Drug, Set, and Setting

Norman E. Zinberg, M.D.

7.   Reflections on Social Policy and Drug Research

INDIVIDUALS WHO EITHER DO NOT USE intoxicants (whether alcohol or illicit drugs) or who use them only infrequently in order to keep up with their friends often fail to recognize that others may benefit from regular, controlled use because it brings them relaxation and a sense of freedom from inhibition. This lack of understanding does not necessarily mean disapproval. At a cocktail party someone who has an extra drink or two may be treated with amused tolerance and, especially in middle-class circles, may be looked after and even seen home safely. In other social groups permission may be granted to "turn on" with marihuana, take a sniff of white powder, or tell of an experience with a psychedelic. Nevertheless, the general lack of understanding of those who use intoxicants, particularly the illicit variety, has led to public disapproval and moral outrage and to a desire to prohibit drug use rather than find out how to bring it under control. This prohibitionary attitude presents a major problem for contemporary America in at least two ways.
First, the prohibition mentality directly opposes the interests of most users, who place intoxicants near the top of their hierarchy of values. According to interviews conducted with people who were not specially selected because of their drug use, intoxicants (and food) rank next to the two activities that Freud claimed were the most important in life: "to work and to love. " It is undoubtedly true that our commitment to work and thus to self-esteem and our relationships with others are our overriding daily concerns; much of our energy is spent in balancing, developing, and at times deprecating them. Religion used to be considered the third most important interest; but now the interest in intoxicants and food has begun to claim that position. This concern for ingesting, however, differs from interest in work and love in that most people disapprove of it and hesitate to admit it to others or even to themselves. Because society and therefore government reflect this personal ambivalence, they have refused to invest the time and thought that are needed to formulate coherent personal and institutional policies about such substances.
The second aspect of the cultural problem results from the recent very rapid growth of the use of intoxicants other than alcohol and the timing and pace of their acceptance (or rejection) by society. Since about 1962, America has been in the throes of a drug revolution in which millions of people (in the case of marihuana, 57 million; psychedelics, 16.5 million; and cocaine, 22 million) (Miller & Associates 1983) have tried substances that previously had been used only by a very small minority who were easily dismissed as deviant. By the early 1970s the enormous growth in the use of psychedelics, marihuana, and especially heroin had led to the creation, in the White House itself, of a Special Action Office for Drug Abuse Prevention (SAODAP), and to the appointment of the National Committee on Marihuana and Drug Abuse (the Shafer Commission). The Shafer Commission, made up of distinguished and acknowledgedly conservative (anti-drug) professionals from various fields, issued two reports—Marihuana, A Signal of Misunderstanding (National Commission on Marihuana and Drug Abuse 1973) and Drug Use in America: Problem in Perspective (National Commission on Marihuana and Drug Abuse 1972)—which considered the terrible difficulties that could arise from the new and extensive use of illicit substances. Nevertheless, their main message was a plea that society come to grips with phenomena that were not going to go away in the foreseeable future. These reports (whose antihysteria message is central to this book) were also noteworthy because they paid only slight attention to the use of cocaine. When they were written, no one could have predicted that interest in cocaine would expand as it has in the last few years.
Yet in the last twenty years use has not been confined to the four drugs mentioned. Significant interest has also been shown in amphetamines, PCP, and a variety of "downers" such as Valium and Quaaludes. But the four waves of psychedelic, marihuana, heroin, and cocaine use have been the most prominent, and they have given rise to the speculation that our culture, in an unconscious and inchoate way, is engaging in a vast experiment. A sustained effort is being made by at least parts of the culture to "find out" about various intoxicants and to see whether they can be used in a controlled and reasonable manner, despite the public wish that the use of such substances will go away.

Critique of Current Social Policy

Because this vast social experiment is going on, the question of what our society is willing to pay for the regularization of the use of any intoxicant must be raised and answered. It is certainly clear that our present prohibitionist policy, which requires society to regard all illicit drug users as criminals, deviants, or even "miscreants," and which encourages physicians to diagnose all such users as mentally disturbed, is being maintained at a heavy cost. Nor has it been successful, if success is measured by the number of smugglers and traffickers arrested, the number of individuals who have been persuaded not to try illicit drugs, the number of users who have been prevented from becoming compulsive, and the number of compulsive users who have been induced to take treatment. Moreover, debates over drug policy continue to ignore two related factors that make the issue of permanent prohibition largely academic. First, although drug use, like pregnancy, could be avoided by abstinence, mankind has not yet opted for total continence in the case of either drugs or sex. And second, the attempt to prohibit the use of drugs in this country has not been any more effective than the attempt to outlaw alcohol use in the 1920s.
The framers of current social policy, who hope to reduce the number of users by restricting drug supplies and punishing any use, argue that if there are fewer users there will automatically be fewer cases of dysfunctional use (Moore 1982). For example, if there are l0,000 users and 10% of them get into trouble, there will be l,000 cases of misuse; but if the number of users is reduced to 2, 000, there will only be 200 cases of misuse. This argument implies a straight-line arithmetical relationship between use and misuse, which does not exist. If the same type of argument were applied to alcohol use, it might lead to the highly debatable decision to raise the price of alcohol in order to discourage use! A rise in price would discourage some use, which supposedly would result automatically in fewer misusers. This, of course, ignores the strong probability that only the less committed moderate users who propound the social sanctions would be the ones discouraged. Interfering with existing alcohol consumption patterns with the aim of promoting reduced overall consumption rather than promoting moderate controlled using patterns is different from the use of formal legal controls with intoxicants where there has been little opportunity for informal social controls to develop, as with heroin, for example. However, by following the same mathematical argument and adding the assumption that all users are misusers, advocates of current social policy conclude that total prevention of use is crucial because of the large number of users. What is needed, they say, is not a reassessment of policy but more of the same policy— that is, better law enforcement and stricter penalties for trafficking and consumption .
But what have been the results of our present drug policy? Unsophisticated anti-drug legislation has led to a loss of respect for the law and the persistent flouting of it, to increased corruption among enforcement and other public officials, and to a virtual consensus among informed persons that although they may support these laws in principle, they will go to great lengths to circumvent them if a close friend or relative is involved. The labeling of individuals as criminal who would otherwise not be so considered has been more widespread under the drug laws than under the Volstead Act. The huge majority of those affected are young, the penalties are more severe and therefore more life-changing, and often the offender is forced to choose either to be branded as a criminal or to submit to "treatment." This choice, which ties the therapeutic process to criminal justice, has bastardized and denigrated a significant aspect of the mental health system and has had a profound effect on the way the individual drug-taker functions in society and views himself. These legal and social conditions have actually affected mental health more severely than has the controlled use of drugs themselves, and in some instances just as destructively as compulsive use. Finally, it is likely that current social policy is discouraging primarily those who use drugs only moderately, while heavy users, to whom the substance is more vital, are flouting the law in order to make their "buys." Thus, since it is the moderate, occasional users who develop controlling sanctions and rituals, the policy whose goal it is to minimize the number of dysfunctional users may actually be leading to a relative increase in the number of such users.
In 1972 the Shafer Commission recommended a change in our drug policy in the direction of dealing with each intoxicant individually and realistically. The Liaison Task Panel on Psychoactive Drug Use/Misuse of the President's Commission on Mental Health made a similar recommendation in 1978. In addition, the government'sWhite Paper on Drug Abuse (1975) and the Strategy Council on Drug Abuse's Federal Strategy for Drug Abuse and Traffic Prevention (1977), both of which were aimed at the elimination of drug abuse, called for more distinctions between types of use, acknowledging that the elimination of "drug abuse" from our society was an unrealistic goal (1975) and that drugs were "dangerous to different degrees" (1977). But the Shafer Commission to a certain extent, and the President's Commission on Mental Health to a much greater extent, went further. These two commissions, which were well funded and had large staffs, concluded not only that it was important to make distinctions among different types of drugs and different types of use but also that the failure to make such distinctions had resulted in an extremely costly social policy, just as the Volstead Act had.
After the publication of the Shafer Commission's report in 1972, about a dozen states decriminalized marihuana use; that is, while continuing to impose criminal penalties for selling the drug, they reduced the first-offense penalties for possession of small amounts for private use to a fine similar to that for illegal parking, without labeling the individual a criminal. Few authorities, including the Shafer Commission, believed that this policy, which punished the seller more than the buyer, would resolve the marihuana issue. Decriminalization was intended as an interim solution: it would buy time to see whether the use of this particular drug could be integrated by society—that is, whether serious health and social consequences could be avoided.
The Shafer Commission also gave the traditional conservative response to the drug dilemma. Its members sought to delay major decisions by calling for more research. They assumed, or hoped, that researchers would come up with new facts that would provide clear, complete answers to difficult issues of social policy—that new data would magically eliminate the necessity for difficult intellectual or moral choices. Research might even show that the nonmedical use of drugs was severely damaging to health!
The experiment of decriminalization itself did provide critical data. Studies done in several states, notably Oregon (Marihuana Survey—State of Oregon 1977), California (Impact Study of S. B. 95 1976), and Maine (An Evaluation of the Decriminalization of Marihuana in Maine 1978; Maine: A Time/Cost Analysis of the Decriminalization of Marihuana in Maine 1979), indicated that the use of marihuana had not increased at a significantly greater rate since decriminalization and that some law-enforcement resources had been freed to deal with more serious criminal activities. But in spite of this evidence, drug policy did not change in such a way as to encourage the establishment of formal social controls; that is, it did not encourage the passing of new laws and institutional regulations. Instead, it tended to move in the opposite direction.
Several papers appeared claiming that marihuana presented greater health hazards than had been previously supposed. The validity of these studies, apart from those showing that the drug may cause lung damage as severe as that caused by tobacco and that it is probably bad for heart patients, is at best debatable (Marijuana and Health 1982). But even more damaging to those who hoped to move away from the policy of total prohibition was the appearance of survey research indicating that the age of first use of marihuana had dropped substantially and that heavy use among the younger groups had increased substantially. These findings led to the formation of parents' organizations that worked to "save" their children by campaigning for "education and prevention" (anti-marihuana indoctrination and prevention of all use) and by advocating stricter penalties and more stringent law enforcement. These groups were very effective in bringing direct pressure to bear on political officials to put their wishes into action.

Interaction of Formal and Informal Controls

One of the implications of my research on the controlled use of intoxicants is that in the absence of reasonable formal social controls, the age of first use will tend to drop. This is becauseinformal social controls—sanctions and rituals—are less effective when there are no acceptable formal social controls to support them. (As it happened, in 1979, 1980, and 1981 the earlier drop in the age of first marihuana use was reversed; whether this resulted from increased anti-marihuana activity or whether even under unfavorable circumstances some informal social controls were beginning to function is a question for later evaluation. )
The relationship between formal and informal controls is astonishingly complex. There are two kinds of formal controls: those enacted by law and those provided by controlling institutions. A high school, for instance, can forbid the consumption of alcohol at a senior prom and punish those who disobey—even if some students, according to state law, are old enough to drink. Similarly, such an institution can expel a marihuana user even though the state has decriminalized use. An example of the interaction between an informal control and a formal control is the case of the boy who is nineteen and legally entitled to drink, who happily gives a beer to his eighteen-year-old brother but will not give one to his thirteen-year-old brother.
The absence of any clear formal standard for marihuana use, such as an age limit, has led youngsters to think that they can lower the actual age of first use without arousing concern or opposition. These youngsters know that even though society has outlawed marihuana, the effect is not the same as if the drug were socially unavailable. Very different degrees of deviance and of punishment are involved. At the same time, official disapproval of marihuana use, for example, by those under eighteen may be more effective than all-out prohibition in setting discriminating standards. The high-school rule that forbids the consumption of alcohol at a senior prom does not forbid students to drink on all social occasions. The rule does indicate, however, that it is neither safe nor appropriate for them to drink if they cannot control their use. In the same way, the social sanction "Know your limit" does not condemn drinking but does condemn drunkenness.
The interaction of formal and informal social controls is most crucial in the case of young adolescents . In the first place it has been traditional in our society for this age group not to be allowed to use any intoxicants, licit or illicit. Second, when they do experiment with illicit drugs (and such use always goes on underground), it is particularly difficult to set standards for use, either formal or informal (parental). Many parents have said that they can deal more easily with their children's tobacco smoking than with their marihuana smoking. As one parent put it, "We can at least talk about cigarettes. I can bribe, wheedle, cajole, or threaten. But with illicit drugs there is a code of silence. I'm afraid that this attitude may move over to alcohol, which we used to be able to talk about." As has been noted in earlier chapters, parents today are in a very difficult position in relation to illicit drug use. In regard to the licit drug, alcohol, they have a much easier task, for the formal social controls associated with it (such as a legal age limit), insofar as they promote safety, often match the parents' aims, and thus many families can inculcate and strengthen their own informal sanctions and rituals about its use.
In the case of illicit substances, institutional controls can at least offer some help. A secondary school, by enforcing such formal controls as the banning of illegal alcohol and drug use while at the same time offering a reasonable educational program about these substances, can strengthen the parents' hands. Then youngsters eager to experiment cannot claim, ' It must be OK any time, any place, because even the school doesn't make a fuss." Such attempts at institutional regulation give the parents the opportunity to think through with their children such questions as what intoxicants to use, where, when, how, and with whom—questions that are critical to the development of both formal and informal controls.

Drug Research and Social Policy

Because current social policy is aimed at decreasing the use of illicit substances (Report of the Liaison Task Panel 1978), the question arises whether research efforts must adhere to this policy in order to be considered ethical. If research is to be judged in ethical terms, and to a large extent it is, what effect does this have on the selection of research projects to be funded, how the research is done, and how the findings are treated by the public, as represented by both professionals and the media?
Almost everyone doing drug research would agree that it is extremely difficult to have one's work in this field perceived as objective and relatively value-neutral. Not only do popular presentations of any information about drugs insist on a "balance" that includes specific "anti-drug" material, but often scientific programs have been obliged to follow a similar procedure. In this kind of climate almost any work or any worker is quickly classified as being either "for" or "against" use, and halfway positions are not acknowledged. A diehard advocate of the National Organization for the Reform of Marihuana Laws (NORML), for example, will dispute any evidence that marihuana use can be disruptive. At a recent scientific meeting, when it was suggested that marihuana users should not drive when intoxicated, several floor discussants were quick to point out that some experienced users claim they can drive better when intoxicated. Conversely, a later statement that no deaths had been attributed to marihuana use during the past fifteen years, although over fifty-seven million people had used the drug in that period, was greeted by a retort from the floor that marihuana is not water-soluble and therefore is retained in the body. This reply was obviously not intended to counter the original statement but merely to show that no one could get away with saying something good about marihuana.
It is easy to ridicule these extreme positions, but the ethical issues themselves are serious; and the results of publicizing and exploiting drug effects in order to make use glamorous, in the Timothy Leary fashion, have given rise to grave concern. There is little doubt that the explosion of LSD use in the sixties was touched off by the wide publicity given such use. Although this explosion did not result primarily from the presentation of drug research, the drug hysteria very quickly affected research, as was evidenced by the declaration of one previously objective inquirer that he was setting out to prove the drug's potential for harm (Cohen, Marinello & Bach 1967; Cohen, Kirschhorn & Frosch 1967). Since the appearance of this kind of attitude—and it has surfaced in many places, including even the premises of the National Institute on Drug Abuse (1977, 1980; Johnston, Bachman & O'Malley l982)—every researcher has had to consider whether his work is more concerned with discouraging use than with looking for the facts.
Truth in its basic sense is not the issue. Probably no one in the field, no matter how misguided he or she may be thought to be, has set out purposely to falsify the facts. But within a certain framework of values—the outlook that any illicit drug is so bad that efforts to prove it so are legitimate and serve the greater good—the search for truth tends to become deductive rather than inductive. And since all scientific inquiry must begin with an operating hypothesis, the issue of the aims of research is not a black and white matter. It raises the subtle question whether the culture's current policy of attempting to reduce illicit drug use should be allowed to outweigh objectivity. Researchers who treasure objectivity and neutrality and who accurately present their data, whatever these are, may end up carrying on work that contravenes dearly held cultural beliefs. These beliefs are felt to be sacrosanct because they supposedly help to prevent something bad from taking place, namely, an increase in illicit drug use.
As mentioned in the preface, in 1968, when Andrew T. Weil and I with Nelsen began to conduct the first controlled experiments in administering marihuana to naive subjects in order to study the effects of acute intoxication (Weil, Zinberg & Nelsen 1968), we were heavily criticized. Our critics thought that if marihuana should prove to be as dangerous to health as many people believed it was, we would be running the risk of addicting or otherwise damaging innocent volunteer subjects. But we were also told by many (most amazingly, including a senior partner in the law firm representing Harvard Medical School) that if marihuana should not turn out to be so deadly, our findings could be morally damaging because they would remove the barrier of fear that deterred drug use. It is, of course, impossible to say whether these experiments and others that produced similar findings were significant in increasing the popularity of drug use. Even in 1968, when the experiment took place, it was clear that marihuana was not the devil drug of "Reefer Madness. " During that initial period of criticism (and ever since then) Weil and I believed that supplying credible and responsible information about the drug was essential, whether that information supported our biases or not.
In this field, those who either withhold or distort information in order to support the current social policy run the risk that potential users will detect this falsification and then will tend to disbelieve all other reports of the potential harmfulness of use (Kaplan 1970; Zinberg & Robertson 1972). Conversely, those presenting the information that not all drug use is misuse, thus contravening formal social policy, run the equally grave risk that their work will be interpreted and publicized as condoning use.
It is a frightening dilemma for a researcher, particularly for one who cannot believe that the truth will set one free in some mystical, philosophical way. Of course, neither can one believe that hiding facts, hiding the truth, will make everything come out all right. And when the research concerns powerful intoxicating substances, abstract principles about truth and objectivity are not all that is involved: human lives are at stake.
It was relatively easy to face up to the criticism of our marihuana research. The growing popularity of the drug was evident, no fatalities from its use had been reported, and there was a need for more precise information about its effects in order to differentiate myth from fact. For example, at that time police officers and doctors believed that marihuana dilated the pupils, and this misconception had to be cleared up because it was affecting both arrests and medical treatment. But when it came to studying drugs like heroin, whose physical properties, unlike those of marihuana, can cause disastrous effects if control is not maintained, the ethical problem grew more serious. Moreover, the effort to inform the professional community and also the public (by way of the media, to which anything in the drug area is good copy) that heroin use is not inevitably addicting and destructive involved the risk of removing that barrier of fear that might have deterred someone from using. This has been and continues to be a tormenting possibility. However important knowledge may be, research cannot be countenanced if subjects are not protected from the harm that may be caused by it, either directly or by withholding information—as, for example, in the case of the unfortunate U.S. Public Health Service research on syphilis, which withheld a treatment long after it had been proved effective (Hershey & Miller 1976).
Nevertheless, even my preliminary investigations of heroin and other opiate use confirmed what had been found in every other investigation of drug use: that the reality was far more complex than the simple pharmacological presentation given in medical schools. Certainly, heroin is a powerfully addicting drug with great potential for harm, but some users managed to take it in a controlled way, and even those who did get into trouble displayed patterns of response very different from those of the stereotypical junkie. In addition, other investigators, such as Leon Hunt and Peter Bourne, were beginning to report similar phenomena (Abt Associates 1975; Bourne, Hunt & Vogt 1975; Hunt & Chambers 1976). Once it became clear that these phenomena were extensive and significant, it was also clear that any attempt to remove such behavior patterns from the scientific purview because they were morally reprehensible or socially disapproved would reduce the credibility of all scientific enterprise. Further, it was possible that these heroin users, in the process of controlling their use, had developed a system of control that could be an extremely valuable basis for designing new approaches to the treatment of addiction (Zinberg, Harding & Winkeller 1981; Zinberg, Harding & Apsler 978; Zinberg et al. 1978; Zinberg & Harding 1982).
That such research has a potentially positive application and is not for information alone does not, however, figure in the principle of what makes work scientifically acceptable. Basic research needs no defense here. But the way in which the work is received and treated, particularly by the media, can raise grave problems. Though researchers may be as accurate and careful in their statements as possible, they cannot control what others say or do with the information. Yet in the present climate of emotionalism about drug research, they would be naive indeed if they did not realize that certain findings are susceptible to distortion by the press. Unfortunately, several researchers have called press conferences before publication in order to herald their findings (New York Times 4 February 1974 and 9 April 1974), and they have not been unwilling to venture into far-reaching speculations that go well beyond the published data.
It is not enough to avoid carelessness in one's work and the reporting of it. Researchers must also do their best to avoid causing those who would not otherwise use drugs to do so. One way to shift attention away from the preoccupation with illicit use is to emphasize the potentially positive application of the work. Even here, however, the researcher who discusses his work as a therapeutic aid can run into another brand of sensationalism and misrepresentation.
The difficulty of defining and maintaining objectivity and the ethical problems associated with carrying out certain research and imparting its results are not confined to research on illicit drugs. Few investigators today, when individuals are faced with an overwhelming number of choices, are able to preserve the image of the disinterested scientist actuated solely by dedication to the purity of science. A searching article by a prominent jurist, David L. Bazelon, published in Science in 1979, comments on matters that are pertinent to this discussion even though it does not mention illicit drug use specifically:

In reaction to the public's often emotional response to risk, scientists are tempted to disguise controversial value decisions in the cloak of scientific objectivity, obscuring those decisions from political accountability.
At its most extreme, I have heard scientists say that they would consider not disclosing risks which in their view are insignificant, but which might alarm the public if taken out of context. This problem is not mere speculation. Consider the recently released tapes of the NRC's deliberation over the accident at Three Mile Island. They illustrate dramatically how concern for minimizing public reaction can overwhelm scientific candor.
This attitude is doubly dangerous. First, it arrogates to the scientists the final say over which risks are important enough to merit public discussion. More important, it leads to the suppression of information that may be critical to developing new knowledge about risks or even to developing ways of avoiding those risks.

Who is willing today to assume the responsibility for limiting our scientific knowledge? The consequences of such limitation are awesome. The social risk of opening up areas of research on heroin use can hardly be equated with the frightening consequences of failing to disclose problems associated with nuclear reactions, but the principles are similar. It is understandable that government agencies, already overwhelmed by the number of factors that must be considered before reaching a decision, and buttressed by the righteous sense that what they are doing is for the public good, would want to protect society from the confusion that might be engendered if still more controversial information were made public. In principle, a bureaucracy wants to get all the information possible, but once it has settled on a course or a value position, it believes that new information raising further doubts may lead to greater risks and therefore should be kept quiet. As our cultural belief in the disinterested scientists wanes and our disillusion with the omnipotent court decision as a righter of wrongs grows, bureaucratic paternalism becomes the obvious alternative. But unfortunately, when the governmental acceptance of responsibility for a decision shifts to the assumption that the belief that supports a decision (illicit drug use is bad) is more important than the decision itself, there is bound to be difficulty in achieving a flexible social policy. This is exactly what has happened to the policy on illicit drugs.
Bazelon (1979) makes another point that upholds my position as well as that of John Kaplan (1970, 1983) and other researchers (McAuliffe & Gordon 1975; Herman & Kozlowski 1982; Waldorf & Biernacki 1982). Regulations that attempt to limit risks have their own social cost. This does not mean that we should not have regulations. But there must be a keen assessment of the risk cost of the regulations themselves. This is especially true in the area of drug use, where much of the damage being done today results from the illicit status assigned to marihuana and heroin and not from their pharmacology.

Policy Proposals

Many experts who have offered critiques of our current drug policy have made the radical proposal that all illicit drug use should be either decriminalized or legalized. A case in point is Thomas Szasz's laissez-faire approach (Szasz 1975). However, as John Kaplan (1982) and Mark H. Moore (1982) have pointed out in recent articles, such an approach would increase the number of drug users and consequently, at the very least, the absolute number of drug casualties. Because of this risk a more cautious approach to change is needed, and one that offers a responsible and workable alternative to the present policy of prohibition.
The leading recommendation to come from my years of research on controlled drug use is that every possible effort should be made—legally, medically, and socially—to distinguish between the two basic types of psychoactive drug consumption: that which is experimental, recreational, and circumstantial, and therefore has minimal social costs; and that which is dysfunctional intensified, and compulsive, and therefore has high social costs (Report of the Liaison Task Panel 1978). The first type I have labeled "use and the second type "misuse" or "abuse."
In order to distinguish use from misuse, greater attention will have to be paid to how drugs are used (the conditions of use) than to the prevention of use. Researchers must study both the conditions under which dysfunctional use occurs and how these can be modified and the conditions that maintain control for the nonabusers and how these can be promulgated. The goal of prevention should not be entirely abandoned, but emphasis should be shifted from the prevention of all use to the prevention of dysfunctional use. When this new focus is adopted, policymakers may decide not to treat all intoxicating substances as if they were alike. Careful studies of the use of various kinds of drugs and of the varying conditions of use may reveal the need to create a different policy strategy for each type of drug.
To study the conditions of use for each drug will require consideration of the following topics: dosage, method of administration, pattern of use (including frequency), and social setting, as well as the pharmacology of the drug itself. Consider, for example, the question of frequency of use. It is only at the extremes that frequency is not necessarily related to the harmfulness of a drug, as described in chapter 2. A policy aimed solely (or mainly) at reducing frequency would not only mask the significant differences between the drugs themselves but would deny the importance of the social setting, including when, where, and with whom the drug is used. These social factors, which may vary across cultural and ethnic lines, combine with frequency and quantity of use to determine the quality of use. A policy aimed at encouraging a shift from those drugs that are generally considered to be the most harmful to those that on all counts are the least harmful (even though some may at present be illicit) would result in a considerable reduction in social cost.
Further study of those conditions and patterns of drug consumption that enable users to establish and maintain control will underscore what my research has already suggested—that significant informal social controls over illicit drug use are now in the process of development. Drug policy should encourage the development and dissemination of these controlling rituals and social sanctions among those who are already using drugs, while at the same time continuing to discourage the general use of illicit drugs. The 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.
Informal social controls cannot be provided to users ready-made, nor can formal policy create them. They appear naturally in the course of social interaction among drug-takers, and they change gradually in response to changing cultural and subcultural conditions. This is the primary reason why any abrupt shift in present policy would be inappropriate. The sudden legalization of marihuana, for instance, would leave in limbo those who have not yet had the time to internalize informal social controls. There are, however, several steps that can be taken now to demystify drug use and thus to encourage the development of appropriate rituals and sanctions. These steps include disseminating information (education), improving treatment programs, encouraging medical research, correcting negative attitudes toward drug users, and undertaking legal reform. The first two of these steps, education and treatment, will be discussed in some detail.

Education and Prevention

Many policymakers have assumed that behavior can be shaped by providing individuals with "information" on the consequences of behavioral decisions. The emphasis, however, has always been placed on the prevention or avoidance of behaviors presumed to have a negative impact on the individual or society. Such information has frequently been laden with ethical and moral judgments so that the "proper" decision for the individual has been preordained.
Drug abuse education and prevention efforts in the United States have burgeoned since 1968, coinciding with the rapid increase in the use of illicit psychoactive substances, starting with marihuana and LSD. Between 1968 and 1973, for example, the National Institute of Mental Health produced and distributed more than twenty-two million pamphlets on drug abuse and supplemented this effort with a continuing mass-media public-service campaign. During that same period departments of mental health in the individual states initiated drug education programs, and many of the 17,000 school districts in the United States followed with their own drug education efforts. The Advertising Council, a national body representing the advertising industry, estimated that the value of time and space donated by the private sector for the dissemination of drug information approached $937 million in 1971. In addition, numerous drug education programs were conducted by churches, civic groups, businesses, national voluntary organizations, and the military services. It was, as President Nixon had proclaimed, an all-out war on drugs, with education and prevention efforts centering on the elimination of illicit psychoactive drug use.
Both the private and the public agencies that promoted drug education added their own values to their educational materials, often distorting the information and discrediting its sources. In 1973, when the National Coordinating Council on Drug Education reviewed 220 drug education films for accuracy and appeal (Drug Abuse Films 1973), it found that 33% of the films were so inaccurate or distorted as to be totally unacceptable, 50% were not suited for general audiences unless a skilled instructor was present, and only 16% were scientifically and conceptually acceptable. Another government publication, Federal Strategy (1977), noted that even the best factual information often helped to stimulate curiosity about drugs, and that curiosity was becoming a major cause of experimentation. According to the Shafer Commission, these massive efforts, focused exclusively on promoting abstinence, may have actually increased psychoactive drug use.
In 1973 the Shafer Commission drew two conclusions about drug education and prevention programs: most information in the field was scientifically inaccurate; and most education programs were operating in total disregard of basic communication theory. The commission recommended a moratorium on all drug programs in the schools until existing programs had been evaluated and a coherent approach with realistic objectives had been developed. A federal moratorium on drug abuse prevention materials was ordered in the same year.
New federal guidelines were issued in 1974, emphasizing the notion that it was possible to develop "discriminating" materials that could reinforce or encourage drug-free behavior. Presumably, these materials would delete all references to the positive reasons given by individuals for using drugs, would avoid differentiating between the relative benefits and harms of a variety of drugs and patterns of use, and would emphasize the values of a drug-free existence. This sounded strangely like the approach abandoned in 1973, except that the new thrust would be labeled "discriminating and sophisticated."
A discussion of recent national education and prevention strategy is contained in an interagency report, Recommendations for Future Federal Activities in Drug Abuse Prevention (Cabinet Committee 1977), prepared in 1977 with the National Institute on Drug Abuse as the lead agency and presented as a "major refinement" in federal prevention-policy development. The federal strategists suggested three ways to reduce what they called drug casualties: limit the variety of drugs used, reinforce the drug-free experience, and reduce the frequency of use. The focus on prevention activities, they believed, should be on the drug use that had the highest social cost, as well as on the general drug-taking experience; the main efforts should be directed toward moderating the effects of taking drugs. The strategists, accepting adolescent experimentation with psychoactive drugs as part of the normal maturing process, did not view such experimentation as particularly distressing. The overall objectives of the federal government, they said, should be to reduce the number of new users (incidence), to delay incidence, and to reduce frequent or daily use. Their report suggested the following specific targets (Report of the Liaison Task Panel 1978):

to reduce the percentage of frequent users of three gateway drugs (tobacco, alcohol, and marijuana) by 15% among 8- to 20-year-olds;

to reduce the destructive behavior associated with alcohol and other drug abuse by 20% among 14- to 20-year-olds as evidenced by a reduction in overdose deaths, emergency room visits, DWI [driving while intoxicated] arrests, and other alcohol/drug-related accidents;

to promote and reinforce restraining attitudes toward the use of psychoactive substances, especially use of the gateway drugs, by maintaining current levels of awareness regarding the addictive nature of heroin and alcohol, and by raising the awareness level of the addictive nature of tobacco by 50%.

That drug education and prevention programs should be broadened to include alcohol and tobacco (the first two psychoactive substances used by most youngsters) has also been indicated by my research. To ignore them would destroy the credibility of such programs because, although these drugs are legal, they are certainly drugs, are certainly intoxicants, and are certainly psychoactive—and yet alcohol may be useful. Moreover, the reasons why society is able to exercise some control over alcohol use but is not able to exercise control over tobacco use should be made an important focus of educational efforts.
My research findings also suggest that attention should be given to the various patterns of use that may be followed for different types of drugs, and to the consequences of these differing use patterns. Then more sophisticated educational efforts can be made to reduce destructive drug-related effects, such as overdose deaths, accidents, and arrests for driving while intoxicated; and these efforts can be conjoined with those aimed at reducing alcohol-related effects. For such campaigns to be credible and successful they must recognize that there is an enormous difference between drug use patterns that have potentially dangerous consequences and those more common, controlled patterns of use that are not destructive per se. Drug-using behavior that impinges upon public safety must be strongly discouraged, but this presumes public acceptance of the notion that not all psychoactive drug use is destructive.
In those health and mental health areas that are unrelated to drug use it is common for prevention efforts to be aimed at positive outcomes as well as at the avoidance of deleterious consequences. For example, although our society does not condone teenage sexual activity, it has decided that those who are unwilling to follow its precepts should be given the basic information needed to avoid disease and unwanted pregnancy. Drug education and prevention efforts should do no less. They should provide information on how to avoid the effects of destructive drug combinations (for example, barbiturates and alcohol), the unpleasant consequences of using drugs of unknown purity, the hazards of using drugs with a high dependence liability, the dangers of certain modes of administration, and the unexpected effects of various dose levels and various settings. These potential hazards are a particular threat to youthful experimenters, who unwittingly expose themselves to a wide range of untoward drug reactions. Does society really wish to continue tolerating education and prevention strategies that suppress information which could help hundreds of thousands of youngsters stay out of trouble? The posture that "they deserve what they get" is no longer tenable, and it is no longer officially espoused. Yet the fear still remains that if our education and prevention efforts do not condemn intoxicating substances, then potential users may interpret the lack of condemnation as tacitly condoning drug use. This dilemma has inhibited effective teaching in the drug area.
These recommendations for a change in the purpose and content of drug education programs apply equally well to some of the "new" prevention efforts that claim to represent a major departure from traditional approaches. One of the most prominent of these programs advocates the theory of a drug-free existence by promoting interest in such "natural highs" as yoga, meditation, and other nonchemical experiences. But many parents would rather have their children receive information on the responsible use of marihuana than be encouraged to seek "higher" states of consciousness. These parents may be skeptical about drug use, but they are also uneasy when traditional education promotes nonchemical highs.
A further problem with the so-called natural high is that it may not be regarded by adolescents as equivalent or superior to a drug-induced high. And even when the two are experienced as similar, many adolescents may seek to expand their repertoire of ways to get high rather than abandon drugs. Several years ago, when an exclusive preparatory school was considering the pros and cons of building an expensive swimming pool, it was persuaded that swimming would provide a recreational alternative to drug use. After the decision to build was announced, the administration was shocked to hear several students expressing joy at the prospect of swimming while stoned! It is not surprising that if adolescents find they cannot get high on swimming or in some other "natural" way, they may turn to drugs to achieve that well-advertised state.
Another relatively new drug education strategy has turned away from the earlier emphasis on the direct transmission of information through drug courses by offering the same information in courses on family development, nutrition, hygiene, safety, or interpersonal relationships. Although this diffuse educational approach relies upon different techniques, the message is the same. The older line that psychoactive drug use is destructive has simply been carried over into "values clarification." This new approach also overlooks distinctions between drug use and misuse, and it does not offer information on how to minimize or avoid drug-related difficulties.
If the "facts" about the consequences of drug use fail to convince the potential consumer of the impending peril, should these so-called facts be doctored to fit the policy, or should the policy be changed to fit the real facts? Prevention strategies talk about the need to develop more "persuasive" lines of communication and more "discriminating" materials. But doesn't this mean not just presenting the facts in a more attractive package but also altering them or suppressing helpful information? Wouldn't it be better to recognize explicitly the benefits some individuals get from some psychoactive drugs, licit or illicit? Or are we to continue to accept the notion that illegal drugs are ipso facto harmful, quite apart from the way in which they are used? Understandably, the legality-illegality quandary is especially difficult for drug educators to handle.
Several obstacles must be overcome before drug education and prevention can proceed from realistic premises. The foremost obstacle is the lack of knowledge on the part of those who are the most involved in educational efforts, particularly the physicians. Medical students are trained to view all nonprescribed drug use as misuse or abuse. A survey of medical school courses has shown that they deal only with the pathology of extreme drug consumption, including alcoholism, and neglect the possibility of controlled use and moderation. Hence physicians are often unable to answer patients' inquiries concerning different patterns or frequencies of use. Unless physicians are taught to differentiate between the various drugs and their effects, their patients' questions will remain unanswered. Medical education should be broadened to include comprehensive information on the effects of psychoactive drugs, the various patterns of use (including alcohol use), and the factors that promote control, as well as the signs and symptoms of dysfunctional use. Physicians would then be in a position to predict positive outcomes, counsel the avoidance of deleterious consequences, and give early diagnoses of drug-related dysfunctional behaviors. Physicians and other health professionals must be taught to recognize the subtle, individual, drug-related behavioral changes that foreshadow serious dysfunctions. They must also learn to identify the consequences of the differing patterns of use, ranging from the experimental to the compulsive, and to understand that not every nonmedical use of drugs is necessarily dangerous.
It is important that the use of psychoactive drugs for mind and mood alteration be considered in a social, scientific, and literary context. Educators should be familiar with the historical importance of the opium wars, the traditional ritualistic use of various psychoactive drugs, and the literary allusions to drugs by such great writers as Homer, Ovid, Baudelaire, de Quincey, and Coleridge. Then students will learn that man has always had psychoactive drugs at his disposal, that attitudes toward them have been constantly shifting, and that such drugs have been used for a variety of purposes. As the emotionalism surrounding drug use recedes, it will be possible to build such an approach into the educational process.

Treatment Systems

Because the focus of my research was on controlled use and controlled users relatively little attention has been paid in this study to dysfunctional users and their obvious need for treatment and regulation. My long-term contacts with such users have revealed that today the drug treatment system is caught in a confusing dilemma about what it is supposed to be treating. The formal institutional structures of the system are not only unwilling to explore the distinction between the use and misuse of psychoactive drugs but do not know whether they are treating drug abuse or crime. Who, in fact, is to identify and pass judgment on the adverse consequences of drug use—the patient, the physician or counselor, or the agencies affiliated with the criminal justice system? The law labels any use of illegal psychoactive substances misuse (or abuse), while the medical establishment calls only nonmedical use misuse. Thus, by legal definition, any psychoactive drug use is seen as demanding legal intervention, while by medical definition any nonmedical use necessitates medical treatment.
All treatment programs, including so-called methadone maintenance, are abstinence-oriented, differing only as to the time period permitted to achieve that goal. This has not always been the case. The pioneer Dole-Nyswander projects on methadone maintenance (Dole & Nyswander 1965, 1966, 1967; Dole, Nyswander & Warner 1968) were designed as genuine maintenance programs. Although the patients' addiction to opiates (especially heroin) was initially replaced by addiction to methadone, the project workers expected that eventually the compulsive use of methadone would change to controlled use and that this improved situation would become the basis for social and psychological rehabilitation. Thus the use of a substitute drug was not the dominant factor. Methadone had several advantages: it could be taken orally, was long-lasting, seemed not to interfere with the individual's capacity to function, and, above all, was legal. But the basic aim of the program was to establish a clinical situation (controlled use of a substitute) in which patients freed from heroin addiction would be able to think through their problems and gain confidence in their capacity to manage their inner state and function reasonably well in society.
From the start, maintenance programs were highly controversial because of their retreat from abstinence and the introduction of a synthetic opiate. Since it was necessary to present some justification for their use, and since crime and drugs were being linked as the nation's number one domestic problem, it seemed reasonable to measure "treatment success" in terms of a reduction in arrest rates and criminal activity. Justifying treatment in this way made the use of a synthetic drug to treat heroin addiction more acceptable to those who saw abstinence as the only acceptable solution.
As a matter of fact, the initial evaluative studies showed that patients on methadone maintenance did improve considerably according to most social indicators. These studies, coupled with political pressure to do something about crime, led to a tremendous expansion of this treatment system. Methadone maintenance, which had been conceived originally as a medical treatment for voluntary patients, was presented to the public as a means of stopping drug abuse and crime by getting deviants off the streets.
Today the term methadone "maintenance" is a misnomer. Methadone treatment clinics have changed radically in that they have become openly abstinence-oriented. By federal regulation they are required to have physicians and nurses to dispense the medication. Some also offer a variety of ancillary services, such as vocational rehabilitation and individual and group counseling.
The other broad class of treatment programs, the various nonprofessional therapeutic communities, have always had goals that are wholly compatible with those of the larger society. They have aimed to eliminate drug use and have assumed that once abstinence was achieved, the client would become a model citizen. The early communities dealt with a few carefully selected, voluntary, heroin-dependent clients; but when enrollments burgeoned in the late 1960s under the pressure of the "drug epidemic," these communities began to test the client's motivation to rid himself of heroin use by putting obstacles in the way of his enrollment, in much the same way that a fraternity ritual screens candidates. It was assumed that if the individual could overcome these obstacles, his desire to become drug-free was genuine.
Therapeutic communities stress self-help, as does Alcoholics Anonymous; and in order to reinforce drug-free behavior they encourage intense interaction within the group and enforce firm rules of conduct by punishing infractions. The community setting promotes reform of the individual, not only by helping him to overcome drug dependency but by giving him a positive image of himself. Nevertheless, becoming socialized in the hothouse atmosphere of a therapeutic community does not guarantee success in the larger society. Initially, during the period of rapid growth of such heroin treatment programs, many successful "graduates" were able to remain in the field, working as counselors or administrators. Later on, when the employment opportunity disappeared and "graduates" had to return to the broader community for employment, they found it increasingly difficult to survive. One early community, Synanon, at one time tried to respond to this problem by developing self-contained communities where individuals lived and worked, abandoning reentry to society. Follow-up studies confirm that the self-help techniques of therapeutic communities can be beneficial, but retention rates are far lower than those of methadone programs.
The confusion about the goal of drug treatment programs—whether it is to cure drug dependency or to reduce criminal activity—worsened in the 19705 because of the increasing use of the nonopiate psychoactive drugs (cocaine, Quaaludes, Valium). These were assumed to have the same effects and consequences as the opiates—dependence liability, amotivation, and crime—and therefore the solutions were seen as the same: either to send users to jail or to remand them to treatment. The spread of such drug use among youth, added to the continuing heroin "epidemic, " led to the rapid expansion of what the Shafer Commission termed a "drug abuse industrial complex." The budget for treatment services funded by NIDA grew from $18 million in 1966 to $350 million in 1977, shrinking to $155.4 million for fiscal 1981, with a total of 3,449 drug treatment centers and a static treatment capacity of 208,000 slots, of which federal funding provided approximately 102,000. But unfortunately the commitment to treat all psychoactive drug users ignored the essential differences among the various types of drugs and their using patterns.
The treatment services required for opiate dependents differ from those needed for users of other drugs. Services are also needed for those clients with emotional difficulties that are unrelated to drug use. With the trend toward polydrug use, there is a greater need than ever to integrate and coordinate drug treatment services with the broader health and mental health delivery systems to meet a variety of diverse client problems. According to data from the National Institute on Drug Abuse (Miller & Associates 1983), for the year 1981, 15.1% of all clients entering drug treatment programs reported no use of their drug during the month prior to admission; 5.9% had used it less than once a week; and an additional 5.1% had used it only once a week. Among those clients who did not take opiates, 19.1% used marihuana, 8.5% alcohol, 7.7% amphetamines (nonprescribed), and 5.8% cocaine; the use of inhalants (1.1%), barbiturates (nonprescribed) (2.9%), hallucinogens (4%), and other sedatives and hypnotics (3.1%) ranked lowest (Miller & Associates 1983). All of these nonopiate users required treatment that was drug-free.
Similar treatment problems exist with regard to the legally prescribed amphetamines, barbiturates, and minor tranquilizers. Users of these drugs, which have a high dependence liability, may require hospitalization for detoxification. Because they tend to be far more emotionally disturbed than opiate users (Benvenuto & Bourne 1975; Khantzian 1978; Smith l975b; Vaillant 1978), their needs are only superficially addressed by the typical drug treatment program; and yet they do not readily fit into any of the other conventional areas of mental health treatment. It is likely that they could be more effectively served in a community mental health setting if space and expertise were available. Then drug treatment slots and funds could be exclusively devoted to providing services for clients who are suffering from the dysfunctional effects of chronic and long-term use of the opiates.
Opiate users in treatment centers usually live in areas characterized by glaring poverty, unemployment, and discrimination, where the use of drugs may seem to be the only alternative to despair. As of 1981 (Miller & Associates 1983), about 64% of these patients were black or Hispanic, although these two ethnic groups together made up only 18.1% of the national population (11.7% black and 6.4% Hispanic) (U. S. Bureau of the Census, 1980a, 1980b). Nearly 74% of these groups in treatment were black males, nearly 50% had had less than a high-school education, and 60% were twenty-six years old or over. Slightly less than half had been arrested within the past twenty-four months; about half of those with an arrest record had had one or more arrests.
The minority groups have often viewed drug treatment as a noxious form of social control, particularly if it substitutes one chemical dependency for another. This concern becomes even stronger when long-term maintenance programs are proposed. But recently many minority group leaders have begun to be less preoccupied with the evil magic of drug use per se and more concerned with the quality of treatment programs and the need for staffing patterns that are diverse enough to fit a range of cultural differences. The increased emphasis that minority leaders are placing on thequality of treatment services may be an important factor in improving these services.
Although treatment programs that are targeted at interrupting illicit drug use are important, treatment can be considered successful only if it prevents clients from returning to destructive drug use and gives them the emotional stability and technical skills needed to function adequately in society. The records show that this is not taking place. In 1981 65% of opiate users under treatment were unemployed at admission and at discharge; only 3.5% completed a skill-development program during treatment, while an additional 11.5% were in an educational or skill-development program at the time of discharge. Two-thirds of the clients entering treatment had been in treatment previously, and nearly two-thirds were discharged from the program for noncompliance, were incarcerated, or dropped out before completing treatment. Obviously, the rehabilitation needs of these drug treatment clients simply were not met.
In 1977 V. P. Dole and H. Joseph surveyed a stratified random sample of 85,000 current and former methadone-treatment clients in New York City. The results, which were consistent with reports from comparable studies, indicated that treatment "success" (defined as abatement of illicit opiate use accompanied by good functioning) was most likely for those patients who remained in treatment for the longest time, but that the overall level of success was low. The follow-up data on those who left the treatment program showed that although there was a dramatic reduction in their illicit opiate use during treatment, the majority relapsed after leaving treatment. This was also true of those who reentered treatment for a second or even a third time. In general, then, maintenance treatment is effective while the medication is being taken, but it usually does not cure the underlying problem, whatever that may be.
Obviously, those who have a long history of intractable heroin use should remain in treatment, whether drug-free or chemotherapeutic. Their earlier immersion in a deviant subculture has given them an identity, a community, and a way of life that have isolated them from the mainstream culture. Retention in treatment is essential in order to establish the kind of therapeutic relationship these people need to begin the long, slow process of working through their personal, social, and economic problems.
The indications of a need for long-term treatment are less clear for those with a favorable cluster of attributes—for example, for responsible young people who have a job, a stable home situation, and no history of alcoholism. For such a group, which is somewhat similar to the sample of controlled users described in this book, the expectation of a good outcome after detoxification is significantly higher than it is for all patients as a whole.
It is not easy to define "quality care" in terms that satisfy everyone who is concerned with the health, mental health, and drug treatment services. The difficulty of reaching a consensus on what constitutes such care in a health or mental health setting is multiplied in a drug treatment setting by the common practice of using abstinence as the criterion for success. If the less demanding criterion of controlled use were substituted, these programs would be able to achieve a much higher degree of success. This conclusion, at least, is suggested by the fact that almost 50% of the controlled opiate users in my research project were former addicts. It is clear that many individuals who have long histories of getting high and who do not want to give up an experience they find pleasurable may still be shown how to control their use. Unfortunately, such a criterion is unrealistic today and will continue to be so as long as the present policy of prohibition remains in force. Any program adopting it could be justly accused of condoning an illegal act—the use of illicit drugs.
Nevertheless, once it is clear that the purpose of drug treatment is to alleviate drug abuse, particularly dysfunctional aspects of opiate dependency, then the false hopes that have been raised regarding the elimination of all drug use and the reduction of criminality will be replaced by more reasonable criteria for success—such as reduced use, increased employment, and more adaptive social relationships.
The narrow and unreasonable assumption underlying the goal of abstinence—namely, that any drug use is misuse or abuse—not only has given society a drug policy with an unrealizable goal but has often prevented those in authority from recognizing dysfunctional use and dealing with it constructively. This is particularly true in the case of young adolescents. Recently a group of parents expressed concern about the frightening extent of drug and alcohol use in a regional public high school. A survey was made and the stories were found to be exaggerated: intoxicant use in that school turned out to be somewhat below the national average. When in-depth interviews were held with teachers, parents, administrators, and students, only a very few students were found to be in real trouble, and there was high consensus in regard to their identity. Then it became clear that the exaggerated reports of use had so preoccupied parents and administrators that constructive efforts had not been made to get those who were in serious trouble into treatment. Overconcern about use by the many had stood in the way of active attention to the misuse and serious difficulty of the few.

Future Research

It is my hope that this research will stimulate other investigators to undertake long-term, longitudinal studies of psychoactive drug-using behavior as a socially evolving process which develops controls that affect a majority of the using population. Since such studies will require careful selection and special training of researchers, modest budget increases for research may be required; but the focus of the research rather than the total dollar amount should be the primary concern.
To date, five large and important areas of longitudinal research have been either neglected or treated only superficially: (1) the sequence of drugs used and the development of different drug-using patterns; (2) the individual, group, and cultural factors influencing low-risk and high-risk outcomes among equivalent drug users; (3) the changing attitudes of both users and nonusers toward psychoactive drug use; (4) the impact of the media on drug use and drug choice; and (5) the process of socialization as it applies to patterns of drug use. Three other topics need to be investigated by prospective studies: how drugs influence individual health and behavior, what use is being made of drug research, and how its findings influence public policy decisions.
Because of the expense of identifying illicit opiate users, who make up less than 1% of the U. S . population (see appendix C), it might be wise to adopt the suggestion made by Lee N. Robins in 1980. She proposed that when survey researchers identify an opiate user, they should ask if he or she "would be willing to be followed [up] at another time," thus permitting the creation of a pool of randomly selected subjects for intensive longitudinal study. This subject population would be more representative of the normal population than either the groups of subjects commonly used now, who are drawn from institutional settings, or the group analyzed in this book, which was a collected rather than a random or representative sample.
Besides the expense of conducting research on use of illicit drugs, there is the definitional problem. It is often very difficult for one researcher to know exactly what another researcher means by his terminology (see chapter 3). To minimize this problem, investigators could include detailed case studies to illustrate the category of use or user under discussion. To a certain extent, my study has employed that method, as have other investigators such as Bruce D. Johnson and P. J. Goldstein (1979). They interviewed their subjects daily for at least twenty-eight days at intervals of a few months. Their preliminary data include valuable details about the patterning, stability, and consequences of use (for example, the amount of money spent on drugs), which make it easier for other investigators to understand the meaning of their categories. Many of their subjects, incidentally, resemble my sample of controlled users.
Comprehensive and detailed case studies, tedious as they are to compile, would also supply the natural history of use called for by L. G. Hunt and others (Hunt 1977; Zinberg & Harding 1982). Today misconceptions abound about the patterns of use of all the illicit drugs, most particularly the opiates. At the least, what is needed is some knowledge about the change or transition from one stage of opiate use to another. For example, the latest data (Johnson & Goldstein 1979) show that, contrary to the popular view that heroin addicts inject themselves at least once a day throughout their using career, only 10% to 20% of the entire using careers of most addicts is spent using.
These kinds of data have powerful implications for treatment programs. Unfortunately, not many program evaluators attempt to identify the using styles of clients prior to and following treatment. It should be possible, however, to identify those in treatment who have the potential for controlled use. If a number of variables pointing to that potential (such as the ability to keep drugs on hand for some time without using them) could be isolated, questions relating to those variables could be incorporated into the screening procedures employed by drug treatment programs. Similarly, the characteristics of addicts who have been unable to achieve control over their opiate use could be identified and compared with the characteristics of ex-addicts (like those in our sample) who have managed to change their addictive pattern to one of controlled use.
When the proportion and characteristics of addicts who seem to have a reasonable chance to become controlled users have been determined and some understanding of the factors that facilitate the transition to controlled use has been gained, the stage will be set for a small, experimental program in which a few carefully selected addicts can be helped to establish control, and their capacity to maintain controlled use can be evaluated. Such an experiment is feasible; it could be done with some dispatch; and it would provide an enormous amount of useful information about heroin use and the treatment of those who are addicted to it. In the current climate of opinion about drugs, the major obstacle to launching such an experiment would be the reluctance of government agencies to support research on a treatment program condoning the continued, recreational use of heroin or some other opiate.
Probably the most convincing demonstration that control breeds control comes from the longitudinal studies of George E. Vaillant (1983). Through a variety of circumstances he had access to data on two groups of subjects from quite different economic backgrounds, collected over forty years ago, and he has continued long-term follow-up on these groups. On measures such as capacity to relate to others, to maintain close friendships and family ties, and to continue in good physical and mental health, the abstinent or near-abstinent score as poorly as the serious problem drinkers or the alcoholics. Statistically, moderate drinkers score significantly higher on each item. Vaillant says, only partially in jest, that his ''findings have caused me to increase my drinking."
This approach to research—the development of long-term samples for study, the publication of detailed case histories, and the analysis of controlling and noncontrolling variables—would go a long way toward answering questions raised concerning the changing historical patterns of use. Some questions about the past are, of course, unanswerable. How can we find out, for example, whether occasional opiate use and the influence of the social setting on users' behavior have a long history or are relatively recent phenomena? Nevertheless, such an approach could still reveal important information about changing use patterns—what drugs are being used, how they are being used, and how that use is being socially integrated. Certainly, if our understanding of drug use is to improve, we must obtain more information about the social context of use including a knowledge of how group customs and norms operate to shape different styles of use, how these customs (controls) arise, and how new users acquire them. Further research can discover ways to strengthen these informal social controls (sanctions and rituals) that encourage abstinence, promote safer use, and discourage misuse.
A final caveat. Throughout the duration of my project my subjects continued to make one point clear: at certain times, if not during the whole of their using careers, they experienced benefits from their intoxicant use and from different patterns of use. Thus, despite the reigning cultural morality, future studies of intoxicant use should take into account not only the liabilities but also the benefits of drug use itself and also of the differing patterns of use.