacco and alcohol, but they do not clearly indicate what patterns of consumption exist. An increase in per capita consumption may mean either that the number of users has increased or that individual users have increased their consumption. The complication with which Hunt is most concerned is the time that elapses between the use of a drug and the emergence of unequivocal and easily assessed evidence of its misuse. With alcohol, for example, the development of cirrhosis may take years, even for the heaviest drinkers. The problem then is that what may have been counted as use at one time may turn out much later to have been misuse. ,

Hunt offers a three-step solution to the problem of measuring level of misuse: (1) define misuse as opposed to use; (2) describe the natural history of misuse, including the probability that a user will change from one pattern of consumption to another as develops and (3) determine the classified by their various patterns of use.

While Bunce's article on transient adverse effects shows that a change in the proportion of one kind of misuse can be determined reliably, Hunt's paper indicates that methodological problems, such as the very late appearance of harmful effects of some drugs, can be overcome. Thus it appears that the obstacles to understanding the relation between misuse and prevalence of use are less technical than political and economic.

Formal regulation of illicit use.

John Kaplan's article, a brief that opposes heroin maintenance, is an example of lawyerlike reasoning at its best. He examines two models of heroin maintenance: (1) the prescription system, in which the addict redeems a prescription from an authorized clinic for enough heroin to maintain him for a reasonable period; and (2) the "on the premises" system, in which the addict must consume heroin under direct supervision. Kaplan argues that the one major "intractable disadvantage" of the prescription system is the high probability of drug diversion to the illicit market, which would cause an increase in illicit use and an "unacceptably high addiction rate." Perhaps the chief disadvantage of the "on the premises" system is that the very restrictions and supervision that recommend this approach as a way of limiting diversion would probably prove very unattractive to addicts. It is hard to imagine a great many addicts being interested in running back and forth to a clinic several times a day to administer the drug under someone's watchful eye.

Kaplan's very practical arguments against heroin maintenance are clearcut. But as Kaplan himself indicates, some issues remain that are not so clearcut. One is the question of the advantages and disadvantages of current policy. Even granting all the limitations and problems of heroin maintenance that Kaplan outlines, some observers might still prefer it to the present prohibitionist policy with its enormous social costs. And the weighing of the alternatives will always be very closely related to moral and ethical questions: Would the expectedly larger number of drug casualties under heroin maintenance be more or less acceptable than the social costs of the present system? Is a regulatory system that limits individual choice about 'which substances to consume more or less acceptable than one that would increase choice?

Kaplan himself finds the relevant arguments difficult to judge with precision. For example, he states that a disadvantage of heroin maintenance is that it might undermine "cultural constraints against heroin ... might weaken the simple fear that many have of initially trying the drug." But on the other hand, he notes that "the more we treat addiction as a sickness, the less glamorous and attractive it might become." Though the "demystification" of heroin that might accompany heroin maintenance might make the drug less attractive and though more responsible heroin use might develop through increased opportunities for social learning, Kaplan feels that the dangers Of heroin maintenance would outweigh these advantages. This comparison of arguments, however, rests more on supposition than on fact.

Indeed a fundamental problem underlying any policy discussion is that in order to be reasonably confident about which policy is correct, more precise information is required than is now available. Critical questions remain unanswered: What is a reasonable estimate of the number of users who will retrogress to misuse of heroin? What is a reasonable estimate of the proportion of people who will try opiates and like them? What proportion of drug casualties would have been disabled even if they had not had access to drugs? Without crucial information like this, it would be very risky to implement heroin maintenance. But if such information should become available and if new attitudes toward use of opiates naturally evolve, and if using patterns should shift, reassessment of these and other alternatives might be appropriate.

Finally, it might be possible to evade Kaplan's criticism by considering models of heroin maintenance other than the two he discusses. Kaplan states that the burden of proof as to the advantages of other systems rests with those who propose them. Though we have no wish to take on that burden, it might be fruitful to consider mongrel approaches, such as the provision of heroin in take-home, weekend doses while administering methadone during the week. This sort of alternative, even if it is reserved as a reward for "good" patients, might make treatment more appealing to the current active "street" addicts who may well be more numerous than those who are now in treatment (Zinberg et al., 1978b). At the same time, diversion of heroin might be small enough to avoid contributing to a black market and to increased misuse.

Underlying the ongoing debate over heroin maintenance and all existing treatment programs are other fundamental issues: how control over a drug develops, how it is lost, how or whether it can be regained. One way to increase our understanding of how treatment works would be to study how control that has been lost is regained naturally, without any treatment. Waldorf and Biernacki have contributed to such study by reviewing the research literature on spontaneous remission from heroin addiction. This review leads them to two conclusions: (1) that such remission is not nearly so rare a phenomenon as is commonly assumed and (2) that non treated addicts may recover at the same rate as those who receive treatment. As Waldorf and Biernacki note, the shortcomings of the research reviewed keep these conclusions tentative, but the evidence is sufficient to challenge the popular conception of heroin as a drug so seductive that recovery from addiction requires intensive and prolonged assistance followed by lifelong abstinence. 'Me research indicates that addicts can recover (regain control) without treatment, and in some instances they may even become occasional non addicted users. Obviously it would be extremely beneficial to learn how "natural" recovery takes place and to incorporate the findings into the design of treatment programs. This is one of the goals of Waldorf and Biernacki's ongoing study of spontaneous remission.

The last article in this collection, by Mark Moore, is a detailed defense of the current supply reduction policy. That policy attempts to eliminate certain drugs or to greatly reduce their availability on the ground that reduced availability makes it harder to lose control (in the sense of increasing consumption) and even harder to begin use. Moore's analysis is as enlightened as it is sophisticated. He recognizes the need to supplement enforcement efforts aimed at reducing supply with viable and 'attractive treatment opportunities. Policy, he states, must take into account the fact that the magnitude of the treatment should differ for various drugs, and that not all illicit use is equivalent to abuse. He acknowledges that despite all efforts some drugs will still reach illicit markets. And he says that enforcement efforts should concentrate on traffickers and heavy users.

Ironically, Moore's own analysis, which shows up the problems and uncertainties of designing an efficient supply-reduction system, makes us question the ability of such a system to substantially reduce the number of casualties from drug use below present levels. The basic stumbling block discussed by Moore is that the production and distribution systems for illicit drug use are intricate, well defended, and appear to differ from drug to drug, involving both totally illicit systems and diversion from licit systems, This means that any supply-reduction strategy must strike an artful balance between being diversified enough "to minimize the chance that we miss a major choke point in the system" and specific enough to be efficient and manageable.

Moore draws three major conclusions: (1) "a successful supply-reduction policy depends on a variety of specialized capabilities," which in turn "poses a significantorganizational design problem" ? , ~ flit, major requirement for action is a capacity to immobilize major trafficking organizations; and (3) improved control of amphetamines and barbiturates depends critically on a strengthened regulatory program. Moore advances these conclusions as a blueprint for planning a more effective policy, but from our more pessimistic point of view each of these steps seems enormously complicated. Some, such as targeting traffickers, have been tried with only limited success for years; and according to Moore's own estimate it may require between five and ten years to develop the necessary capabilities. The prognosis for a more successful supply-reduction policy seems dim indeed.

Policy Implications

The existence of a wide range in the degree of individual control over virtually any intoxicant raises a fundamental question about present policies toward illicit drugs: If the controlled use of marihuana, psychedelics, cocaine, heroin, and other illicit drugs is possible, why not promote this control as an adjunct or alternative to present prohibitionist policies? Maloff, for example, wonders whether the existing informal controls that help to prevent abuse could be sufficiently strengthened to replace formal controls. Apsier asks whether alternative prevention and treatment strategies could be developed to teach "style of control" as a means of reducing harm from illicit use. Certainly the shortcomings and vagaries of present policy make consideration of alternatives especially tempting.

The financial costs of prohibition are enormous. Under black market conditions the potency, purity, and even the identity of drugs are uncertain, which increases the risks of overdose and other adverse effects. For some drugs-marihuana is a good example-punishment for using may be more harmful to the offender than the pharmacological effects of the drug. Prohibition also severely limits opportunities to learn how to control the use of illicit drugs.

Deviancy amplification is another hazard of present policy. The impact on individual personality structure of being declared deviant-"sick" and in need of treatment, or "bad" and deserving punishment-may create a self-fulfilling prophecy (Young, 1971). Some users come to accept an identity which includes an antisocial component not originally present. Others may incorporate the mainstream culture's view of them as weak and dependent, and come to feel they cannot cope without the drug or institutional care or some other prop. This kind of dependent personality structure, whether it developed before or after long-term drug use, is notoriously difficult to treat. Few if any drug treatment programs can be "successful" or even reasonably palliative when such severe life difficulties are created for drug takers.

There is considerable uncertainty about the degree to which present policy succeeds. Just how many people are persuaded not to try illicit drugs, how many users are prevented from becoming compulsive, and how many drug takers are driven into treatment is unknown.

All too often this sort of critique of present policy is accompanied by radical proposals that all illicit drug use should be decriminalized or legalized. A case in point is Thomas Szaszs laissez-fair approach (Szasz, 1975). However, as Kaplan and Moore point out in their papers, an increase in the number of drug users would mean an increase in at least the absolute number of drug casualties. Because of this risk in radically increasing access to any drug (licit or illicit), a more cautious approach to change is needed than is provided by Szasz and by most other critics of present policy.

Weighing the economic and social costs of present policy against its benefits and comparing this balance sheet with one that might be drawn up for an imaginary alternative policy is astonishingly complex. There is, however, a way out of this dilemma, which is a middle-of the-road approach based on the observation that significant informal social controls over illicit drug use are now developing (Zinberg et al., 1978b; Harding and Zinberg, 1977). That strategy would involve continuing to discourage the use of illicit drugs while at the same time encouraging development and dissemination of controlling rituals and social sanctions among those people who do use drugs. The basic aim of this strategy would be to alleviate the worst effects of the current social setting on drug takers without greatly increasing access to drugs.

As Maloff points out, informal social controls cannot be provided ready-made to users, nor can they be created by formal policy. They arise by largely unknown processes in the course of social interaction among drug takers. They are not the work of the moment; they develop slowly in ways that fit changing cultural and subcultural conditions. This is the primary reason why any abrupt shift in present policy would be inappropriate. The sudden legalization of even marihuana might leave some users ill equipped to handle the drug because the social controls needed to moderate use and prevent abuse might not have had time to develop. There are, however, a variety of cautious steps that could be taken now to demystify drug use and thus to encourage the development of appropriate rituals and social sanctions.

These steps concern information (education), medical research, attitudes toward drug users, treatment programs, and legal reform.

More value-neutral, accurate information about licit and illicit drugs can be provided to the general public and to current and potential drug users. In addition to rudimentary pharmacological information, the consequences of various styles of drug use should be described. Drug education efforts should recommend abstinence and make it clear that there are unavoidable risks attached to any drug use. If these educational efforts are to be credible, however, they must include what most drug users and nonusers already know: that drug use can be pleasurable and that by taking appropriate precautions the risks of use can be greatly reduced. Educational programs should avoid communicating the sense that the difference between licit and illicit drugs is a difference between "good" and "bad." More emphasis should be placed on the need to control all drugs, including alcohol and caffeine. Stressing the potential problems associated with their use allows for consideration of the general principles that cause drug problems. This is particularly difficult now when excessive attention and emotionalism are attached to pointing out the harmfulness of a substance like heroin, which in fact is used very rarely.

Demystification of illicit drugs can also be hastened by increasing research on the possible medical applications of marihuana, the psychedelics, and other illicit drugs. If work is sufficiently publicized, it may help dispel the public's sense that such drugs are so bad that there is no point in investigating the possibility of their medical value. Further, the use of these drugs or their appropriate pharmacological components should be permitted in medical practice if and when they are proved useful. There has already been important progress in this area. Potential medical applications of marihuana in the treatment of glaucoma and as an antiemetic agent and as an anti-convulsant drug have received research attention, and even the efficacy of using heroin as an analgesic is now the subject of careful research.

Steps can be taken to encourage more open discussion between drug users and nonusers, particularly in counseling and treatment situations. This would permit the dissemination of controlling rituals and social sanctions about drug use in general, and it might also alleviate the alienation of drug users and prevent deviancy amplification.

Better training can be provided to doctors, teachers, counselors, and other professionals who regularly encounter drug users. A scant decade ago many young people whose parents discovered they were using marihuana were unceremoniously rushed off to counselors and psychiatrists. Many of these counselors genuinely thought that any use indicated a need for treatment and even that any continued use made treatment impossible. The mythic fears and moral prohibitions of the larger social setting often intruded; and preoccupation with the drug itself interfered with reasonable communication between counselor and patient.

This situation has eased. The tendency to routinely condemn any and all use is being replaced by a sense of appropriate concern. There is still a need, however, to provide professionals with more accurate and up-to-date information about drugs and, more important, about the ways in which they are being used. There is still no comprehensive typology of drug use which can assist professionals in distinguishing between varying patterns of use so that they can be clear about whether the issue is drug use or a genuine drug problem. In the interest of providing accurate information about drugs, more low-cost laboratories for confidential analysis of drugs should be established. This service can assist users in avoiding untoward drug effects and may contribute to the idea of quality control.

As a critical part of the social setting, both influencing it and being influenced by it, treatment programs must be made more responsive to drug users with actual or potential problems, and must be designed to avoid substituting therapeutic dependence for pharmacological dependence. Like drug education, treatment programs should discourage use of drugs but should also be willing to advise those users who have little interest in abstinence how they can use drugs more safely. Treatment programs should provide appropriate referrals and assistance for a broad spectrum of health and other problems. As Dole and Nyswander (1976) have argued from the beginning, it is the psychological and social rehabilitation that is crucial in drug treatment. The reintegration of the patient into a reasonable social setting is certainly as important as any of the programmatic elements aimed at dealing with the drug use itself.

When it comes to the possibility of changing the laws prohibiting use, access to drugs is directly affected and therefore an extremely conservative approach is recommended. At present the only major change with an acceptable level of risk would be to gradually extend decriminalization of marihuana beyond those few states where it has already been adopted. Four facts suggest that extending decriminalization would be reasonable policy: (1) marihuana appears to be a relatively benign drug when used occasionally and in low doses; (2) occasional marihuana use is the predominant pattern of consumption; (3) limited research data indicate that prevalence has not increased sharply in some states that have decriminalized marihuana; and (4) because marihuana use is now normative behavior among some age groups, it is unlikely that prohibition will substantially reduce its use. No similar change in the law respecting other illicit drugs is proposed. Such change should not be contemplated until the consequences of decriminalizing marihuana are better understood, until it can be shown that these drugs are being used in predominantly moderate and reasonable ways, and until public attitudes toward them become more enlightened. The only additional legal recommendations are that, as Mark Moore suggests, the penalties for use reflect the distinction between the experimenter or occasional user and the abuser, and that enforcement be directed against traffickers rather than users.

The primary advantage of this approach to policy is that it is conservative; it aims simply to keep pace with informal social controls. Exactly what steps should be taken and when will depend on how well informal social controls appear to be working. All steps should be incremental, and policy response should be flexible, allowing for frequent changes as drug use and the social setting evolve and as the impact of previous steps is evaluated.

Future Research

The major problem in evaluating any drug policy, old or new, is that many questions about how control over drug use is affected by policy remain unanswered. We need not wait for all the answers before taking the first tentative steps toward changing current policy, but more research on control is needed to guide the direction and the pace of change in the future.

A prime example of research which is directly related to policy considerations is that of determining the impact of decriminalization on marihuana use. Studies of this impact have been carried out in both Oregon and California, but neither study has satisfactorily compared quality of use before and after decriminalization. What is needed is long-term study of the impact of decriminalization on prevalence and incidence of use and also on the quality of use, quantity and frequency, adverse effects, style of control, and so on. Research of this sort should be done in states that have already decriminalized and also in states that have not yet decriminalized but might do so in the future, so that comparisons of the situation both before and after the change can eventually be made. Decriminalization of marihuana is a critical social experiment that must be studied more closely in order to plan effective drug policy.

The following list gives additional examples of research that should be done:

(1) As Maloff points out, research is needed on how customs and norms surrounding drug use arise, and on the degree to which these customs and norms express good (rational) judgment about optimum use of a substance.

(2) Herman and Kozlowski suggest that research is needed on various substances to determine how much individual thresholds vary, what may alter these thresholds, and the degree to which they may be innate rather than acquired.

(3) Longitudinal studies of drug use are needed to determine how control may vary with spontaneous changes in the environment, such as the loss of a job, death of a mate, geographic shift, or increased access to drugs.

(4) More research is needed to describe the relationships between different patterns of use and the users' health and capacity to function socially. A primary goal would be to specify what constitutes use as distinct from misuse.

(5) There is need to analyze the events that propel users into drug treatment and also to determine whether the reason for seeking treatment varies systematically with treatment outcomes.

(6) Research should be done to discover what keeps users out of treatment-especially those who suffer the consequences of dysfunctional use. Learning how street addicts endure heavy addictive involvement with heroin may help explain why present policies have so little effect on their use, and may also suggest ways of making treatment more attractive to them.

(7) As suggested by Waldorf and Biernacki, drug takers who recover spontaneously from abuse should be carefully compared with those who have been treated. This work would indicate to what degree treatment makes a significant contribution to recovery, as well as the nature of that contribution.

(8) Studies should be made of users who have succeeded in developing patterns of occasional use to replace more intensive (abusive) using patterns.

(9) As Apsler suggests, research should be done to isolate the appropriate measures for different dimensions of control, which in turn should be incorporated into survey research.

(10) Much more needs to be learned about early socialization in the use of various intoxicants. Marihuana may be of special interest in view of the growing number of marihuana-using parents whose children are entering early adolescence and will soon have to decide whether or not to use the drug.

(11) As mentioned earlier, Hunt argues the need to study the natural history of substance use and proposes that these findings be incorporated into surveys to determine how much misuse occurs and how the proportion of misuse may change over time.

(12) Although research has been done on the use of prescription drugs, hardly any of these studies have Laken into account what the physician intended, how the patient understood the physician's instructions, how the patient used the drug, and whether the prescription as given constituted good medical practice. To understand how well prescription drugs are being controlled, all these factors need to be considered.

As this partial list indicates, a great deal more research is needed on control of drug consumption. Much of it will require gathering longitudinal data over many years, which is a particularly expensive process. Until now, major changes in drug policy have been made through the dynamics of the political process without much regard to the state of knowledge about drug use. This situation can be expected to continue unless a major investment is made in further research.

NOTES

1. National Institute on Drug Abuse Research Grant #1-ROl-DA-0136001AI-A3, "Processes of Control among Different Heroin-Using Styles."

2. Our use of the terms rituals and social sanctions differs from their use by anthropologists and sociologists. We see drug-using rituals as primarily behaviors or practices, and social sanctions as primarily beliefs or dogmas. But in anthropology, terms such as ritual beliefs and ceremonial beliefs are used instead of social sanctions; and in sociology the term social sanctions usually refers to the actions taken to enforce normative behavior (as in Maloff's paper in this collection). We agree that social sanctions can refer to both the belief and the actions taken to enforce it. These differences in terminology and the reasons for them are discussed in detail in Harding and Zinberg, 1977.

3. For the detailed history of alcohol use from which this discussion has been excerpted, see Zinberg and Fraser, 1979.

*Norman E. Zinberg, M.D. is on the Faculty of the Harvard Medical School and the Boston Psychoanalytic Institute. He is Psychiatrist-in-Chief at the Washingtonian Center for Addictions. Jamaica Plain, Massachusetts, and is the author of more than 100 publications which have appeared in both professional and popular journals. He was a Guggenheim Scholar and the recipient of a Fulbright-Hays Senior Faculty Lectureship Award, London School of Economics and Political Science. Dr. Zinberg was Coordinator of the Task Panel on Psychoactive Drug Use/Misuse of the President's Commission on Mental Health and is currently a member of the National Advisory Council on Drug Abuse, ADAMHA.

*Wayne M. Harding, Ed.M., a research associate at The Cambridge Hospital, Cambridge, Massachusetts, is currently coprincipal investigator on a NIDA-sponsored grant entitled "Processes of Control in Different Heroin-Using Patterns." His research interests are control over substance use and the relationship between social policy and customs and norms.

The help of Dorothy C. and Leonard W. Whitney, Shirley M. Stelmack, Ellen Dubach, Jack Barrett, and Miriam Winkeller was consistent and inestimable in preparing our section of this publication. and Miriam Winkeller's valuable assistance extended to the editing of this entire issue. Richard L. Rachin was patient and supportive throughout, despite some trying difficulties and delays.

Although this collection considers with care a wider range of drug-axing patterns than is generally studied or even acknowledged, this information is in no way intended to condone, endorse, or encourage any use of any drug, licit or illicit. Rather this Information is intended to be put in the service of the prevention of drug abuse.

Norman E. Zinberg. M.D. Wayne M. Harding. Ed.M.

 

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