Drug Abuse

Concern over the abuse of psychoactive drugs implies a standard for normal or nonabusive drug use. Yet, with the exception of alcohol and tobacco, there have been no studies of the drug-using experiences of normal populations Cisin and Cahalan's (1966) study of alcohol use is the most recent and extensive national study of what a representative sample of citizens does in regard to the use of one mind-altering drug. For most other drugs we do not know what normal use is; thus, we are not provided with a standard for comparison with individuals of interest, nor, on epidemiological grounds, can we see what national syndromes of use emerge or how such syndromes, once isolated, are associated with other factors which might play a role in producing different kinds of drug use, drug responses, or immunity to adverse reactions or styles of use.1

In 1964, we became interested in studying the drug experiences of a normal population. We wanted to know something about the lifetime prevalence of use of various classes of psychoactive and self-modifying agents, to identify patterns of use, and to identify social and individual correlates of these patterns. We had hoped to undertake our work on a fairly large scale but lack of funds limited us to a pilot study. This paper presents some of the results of that work. In view of its exploratory nature, we have tried to keep our presentation relatively informal.

SAMPLE AND METHOD

A quota sample of 200 noninstitutionalized adults was drawn. The quota characteristics were defined by the most recent United States Census data. Because we were originally interested in a rough comparison of drug use in two cities within the larger San Francisco Bay area, we drew two separate subsamples of a hundred each, the quota of each defined by census data for the community. That initial interest in crude intercity comparisons soon faded and we combined the two samples for our pattern and correlate analyses. It cannot be assumed that either sample provided an accurate estimate of total-population drug behavior or that the combined samples are representative of the larger metropolitan region. We do assume that the findings from the two subsamples and the larger combined sample reveal drug behavior not radically different from what occurs in the normal adult population, that hypotheses tested in the sample and found fruitful bear further testing in other populations, and that drug-use patterns as identified in the sample may be useful classifications or syndromes for others who undertake large-scale endeavors. The instrument employed was a pretested questionnaire requiring about one and a half hours per respondent. The interviewers were a psychiatric social worker and three graduate students in psychology. Location of interviews was by assignment to neighborhoods of known socioeconomic level and racial composition. Within neighborhoods respondent selection was by quota requirements.

AREAS OF INQUIRY

Difficulties arise from seeking to describe individual patterns of psychoactive drug use, for what constitutes a pattern? The focus may be on lifetime histories or only on a recent time period. One may wish to determine amounts ingested or simply use per se. One may wish to describe occasions of use by time or setting (social, private, institutional, medical, and so on) or to establish only average frequency rates (weekly, for example). One also has to decide whether dosage, or amounts, are to be inquired about, as well as manner of drug administration. The decision as to what classes of drugs are to be included as psychoactive is, of course, a critical one and once they are decided (inevitably with forebodings) the job is to find a way to ask people what they have taken so that they discuss at least something of what they know about their own drug behavior.

We decided to ask about the lifetime-use history of a number of subtances, some of which are not psychoactive in any conventional sense. For example, we wanted to know about such things as laxatives, aspirin, "health" and "appearance-enhancing" drugs, sexual-appetite changers, and even birth-control pills. Aside from simply being curious, we believed that a number of substances can play psychic functions, even though their pharmacological sites or modes of action are not of the kind that ordinarily and directly produce mind alterations. Such changes, if they occur, might be placebo responses, reactions to changed excitational or arousal (motivational) states, altered self- or role-conceptions, responses to physiological changes (pain reduction, contraception), and so forth. We did not have time to explore all possible "secondary" mind-altering substances (if they be that) ; therefore, our choice of substances for inquiry was limited to those cited by respondents during the pretests of the interview or to those we assumed to be widely known and employed.

In an inquiry about drugs used, one can ask in terms of common parlance, most of which are functional categories such as "stay-awake" pills or sleep aids, or one may inquire about more limited classes of drugs ranging in breadth from generic groups such as tranquilizers or sedatives to pharmaceutical families (barbiturates, amphetamines) or to specific agents (Demerol, heroin). Our assumption in approaching a normal population was that there would be a considerable variation in accuracy of reporting depending upon how we asked the question. Pretests of the questionnaire supported that fear. In consequence, we asked two different types of questions: one set based on the purposes for which drugs might be used ("Have you ever used any drug or drinks to help you stay awake, to make you more alert, less tired?") and the other set listing particular substances ("What has been your experience with such stimulants as amphetamine, benzedrine, dexadrine, dexamil, goof balls, or other pep pills?").'

We did not ask about dosage or routes of drug administration. We did ask about present use in terms of gross frequency (regular, occasional) and we inquired about the circumstances of initial use of each drug—who had suggested it and at what age the opportunity had arisen.

Childhood experience. One perspective from which we view drug use is based on the simple notion that people learn to use drugs from the same respected older people who teach them other things about living—primarily their parents but also physicians, teachers, older siblings, and so on. "Teach" is not meant formally; it refers to the transmission of knowledge, viewpoints, and habits—the whole culture which surrounds the growing child. Correspondence between what parents do and what children learn to do has already been shown in studies of two social drugs: alcohol (Knupfer, Rink, Clark, and Goff-man, 1963) and tobacco (Salber and MacMahon, 1961). In addition, the role of prestigeful or dominant persons (husbands, employers, respected persons) in the initiation of less dominant persons into LSD has been shown (Blum and Associates, 1964). The role played by older persons as "immunizing" factors has also emerged in studies of heroin transmission (Stevenson, 1956; Chein, Gerard, Lee, and Rosenfeld, 1964).

We expected to find that parents also play a role in initiating their children into drug use not only through their social practices but through their "teaching" of medical care. By that we mean parental attention to illness, their use of prescription drugs and home remedies, and their transmission of views on the efficacy of pharmaceuticals as cures for ailments. We also expected to find a different kind of influence resulting from the way parents handle the emotions of their children. Making the assumption that parents who react adversely to emotionality in their child make him uncomfortable (conflict ridden) about his own emotions and that excessive, voluntary drug use represents an effort to alter felt emotionality, we expected that those children in our study who characteristically received adverse parental handling of emotionality would be in a higher-drug-using group. Although the memory-dependent data of this study prevented any final test of that latter expectation, we did make an initial test.

Orality: food habits. For the most part, drugs are taken orally. We expected that drug taking as one kind of oral behavior would be related to other kinds of oral behavior—specifically to food cravings, to intense food likes and dislikes, and to the presence of feeding problems in childhood or food aversions in adulthood. Since our expectation was that excessive or intensive drug experience (defined by its contrast to normal or common drug use as described later in this study) is likely to involve psychic conflicts centered about drug ingestion (such as cravings, dependency, and magic), we expected that people with other symptoms or intensive interest in the orality sphere would be in the high-drug-use group.

Relations with parents. We have already referred to parental handling of children's emotions as one factor we expected to be associated with drug use. Another factor, which is by no means independent, is how the adult recollects his view of his parents when he was young. We expected that persons who were hostile to their parents —or, at least, recollected as having been so—would be more troubled individuals who would express their general distress in excessive drug use.

The conventional psychodynamic thesis is that hostility to the father in particular is associated with rebellion against other kinds of authority; thus, the expectation is that persons engaging in illicit drug use will be particularly critical of their fathers. However, parent-directed expressions of hostility may be expected among the illicit drug-using group on other than simply psychodynamic grounds. Our preliminary observations of the hippie crowd suggest that the younger psychedelic set may find it fashionable to be critical of the Establishment—parents included, to exaggerate intergeneration conflict, and to present oneself in the pseudo-sophisticated psychological deterministic way as being the still-suffering child whose woes are attributable to inept parents. Consequently, subgroup fashions, as well as individual psychodynamics, may shape the expression of views of parents and thus contaminate efforts to measure hostility as such. Conceivably, the silent conservatives who abuse neither drugs nor the images of their parents may harbor strong resentments too. No conclusive test can be made by any interview method, but we inquired to sense the lay of the land.

Life satisfactions. We expected respondents' expressed satisfactions with themselves, their social relations, and their work to be least in the group with the greatest drug experience. A number of reasons underlay our thesis. The first was that the felt distress and conflict coloring views of parents might be one part of a more general outlook, a sour point of view which might reflect individual frustration, neuroticism, or despair but which, in any event, was an intrapsychic problem that might be associated with escapist or anxiety-suppressing drug use and with the search for new means to reduce unpleasant inner experiences. Another possible component in dissatisfaction might be sensitivity; the presumably idealistic person turning to inward experiences might do so because of disillusionment with the world as it is. Another component might be in the culture of the hippies and the New Left, which can elevate criticism into a cult of displeasure. Clearly, a diversity of possible reasons for expressed life dissatisfaction might be in order—a diversity which complicates and retards sound inference about the state of the inner man. Nevertheless, the essential expectation that dissatisfaction with self and others is a correlate of high drug use was, we felt, worthy of exploration.

Feelings and cathexis.8 We asked respondents several questions about wanting things, craving things, disliking things, distrusting things, and fearing their own relationships to desired or suspect objects. Some of the questions centered on foods, cravings and aversions for which we have already discussed in terms of our notions of orality and drug use. But these same feelings, and related ones, may also be conceived in terms of cathexis, its intensity and polarity, and the conflicts, compulsions, and anxiety which center about that which is the object of such strong ties of emotion and desire or repulsion. We found it convenient to consider drug-dependency fears and suspicion about drug contents as part of a feelings-and-cathexis concept. One of our expectations, a straightforward one, was that those who used drugs least would be those with aversive responses—that is, the people who would most fear dependency and most suspect drug contents would be in the low-drug-use groups. That notion was predicated on a hidden assumption that we are, as a society, a drug-using culture, so that high drug use is normal and that those who use less than ordinary are reacting defensively against dominant influences. As our study shows, we were totally in error about the relationship of dependency fears to drug use. On the other hand, as our study will also show, there was reason to believe that the concept of cathexis intensity, measured by cravings and fears thereof, might indeed bear on drug-use patterns.

Other experiences. We were interested in aspects of drug use itself which we did not wish to include in our measures of use or in our pattern-identifying efforts. Are heavier drug users, for example, more sensitive to drug-induced mood changes in the social situations where psychoactive drugs are typically employed? We expected high drug users to be more responsive than low drug users to this social-facilitation effect. What about proselytizing and sensitivity to social criticism? Do heavier users admit to what others have observed (Blum and Associates, 1964), that they do have a missionary spirit and are sensitive to criticism? We thought they would be. If heavy drug users orient their life around drugs, as we believed they did, then wouldn't one find that they have used drugs in some uncommon way as tools or experiments? Might not these range from suicide attempts to religious experience? We tried to find out.

Background characteristics. Whatever explanations are offered for the differential patterns of experience in drug use or for the use of illicit-exotic drugs in particular, an identifiable pattern of drug use should be expected to be but one feature of a life style which has other distinguishing characteristics as well. In terms of the comparisons of groups differentiated by a pattern of drug use, certain constellations of background and behavior might be expected to be associated with the experienced drug users that do not characterize—or at least not so often—the less experienced, "lighter" users. Such expectations are based on the assumption that the personality and motives, social circumstances, learning opportunities, and even genetic predispositions possibly associated with drug-use patterns are but part of the larger fabric of life. By drug-use patterns we mean the patterns of medical care and prescription-drug use fully as much as social drinking or the more private use of heroin. Given these elementary expectations, we inquired about background features and then compared the status of the several drug-using groups. We expected to observe, for example, what others have already found: that exotic-drug use is primarily an activity of young males.

RESULTS

Our first task was to describe population subgroups based on lifetime drug use which would prove meaningful for identification and analysis. We first ranked classes of drugs—by name or function—by the number of persons in the combined (N:= 200) sample' who reported one-time-or-more use in their lifetimes. Figure 1 presents those data. From Figure 1 we see that aspirin (and compounds containing it) is reported used by the largest number of persons and that any drug used to alter sexual appetites is least often reported. ,
The next step was to select cut-off points by which to divide our psychoactive (and self-modifying) drug spectrum into those classes of drugs most used, moderately used, and least used. Cut-off points were made at what appeared to be natural divisions in the kinds of use cited and, also, where relatively large step decreases in frequency of persons reporting experience with that class of drug could be seen. "Class of drug," of course, includes combined pharmaceutical, folk nomenclature, and functional (motivational) categories as a consequence of how we inquired about drug use and how it was reported back to us. The three cutting points can be seen in Figure 1. The first group of substances are what we term "Class I," the most commonly employed drugs, and include the typical social drugs (alcohol and tobacco), the common home remedies (aspirin and laxatives) and the medical mainstays, and the painkillers (prescribed opiates, anesthesias). As we can see, all of these have been used by two thirds or more of our sample (save laxatives at 64 per cent). The second group, Class II, contains mostly drugs prescribed by physicians, although over-the-counter vitamins, sleeping aids, and weight-control preparations are included. The range is from a high 46 per cent for drugs to control anxiety to a low 10 per cent for antidepressant compounds. The third major division, Class III, consists entirely of exotic and illicit drugs except for one functional category, drugs used to alter sexual appetites (the drugs so used need not be exotic or illicit; alcohol was one). The range in Class III is from 9 per cent reporting marijuana experience to 2 per cent reporting having taken something to depress sexual desire.

Our next step was to set up four categories of persons based on their experience with the several drug classes. Members of Group I had no experience with any drug type or any drug-use function in our inquiry spectrum (N ---- 2). Group 2 (N = 28) were persons who had used one or more Class I drugs but had not used any drug in Class II or Class III. Group III (N= 135) included those subjects who had used one or more Class II drugs in addition to having used Class I drugs, but had not used any Class III drug. Group IV (N 34) included those subjects who had used one or more drugs from Classes I and II and had also used a Class III drug. These groups, our "patterns" of lifetime drug experience, were derived from an inspection of the data. The progression (no temporal sequence implied) which defines an individual's group membership on the basis of experience with all preceding, but no following, drug classes is analogous to the cumulative property of Guttman scales (Guttman, 1944). This "scalogram" concept fits our data well, but certainly not all individuals in the population at large would fit into any of our four groups. We do think that the scheme—including, perhaps, work on coefficients of reproducibility—merits further investigation.

Group I was the most unusual group, since its two members had used no drugs of any kind. Statistically a dwarf, Group I is mentioned separately in our later analysis only because of our special interest in its members. Group I cases should be sought out for special study in larger numbers. Group II was also a small group, about an eighth of our sample; its drug experience was limited to common social drugs (alcohol, tobacco), common home remedies, and painkilling drugs given on prescription or as anesthesia during surgery. Group III is the modal category consisting of persons who had only used social drugs and home remedies but who had also had considerable experience using prescription psychoactives or over-the-counter preparations for control of a wider variety of psychic, somatic, and self-modifying functions. Group IV, about a sixth of our sample, had used social drugs, home remedies and proprietary mind-and-body altering substances, psychoactive prescriptions, and also illicit drugs—and, in some cases, conventional drugs for exotic purposes, such as cortisone to get "high," alcohol to suppress sex, and nonopiate cough syrups for "kicks." We would define Group IV as heavy users in terms of their variety of drug experiences.

Figure 2 shows the distribution of the variety of drug use by person, as opposed to reported frequencies of use by drug class (as in Figure 1). The distribution approximates a normal curve, and we feel safe in assuming such a distribution for drug experience in general. In our sample the modal frequency is seven varieties of reported drug experience. Only a few persons have had less than four of the different drug experiences on our spectrum and only a few have had four,teen or more.

Implicit in the scheme of classifications set forth in Figure 1 and in the notion of a normal distribution seen in Figure 2 are not only a search for constellations of drug use (or experience) but also a possible progression and prediction. Unfortunately, the present classification scheme offers only a little help in these directions. For example, by knowing a person's drug group we know, for Groups I, II, and III, what kinds of drug experiences he has not had. At the upper end, Group IV, there is also some increased ability to estimate the drugs he has had, depending on the class of the drug. At one end, with aspirin, the best guess is that everyone except those in Group I has had it. At the other end of the spectrum are the hallucinogens. Only 4 per cent of our population have used such drugs, and all are in Group IV, one fifth of whom have had hallucinogens. In terms of the constellation of drug experience, no person reporting hallucinogen use has had less than twelve other drug experiences on the spectrum. For marijuana, the most common Class III drug, the average number of other drug experiences for marijuana users is eleven although one person reported he had used only six other drugs. Figure 3 shows the minimal (not average) variety of other drug experiences among persons reporting the use of each of the drug classes in the spectrum.

Present use. We asked all respondents about their present use or nonuse of the various substances in the spectrum. Regular was defined as "often" or "periodic" use within the twelve months prior to the interview; occasional use was "rarely" or "sometimes" but "at least once" during the prior twelve months; no present use indicated no use of that drug within the last year. Table 19 shows that present-use practices closely approximate the lifetime experience for it and indicates the rank orders for frequency of lifetime use from Figure 1 as compared with frequency of present or occasional use from Table 19. Ranks are the same, or within two rank steps, for all but two major exceptions, the painkillers and heroin.5 The great discrepancy is for painkillers, which were much more widely experienced than now used. That finding is consistent with the medical employment of these substances during acute injury or illness but not under normal care. Heroin (including cocaine and smoking opium) also has a greater lifetime-experience frequency than present-use frequency. (The implication is clear—if respondents were accurate—that past use of hard narcotics, either used medically or illicitly, is a transient phenomenon not necessarily leading to chronic use.) We conclude that the drug class,es of lifetime-experience frequency of Figure 1 correspond well to the popularity of drugs as defined by their use within the last year.

Source for initial use. We asked all respondents who had first suggested they use the drugs about which we were inquiring. We find that although a variety of initiating sources do appear, there are, for each class of drug, one or two most common sources. Substances offered primarily by parents include aspirin, laxatives, and so-called health and appearance-enhancing drugs (such as vitamins). Parents also played an important role—although they are not the source most often mentioned—in introducing their children to beer, wine, and spirits. The latter substances were among the home remedies and acceptable social drugs offered early in life to most respondents. The ages of opportunity for taking these drugs as cited by respondents show modal frequencies for all but spirits during early childhood and the teens. Alcoholic spirits were not ordinarily offered until the mid-teens or later.

The physician is cited as a primary source for the following substances: painkillers (opiates), anxiety-reducing agents, sedatives, anti-allergy compounds, birth-control and weight-control prescriptions, antidepressants, and sex-decreasing drugs. The physician played an important role as source, but not as the major source, in initiating respondents into the use of laxatives, health and appearance-enhancing drugs, "stay-awakes" of all kinds (amphetamines specifically), sex-increasing substances, and, interestingly, remedies (such as cough syrups) which the patient might then use for "kicks." These drugs are, for most of our sample, medically employed substances, although it is also clear that many of these drugs may first be offered by nonmedical sources.

Friends were the primary source of beer, wine, spirits, tobacco, "stay-awakes" in general and amphetamines specifically, marijuana, remedies used for "kicks," narcotics, hallucinogens, and volatile intoxicants (sniffed). It is worth while to note that some respondents differentiate between friends and acquaintances, the latter playing an important role in introducing respondents to narcotics, hallucinogens, and marijuana. Since the preceding drugs are all social drugs primarily diffused among peers, the role of casual acquaintances rather than friends in the distribution of illicit substances suggests a somewhat different (more casual, less intimate) social and transmission structure in association with them. The ages of opportunity for these peer-diffused drugs cluster in the teen years and the twenties. The generally acceptable (even if illicitly used) substances such as alcohol and tobacco become available earlier than do narcotics. In this sample, LSD and other hallucinogens make a later appearance than any other drug group. This means that in terms of age of initiation, interest groups, and diffusion routes the hallucinogens are to be differentiated from narcotics.

Only one other source remains to be mentioned; it is the drug user himself who on his own seeks a drug without an interpersonal recommendation or initiation. No drug in our sample appears to be predominantly self-introduced, although for aspirin, sleeping compounds, health and appearance substances, "stay-awakes," antidepressants, volatile intoxicants, and sex-increasing drugs, self-initiation is mentioned not infrequently. Such drugs must be available over-the-counter or in some other "nonsocial" way for self-initiation to
OMIT.

Correlates of lifetime experience. There were a number of items of behavior and viewpoints about which we inquired and for which we expected differences among the several groups as defined by their reported lifetime drug experience. In order to present these findings as clearly as possible and with an economy of space, we will, for the most part, set them forth as a series of statements. The statements include proportion for low- versus high-drug-experience persons.° In many instances we have combined Groups I and II into a lowdrug-experience group and Groups III and IV into a high-experience group when inspection reveals little difference between III and IV. We have selected the more detailed presentation of data for each group to show distributions of particular interest.

BEHAVIOR AND ATTITUDES

The first question we asked was whether the pattern which we selected as a criterion for constructing population groups—the reported variety of lifetime drug experience based on the classification of frequency of use of psychoactive and self-modifying drugs—had any relationship to other measures of drug use, for example, current use. The two persons constituting Group I report no drug use of any kind during the past year. Group II (N= 28) report an average use of 1.6 drugs and the occasional use of another 0.8 drugs. Group III (N = 135 ) report averaging 3.2 regularly and another 1.6 occasionally. Group IV (N 34) report averaging 3.4 drugs regularly and another 2.2 occasionally. The trend is consistent in the expected direction. To express the relationship statistically, a correlation between current drug use (regular and occasional combined) and lifetime experience (each of three groups assigned equidistant values, Group I exclUded) yields r = .425 significant beyond the .01 level. (For regular use only, the correlation between current and lifetime [by group] experience yields r = .265, significant beyond .01.)

Drugs kept at home. Another factor which we expected to vary with lifetime experience—assuming that experience reflects a propensity to take drugs—was the number of drugs kept on hand at home. (It is to be noted that many people, when asked this question, tend not to reply in terms of alcohol, tobacco, marijuana, or even home remedies; consequently, response may be biased toward prescription substances.) A count of drugs on hand reveals that the two people in Group I have no drugs in the home. Group II averages 1.6 drugs on hand at home, Group III averages 3.3, and Group IV averages 3.5. These quantities are consistently in the expected direction.

A simple correlation between drugs at home and lifetime experience (Groups I, II, and III assigned equidistant values) yields r -= .262, significant beyond .01. Whatever the trends, one must be impressed with the similarity between Groups III and IV in terms of their home supplies and the reported regularity of drug use. Both groups are frequent drug users compared with Groups I and II. What is suggested is that experience with illicit-exotic substances need not reflect itself in a fuller medicine chest or in a strikingly increased regularity of drug use.

Medication efficacy and practices. High drug users (Groups III and IV combined) more often than low drug users (Groups I and II combined) report that medicines have made a difference in how they feel (81 per cent vs. 60 per cent).

High drug users (III and IV) medicate themselves when feeling ill more than do low (I and II) drug users (33 per cent vs. 7 per cent).

High drug users (III and IV) more often than low (I and II) report giving medication to their children (22 per cent vs. 9 per cent).

High drug users keep proportionately more prescription drugs on hand compared with proprietary substances (1/3 vs. 1/22), whereas more low drug users keep special health foods and beverages on hand than do the high drug users (7 per cent vs. 2 per cent).

Health and medical care. High drug users report more frequent visits to the doctor in the prior year than do low drug users. Twenty-five per cent of Groups III and IV made four or more medical visits; 10 per cent of I and II made four or more visits. Most persons in all four groups consider themselves healthy. Ten per cent in Groups III and IV (combined) say they are ill, while 7 per cent in Groups I and II report present illness. Another 8 per cent of the high drug users say they have been neither sick nor well, while 10 per cent of the low drug users indicate an up-and-down health state. We take it that patterns of medical care differ between the high- and low-druguse groups and that these differences may reflect other than health status per se.

As children, high drug users recall more serious illness than do low drug users (16 per cent vs. 7 per cent).

There is a general consistency in the amount of sickness reported by a respondent for himself as a child and for his present health status. Nevertheless, more shifts in health status between childhood and the present occur among high-drug-use groups than among low-drug-use groups (21 per cent shifts vs. 8 per cent).

As children, the high drug users recall more medicines in their childhood home than do low drug users (14 per cent of III and IV combined recall four or more different remedies; none in I and II recall that many medications on hand).

As children, more high than low drug users recall that they liked to be sick (17 per cent vs. 3 per cent).

More high than low users are able to recall advantages in addition to disadvantages to being ill as children. The figures by group are as follows: I, 0 per cent; II, 4 per cent; III, 25 per cent; and IV, 48 per cent.

Eating problems. High drug users report they had more childhood eating problems than do low drug users. The percentages are as follows: Group I, 0 per cent; II, 7 per cent; III, 28 per cent; and IV, 50 per cent.

High drug users report more eating problems as adults than do low drug users. The progression is Group I, 0 per cent; II, 4 per cent; III, 26 per cent, and IV, 41 per cent.

Parental handling of children's emotions.7 High drug users more than low report that their parents responded with reactions which they rated as negative handling when they, as children, were excited or overexcited (0 per cent vs. 8 per cent). [Results are vitiated by the large "don't-know" response, which is greater among the low users (33 per cent) than highs (20 per cent ) .]

High drug users less than low recall negatively rated handling of their childhood anger by their parents (28 per cent vs. 53 per cent). [Differences are vitiated by the higher rate of not remembering among the high-drug-use group (20 per cent) than among the low (2 per cent)]

No differential trends are visible in ratings of parental handling of upsets and tears (low drug, 3 per cent negative handling; high drug, 5 per cent). Lows, more than highs, do not recall or don't answer (24 per cent vs. 15 per cent).

When respondents as parents describe their own methods of handling their children's emotions, high drug users (III and IV) are rated as more often responding with negative reactions to their children's anger than are the low drug users (27 per cent vs. 2 per cent).

As parents, low drug users more than high often describe reactions to their children's tears and upset which are rated as positive or ego syntonic (65 per cent vs. 50 per cent). There is a high "no-children" or "don't-know" reply rate (27 per cent for lows, 29 per cent for highs).

Response to a loving mood in their own children led to reactions rated as "ill-at-ease" or "unusual" (and potentially ego alien) only among the high-drug-use group (7 per cent of those with children replying vs. 0 per cent in Groups I and II).

High drug users report more negatively rated responses to their own children's excitement or exuberance than do low drug users (19 per cent vs. 0 per cent). (Low drug users more often can not destribe their own reactions or deny overexcitement in their children, 26 per cent vs. 18 per cent).

Views of their parents. High drug users more often than low say they do not like their mothers (Group I, 0 per cent; II, 7 per cent; III, 15 per cent, and IV, 18 per cent).

The exotic-illicit drug users stand out as most often reporting dislike of their fathers (Group I, 0 per cent; II, 24 per cent; III, 16 per cent; and IV, 40 per cent).

High drug users more than low report disliking both their father and mother than do low users (Group I, 0 per cent; II, 0 per cent; III, 4 per cent; and IV, 12 per cent).

Varied dissatisfaction. With self: High drug users more often say they are dissatisfied with themselves than do low users (Group I and II, 0 per cent; III and IV, 15 per cent).

With social relations: High drug users more often than low say they are dissatisfied with how they get along with other people (Group I, 0 per cent; II, 0 per cent; III, 5 per cent; and IV, 15 per cent).

With work: High drug users more than low express dissatisfaction with their work (Group I, 0 per cent; II, 3 per cent; III, 11 per cent; and IV, 32 per cent).

Cathexis and dependency.8 High drug users more than low say that they like certain things too much or that they overdo; eating, activities, and sex are most often cited as examples (Group I, 0 per cent; II, 9 per cent; III, 31 per cent; and IV, 38 per cent).

High drug users more than low report cravings, never getting enough of something (ungratifiable strivings). Most often cited are love and emotion (Never gratified in at least one area, Group I, 0 per cent; II, 12 per cent; 111, 51 per cent; and IV, 63 per cent).

High drug users more than low report cravings for particular foods (Group I, 0 per cent; II, 7 per cent; III, 39 per cent, and IV, 50 per cent).

More high drug users than low report extreme or unreasonable dislikes. Most often cited are certain foods or activities (Group I, 0 per cent; II, 18 per cent; III, 40 per cent; and IV, 48 per cent).

High drug users more often express concern about becoming dependent on drugs than do low users° (Group I, 0 per cent; II, 3 per cent; III, 31 per cent; and IV, 56 per cent).

On a cross-analysis, persons expressing dependency fears tend to report food cravings. Using Chi Square, one finds that the association-is significant beyond the .01 level (Chi Square = 11.92).

On a cross-analysis, persons expressing dependency fears also tend to report unsatisfied strivings for things other than food. Using Chi Square, one finds the association significant beyond the .01 level (Chi Square 24.68).

Dependency fears were compared among persons on the basis of the number of drugs they said they used regularly. Constructing four groups on this basis (not on the lifetime-experience patterns), one finds that those who use the most drugs regularly are those who most often express fears of becoming drug dependent. (Of those using zero—one drugs regularly, 0 per cent are fearful; two—three drugs, 31 per cent fearful; four—five drugs, 33 per cent fearful; and six-or-more drugs, 62 per cent are fearful of drug dependency.)

High drug users more than low say they are taking things they ought not to be taking" (Groups I and II, 0 per cent; III and IV, 16 per cent).

High drug users more than low are suspicious of the contents of drugs they have taken (Group I, 0 per cent; II, 4 per cent; III,
12 per cent; and IV, 35 per cent).

Drug experiences. High drug users more often than low say they have had accidental overdoses of drugs (Group I, 0 per cent; H, 0 per cent; III, 9 per cent; and IV, 15 per cent).

High drug users more often than low say that they ingest more when they are with people than when alone." Smoking, drinking, foods are all included (Groups I and H, 13 per cent vs. HI and IV, 53 per cent).

High drug users more than low report mood-changing and sociability-enhancing drug effects in social situations. Often cited are stimulation and relaxation" (Groups I and II, 25 per cent; III and IV, 43 per cent).

High drug users more than low report having used a drug for religious purposes (Group I, 0 per cent; II, 4 per cent; III, 16 per cent; and IV, 30 per cent.

High drug users more than often than low report the use of drugs to reduce fear or induce courage (Groups I and II, 0 per cent; III and IV, 12 per cent).

High drug users more often than low report drug taking in response to being dared to by someone else (Group I, 0 per cent; II, 0 per cent; III, 14 per cent; and IV, 21 per cent).

High drug users more often than low report drug use as a matter of curiosity or experimentation (Group I, 0 per cent; II, 0 per cent; III, 32 per cent; and IV, 76 per cent).

High drug users more often than low report introspective, self-exploratory drug use (Group I, 0 per cent; II, 0 per cent; III, 2 per cent; IV, 21 per cent).

High drug users more than low seek to prolong any good moods they have; they may use drugs for this purpose (Groups I and II, 7 per cent seek to prolong good moods, but none uses drugs; III and IV, 22 per cent prolong good moods, and 5 per cent—of total—use drugs to do so).

High drug users more than low have "taken something" in suicide attempts (Group I, 0 per cent; II, 0 per cent; III, 4 per cent; and IV, 6 per cent).

Altered social relations. High drug users more than low report proselytizing for drugs, offering them and trying to persuade friends to try them (Group I, 0 per cent; II, 3 per cent; III, 31 per cent; and IV, 45 per cent).

More high drug users than low feel that persons taking drugs can fall under the (undesirable) control of another person" (Group I, 0 per cent; II, 7 per cent; III, 25 per cent; IV, 30 per cent).

More high drug users than low feel others are critical of them for their drug use" (Group I, 0 per cent; II, 0 per cent; III, 20 per cent; and IV, 44 per cent).

High use of dependency-producing drugs. For a subsidiary analysis we identified those respondents who were regularly using the greatest number of those drugs which we deemed to have the greater dependency-producing potential. Our list—perhaps overly broad—included alcohol, tobacco, narcotics, remedies for "kicks," volatile intoxicants, "stay-awakes," weight-control products, sedatives, anxiety-controlling agents, marijuana, and the hallucinogens. We do not argue for any physiological addiction with most of these—only that they seem to be the drugs employed by persons who become identified as drug-dependent. In our sample 17.5 per cent say they use none of the foregoing regularly, 68 per cent say they use from one to three regularly, 11 per cent say they use four regularly, and 3.5 per cent say they use five or six. Prior to testing, we did not assume that the regular use of many drugs which are associated in some persons with dependency is any proof of dependency, nor did we assume that dependency occurs only with "multihabituation" (Cohen and Ditman, 1962) and not with single drug use. What we did assume was that—consistent with our focus on variety of drug use—persons regularly using many potentially dangerous substances are subject to greater risks. We expected the people in our sample to show the greatest amount of drug-associated worry. We also expected them to fall in our Group IV exotic-illicit category.

We were wrong on nearly all counts. Case analysis shows that six out of the seven multiple regular users are in the normal, high-druguse Group III. Although five out of seven are worried about drug dependency, three limit their concern to conventional remarks about tobacco—"I ought to stop smoking"; two say they became dependent in the past on morphine but then withdrew themselves and now deny any present opiate use. Their expressed anxiety reflects their past, medically prescribed morphine experience, not any worry about present practices. With only one exception, none of these respondents expresses guilt or fear over his drug use, suspicion over drug contents, or fear of falling under the control of other drugs; nor have they suffered overdose effects or used drugs in suicide attempts. The one exception, the most worried person (and not very worried at that!), is a Group IV user. It is clear that in our sample the multiple use of many drugs considered to have dependency-producing potentials can occur without any excursions into exotic-illicit drug use, can occur as part of a normal, high drug use as statistically defined and culture-compatible, and need not be associated with any expressions of unusual concern or distress about drug effects or drug use per se.

BACKGROUND CORRELATES

Age
Groups I and II: the majority are age forty or over Group III: half are under forty; half over
Group IV: 70 per cent are aged thirty-nine or under

Religion
Groups I and II: the majority are Protestants; about a quarter are Catholic; 3 per cent nonaffiliated
Group III: half Protestant; a quarter Catholic; 2 per cent Jews (and only in this group) ; 15 per cent no answer or "don't know"; and 4 per cent agnostic
Total: 19 per cent nonaffiliated
Group IV: 35 per cent "don't know" or no answer; 9 per cent agnostic; almost a third Protestant; a quarter Catholic
Total: 44 per cent nonaffiliated
Church attendance within the last year:
Groups I and II: 82 per cent
Group III: 62 per cent
Group IV: 38 per cent

Education
Groups I and II: 18 per cent with some college education or more Group III: 46 per cent with some college or more
Group IV: 59 per cent with some college or more

Family income
Groups I and II: 75 per cent with $10,000 or less; 7 per cent with $15,000 or more
Group III: 61 per cent with $10,000 or less; 13 per cent with $15,- 000 or more
Group IV: 72 per cent with $10,000 or less; 6 per cent with $15,000 or more

Sex
Groups I and II: two-thirds male Group III: two-thirds female
Group IV: two-thirds male

Race
Groups I and II: 72 per cent white; 11 per cent Negro; 18 per cent Oriental and other
Group III: 91 per cent white; 7 per cent Negro; 2 per cent Oriental and other
Group IV: 97 per cent white; 3 per cent Negro; no Oriental or other

Marital status
Groups I and II: 14 per cent single; 69 per cent married; 14 per cent widowed; 3 per cent divorced
Group III: 12 per cent single; 77 per cent married; 7 per cent widowed; 4 per cent divorced
Group IV: 15 per cent single; 65 per cent married; 15 per cent divorced; 5 per cent widowed

Children
Groups I and II: none, 23 per cent; one—two, 33 per cent; three plus, 43 per cent
Groups III and IV: none, 29 per cent; one—two, 42 per cent;-three plus, 29 per cent

Political preference
Groups I and II: Democrat, 42 per cent; Republican, 34 per cent; Independent, 25 per cent
Group III: Democrat, 45 per cent; Republican, 33 per cent; Independent, 19 per cent; other, 3 per cent
Group IV: Democrat, 47 per cent; Republican, 18 per cent; Independent, 32 per cent; other, 3 per cent

YOUNG-AGE GROUP RECONSIDERED

Clearly, an association does exist between age and varieties of drug experience. In our sample the drug "conservatives" (Groups I and II) were older, the great middle group of high normal users (III) corresponded to the total population, and the illicit-exotic drug users
(IV) were mostly under thirty-nine. No doubt, much of the variation in response to all the interview items can be considered as part of the constellation of background differences among these groups. Because of our special interest in youthful drug users, our focus was on all respondents age twenty-nine or under (N 57), distinguishing within that population the four subclasses of drug users. This method held age constant while observation was made of other background characteristics. The distribution of our young people was as follows: Group I, 0 per cent; Group II, 9 per cent; Group III, 72 per cent; and Group IV, 19 per cent. Only a minority of the young people in the sample, then, were in the exotic-drug-experience category, and they comprised only a third of the total exotic-drug-use group (N = 34).

Comparing these Group IV exotic-drug-experience respondents with the other (Groups I, II, III) respondents, age twenty-nine and under, we find the following:

Most (64 per cent) exotic users have no religious preference; most persons (80 per cent) in the other three drug groups have religious preferences.

Those with preferences and those with only nominal ties are Protestant in the majority—both in Group IV and in Groups I, II, and III combined.

Most exotic users have not attended church within the last year; most others (68 per cent) have attended.

Students comprise 36 per cent of the exotic-use group, while students comprise 24 per cent of the others; however, only 9 per cent of the exotic-use group have had graduate work; 26 per cent of the others have had graduate work.

Most young people in all groups are married.

The modal political preference for exotic users is Independent; for others it is Democrat.

The modal income category for exotic users is $5,000 or less; for the others it is $5,000 to $10,000.

The majority of exotic users are male; the others are divided about equally into male and female.

Exotic users are all whites; Negroes and Orientals are found in the other groups.

We see that when age is held constant, the same background features differentiate between the high- and low-drug-experience groups. We can conclude that the high-drug-use pattern is indeed part of a special constellation of sociocultural and psychological variables, not simply a phenomenon of being young alone.

SUMMARY AND CONCLUSIONS

An exploratory study of normal-population, psychoactive and self-modifying drug use was undertaken. Attention was directed to the identification of simple patterns of drug use and to the relationship between drug-use experience and social and personal factors. Two quota samples of a hundred each were drawn to be representative of noninstitutionalized adults in two communities within a larger metropolitan area. Reported drug use by the two samples was quite similar. Probable sampling error, limitations of inquiry method, and likely respondent-recall failures precluded exactness in estimating real population behavior from the samples.

Ranking classes of drugs used by frequency led to a threefold categorization. Class I drugs used by the majority included conventional social drugs (alcohol and tobacco), simple proprietary and home remedies, and the medical painkillers and anesthesias. Class II drugs were primarily prescribed psychoactive substances, but included over-the-counter remedies employed for particular purposes. Class III drugs were illicit and exotic; our definition of "exotic" included the use of a conventional drug for an unusual purpose.

From the grouping of persons according to their experience with the foregoing drug classes, our results show the following: the most unusual group (Group I, 1 per cent) is comprised of those who have had no experience in their lifetime with any psychoactive or self-modifying drug. Group II, about a seventh of the sample, has used only the most conventional social and proprietary drugs and the prescribed painkillers (Class I drugs). Group III, comprising two thirds of the population, has used both Class I and Class II drugs. The fact that the majority of the sample have had relatively wide experience with drugs indicates that normal drug use in a metropolitan area means a high rate of acceptance of drugs as ways for achieving a variety of personal, social, and medical purposes. Members of Group IV, comprising a sixth of our sample, have all taken Class I and II drugs, as well as Class III drugs; they are the heavy users as seen in terms of varieties of drug experience.

Exploring relationships between lifetime drug experience and other facets of drug use, we find that current drug use is greater the more the lifetime experience, r .= .425, significant beyond .01. There is also a somewhat greater number of drugs reported currently on hand at home the greater the lifetime drug experience, r = .262 significant beyond .01.

We expected that the heavier users of drugs, defined in terms of our lifetime-experience categories, would differ from lesser users of drugs in a number of related areas. Our inferences were based on trend data, differences in proportions—these not subjected to statistical testing. Our data suggest the following:

Medical and sickness experience. Persons with the greater drug experience will have had more experience with medical care as such, will believe in the efficacy of medication more, and will both give drugs to others and self-medicate more; they will also have been more willing to be "ill" as children, having found advantages in taking the patient's role.

Orality. Persons with the greater drug experience will have had more psychological conflicts centered about orality, measured by reported eating problems, both as children and adults.

Parental handling of emotions. Vitiated by high rates of not recalling and by inconsistent directions of response, no clear-cut trends exist in reports of how respondent's parents reacted to their children's emotions. There is more consistency on the "turn-about" side, suggesting that high-drug-use respondents as parents may handle their own children's emotions more negatively. Our expectation that emotions would become ego-alien during the course of childhood development, so that adult emotionality would be handled by suppressive or dissociative drug use, remains, in the self and in children, at best unresolved.

Views of parents. The high drug users more than low express dislikeof their fathers and mothers; important in terms of rebellion against authority, the greatest expression of dislike comes from illicit-exotic users and is directed toward the father.

Dissatisfaction. The high drug users are more dissatisfied with themselves, with their relations with others, and with their work.

Cathexis and dependency. The high drug users appear more subject to cravings, unsatisfied (insatiable?) desires, extreme likes and dislikes, possible compulsive activity, possible guilt over ingestion habits, evident suspicion of drug contents, and drug-dependency fears—all of which we infer to be related to more intense, polar cathexis, the latter reflecting psychodynamic conflict. On theoretical grounds we proposed a specific relationship between dependency concerns and cathexis intensity. Trends are in the predicted direction. Statistical tests of association between dependency fears and (1) food cravings and (2) unsatisfied desires reveal both to be significant beyond the .01 level. Dependency fears are also tied to drug use per se; the more drugs used regularly, the more likely that the respondent will report concern over becoming drug-dependent.

Social responsiveness. The high drug users appear more subject to social facilitation as a spur to their oral-ingestion behavior in general and to drug taking in particular, for when they are with others, they say they take more food and drugs. They are also more responsive in the sense that, when young, they more often tried a drug on a "dare." Furthermore, they appear more subject to mood-enhancement or social potentiation of drug effects when in the presence of others.

Anxiety over social relations. It is in the high-use group that drug proselytization, sensitivity to the criticism of others for drug use, and fear that a drug user can fall under the control of another (nonuser) are most often expressed. We take these as indications of anxiety over social relations which are affected either by drug use per se or by the fact of membership in an "outside" group (Becker, 1963).

Drugs as tools. The high users more often use drugs to achieve ends which were not part of our initial-inquiry spectrum. So it is that they report drug use for religious, courage-enhancing, introspective, or self-analytical purposes. Outstanding is the frequency with which the high users report drug use as a matter of curiosity or experimentation. We infer that a generalized notion of drug utility underlies such use, as does a qualified confidence in outcomes—"qualified" where there is conflict-ridden cathexis, anxiety over social relations, or experience with bad effects.

Bad effects. More accidental overdoses are reported in the high-drug-use group.

Suicide. Only in the high-drug-use groups does one find reports of the use of drugs in suicide attempts. The trend for Group IV is to report more (6 per cent) such drug attempts than Group III (4 per cent). We have no data on differential suicide-attempt rates by groups as such; the present findings suggest, for preventive work, which persons are liable to use drugs as suicide weapons.

Background differences. In our study, considerable and consistent background differences separated the two least-drug-using groups (I and II) from the normal high users (III) and these, in turn, from the illicit-exotic Group IV. As one moves from least to most drug experience, one finds education, divorce, and the proportion that is white and youthful increasing. Conversely, as one moves from high to low drug experience, both church affiliation and church going increase as do age and Negro or Oriental ethnicity. Males predominate in the least- and most-drug-use groups, while females predominate in the high normal group. The high normals also have the highest average income and the least independence in political-party affiliation; the illicit-exotic group are the most often politically independents. We find no one word that aptly summarizes the background findings, especially since each group contains diverse elements. Perhaps "conservatives" comes close for the least-drug-experience people, "middle class" for the high normals, and "liberal disaffiliated" for the illicit-exotic people.

COMMENT

Given the limitations of this study, ranging from sampling errors through the overlapping drug classes reported and the inability to control for psychological sophistication as a source of differential-response bias among the groups, we do not contend that our observations constitute more than leads for more thorough work. It does appear that a measure of lifetime drug experience can be a useful one for approaching drug use and abuse, that "normal" drug use is considerable, and that individual differences are related to such factors as learning drug use in childhood, being socially responsive to others, being exposed to drug use by virtue of group membership (including institutional as well as peer-group affiliation), being disaffiliated with mainstream traditions, and, on a personal level, with psychodynamic factors possibly related to ingestion and orality, to cathexis intensity and polarity, to parental relations, and to satisfaction-dissatisfaction. By implication drug abuse must be considered as multidetermined, ranging from genetic and biochemical levels, not discussed here, through the individual psychological social and cultural levels touched upon in this study. It would appear that normal processes such as learning and social interaction must be considered in the development of use patterns—including abuse—along with pathological processes.

1 Subsequent to the completion of this study, Cisin, Mellinger, Mannheimer, and their colleagues, working in cooperation with NIMH, have undertaken a national study of drug use and its correlates. Their study, with adequate samples and sophisticated inquiry methods, will be of great interest. Another study, reported by Robins and Murphy in 1967, reports on drug use in a population of Negro men in their thirties. Ten per cent of their sample admitted to heroin use, 50 per cent to illicit use of some drug. High school drop-outs were most prone to illicit experimentation; a drop-out with an absent father and a delinquency record was likely to use heroin.

2 One method which we would have employed—had we thought of it! —to facilitate drug identification is that now being used by Cisin, Mannheimer, Mellinger, et al. in their national study of drug use. Here the respondent is presented with pictures taken from the Physician's Desk Reference. Another method—to enhance accuracy of reporting for current behavior—which we are using in a subsample of our present study of student drug use requires the respondent to keep a daily diary of drugs ingested.

3 Cathexis refers to the energy valence attached to objects (including persons) by a person. It includes both intensity and sign (negative or positive) and may include emotional, motivational-arousal, like-dislike, and other attitudinal components. As a psychoanalytic construct, it has potential utility in analyses of addictions and dependency.

4 It may be of interest to see what similarity exists in drug use as reported by the two subsamples, one an N of 100 from the metropolitan center, the other an N of 100 from a wealthier suburban city. The greatest differences are in reported experience with anti-allergy substances; 21 per cent (city) vs. 35 per cent (suburb) for a spread of 14 per cent, and in sleep aids 37 per cent (city) vs. 49 per cent (suburb) for a 12 per cent spread. Most other figures are much closer, yielding an average difference in reported experience on twenty-two measures of only 5 per cent between the two samples. To what extent these differences reflect reality or sampling error cannot be said; it is of note that the metropolitan area more often yields the higher-use rates for illicit substances and social drugs. The relative similarity of the two samples allows us some comfort in believing that general patterns of use as described in the two surveys do not differ radically from the behavior of the populations from which the samples were drawn.

5 Another shift of interest—one not seen in Table 19 since ranks are not affected—is for tobacco. Of the sample, 37 per cent report past but not present use; only 52 per cent report present use. If not reflecting wish fulfillment among respondents, the drop may indicate some response to health warnings by the sample interviewed.

6 With reference to the percentage reporting here, we caution the reader that the percentages represent those giving information-bearing replies and exclude the "no-answer" or "don't know" subjects. For most items the "no-answer" or "don't know" group is quite small.

7 The term "ego alien" employs some part of the person which is subject to unconscious conflict, something which does not fit and which may be rejected, dissociated, or otherwise handled in a stressful way. An emotion may be ego alien if the person does not admit it or express it integratively; the presumption is that a parent who disruptively rejects a child's emotion (perhaps because it is alien to the parent) is likely to create an ego-alien element. Parental responses to a child's feelings which are ones of guilt, hostility, denial, or rejection we consider to be negative. "Ego syntonie," on the other hand, indicates an integrated and harmonious situation which we presume develops out of positive parental handling of children's emotions.

8 WC infer that overdoing may contain a compulsive component or involve stimulus-bound behavior.

9 The reader will recall our hypothesis that low drug users, a culturally anomalous group in terms of the norms of use seen here (Group III as modal), would be the most fearful and suspicious of drugs. We saw their nondrug use as containing a defensive component. However, at the level of admitted feelings (we have no data on psychodynamics), this, we find, is not the case.

10 One may infer either fear or guilt from the affirmative replies.

11 Our expectation, as the reader will recall, was in the opposite direction: that nonusers would be suspicious. The finding may reflect genuine bad experiences or that bad feelings as well as good ones are attributed to drugs, or that anxiety over drug use expresses itself in paranoid ideation,

12 One may speculate that the high drug users are more suggestible and thus do as others do (more subject to social facilitation), that they "run" with a more oral crowd, which accounts for some part of their wider drug experience in the first place, or that individually they need a drug to enjoy their social relations.

13 Here again, our findings mn contrary to our expectations that the low-drug-use group would have the strongest distrust of drugs. Instead, as before, it is the more experienced drug users who worry the most about what drugs can do.

14 One may infer a sensitivity to genuine disapproval or an expression of fear or guilt which is projected onto others.

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