Drug Use, Policy, and Management 9780313013065, 9780865693333

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Drug Use, Policy, and Management

Drug Use, Policy, and Management Second Edition

Richard Isralowitz

Auburn House Westport, Connecticut • London

Library of Congress Cataloging-in-Publication Data Isralowitz, Richard. Drug use, policy, and management / Richard Isralowitz.—2nd ed. p. cm. Includes bibliographical references and index. ISBN 0–86569–333–1 (alk. paper) 1. Drug abuse—United States. 2. Drug abuse—United States—Prevention. HV5825.I85 2002 363.4′8′0973—dc21 2002020069

I. Title.

British Library Cataloguing in Publication Data is available. Copyright © 2002 by Richard Isralowitz All rights reserved. No portion of this book may be reproduced, by any process or technique, without the express written consent of the publisher. Library of Congress Catalog Card Number: 2002020069 ISBN: 0–86569–333–1 First published in 2002 Auburn House, 88 Post Road West, Westport, CT 06881 An imprint of Greenwood Publishing Group, Inc. www.greenwood.com Printed in the United States of America

The paper used in this book complies with the Permanent Paper Standard issued by the National Information Standards Organization (Z39.48–1984). 10

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Copyright Acknowledgment The author and publisher gratefully acknowledge permission to quote from the following: Richard Isralowitz, Gary Sussman, Mohammed Afifi, Richard Rawson, Thomas Babor, and Maristela Monteiro, Substance abuse policy and peace in the Middle East: A Palestinian and Israeli partnership. Addiction (July 2001), 96:973–980. We appreciate the journal’s cooperation regarding this effort (http://www.blackwellpublishers.co.uk; http://www.tandf.co.uk).

Contents

Preface

vii

Acknowledgments

xv

1. Drug Use and Abuse: Definitions and the Social Context of Reality—Tobacco Terms and Definitions: An Overview The Classes of Drugs: A Review The Social Context and Reality of Drug Use Conclusion

2. Theoretical Considerations and Risk Factors The Social Order Social Forces: Physical Environment, Values, and Morals Interpersonal Relations Labeling/Criminalization Process Biological and Psychological Characteristics Conclusion

3. Heroin: The “King” of Illegal Drugs Historical Perspective Trends International Perspectives The Heroin Addict: Personality Characteristics Cross-Cultural Perspectives of Heroin Addicts: The Russian Crisis

1 1 6 12 19

25 26 27 30 36 38 40

49 49 54 57 61 64

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Contents

4. Alcohol and the Alcoholic Historical Perspective The Alcoholic: Theories and Personality Characteristics Trends Alcohol Use and Culture: An International Perspective

5. Cocaine and Crack Historical Perspective Trends The Cocaine User: Personality and Other Characteristics Cocaine: The Latin American Plague Cocaine Highlights

6. Marijuana: Is It Really a War of Values and Special Interests? Historical Perspective Marijuana: The Facts—Who and What to Believe? Social, Political, and Economic Factors Leading to Policy Formation Trends Marijuana Use: Reflections on the Dutch Experience

7. Management: Elements of Drug Treatment Services Organization and Development The Human Services Perspective Drug Treatment Services Management of Drug Services Drug Service Agencies: Organization and Management Needs and Problems Treatment and Relapse Prevention Strategies Research, Evaluation, and the Dissemination of Information Drug Information Center Development: Case Example

Epilogue: The Final Straw—A Response to the War against Drugs Perspectives: What Is Being Said? Numbers: What Do They Show? Money: What Does All This Cost? Prevention and Treatment The War: And the Debate Goes On

Index

87 88 90 92 97

107 107 112 117 117 120

131 131 137 142 144 149

155 155 156 157 158 163 164 164

171 171 173 174 176 178

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Preface

Whether it be illegal substances such as marijuana, heroin, and cocaine or legal substances including cigarettes and alcohol, drug use is a deeply embedded characteristic of society. It shows itself in the form of illness, death, crime and violence, police action and imprisonment, property confiscation, and massive allocations of federal, state, and local resources, as well as in many ways of human suffering. It attracts more public concern and attention than any other social issue. It is estimated that 11 percent of the adult U.S. population suffer from substance abuse or dependence during the course of a year. About 13.7 million adults each year abuse or are dependent on alcohol and about 5.3 million abuse or are dependent on illicit drugs.1 Almost two million Americans are either in prison (after conviction) or jail (waiting for trail). Of every 100,000 Americans, 481 are in prison. This is the highest rate in the Western world, second only to Russia. In the United States, 1.5 million children have at least one parent in prison, 500,000 more than in 1991.2 In terms of illegal drugs alone, the U.S. drug market has been estimated to be $150 billion a year; the current cost to construct and operate federal, state, and local prisons is $40 billion a year. “The cost of substance abuse to the US economy each year is estimated [to be] over $414 billion [in 1995].3 The annual federal anti-drug budget for law enforcement is about $12 billion per year, and about $3 billion goes to overseas drug wars alone with about half of that amount going to Colombia to eliminate opium and coca cultivation. It has been reported that substance abuse and addiction will add at least $41 billion to the costs of elementary and secondary education for 2001 due to class disruption and violence, special education and tutoring, teacher turnover, truancy, children left behind, student assis-

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tance programs, property damage injury, and counseling.4 The cost to the nation for each of its hard core addicts is about $30,000 per year. Nearly $300 per year is being spent on the drug problem for every man, woman, and child in America to convince the public that there is “an abiding willingness on the part of the government and the people to fight back.”5 The numbers and costs associated with the drug issue are overwhelming, and understanding the extent of the problem is not made any easier by drug policy makers and experts who explain the problem in different, often contradicting, ways in order to justify support for their perspective. Take for example the statements of Barry McCaffrey, director of the Office of National Drug Control Policy for President Clinton, and Mathea Falco, president of Drug Strategies, a nonprofit policy institute in Washington, DC, who served as a U.S. Assistant Secretary of State for international narcotics matters from 1977 to 1981, that appeared in the same publication, Global Issues, published by the U.S. Information Agency in June 1997.6 Barry McCaffrey: As a nation we have made enormous progress in our efforts to reduce drug use and its consequences. . . . While America’s illegal drug problem remains serious, it does not approach the emergency situation of the late 1970’s, when drug abuse skyrocketed, or the cocaine epidemic of the 1980’s. In the past 15 years, we have reduced the number of illicit drug users by 50 percent. Just 6 percent of our household population age 12 and over was using drugs in 1995, down from 14.1 percent in 1979. Cocaine use has also plunged . . . More than 1.5 million Americans were current cocaine users in 1995, a 74 percent decline from 5.7 million a decade earlier. Cocaine is on its way out as a major threat in America. Mathea Falco: Two-thirds of the public think that drug abuse is worse today than five years ago. . . . Since 1980, we have spent $290 billion on federal, state, and local anti-drug efforts. This amount—some $20 billion a year—is twice as much as the federal government spends annually for all biomedical research, including research on heart disease, cancer and AIDS. . . . Despite a fivefold increase in federal expenditures for supply reduction efforts since 1986, cocaine is cheaper today than it was a decade ago. Heroin is sold on the streets for $10 a bag at purities exceeding 60 percent compared to less than 30 percent in 1990. . . . Despite America’s overseas efforts, worldwide opium and cocaine production has doubled in the last 10 years. The number of countries producing drugs has doubled as well, making drugs a truly global business. . . . Marijuana remains the most widely used illegal drug, among both adults and teenagers. . . . Heroin . . . [b]ecause of its higher purity . . . can be snorted or smoked, increasing its appeal to those reluctant to inject drugs. . . . Methamphetamine abuse is also increasing. . . . Among medical professionals, the legal narcotic fentanyl—10 times more powerful than heroin—is frequently abused. . . . Mood altering pharmaceutical drugs, [such as Ritalin which is a central nervous system stimulant, Rohypnol which is a tranquilizer that lowers inhibitions, suppresses short-term memory and has led to some women being raped] . . . and glue, aerosol sprays, lighter fluid and paint thinner are gaining new popularity . . . and [are being used] by growing numbers of children. B.M.: Drug education and prevention are the centerpiece of the national drug strat-

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egy. . . . Our diverse drug prevention and education campaigns have been successful. . . . There is no question that effective treatment programs can put people in a position where they no longer suffer from addiction. . . . [T]reatment lowers medical costs, reduces accidents and worker absenteeism, diminishes criminal behavior, and cuts down on child abuse and neglect . . . Unfortunately, there is no cure for addiction, and treatment is often a lifelong undertaking. . . . A 1994 study by the Rand Corporation demonstrated a cost-benefit ratio of seven to one for drug prevention and treatment compared to supply reduction. In other words, for every dollar not spent on drug prevention and treatment, we would have to spend $7 on reducing the supply of drugs. The question is not whether we can afford to pay for treatment. Rather, how can we afford not to? M.F.: [M]ost children do not get effective drug prevention teaching. . . . In addition one million prison inmates in this country have serious drug habits, regardless of the crimes for which they were convicted. Treatment for drug abuse is not readily available inside the criminal justice system or in many communities. Yet, extensive research confirms that treatment is the most cost-effective way to combat addiction and drug-related crime. [Note: Treatment represents less than 20 percent of the annual federal budget used for dealing with the drug problem.]

For years, efforts to combat the drug problem have been referred to as a “war.” Now it appears that there is a retreat from the “war” terminology by government officials. According to General McCaffrey, “the metaphor of a ‘war on drugs’ is misleading. It implies a lightning, overwhelming attack. We defeat an enemy. But who’s the enemy in this case? It’s our own children. It’s fellow employees. The metaphor starts to break down. The United States does not wage war on its own citizens. The chronically addicted must be helped, not defeated. . . . A more appropriate conceptual framework for the drug problem is the metaphor of cancer. Dealing with cancer is a long-term proposition. It requires the mobilization of support mechanisms—human, medical, educational, and societal among others.”7 While the general’s remarks raise a number of questions including the meaning of “war,” who is the enemy and the victim, and the use of a medical model approach for defining the drug problem, the important point is that perhaps his words reflect a government shift in terms of how the public is now being led to perceive the drug problem. From another perspective, there is a war at hand—one rooted in rogue states and terrorism, including the attack on America, September 11, 2001. It should not be surprising if proceeds from the production and sale of drugs such as opium and heroin were used to finance the September 11 event and other acts against people and property. In spite of Afghan declarations to ban opium farming, nothing has been said about opium selling. “Raw opium is openly available in shops all over Afghanistan, and its heroin continues to saturate the European market. Massive overproduction in the 90’s drove down heroin prices in the West and created huge unsold inventories in Afghanistan. International law enforcers estimate that the big traders are now holding as much as 3,000 tons of raw opium or its equivalent in processed heroin” (Newsweek, September 17:21).8 This second edition of Drug Use, Policy, and Management provides a unique inside report of the drug trade involving Afghanistan, including desperately poor republics of the for-

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mer Soviet Union. In the Bekaa Valley (Lebanon), another region known for harboring terrorist activity, drugs have a long tradition. There cultivators and tribal drug lords working with militias have built up a thriving trade bringing billions of dollars each year of illegal revenue (Newsweek, September 17:34).9 In the first edition of this book, high hopes were laid on the landmark settlement between the U.S. government and the tobacco industry in 1998 that was to put an end to Joe Camel and the Marlboro Man. The broad goals of the settlement were to reduce the exposure of young people to tobacco marketing, to generate comprehensive smoking-prevention efforts in every state, and to counteract the effect on children of marketing by the industry. Specifically, the industry agreed to pay the states $206 billion over a 25-year period (four other states settled their lawsuits separately for a total of $40 billion), to respect certain limits on tobacco advertising, and to fund a nation-wide campaign of public education.10

Less than four years later, it is clear that the Master Settlement Agreement has not lived up to its promise . . . young persons continue to be bombarded by tobacco marketing. The industry has simply shifted its resources to concentrate on areas that were not restricted by the settlement. . . . Equally disturbing, the states have not used the money from the tobacco settlement as was intended. . . . Even the public-education campaign carried out by a foundation created by the Master settlement Agreement is not likely to have the effect that was envisioned. . . . In short, the Master Settlement Agreement by itself will do little to change the fact that 400,000 Americans still die every year of tobacco-related diseases and that more than 3,000 children become regular smokers every day.”11

With some limits on liability in place, cigarette manufacturers including Philip Morris, R. J. Reynolds, and Brown and Williamson, which have banded together to form the United States Cigarette Export Association, have moved on to other market places in the world. This is precisely the case for such countries as Japan, Taiwan, and South Korea, where their markets have opened up to U.S. brands, and have allowed U.S. companies a far greater promotional latitude than the state monopolies enjoyed. “The results [have been] dramatic: between 1985 and 1995, the market share of imported cigarettes jumped from 2 to 6 percent in South Korea, 2 to 21 percent in Japan, and zero to 22 percent in Taiwan.”12 In China, smoking is causing about 750,000 deaths a year, and it has been predicted that this will rise to three million a year by the time the young smokers of today reach middle and old age.13 “Worldwide, by the turn of the century, cigarettes will already be causing about 4 million deaths a year, half in rich countries, half in poor countries . . . if current smoking patterns persist then by about 2030 this will have risen to 10 million deaths a year, 70% of them in developing nations.”14 Time is needed to address many of the details of the settlement. Based on evidence regarding the addictive properties of tobacco, however, it seems that had it not been for its legitimate status gained through big business tactics and political

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influence, cigarettes and other tobacco products could have been declared an illegal controlled substance a long time ago. Many factors affect drug policy, the determination of whether a drug is legal or illegal, its control, and the way it is addressed through prevention and treatment, as well as other factors. The decisions are many and complex. Strong legislation may offer the best hope for reducing the negative consequences of drug use, but it is not a panacea.15 It is only one way to address the problems and needs of people involved. A new national priority and resolve swept through the United States to address terrorism at the time this edition of Drug Use, Policy, and Management was prepared. This mission will not be accomplished in the short run; it will take time, patience, and resources. It is a crisis, however, that offers to government officials and leadership the opportunity to declare to the nation that the time has also come to quickly assess what it is being done to deal with the drug problem and what measures must be taken in order to move on to other important issues. It is an opportunity to consider which drug-related initiatives are effective and which ones are not. It is a time to take those measures needed to back off of misdirected policies, actions, and spending habits in order to provide sensible and effective strategies for ameliorating the situation. This is not a retreat from the “war” on drugs; it is responsible decision making to move the nation forward in a very challenging time. Hopefully, the leadership of the United States will take advantage of this opportunity and will make the reforms needed and provide a model response for other nations. It has the ability and responsibility to do nothing less. ABOUT THIS BOOK Addressing the problem of drug use, regardless of the nature of intervention, may be likened to craftsmanship. Many skilled drug prevention educators, therapists, counselors, social workers, managers of drug treatment services, and others have acquired and mastered knowledge of the problem and have developed individualized approaches to intervention. Many others, however, involved with the drug problem including those coming from perspectives of policy and program decision making as well as those providing individual, group, and family services will benefit from the material presented in this book. The materials selected for inclusion have been gleaned from government publications and reports, professional books and journals, newspaper and magazine accounts, and other sources to present a useful, provocative, and readable book that relates to major stages of the helping process. This book begins with definitions of key terms commonly used in discussing drugs and drug use: what is a drug, the meanings of use and abuse, and addiction and dependence—no simple task because these terms are used in many different ways in many different settings. Next, the classes of drugs including cannabinoids, opioids, cocaine, alcohol, amphetamines, methamphetamine, hallucinogenics, and designer drugs have been revised. With this background information in place, an examination is given to the social context and reality of drug use. To promote un-

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derstanding of the importance of this dimension of the drug problem, tobacco is used as a focal point of discussion. This example has been brought up to date in response to the Master Settlement Agreement of 1998. In Chapter 2, the focus shifts to a review of the theoretical considerations and risk factors commonly associated with drug use. Elements of social order, social forces (e.g., environment, values, and morals; interpersonal relations—family and peers; education and the media), the labeling and criminalization process, and biological and psychological characteristics are summarized. The chapter has been strengthened by adding new reports and research studies. Chapters 3 through 6 deal with heroin, alcohol, cocaine, and marijuana, four substances that underpin the drug problem. These substances, described in terms of historical background and present patterns and trends of use, personality characteristics of those who use the substance, case examples of individuals who have sought treatment, and multinational research that provides a cross-cultural perspective of the issue have been revised for this edition. Noteworthy is Chapter 3, which focuses on heroin. Research on Russian-speaking immigrant drug use, a concern for the United States, Germany, and Israel, where most of the immigrants settled during the past decade, is presented. This issue is complemented with case studies and unique insight of the role of Afghanistan and its neighboring countries in terms of distribution of heroin. Chapter 6, which deals with cocaine use, has been revised to include reported highlights of the problem over the last fifteen years. An often overlooked aspect of the drug problem is the organization and management of drug services provision. Chapter 7 examines this issue with an overview of the human services perspective, including drug treatment services management. Also, the description of a model method of drug information collection and dissemination, RADAR (Regional Alcohol and Drug Abuse Resource Centers) is presented. Finally, the Epilogue to this book reviews the “War against Drugs” in terms of public and professional opinions, numbers of people involved, and cost. These three perspectives raise questions about present policies and provide information relevant to future efforts. NOTES 1. Coffey, R., Mark, T., King, E., Harwood, H., McKusick, D., Genuardi, J., Dilonardo, J., and Chalk, M. (2001). National Estimates of Expenditures for Substance Abuse Treatment. DHHS Publication No. SMA 01-3511. Rockville, MD: U.S. Department of Health and Human Services, p. 1. 2. Murphy, C. (2001). Crime and punishment: Think that stuffing prisons with lawbreakers makes sense? Fortune, April 30 (reported in Harm Reduction Coalition, April 2). 3. Swan, N. (1998). Drug abuse cost to society set at $97.7 billion, continuing steady increase since 1975. NIDA Notes, NIH Publication No. 98-3478. 4. Sweet, R. (1996). The war on drugs is lost. National Review, February 12, p. 44; Join Together Online (JTO) (2001). U.S. prison spending quadruples, February 16; DRCNet (2001). Issue No. 182, April 20; Bertram, E., and Sharpe, K. (1996). The unwinnable drug war. What Clausewitz would tell us. World Policy Journal (Winter):44; JTO (2001). US official says to expect costly Colombian drug war, April 6; NEWS, The National Academies

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(2001). Data sorely lacking on effectiveness of nation’s drug-enforcement programs, March 29; New York Times (2001). Adjusting drug policy, February 27:A22. 5. Grassley, C. (1997) The U.S. effort to fight drug use. Focus: Journal of the United States Information Agency, Vol. 2, No. 3, June, p. 10. 6. McCaffrey, B. (1997) Dealing with addiction. Focus: Journal of the United States Information Agency, Vol. 2, No. 3, June, pp. 5–9; Falco, M. (1997). Drug prevention makes a difference. Focus: Journal of the United States Information Agency, 2(3):20–23. 7. McCaffrey, p. 6. 8. Caryl, C. (2001). The new ‘Silk Road’ of death. Newsweek, pp. 21–24. 9. Hammer, J. (2001). Hash makes a comeback. Newsweek, p. 34. 10. Kessler, D., and Myers, M. (2001). Beyond the tobacco settlement. New England Journal of Medicine, August 16, 345(7):535. 11. Ibid., p. 536. 12. McGinn, A. (1997). The nicotine cartel. World Watch, July/August, p. 22. 13. Liu, B., Peto, R., Chen, Z., Boreham, J., Wu, Y., and Li, J. (1998). Emerging tobacco hazards in China: Retrospective proportional mortality study of one million deaths. British Medical Journal, 317:1411–1422. 14. Lopez, A. (1998). Editorial: Counting the dead in China. British Medical Journal, 317:1399–1400. 15. Kessler and Myers, p. 537.

Acknowledgments

Appreciation is expressed to Jane Garry of Greenwood Publishing Group, who provided support, encouragement, and expertise for promoting this and other initiatives related to the drug problem. Terri Jennings, production editor, is acknowledged for bringing the book to the level of production. Finally, I want to express my gratitude to Sofia Borkin, M.D., and Ricki Valdman, who contributed to promoting an understanding of the problem of substance abuse among Russian-speaking addicts. This book is dedicated to my parents—Sam and Helen; and children—Noa, Jesse, Orli, and Danny—who gave me their time to complete this initiative.

Chapter 1

Drug Use and Abuse: Definitions and the Social Context of Reality—Tobacco

TERMS AND DEFINITIONS: AN OVERVIEW When asked what is a drug, most people will mention some characteristics they have heard about, like being illegal or causing addiction. But not every drug is illegal. Alcohol and tobacco, for example, are legal in most countries. And not every drug causes addiction. LSD, for example, is generally not considered addictive. Even the word “addiction” has to be clarified. For the most part,“addiction” has been substituted by the term “dependence” which refers to: (1) a behavioral syndrome, also known as psychological dependence, and (2) a physical or physiological dependence. Furthermore, the professional literature tends to avoid defining the term “drug”; rather, the preference is to refer to psychoactive substances with reference to classifications and names. For example, the Diagnostic and Statistical Manual of Mental Disorders (DSM—Fourth Edition) of the American Psychiatric Association (1994) lists 11 classes of pharmacological agents: alcohol, amphetamines or similar acting agents, caffeine, cannabis, cocaine, hallucinogens, inhalants, nicotine, opiates, phencyclidine (PCP) or similar agents, and sedatives, hypnotics, and anxiolytics. There is a 12th residual category for everything else including anabolic steroids, nitrous oxide, and others. Even after reading the list carefully, one still does not know the meaning of “drug.” The reason for the lack of a clear definition is that almost anything may be a drug. What makes a drug out of a substance is not its chemical properties, but how it is used by people. A typical example of this is the use and abuse of medications such as substituting an abused opiate substance such as heroin with methadone, a controlled opiate substance. Methadone, dispensed in 100 cc. bottles, contains 40 mgs. of the active substance. If a doctor prescribes 30 mgs. of methadone a day for

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a patient, then 75 cc. are needed from the bottle. If the patient drinks the entire contents of the bottle (100 cc.) instead of the prescribed 75 cc., the addict has ingested 40 mgs. of methadone instead of 30 mgs. The first 30 mgs. were medically and legally prescribed; however, were the other 10 mgs. taken illegally? Morphine, when used in a hospital by a doctor to treat a patient, is a valuable medication against pain. But if the same ampoule of morphine was stolen from the hospital and used by somebody who is not a physician, the substance may be considered an illegal drug. If the same ampoule of morphine was used by the same doctor in the same hospital, not as a medication against pain but because someone, say an opiate addict, paid him to inject the substance, then the doctor may be considered a drug dealer subject to being imprisoned and/or having his medical license revoked. It is commonly believed that laws exist covering every substance considered to be a drug. Indeed, there are international agreements among many countries, such as the Geneva Convention, that bans the use of certain substances except for purposes such as medical and experimental research. Such agreements, however, are subject to laws and means of enforcement that vary from country to country. Heroin, for example, may be used by those addicted to the substance for maintenance purposes in some countries but not in others. Cannabis oil may be used medically in the United States but not in many other countries. Other substances may be used on a country-by-country basis, for example, kat in Yemen and cocaine in Peru and Bolivia. The use of alcohol is permitted in most countries, but not all—Saudi Arabia and other Moslem-dominated countries have very strict laws prohibiting its use. Other substances present complicated legal problems because of their chemical composition. One such example is the illegal hallucinogenic substance popularly called LSD, which in chemical terms is “LSD 25” because it is the 25th of the possible 32 derivatives of lysergic acid. If someone sells or uses LSD 26 instead of LSD 25, which has been the case, that person may be well within the law since there is no law prohibiting the use of LSD 26. Another legal problem is the amount of substance possessed or used. Some laws permit the possession of a determinate amount of marijuana (usually up to one ounce or 28 grams) or at least consider the violation a minor offense and not a crime like drug dealing. Other legal systems, depending on the country, consider all possessions of an illegal substance, regardless of the amount, a crime. Still others make a distinction between “for one’s own use” and “for dealing.” Consequently, even the term “legal” has to be defined on a country-by-country as well as a situation-by-situation basis. The status of substances is not dependent solely on legal considerations. Laboratory analysis may be needed to determine whether a substance is known and has been categorized for response. Drug producers and dealers have come to realize that by modifying certain illegal substances they may avoid legal prosecution for a year or two until the new substance is proven to be harmful or at least determined to be illegal. Consequently, they tend to stay ahead of the laboratories and law by continuously producing new substances.1

Drug Use and Abuse

3

The meaning of the word “drug” often varies with the context in which it is used. Because terms such as “drug,” “drug dependence,” “drug abuse,” and “drug addiction” are used so often and in so many different ways—varying across geographic locations, from country to country, and changing over time in response to social and economic pressures—it is often difficult to provide accurate, up to date, definitions of the terms. In the Guide to Drug Abuse Research Terminology published in 1982 by the National Institute on Drug Abuse in the United States, nearly three pages were used on these four terms without providing a simple definition for any of them.2 From a strict scientific viewpoint, “a drug is any substance other than food which by its chemical nature affects the structure and function of the living organism.”3 From a sociological perspective, the concept of “drug” is a cultural artifact, a social fabrication—something that has been arbitrarily defined by certain segments of society as a drug.4 Clearly, society determines what a drug is, and this social definition influences our values, attitudes, and behavior toward substances, whether they be of a licit or illicit nature. In a sense, therefore, the definition of a drug lies in the subjective realm. In a study conducted in the United States, substances such as heroin, cocaine, marijuana, amphetamines, and barbiturates were regarded by the public as being drugs.5 Psychoactive substances such as alcohol and tobacco are generally not regarded as drugs at all. In neither public law nor public discussion is alcohol regarded as a drug.6 At present, however, there are few experts in the drug field who would argue that alcohol is not a drug.7 In 1973, little if any mention was made of tobacco being a narcotic substance, but tobacco is now widely recognized as being one of the most harmful drugs in use.8 In 1988, the Surgeon General of the United States, C. Everett Koop, stated that all of the criteria used to define addiction are met by tobacco.9 Yet, a spokesman for the Tobacco Institute in the United States has stated flatly that the claim to tobacco’s addictive properties “contradicts common sense.”10 In sum, a drug may be legal or illegal, harmful or helpful (as is the case of those substances used in medical therapy, such as penicillin). For purposes of this book, the term “drug” refers to those substances having psychoactive properties that influence the mental functioning of humans, and consequently have a physical effect on the body as well, or refers to substances used without medical advice in order to improve mood. Use/Abuse The terms “drug use” and “drug abuse” are often applied interchangeably. For example, the use of an illegal drug may be considered an abuse. For many people who use marijuana on occasion in order to achieve a state of euphoria, pleasure, or relaxation, it may be argued that they do not abuse the substance. Other perspectives of abuse rely on the notion of potential or actual harm. The use of almost any drug, even those under the guidance of a physician, has at least some potential for harm.11

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The American Medical Association once referred to abuse as the use of a drug outside a medical context. Used in this sense, abuse conveyed the impression that a behavior is measurable, and announced to the world that the nonmedical taking of drugs was undesirable.12 In 1973, the National Commission on Marijuana and Drug Abuse stated that the term “drug abuse” must be deleted from official pronouncements and public policy dialogue. “The term has no functional utility and has become no more than an arbitrary code word for that drug use which is presently considered wrong. Continued use of this term, with its emotional overtones, will serve only to perpetuate confused public attitudes about drug-using behavior.”13 More than 20 years later, however, the term has been found useful to differentiate users and abusers. “Users are those individuals who have tried or continue to use alcohol or other drugs but who are not dependent or addicted. They also fall into different subgroups: a) those who have tried a substance but have discontinued use; b) those who use infrequently and primarily in response to social circumstances; and, c) those who use periodically but infrequently enough to avoid dependence or addictions. . . . Abusers are heavily involved in alcohol or drugs use; [and] treatment is clearly the appropriate intervention.”14 A more recent definition of substance abuse is presented by the American Psychiatric Association. “The essential feature of ‘substance abuse’ is a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances. There may be repeated failure to fulfill major role obligations, repeated use in situations in which it is physically hazardous, multiple legal problems, and recurrent social and interpersonal problems. . . . Unlike the criteria for ‘substance dependence’, the criteria for ‘substance abuse’ do not include tolerance, withdrawal, or a pattern of compulsive use and instead include only the harmful consequences of repeated use. . . . Although a diagnosis of ‘substance abuse’ is more likely in individuals who have only recently started taking the substance, some individuals continue to have substance-related adverse social consequences over a long period of time without developing evidence of ‘substance dependence.’ The category of ‘substance abuse’ does not apply to caffeine and nicotine.”15 Addiction/Dependence According to Goode (1989), it has been known for thousands of years that certain drugs “have the power to enslave men’s minds, [but] it was not until the nineteenth century that the nature of physical addiction or dependence began to be understood. It was at that time that a classic definition of the problem was being developed based on the opiates—at first opium and morphine, and then, after the turn of the century, heroin as well. Much later, it was recognized alcohol, sedatives, such as barbiturates, and minor tranquilizers also produced most of the symptoms of ‘classic’ addiction.”16 Classic addiction or dependence is understood to mean that when a person takes certain drugs in “sufficient quantity over a sufficiently long period of time, and stops taking them abruptly, the user will experience a set of physical symptoms

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known as withdrawal” which are likely to include chills, fever, diarrhea, muscular twitching, nausea, vomiting, cramps, and general body aches and pains, especially in the bones and joints.17 Yet, not all drugs, even when used over time and in large quantities, produce withdrawal symptoms when the substance is discontinued. Therefore, not all drugs fit the classic definition of addiction. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM—Fourth Edition) of the American Psychiatric Association (1994), the essential feature of substance dependence is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems. There is a pattern of repeated self-administration that usually results in tolerance, withdrawal, and compulsive drug-taking behavior. These important terms are defined as follows: Tolerance is the need for greatly increased amounts of the substance to achieve intoxication (or the desired effect) or a markedly diminished effect with continued use of the same amount of the substance. The degree to which tolerance develops varies greatly across substances. Individuals with heavy use of opiates and stimulants can develop substantial (e.g., tenfold) levels of tolerance [that] . . . would be lethal to a nonuser. Alcohol tolerance can also be pronounced, but is usually much less extreme than for amphetamines. Many individuals who smoke cigarettes consume more than 20 cigarettes a day, an amount that would have produced symptoms of toxicity when they first started smoking. Individuals with heavy use of cannabis are generally not aware of having developed a tolerance. Withdrawal is a maladaptive behavioral change with physiological and cognitive concomitants. . . . After developing unpleasant withdrawal symptoms, the person is likely to take the substance to relieve or to avoid those symptoms, typically using the substance throughout the day beginning soon after awakening. Withdrawal symptoms vary greatly across the classes of substances. . . . [E]asily measured physiological signs of withdrawal are common with alcohol, opiates, sedatives, hypnotics, and anxiolytics. Withdrawal signs and symptoms are often present, but may be less apparent, with stimulants such as amphetamines and cocaine, as well as nicotine. No significant withdrawal is evident, even after repeated use of hallucinogens. Dependence or compulsive drug taking behavior is when an individual takes the substance in larger amounts or over a longer period than was originally intended (e.g., continuing to drink until severely intoxicated despite having set a limit of only one drink). . . . In some instances of Substance Dependence, virtually all of the person’s daily activities revolve around the substance. Important, social, occupational, or recreational activities may be given up or reduced because of substance use. The individual may withdraw from family activities and hobbies in order to spend more time with substance-using friends.18

According to the World Health Organization (1992), dependence syndrome is a cluster of physiological, behavioral, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviors that once had greater value. A central descriptive characteristic of the de-

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pendence syndrome is the desire [often strong, sometimes overpowering] to take psychoactive drugs [which may or may not have been medically prescribed] including alcohol or tobacco. There may be evidence that return to substance use after a period of abstinence leads to a more rapid reappearance of other features of the syndrome than occurs with nondependent individuals. . . . It is an essential characteristic of the dependence syndrome that either psychoactive substance taking or a desire to take a particular substance should be present; the subjective awareness of compulsion to use drugs is most commonly seen during attempts to stop or control substance use. . . . The dependence syndrome may be present for a specific substance (e.g., tobacco or diazepam), for a class of substances (e.g., opioid drugs), or for a wider range of different substances (as for those individuals who feel a sense of compulsion regularly to use whatever drugs are available and who show distress, agitation, and/or physical signs of a withdrawal state upon abstinence).19

THE CLASSES OF DRUGS: A REVIEW Nicotine Among all licit and illicit drugs, cigarettes are by far the leading cause of illness and death. Smoking is a leading factor related to lung, mouth, throat, bladder, pancreas and kidney cancer. More than 400,000 Americans die from tobacco-related causes each year, and most of them began using tobacco before the age of 18. A detailed examination is given to nicotine and cigarettes under the heading “The Social Context and Reality of Drug Use” that follows this section. Alcohol Alcohol is a central nervous system depressant. It is a liquid obtained by fermentation of carbohydrates by yeast, or by distillation. Ethanol alcohol is beverage alcohol compared to isopropyl alcohol which is rubbing alcohol and methyl alcohol which is produced from wood and used for cooking fuel. The major types of alcoholic beverages are distilled spirits, beer, and wine.20 Alcohol, like heroin, cocaine, and LSD, is a psychoactive substance. Alcohol is addictive. It generates severe withdrawal symptoms when the heavy, long-term drinker discontinues its use. In fact, alcoholism is by far the most common form of drug addiction, except for tobacco. In the United States, it is estimated that there are about 33 million binge drinkers, defined as drinking five or more drinks on the same occasion on at least one day in the past 30 days. Also, more than 12 million Americans drink heavily—five or more drinks on the same occasion on each of five or more days in the past 30 days. All heavy alcohol users are also binge alcohol users. Based on statistics for the same year (1998), for comparative purposes, only 130,000 Americans used heroin at least once during the past 30 days prior to the National Household Study on Drug Abuse.21 Alcohol affects the brain, coordination, poor judgment, slowed reflexes, distorted vision, memory lapses and even blackouts . . . it can damage every organ in the body and it can increase the risk for a variety of life-threatening diseases including cancer. Alcohol depresses the central nervous system, lowers inhibitions, and impairs judgment. . . . Drinking can lead

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to risky behaviors, including unprotected sex that may expose a person to HIV/AIDS and other sexually transmitted diseases or cause unwanted pregnancy.22

Patterns of alcohol use can range from occasional episodes to daily heavy drinking. Dependence can vary from periodic use that cannot be controlled, moderated, or stopped to physical dependence that cannot be stopped without significant and dangerous withdrawal. Indications of alcohol use include a sedated, intoxicated appearance and alcohol odor. Physical addiction to alcohol is characterized by a need to maintain alcohol to prevent physical withdrawal. Abrupt discontinuation of alcohol can be dangerous in cases of physical addition necessitating medical supervision. Additional signs of problem behavior include: getting drunk on a regular basis; lying about how much alcohol is being used; believing alcohol is necessary to have fun; frequent hangovers; feeling run down, depressed, or even suicidal; having blackouts—forgetting what the person did while drinking; and having problems in school and/or at work as well as getting in trouble with the law.23 Opiates Substances derived from the opium poppy are opiates. The most commonly abused illicit substance is heroin. Prescription drugs, usually used for pain relief, include codeine, morphine, oxycodone (i.e., Oxy-Contin and Percocet), and others. Included in this category may be synthetic substances such as methadone and LAAM (levo-alpha-acetyl-methadol), labeled opioids with the property to interact with opiate receptors in the brain.24 Opiate-based substances calm users down, but initially they can produce a state of euphoria. The substances may be eaten, but they are generally smoked, sniffed, or injected subcutaneously or intravenously. The subcutaneous injection, referred to as skin-popping, produces a slower absorption with a lower degree of euphoria but longer-lasting effects including characteristic marks on the skin. Addiction to opiates is rather quick, generally after one or two months of daily use. People under the influence of opiates appear calm, sometimes sleepy, and have a tendency to take everything in stride. The situation changes radically when the first symptoms of withdrawal appear, generally six to eight hours after the last use. Signs of opium or heroin overdose include shallow breathing, pinpoint pupils, clammy skin, convulsions, and coma. Pure opiates cause relatively little body damage. Substances sold on the streets as opiates, however, usually contain a large amount of contaminants including poison which can produce serious damage or even death to the user. Unlike stimulants, opiates do not produce a psychotic state when used in their pure form and have the ability to reduce or eliminate psychotic symptoms in mental patients. Stimulants Stimulates such as amphetamine, cocaine, crack, methamphetamine, and MDMA—methylenedioxymethamphetamine (ecstasy)—produce an increased

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state of arousal accompanied by a sense of confidence and euphoria. Users tend to appear in a state of hyperactivity, agitation, or exhaustion, and when used over prolonged periods of time irrational and paranoid behavior may be evidenced. Other characteristics may include regular episodes of out-of-control use despite increasing negative consequences associated with that pattern of behavior, weight loss, numerous needle marks, hyperactivity, and problems with work and interpersonal relations. Stimulants can be snorted, injected, smoked, or eaten. When used with heroin, the combination is referred to as “speedball.” Considerable attention is being given to methamphetamine, which even in small amounts can produce euphoria, enhanced wakefulness, increased physical activity, decreased appetite, and increased respiration. Other effects include irritability, insomnia, confusion, tremors, anxiety, aggression, and convulsions. A synthetic drug, methamphetamine is related chemically to amphetamine, but produces greater effect on the central nervous system. It is reported that the euphoric effects are similar to but longer lasting than those of cocaine. Also, the substance is cheaper to obtain than cocaine.25 Methamphetamine was used by soldiers to help them fight off fatigue during World War II. Immediately after the war, with the availability of military surplus, the substance became widely used in Japan. “In the United States in the 1950’s, legally manufactured tablets of methamphetamine were used nonmedically by college students, truck drivers, and athletes, who usually did not become severely addicted. This pattern changed drastically in the 1960’s with the increased availability of injectable methamphetamine. . . . [The substance] has been the most prevalent clandestinely produced controlled substance in the United States since 1979.”26 Its production is easy and cheap. “Setting up a lab to produce a substantial amount of the drug may cost less than $2,000 and be enormously profitable—one day’s production may be worth $70,000.”27 Ecstasy Ecstasy (MDMA) was patented as long ago as 1913 by the German company Merck. Rumor has it that the drug was sold as a slimming pill. . . . What ecstasy does is very simple. . . . It combines two opposite effects, stimulation and relaxation, but in addition [it] provides a subtle quality of empathy. The radical psychotherapist, RD Laing, who took MDMA . . . in 1984 when it was still legal, said “It made me feel how all of us would like to feel . . . smooth and open hearted, not soggy, sentimental or stupid.” . . . The effects are similar, though more intense, to the popular anti-depressant Prozac (Fluoxetine): it makes most people feel liberated and good about themselves, less self-conscious and able to feel emotions more clearly, while a small minority become more depressed . . . the drug’s various effects can be reduced to two primary [conditions], one physical and one mental: the relief of muscular tension and the dissolution of fear. People on ecstasy feel able to move and express themselves freely.28 [More recently] despite the health risks associated with ecstasy use, some mental health professionals are incorporating the drug into sessions for patients suffering from severe trauma. . . . Lester Grinspoon, professor emeritus of psychiatry at Harvard Medical School, said that ecstasy “greatly accelerates” the therapeutic process. “It enhances one’s capacity for insight and empathy, and melts away the layers of defensive-

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ness and anxiety that impede treatment. . . . In one session, people can get past hang-ups that take six months of therapy to untangle.”29

Ecstasy is a synthetic, psychoactive substance with stimulant and mild hallucinogenic properties. It is often used in pill form. The substance is structurally similar to methamphetamine and the hallucinogen mescaline.30 According to National Institute on Drug Abuse’s 2000 study, Monitoring the Future, about 5 percent of the 10th graders and 8 percent of the 12th graders, and about 3 percent of the 8th graders said they had used ecstasy in the past year.31 Like methamphetamine, ecstasy (MDMA—3,4-methylenedioxymethamphetamine) has been linked to long-term brain damage that remains after the high has worn off.32 The substance has been associated with verbal memory impairments and poor memory performance, and it may affect the ability to reason verbally or sustain attention.33 The cost for an ecstasy tablet ranges from $10 to $45. Its users tend to be adolescents and young adults, including high school and college students, predominately white with middle and upper socioeconomic status except for certain major populations centers (e.g., New York) where users come from all socioeconomic groups. Ecstasy is used in social settings such as nightclubs and dance clubs, private homes, college dormitories, and bars. The substance is almost exclusively taken orally in pill or powder form; however, it can be snorted or diluted with water and used as a drink. It is often used in combination with other drugs—mostly alcohol, but also with other club drugs such as GHB and Ketamine, marijuana, methamphetamine, psilocybin mushrooms, and LSD. Like its users, those selling ecstasy are predominately white, male, middle-class young adults, who range from 14 to 32 years of age. Usually, the drug is sold as loose pills “on the spot,” meaning at nightclubs, all-night dance or music events known as “raves,” shopping malls, and coffee shops.34 Ecstasy, along with methamphetamine; nitrous oxide—an inhalant often referred to as laughing gas; LSD (lysergic acid diethylamide)—a hallucinogen; Rohypnol and GHB (listed under the category of sedatives); and Ketamine, a prescription anesthetic with hallucinogenic and dissociative properties in liquid or powder form, is referred to as a “club drug.”35 Sedatives and Hypnotics This class of drugs when abused is commonly known as “downers.” They usually include prescription drugs used to reduce anxiety or facilitate sleep. When abused, they induce a sedated, intoxicated state that may eventually result in sleep. The most commonly abused drugs in this class are the benzodiazepines (Valium, Xanax, Ativan, Halcion, and others), barbiturates (Phenobarbital, Seconal, Nembutal, and Amytal), and methaqualone (Quaaludes, which are no longer legally available in the United States through a prescription). All are normally taken in pill form, but they can sometimes be injected. Indications of sedative use include an intoxicated appearance without the odor of alcohol and in some cases complaints of anxiety and insomnia. Addiction to sedative and hypnotic drugs is

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similar to opiate addiction in that there is a physical addiction resulting in a need to maintain enough of the drug in the body to avoid physical withdrawal. The consequences of abruptly discontinuing these drugs can be a life-threatening withdrawal syndrome including seizures. Medical intervention is always necessary in a case of addiction to any of these drugs. Other substances in this category have been refereed to as “date-rape drugs.” They include two substances, GHB (gamma hydroxybutyrate) and flunitrazepam (Rohypnol). GHB is a central nervous system depressant usually sold as an odorless, colorless liquid in spring water bottles or as a powder which is mixed with beverages. In addition to being used in drug-assisted rapes, GHB is used as a “muscle-stimulating growth hormone, sleep aid, and aphrodisiac.” The intoxication effects and potential health consequences are drowsiness, nausea/vomiting, headache, loss of consciousness, loss of reflexes, seizures, coma, and death. Flunitrazepam (Rohypnol), a benzodiazepine, which is smuggled into the United States from primarily Mexico because it is no longer sold in the country, is used mostly with beer as an “alcohol extender” and disinhibitory agent. Also used in drug-assisted rape, the effects of this drug include visual and gastrointestinal disturbances as well as memory loss for the time under the drug’s effects which last four to eight hours.36 Marijuana and Hashish Marijuana is the most commonly used illegal substance. “Marijuana refers to the leaves and flowering tops of the hemp (cannabis) plant. It is also known as cannabis, [pot, weed, and ganja, among other names]. . . . Sinsemilla (“without seed” in Spanish) is a type of high-potency marijuana. . . . Although sixty cannabinoids (certain chemical compounds) are found in marijuana, the psychoactive one that most affects the brain is THC (delta-9-tetrahydro-cannabinol). . . . The THC level in marijuana has increased over the last quarter century [from less than 1 percent to as much as 17 percent]. . . . Hashish and hash oil also come from the cannabis plant. Hashish is a resinous material that is extracted and pressed into different shapes.”37 Marijuana and hashish are smoked and swallowed. Among the intoxication effects and potential health consequences are euphoria, slowed thinking and reaction time, confusion, impaired balance and coordination, cough, frequent respiratory infections, impaired memory and learning, increased heart rate, anxiety, panic attacks, tolerance, and addiction. Other physical signs of marijuana and hashish use include difficulty in walking, red and bloodshot eyes, smelly hair and clothes, and acting silly for no apparent reason.38 The habitual user of marijuana or hashish will experience a withdrawal syndrome characterized by roughly 30 days of irritability, insomnia, and craving for the substance upon its discontinuation. Hallucinogens Hallucinogenic drugs are substances that distort the perception of objective reality. The most well-known hallucinogens include phencyclidine, otherwise

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known as PCP, angel dust, or love boat; lysergic acid diethylamide, commonly known as LSD or acid; mescaline and peyote; and psilocybin, or “magic” mushrooms. Under the influence of hallucinogens, the senses of direction, distance, and time become distorted. These drugs can produce unpredictable, erratic, and violent behavior in users that sometimes leads to serious injuries and death.39 PCP is an illicit substance that affects the user at different times as a stimulant, hallucinogen, analgesic, or sedative. It can be snorted, smoked, eaten, or injected and, since it is fat soluble, it takes a prolonged period to leave the body.40 “PCP is an illicit anesthetic drug that produces hallucinogen-like effects and bizarre behavior. . . . PCP in large doses [causes] a user’s sense of consciousness, identity, memory, and environment, which are usually interrelated, [to fall] apart. Numbness or rigidity of extremities, large motor dysfunction, jerking eye movements, auditory hallucinations, nausea, drooling, dizziness, and memory loss have been reported. “LSD is the most potent synthetic hallucinogen. Commonly known as acid, it is sold in dosage units of small tablets (called microdots); tiny, clear, gelatin-like squares (known as windowpanes), or most often one-quarter inch squares of pieces of paper (known as blotter acid). [Taken orally] . . . the effects last up to twelve hours. . . . [U]sers experience strong changes in mood and report something like a short circuit in sensory perceptions. . . . [F]lashbacks [or] re-experience of the sensations of LSD intoxication [have been reported]. . . . The use of LSD can also precipitate profound, long-lasting psychiatric conditions such as schizophrenia or depression, although the exact role in these instances is unknown.”41 “The peyote cactus contains a psychoactive substance called mescaline that is found in small crowns (called buttons) located on the top of the plant. These buttons are soaked in water to obtain a hallucinogenic liquid, or dried and then chewed. . . . Mescaline can be produced synthetically. . . . Psilocybin mushrooms are native to Central and South America and can be cultivated indoors. . . . They are known as shrooms, or mush. They are eaten dried or fresh or combined with loose-leaf marijuana in a joint and smoked.”42 Other substances included in this category are Ketamine (Special K) which is a depersonalizing, dissociative, anesthetic drug with hallucinogenic properties and ecstasy, described earlier. Inhalants Inhalant solvents are chemical products that are intentionally inhaled to cause an immediate high. Because they affect the brain with much greater speed and force than other substances, they can cause irreversible physical and mental damage. Inhalants include solvents (e.g., gasoline, glues, nail polish remover, lighter fluid, paint thinners, dry cleaning fluid, markers, and correction fluid); gases or propellants used in butane lighters, any aerosols such as spray paints, hair spray, fabric protector, or refrigerants, and volatile nitrates found in room deodorizers.43 Inhalants affect the heart because they starve the body of oxygen and force the heart to beat irregularly and more rapidly. Inhalants cause people who use them to lose their sense of smell, experience nausea and nosebleeds, and develop liver,

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lung, and kidney problems. Chronic use can lead to muscle wasting and reduced muscle tone and strength and can cause sudden death by suffocation, choking on vomit, or heart attack. Warning signs include slurred speech; drunk, dizzy or dazed appearance; unusual breath odor; chemical smell on clothing; paint stains on body or face; red eyes; and runny nose.44 THE SOCIAL CONTEXT AND REALITY OF DRUG USE The use of illicit drugs, alcohol, and other addictive substances is not a new phenomenon, but one that takes on meaning and importance in relation to its social context, which varies over time and geographic location. Social context is a powerful determinant of what the drug is and does to the user. Social context influences at least four central aspects of the drug reality: drug definitions, drug effects, drug-related behavior, and the drug experience. The history of the drug and its use, the social strata of society who uses it, the kinds of situations in which it is used, and the publicity and public opinion about it may all be included in the definition of a drug’s social context. “How a drug is regarded—by the public, the law, its users, and even the medical profession—depends as much on irrational cultural factors as on its objective properties.”45 An examination of tobacco provides insight into how social context affects the reality of substance use. Tobacco Tobacco is a leafy plant, a stimulant, indigenous to North, Central, and South America. Introduced to Columbus by natives of the “new world,” the substance found its way to Europe and its importance was closely tied to economic interests. The Spanish, for example, had a monopoly on tobacco sales for over 100 years until the British colonies, notably Virginia, were able to produce sufficient quantities from the seventeenth century onward. Tobacco use has taken the form of cigarette, cigar, and pipe smoking, snuff, and chewing. In the United States, Native Americans had long cultivated tobacco and used it in various forms. During the colonial period of the seventeenth century, tobacco was an important cash crop and it was a federally taxed commodity that was used to help finance the Civil War. By the 1890s, cigarette machines were perfected that greatly increased production. Consumption increased dramatically between 1900 and the mid-1960s.46 A psychoactive drug, tobacco is one of the major causes of debility and premature death in developed countries. Midway into the nineteenth century and long before authentic scientific evidence emerged about the extent of the health risks they posed, cigarettes were labeled “coffin nails.”47 In 1963, cigarette use in the United States reached an all-time high precipitating the 1964 Surgeon General’s report that definitively linked cigarette smoking to health problems.48 In 1980, the Surgeon General said that cigarette smoking is the single most important preventable cause of death and disease. Among the key arguments against cigarette use have been: (1) smoking is a major cause of coronary heart disease for both men and women; (2) the risk of contracting coronary heart disease and dying from it grows

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with increasing exposure to smoking, as measured by how deeply one inhales, the age at which one starts, the years one has smoked, and the number of cigarettes smoked per day. Overall, the death rate from coronary heart disease is 70 percent higher among cigarette smokers than among nonsmokers; those who consume two or more packs per day incur two to three times the risk; (3) smoking acts synergistically with other risk factors—principally, elevated cholesterol levels and hypertension; (4) women who smoke and use oral contraceptives have a risk of heart attack that is approximately ten-fold higher than that of women who neither smoke nor use oral contraceptives; and (5) smokers have a two- to four-fold risk of sudden death, as compared with nonsmokers.49 In 1988, additional facts revealed that cigarettes and other forms of tobacco are addicting, nicotine is the drug in tobacco that causes addiction, and pharmacological and behavioral processes that determine addiction are similar to those that determine addiction to drugs such as heroin and cocaine.50 Moreover, there appears to be a link between cigarette smoking and illegal drug use. For example, adolescents who smoke are more likely to progress to marijuana, cocaine, and heroin than nonsmokers.51 The gateway theory, however, is being given increased scrutiny as a result of findings that show little evidence that youth who started smoking marijuana in the 1990s would progress to hard drugs such as heroin, cocaine, and crack later in life.52 In the 1989, the U.S. Surgeon General reported that: smoking was the third leading cause of death in the United States; by 1986, lung cancer had caught up with breast cancer as the leading cause of cancer death in women; gender differences in smoking behavior were disappearing; smoking was associated with cancer of the uterine cervix; and 43 chemicals in tobacco smoke were determined to be carcinogenic; approximately 390,000 deaths per year at that time were attributable to smoking; disparities in smoking prevalence, quitting, and initiation between groups with the highest and lowest levels of educational attainment were substantial; and, educational attainment appeared to be the best single sociodemographic predictor of smoking. Also, there was recognition that prevention and cessation interventions were needed to target specific populations with a high smoking prevalence or at high risk of smoking-related disease. These populations included minority groups, pregnant women, military personnel, high school dropouts, blue-collar workers, unemployed persons, and heavy smokers. Regarding youth, one-quarter of high school seniors who ever smoked had their first cigarette by the sixth grade; one-half by the eighth grade. And, that there was a growing body of evidence that economic incentives such as excise taxation of tobacco products, workplace financial incentives, and insurance premium differentials for smokers and nonsmokers affected health behavior particularly in terms of discouraging the use of tobacco products. While over 50 million Americans continued to smoke, it was reported that more than 90 million would have been smoking if there were no changes in the smoking-and-health environment since 1964.53 More than a decade later, smoking is now attributed to about 430,000 deaths per year in the United States and over 500,000 in the European Union.54 More evidence has been found regarding the link between smoking and “cancer of the lung,

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larynx, esophagus, mouth, and bladder in addition to chronic lung disease (emphysema and chronic bronchitis), coronary heart disease, and stroke. Smoking also contributes to cancer of the pancreas, cervix, and kidney. Smokeless tobacco and cigars increase the risk of oral cancer and cancer of the lung, larynx, and esophagus. Smoking accounts for one-third of all cancers and about 90% of lung cancer cases. The overall death rates from cancer are twice as high among smokers compared to non-smokers.”55 Among women, the major problems related to smoking are: an estimated 27,000 more women died of lung cancer than breast cancer in 2000; three million women have died prematurely because of smoking since 1980 and on average they died 14 years prematurely; 22 percent of women smoked cigarettes in 1998, despite awareness of health consequences; smoking may trigger early menopause; and teenage girls who smoke are most likely not to eat properly and to have poor attitudes about their health and nutrition.56 From an environmental perspective, findings on cigarette smoking show that nonsmokers can be seriously affected from the smoke of cigarettes used by others. Drawing upon 50 studies, the Environmental Protection Agency concluded that “passive smoking” not only aggravates one million existing cases of childhood asthma each year, but also causes 8,000 to 26,000 new cases. Also, it was found that environmental tobacco smoke is linked to pneumonia, bronchitis, and reduced lung function as well as middle ear effusion, a leading ailment requiring childhood surgery. It has been estimated that every year environmental tobacco smoke causes about 3,000 lung cancer deaths. Exposure to secondhand smoke could lower the levels of vitamin C in the blood, especially among children, and may be linked to sudden infant death syndrome. In a study of 5,400 children from 1988 to 1994, researchers at the U.S. National Center for Environmental Health determined that secondhand smoke had the strongest impact on young children, with exposure linked to asthma and wheezing. Among older children, environmental tobacco smoke was associated with increased school absence and poor lung function.57 Economic Considerations: Advertising, the Settlement, and the End Game—Show Me the Money Philip, R. J. The modern history of tobacco reflects a population of users from all levels of society, the rich as well as the poor. Production and sales of tobacco have represented big business for hundreds of years, not only for growers and manufacturers but also for governments in the form of tax revenues. In the United States in 1987, it was estimated that about $4.8 billion per year in taxes to the federal government were generated, and an equal amount of tobacco tax revenues filled state coffers. It has been pointed out that when the trade deficit is of concern, the billions of dollars worth of cigarettes exported by the United States is not an insignificant factor.58 The tobacco industry estimates that it directly generates over $40 billion of the gross national product and provides employment for over 700,000 people.59 Additionally, it has been reported that between $12 and $35 billion is spent each year in the United States alone to treat smoking-related diseases—a significant revenue source for health-related services and industries.60 According to a 1992 Price Wa-

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terhouse report, the tobacco industry was responsible, directly or indirectly, for the employment of about 2.3 million Americans in 1990 including 426,000 employed by the industry, 225,000 employed by its suppliers, and 1.6 million supported by their salaries. Price Waterhouse estimated that the tobacco industry and its suppliers generate about $10.6 billion in federal taxes and $8.3 billion in state and local taxes each year.61 Tobacco has secured its position in many societies by controlling the behavior of its consumers through vigorous marketing methods (e.g., the introduction of filter cigarettes in the 1950s, low-tar cigarettes in the 1960s, and then smokeless and perfumed cigarettes) as well as by commanding a special position among governmental policy makers, who for years have protected the substance for reasons beyond the “best interests” of the public. The glamour era of cigarette advertising . . . began soon after World War I, when American servicemen picked up the cigarette habit. Tobacco executives [claimed] that their wares not only tasted wonderful but [also] soothed jangled nerves, prevented weight gain and aided digestion. . . . In the 1920’s, Lucky Strike introduced the slogan “Reach for a Lucky Instead of a Sweet” using celebrity endorsers like George M. Cohan, Amelia Earhart and Helen Hayes to bring the message home. The fight-fat campaign made a giant stride toward capturing a new market of female smokers, already primed by the daring Chesterfield campaign that showed a male smoker and his sweetheart spooning under—what else?—a June moon. “Blow Some My Way,” the caption read. Well into the 1950’s, cigarette advertisers continued to proclaim the health benefits of their product. “How are your nerves?” an ad for one brand asked and proposed a test. Any man who could not button a vest in 12 seconds probably suffered from frayed nerves and should begin smoking immediately. Camels announced that its special Turkish tobacco stimulated the flow of digestive fluids and raised the level of alkalinity in the stomach. Kool, in the brand’s early days, even claimed to offer protection against catching colds. For anyone with medical doubts, the tobacco industry wheeled out legions of unnamed doctors who were absolutely sold on the merits of cigarette smoking, or the virtues of one brand. “More doctors smoke Camels than any other cigarette,” one ad proclaimed. . . . From the outset, cigarette makers relied on athletes, movie stars and newsmakers to lend luster to their product. Even before World War I, cigarette packs came with cards featuring baseball players and boxers. In the 1950’s Ronald Reagan, as an actor, lent his magic touch to Chesterfields, a brand endorsed by Joe Lewis in 1947 as “the champ of cigarettes.” . . . The word chutzpah acquired new meaning when Newport unrolled its “Alive With Pleasure” campaign. One ad showed a group of beautiful young achievers playing a fast-action game of beach volleyball, cigarettes still clenched between their teeth. . . . No one expects a cigarette company to portray the typical customer fighting for breath after climbing a flight of stairs, but the cheerful association of cigarettes with youth, energy and athletic excellence has persisted through the decades, mind bogglingly unchanged. . . . As the century turns, though, no athlete or movie star would get within a mile of a Camel advertisement.62

In a detailed account of the U.S. Food and Drug Administration’s battle with the tobacco companies, Kessler (2001), former director of the FDA, provides much information about the issues of tobacco advertising and marketing techniques. For example:

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After researching gender differences in the 1970’s, some industry researchers concluded that women found it harder than men to quit smoking. “Women are more neurotic than men and more likely to need to smoke in stressful situations” . . . theorized one official. The industry recognized the implications of this “neurosis” for product development [thinking that] women were . . . more likely to respond to publicity about the health risks of smoking by switching to “lighter” cigarettes [which according to one study have more tar and nicotine than consumers think]. . . . [I]ndustry executives cynically did what they could [through female-oriented cigarettes] to make it harder still to quit smoking.63

Although cigarette makers must adhere to advertising restrictions under the 1998 tobacco settlement in the United States, they still have managed to increase their promotional spending activity. For example, according to a Federal Trade Commission report, cigarette manufacturers increased promotional spending 22.3 percent in 1999. “Advertising in magazines rose 25.5 percent to $281.3 million, and direct-mail advertising increased by 63.8 percent to $94.6 million. . . . The FTC report showed that the $8.24 billion spent by the tobacco industry on advertising and promotions in 1999 was the most ever reported by the major cigarette manufacturers.” Because of the 1999 ban on billboard advertising, the tobacco industry has shifted its advertising strategy to other areas such as convenience stores. Additionally, other ways to promote cigarettes have appeared, for example, on clocks, shopping baskets, or display shelving containing tobacco advertising. Philip Morris, the tobacco giant which has one of the worst reputations in American business, according to a poll, donates $60 million a year to charity, and spends another $100 million in advertising to inform the public about its good deeds. “Each year, Philip Morris holds a desert adventure-sports event in Utah aimed at attracting young smokers to the Marlboro brand. The company sends its Marlboro Adventure Team—a major overseas promotional tool for the brand—to Utah with an entourage of foreign journalists. The journals [cover] the annual desert event and bring back footage that [is] broadcast in Marlboro ad campaigns and as a promotion for [future events].”64 During the last few years, the FDA in the United States and the medical community have led a vigorous campaign against the substance by limiting the tobacco industry’s methods of operation. Report after report has revealed collusion and manipulation by tobacco companies to promote and preserve a market for their product—including special populations such as children and youth, women, and minority people. Reports such as “Children and Tobacco: The Problem,” “Relationship Between Cigarette Smoking and Other Unhealthy Behaviors Among Our Nation’s Youth: United States,” “Current Trends in Cigarette Advertising and Marketing,” “Nicotine Addition in Young People,” “Looking Through a Keyhole at the Tobacco Industry” . . . “Nicotine and Addiction” . . . “Lawyer Control of Internal Scientific Research to Protect Against Products Liability Lawsuits” . . . “Lawyer Control of the Tobacco Industry’s External Research Program” . . . “Environmental Tobacco Smoke” . . . “The Brown and Williamson (Tobacco Corporation) Documents,” and others have paved the way for a tidal wave of litigation and legislation restricting advertising and the sale of cigarettes and other tobacco products in the United States.65

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Cigarette companies have been accused of manipulating cigarette nicotine. “Whether by sprayed-on additives, or selection and blend of the leaf or by filters and ventilation devices, cigarette makers have tinkered with their nicotine and tar content since before the first Surgeon General’s report in 1964. Indeed, the National Cancer Institute, presumably as a public service, spent more than $50 million from 1968 to 1978 toward developing a less hazardous cigarette by manipulating the toxic yield of tobacco smoke. As the evidence about smoking [mounted], the FDA or Congress could at any time have put a lid on toxic ingredients in cigarettes, as the manufacturers themselves might have done. What we have witnessed instead [was] a protracted exercise of avoidance by all parties.”66 In response to a New York Times editorial by Anna Quindlen, “Where There’s Smoke” (March 2, 1994) the chairman and chief executive officer of R. J. Reynolds Tobacco Company, James W. Johnston, and the president and chief executive officer of Philip Morris, USA, William I. Campbell, summed up the position of the cigarette companies by stating that “cigarettes are a legal product, and more than 50 million American adults choose to smoke. We are proud of the quality standards in making our product.” By all accounts, cigarette smoking is on the decline particularly in the United States, Western Europe, and other countries despite vigorous marketing attempts as a result of public opinion and politically responsive government. Nevertheless, with people in Western countries already addicted, tobacco industries have focused their efforts on other countries such as those in Asia, Eastern Europe, nations of the former Soviet Union, Latin America, and Africa for new profits. While many governments in Asia have launched anti-smoking campaigns, their efforts have been overwhelmed by the “Madison Avenue glitz” unleashed by the major cigarette companies. Several Asian nations have banned cigarette advertising on television and radio in recent years, but the tobacco companies often find ways around the bans through indirect promotions that skirt the law—sports events, glossy advertisements for clothing brands, or travel agencies that bear the name and logo of a cigarette brand. In foreign countries, the rate of female smokers is much less than that of men. According to a study from the World Health Organization (WHO), selling tobacco products to women is the single largest marketing opportunity in the world. With 1.2 billion people and the world’s fastest-growing economy, for example, China is a primary target of multinational tobacco companies and “physicians say that the health implications of the tobacco boom in Asia are nothing less than terrifying, and there are frequent comparisons here to the Opium War of the mid-19th Century when the British went to war to force the Chinese to accept imports of a dangerous addictive drug—opium, an important cash crop for British merchants. To combat the problem, China is spending funds to remove billboards and a ban was placed on smoking in public places in 1998.”67 It has been noted that “[p]erhaps the most significant events in recent history are the state lawsuits filed against the tobacco industry, the Master Settlement Agreement, and the proposed regulation of tobacco by the FDA. . . . Four states—Mississippi, Florida, Texas and Minnesota—settled their lawsuits with the tobacco industry by early 1998. Each state was awarded several billion dollars [totally

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about $40 billion], and the conditions of each settlement varied by state. In late 1998 the attorneys of the remaining forty-six states announced a historic agreement with the tobacco industry. The $206 billion settlement was the largest financial recovery in U.S. history.”68 Developments since show: In response to the subsequent ligitation in Florida, it was said by the attorney of Philip Morris . . . that it would ruin U.S. corporations, deplete the savings of stock investors, and result in job losses numbering in the hundreds of thousands. He also said that Philip Morris, the world’s biggest cigarette maker, does not deserve a large punitive-damages verdict because the company has reformed its ways in recent years. He cited the $100 million the company now spends on preventing teen smoking, and the money the company is paying out to states as part of the nationwide tobacco settlement.69 The European Union’s Executive Commission confirmed reports concerning a decision in principle by the Commission to launch a civil action in the United States against a number of U.S. tobacco companies. . . . The case concerns the alleged implication of these companies in cigarette smuggling into the European Union.70 Tobacco growers, like many other farmers, have confronted difficult economic circumstances these last few years as tobacco companies increasingly turn to foreign tobacco. . . . In the past three years, U.S. tobacco companies have shifted manufacturing and growing operations overseas, resulting in significant stock cuts for U.S. tobacco farmers. . . . Even as tobacco farmers have seen revenues fall, the major U.S. cigarette companies have increased their overall revenues and profits, the White House said.71 Despite the 1998 nationwide tobacco settlement that requires tobacco companies to pay $246 billion and places limits on its advertising, Big Tobacco continues to turn a profit. . . . Anti-smoking advocates thought a crackdown on tobacco ads and an increase in cigarette prices would result in fewer smokers. But instead, tobacco companies continue to recruit new smokers. . . . Industry figures revealed that consumers have gotten used to paying more for their addiction. And data show that tobacco consumption in the United States is down just 1 percent to 2 percent last year. . . . The tobacco companies have controlled subsequent price increases so they have each been small enough to have a minimal impact on consumption. . . . As a result, Big Tobacco is realizing a profit. In October, Philip Morris posted its largest earnings gain since 1997, while the price of shares in the leading tobacco maker reached its highest level in a year.72 During the last election, the tobacco industry spent millions of dollars in direct and soft money contributions, and the issue is what they want in return. . . . Since Bush was elected, the stock market has pushed up tobacco stocks dramatically. That means people think the administration will be doing their bidding. . . . [T]he tobacco industry donated $120,000 in hard and soft money to the Bush campaign in the last two years. . . . Philip Morris donated $100,000 for Bush’s inaugural . . . the National Republican Senate Committee received nearly $1.4 million from tobacco interests in the past two years.73 Just a handful of states are spending a significant percentage of their tobacco settlement funds on prevention and education, and experts say that’s unlikely to change without some

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intense grassroots lobbying of state officials. . . . The 1998 Master Settlement Agreement between the states and the tobacco industry contained no requirement that states spend any specific percentage of their settlement money—awarded to compensate states for tobacco-related healthcare costs—on tobacco prevention. . . . The result is that state lawmakers have virtual carte blanche on how to spend their share of the settlement funds. Predictably, many found numerous priorities for the money that they feel supersede the need for anti-tobacco programs, from highway repairs to tax relief.74 California, Washington, Arizona, New York, and Ohio have filed separate lawsuits against R. J. Reynolds Tobacco Company for allegedly violating advertising restrictions called for by the 1998 nationwide tobacco settlement. . . . The states charged the tobacco company with marketing to children through magazine advertisements in . . . 75 A Los Angeles, California jury found Philip Morris Co. guilty of fraud, conspiracy and negligence in a lawsuit brought by a 56 year-old smoker . . . who suffers from brain and lung cancer. . . . The jury ordered Philip Morris to pay $3 billion in punitive damages and $5.5 million in compensatory damages.76

CONCLUSION Examination of tobacco reveals the relationship between a dominant interest group and the social context it created and controlled. Clearly, the tobacco industry built an impenetrable infrastructure that remained a bulwark for years against challenges to their products no matter how harmful to the health of individuals and their families. Reasons why and how this substance remained relatively unscathed or immune lie in the realm of economics and politics as pointed out by David Kessler in his book A Question of Intent: A Great American Battle with a Deadly Industry.77 It seemed this industry did nothing by accident [in order to manage] the social climate for tobacco use. In media seen by young people it found ways to mock what it called the “new puritanism.” . . . And the industry tried to shift the argument from a focus on health, which was deemed unwinnable, to broader public policies. [Thus,] cigarette taxes become an issue of a fair and effective tax policy. . . . [T]obacco marketing becomes an issue of freedom of commercial speech. . . . [T]obacco litigation becomes an issue of business liability reform to foster economic development. . . . Understanding whom “to neutralize” was part of the process and explained why Philip Morris made donations to volunteer firefighters [willing] to say publicly that cigarettes do not cause fires. Philip Morris was also ready to assist when the National Women’s Political Caucus as long as they [got] credit for it. . . . International activities included lobbying developing nations and trying to undermine control efforts by the World Health Organization. “We must try to stop the development towards a Third World commitment against tobacco,” wrote one industry official. “We must try to mitigate the impact of WHO by pushing them into a more objective and neutral position.”78

Women and youth were targeted by the industry; and survey results showed that a majority of people did not see tobacco as a threat to teenagers comparable to vio-

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lence, illegal drugs, and pregnancy (p. 336).79 This all led Kessler, based in part on the work of John W. Kingdon, to state I learned that shaping public opinion could be as important as shaping policy itself.80 [It is suggested] that issues gain “agenda status” when three streams come together: the problem is recognized as a result of some sort of “focusing event” or symbol, policy proposals are generated and refined, and there is receptivity from the public or influential political forces.81 In my view, people play a greater role in driving issues and policy changes than . . . generally recognize[d]. What jobs people seek, their decisions about what issues to tackle in those jobs and how to frame the issues for the public, the pursuit of political support, and the ability to prevent their efforts from being derailed all determine what problems are confronted and how they are addressed.82

Kessler’s book about the tobacco industry’s “no limit” strategies to protect its interests is a compelling and provocative read. Many questions surface from the facts and situation presented. Among the questions are: To what extent has “Big Tobacco” been behind the “war on drugs,” particularly the fight against substances such as marijuana? Did “Big Tobacco,” by helping to promote the “drug war,” build a fire wall to deflect the heat it was receiving as Public Health Enemy No. 1? Only now, with a crack in the holy tobacco grail, is it becoming apparent that the tobacco industry learned early on that the way to capture the high ground was to shape public opinion and by doing so it would be able to shape public policy. It succeeded for decades at a huge cost of people’s lives, people’s health, and billions of dollars. Man’s consciousness of drug use and abuse, manifested through attitudes and behavior, appears to be determined by his social being at a particular point in time and in a particular physical setting. The basis of this thinking is not new; it is the fundamental proposition for the sociology of knowledge, which includes the concepts of ideology (ideas serving as weapons of social interests) and false consciousness. To understand the meaning of drug use and abuse among people, it is helpful to be concerned with everything that passes for knowledge in society. “As soon as one states this, one realizes that the focus on intellectual history is ill-chosen, or rather, is ill-chosen if it becomes the central focus of the sociology of knowledge. Theoretical thought, ‘ideas,’ are not that important in understanding the drug issue, since they are only a small part of what passes as ‘knowledge.’ What must be addressed is what people know as reality in their everyday lives.”83 The tobacco industry and its legionaries have shaped social order by shaping people’s attitudes and behavior about which drug is permissible to use. In effect, the industry became the purveyor for entrepreneurs, politicians, law enforcers, and others. Wars have been waged to preserve the social construction of drug reality, the two most notable being the Opium Wars in the nineteenth century and the present “War on Drugs” being fought by many countries. It would be naive to think of the drug problem in only economic terms, the profits made legally through sales taxes, health remedies and treatments, prevention programs, jobs, and other means, and illegally through the manufacturing, marketing, and sale of illicit substances. But it

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would be equally naive to ignore this powerful factor and its role in shaping how and which drugs are made legitimate or criminal for use throughout the world. NOTES 1. Telias, D. (1998). “Terms and Definitions.” In R. Isralowitz and D. Telias, Drug Use, Policy, and Mangement, Westport, CT: Praeger, pp. 1–2. 2. Ray, O., and Ksir, C. (1990). Drugs, Society and Human Behavior. St. Louis, MO: Times Mirror/Mosby, p. 4. 3. National Commission on Marihuana and Drug Abuse (1973). Drug Use in America: Problem in Perspective. Second Report of the NCMDA. Washington, DC: U.S. Government Printing Office, p. 9. 4. Goode, E. (1989). Drugs in American Society, Third Edition. New York: McGraw-Hill, p. 23. 5. Abelson, H., Cohen, R. Schrayer D., and Rappaport, M. (1973). Drug Experience, Attitudes, and Related Behavior among Adolescents and Adults, Part 1. Princeton, NJ: Response Analysis. 6. National Commission on Marihuana and Drug Abuse, p. 10. 7. Ray and Ksir; Goode; Johnston, L., O’Malley, P., and Bachman, J. (1987). National Trends in Drug Use and Related Factors Among American High School Students and Young Adults, 1975–1986. Rockville, MD: National Institute on Drug Abuse (NIDA). 8. Brecher, E. (1972). Licit and Illicit Drugs. Boston: Little, Brown, pp. 226–228; Goode, p. 211. 9. Martz, L. (1990). A dirty drug secret. Newsweek, February 19, p. 44. 10. Tolchin, M. (1988). Surgeon General asserts smoking is an addiction. New York Times, May 17, p. A1. 11. Ray and Ksir, p. 4. 12. Goode, pp. 25–26. 13. National Commission on Marihuana and Drug Abuse, p. 13. 14. Lorion R., Bussell, D., and Goldberg, R. (1991). Identification of youth at high risk for alcohol or other drug problems. In E. Goplerud (ed.), Preventing Adolescent Drug Use: From Theory to Practice. Office for Substance Abuse Prevention, DHHS Pub. No. (ADM) 91-1725. Washington, DC: U.S. Government Printing Office. 15. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Washington, DC: American Psychiatric Association, p. 182. 16. Goode, p. 46. 17. Ibid. 18. American Psychiatric Association, pp. 176–178. 19. World Health Organization (1992). The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization, pp. 72–77. 20. Falkowski, C. (2000). Dangerous Drugs. Center City, MN: Hazelden, p. 95. 21. Substance Abuse Mental Health Services Administration (SAMHSA) (1999). Summary of Findings from the 1998 National Household Survey on Drug Use. DHHS Publication No. (SMA) 99-3328. Washington, DC: U.S. Government Printing Office, p. 66. 22. Substance Abuse Mental Health Services Administration (SAMHSA) (2000). Tips for Teens—Alcohol. Washington, DC: U.S. Government Printing Office. 23. Ibid.

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24. Falkowski, p. 143. 25. NIDA (1996). Facts about methamphetamine. NIDA Notes, November/December. 26. NIDA (1997). Methamphetamine abuse. NIDA Capsules, (C-89-06), October. 27. U.S. Department of Justice (1992). A National Report: Drugs, Crime, and the Justice System. Washington, DC: Bureau of Justice Statistics, p. 41. 28. Saunders, N. (1993). E for Ecstasy. London: Nicolas Saunders. 29. Join Together Online (JTO) (2001). Some Therapists Tout Ecstasy’s Healing Potential, Boston University School of Public Health, March 30. 30. Executive Office of the President, Office of National Drug Control Policy (2001). Pulse Check: Trends in Drug Abuse, Mid-Year. Washington, DC: U.S. Government Printing Office, p. 56. 31. Johnston, L., O’Malley, P., and Bachman, J. (2001). Monitoring the Future: National Results on Adolescent Drug Use. NIH Publication No. 01-4923, Washington, DC: NIDA, p. 28. 32. Mathias, R. (1996). Like Methamphetamine, ‘Ecstasy’ May Cause Long-Term Brain Damage. NIDA Notes, November/December; Fischer, C., Hatzidimitriou, G., Wlos, J., Katz, J., and Ricaurte, G. (1995). Reorganization of accending 5-HT axon projections in animals previously exposed to recreational drug 3,4-methelenedioxymetham-phetamine (MDMA, ‘Ecstasy’). Journal of Neuroscience, 15:5476–5485. 33. Mathias, R. (2000). Ecstasy damages the brain and impairs memory in humans. U.S. Department of Justice, DEA, NIDA Notes, July. 34. Executive Office of the President, pp. 56–71. 35. Ibid., p. 56. 36. Falkowski, pp. 208–209; Executive Office of the President, p. 56. 37. Falkowski, pp. 171–172. 38. SAMHSA (2000). Tips for Teens—Marijuana. Washington, DC: U.S. Government Printing Office. 39. SAMHSA (2000). Tips for Teens—Hallucinogens. Washington, DC: U.S. Government Printing Office. 40. McCann, M., Rawson, R., Obert, J., and Hasson, A. (1994). Treatment of Opiate Addiction with Methadone. Rockville, MD: U.S. Department of Health and Human Services, pp. 28–31. 41. Falkowski, pp. 122–123. 42. Ibid., pp. 121–122. 43. Ibid., pp. 159–160. 44. SAMHSA (2000). Tips for Teens—Inhalants. Washington, DC: U.S. Government Printing Office. 45. Goode, p. 16. 46. Horgan, C. (1993). Substance Abuse: The Nation’s Number One Health Problem. Princeton, NJ: Robert Wood Johnson Foundation. 47. Kluger, R. (1996). A peace plan for the cigarette wars. New York Times Magazine, April 7, p. 28. 48. Goode, p. 211. 49. U.S. Surgeon General (1982). The Health Consequences of Smoking for Cancer. DHHS Publication No. (PHS) 82-50179. Washington, DC: U.S. Government Printing Office; U.S. Surgeon General (1983). The Health Consequences of Smoking: Cardiovascular Disease. DHHS Publication No. (PHS) 84-50204. Washington, DC: U.S. Government Printing Office.

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50. U.S. Surgeon General (1988). The Health Consequences of Smoking: Nicotine Addiction. DHHS Publication No. (CDC) 88-8406. Washington, DC: U.S. Government Printing Office. 51. Goode, p. 204; JTO (2000). Researchers: Cigarettes related to illegal drug use, Boston University School of Public Health, December 7. 52. JTO (2001). Study: Gateway theory less applicable to today’s youth, March 9. 53. Koop, C. (1989). Reducing the Health Consequences of Smoking—25 Years of Progress: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services. 54. United States Department of Health and Human Services, Public Health Service (1999). Centers for Disease Control Prevention. Targeting tobacco use: The nation’s leading cause of death—At-a-Glance. Rockville, MD: U.S. Department of Health and Human Services. 55. Falkowski, pp. 223–224. 56. ABC News.com (2001). Smoking is a major women’s health issue, n.d.; Isralowitz, R., and Troestler, N. (1996). Substance use: Toward an understanding of its relation to nutrition-related attitudes and behavior among Israeli high school youth. Journal of Adolescent Health, 19(3):184–189; JTO (2001). Cigarette smoke may trigger menopause, July 17. 57. Cowley, G. (1992). Poison at home and at work. Newsweek, June 29, p. 49; JTO (2001). Babysitters an overlooked source of secondhand smoke, January 4; JTO (2001). Secondhand smoke lowers vitamin C levels in children, March 7; JTO (2001). Study: Secondhand smoke hurts kids, January 16; JTO (2001). Smoking, dieting linked among teen girls, March 2. 58. Shannon, I. (1989). World cigarette pushers. New York Times, August 20, p. 6 (IE). 59. Ray and Ksir, p. 203. 60. Molotsky, I. (1985). Smokers’ ills cost billions, U.S. says. New York Times, September 16, p. A13. 61. Sullum, J. (1996). Last drag. Across the Board, March, p. 46. 62. Grimes, W. (1997). The next to last whiff of smoke and mirrors, New York Times, 2, IE, April 20, p. 2 63. Kessler, D. (2001). A Question of Intent. New York: Public Affairs, p. 274. 64. JTO (2001). Tobacco makers increase promotional spending, March 20; JTO (2000). Study finds more tobacco ads in stores, July 25; JTO (2000). Philip Morris among companies with worst reputation, July 5; JTO (2001). Philip Morris ties smoking to high adventure, February 14. 65. Kessler, D. (1995). Sounding Board: Nicotine addiction in young people. The New England Journal of Medicine, 333(3): 186–189; Food and Drug Adminstration Press Office (1995). Children and tobacco: The problem, August 10; Willard, J., and Schoenborn, C. (1995). Relationship between cigarette smoking and other unhealthy behaviors among our nation’s youth: United States, 1992. U.S. Department of Health and Human Services: Centers for Disease Control and Prevention, Number 263, April 24; Davis, R. (1987). Current trends in cigarette advertising and marketing. New England Journal of Medicine, 316(12):725–732; Glantz, S., Barnes, D., Bero, L., Hanauer, P., and Slade, J. (1995). Looking through the keyhole at the tobacco industry: The Brown and Williamson documents; Journal of the American Medical Association, Vol. 274, No. 3, pp. 219–224; Slade, J., Bero, L., Hanauer, P., Barnes, D., Glantz, S. (1995). Nicotine and addiction: The Brown and Williamson documents; Journal of the American Medical Association, 274(3):225–233; Hanauer, P., Slade, J., Barnes, D., Bero, L., and Glantz, S. (1995). Lawyer

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control of internal scientific research to protect against liability lawsuits: The Brown and Williamson documents; Journal of the American Medical Association, 274(3):234–240; Bero, L., Barnes, D., Hanauer, P., Slade, J., and Glantz, S. (1995). Lawyer control of the tobacco industry’s external research program: The Brown and Williamson documents; Journal of the American Medical Association, 274(3): 241–247; Barnes, D. Hanauer, P., Slade, J., Bero, L., and Glantz, S. (1995). Environmental tobacco smoke: The Brown and Williamson documents; Journal of the American Medical Association, 274(3):248–253. 66. Kluger, R. (1994). Of course they manipulate cigarette nicotine. New York Times, IE, March 7, p. 6. 67. Shenon, P. (1994). Asia’s having one huge nicotine fit. New York Times, IE, May 15, p. 1.; JTO (2001). Tobacco target foreign women, July 9; JTO (2001). Ads blamed for China’s increased youth smoking, July 10. 68. Falkowski, p. 232. 69. JTO (2001). Lawyer: Big settlement would kill the industry, July 12. 70. JTO (2000). EU confirms US tobacco lawsuit, July 25. 71. JTO (2000). Clinton signs executive order to help tobacco farmers, September 26. 72. JTO (2000). Despite settlement, regulations, big tobacco makers, November 8. 73. JTO (2001). Tobacco industry seen having broad influence on Bush administration, January 23. 74. JTO (2001). Most states underfunding tobacco prevention, cessation, January 26. 75. JTO (2001). States sue R. J. Reynolds, charge settlement violations, March 21. 76. JTO (2001). Philip Morris found liable in California smoker’s case, June 7. 77. Kessler (2001). 78. Ibid., pp. 208–211. 79. Ibid., p. 336. 80. Ibid., p. 360. 81. Kingdon, J. (1995). Agendas, Alternatives and Public Policies, 2nd ed. New York: HarperCollins College Publishers. 82. Kessler (2001), p. 402. 83. Berger, P., and Luckmann, T. (1967). The Social Construction of Reality. New York: Doubleday, p. 15.

Chapter 2

Theoretical Considerations and Risk Factors

A simple explanation of drug use and dependence suggests “the immediate decision to use drugs is driven, basically by one of two types of reasons. One group [of people] seems to use drugs simply to feel good. They are seeking novelty or excitement, to have a good time . . . they use drugs because all their friends are doing it; they just want to join in. . . . [The second reason includes people] who in some way or another are suffering and use drugs to try to make themselves feel better, or even normal. This group often includes people stuck in very difficult life situations—poverty or abusive families, for example. It includes [people] suffering from a variety of untreated mental disorders, like clinical depression, manic depressive illness, panic disorders, schizophrenia.”1 Underlying this explanation is a host of biomedical, psychological and/or sociological factors that include: (1) the history of drug abuse patterns and the changing population of users; (2) recognition that specific drug abuse patterns are culturally determined—that cultures (and subcultures) differ in the availability of drugs and the extent of abuse; (3) demographic (and epidemiological) characteristics of abusers that depend upon the time period, nation, and locale selected for study; (4) the need to delineate the specific drug (or drugs) of abuse, route of administration, and length of dependence; (5) the etiology of social context in which drug abuse begins; (6) the influence of major institutions (e.g., family, community, peer group, schools, and media) on the onset and continuation of drug dependency; (7) why drug abuse is more prevalent in certain populations than others; and (8) determination of institutional supports that promote successful treatment and rehabilitation, including consideration of how persistent behavior in subcultures can be changed.2 Additionally, there tend to be three major theoretical social science per-

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spectives that should be taken into account when considering the nature and scope of the drug problem. They include: (1) society through its policy and decision-making processes (e.g., determining the societal normative order and allocating resources) is a prime force in shaping problems associated with drug use; (2) certain sociological forces shape a person’s personality and cause deviant behavior; and (3) those who use and abuse drugs have physical and/or personality characteristics that precipitate involvement with such activity. The following review of major factors underlying drug use and dependence contributes to understanding the issues involved, their complexity, and their interrelated nature. THE SOCIAL ORDER People are often referred to as deviant when they do not share the values or adhere to the social norms regarding conduct and personal attributes prescribed by society. While the process of identifying deviance involves the use of normative definitions that may vary over time, the essential nature of deviant behavior is that it reflects a departure from the norms of a particular society. Beginning in the mid-1930s, the principal focus of sociologists was on a systematic analysis of social and cultural sources of deviant behavior in order to discover how some social structures exert pressure on certain persons in society to engage in nonconformist rather than conformist conduct.3 According to Robert Merton (1957), a person’s location in the social system offers differential access to societal goals. In this mean/ends schema, deviant behaviors such as those related to drug use represent the individual’s rejection of both the culturally prescribed goals and available means of success. For Merton, the rejection and subsequent behavioral manifestations which are deviant may be labeled a form of retreatism.4 Merton also pointed out that the lack of opportunity was not the only reason for the high frequency of deviant behavior but rather that the differences in the level of accessibility of societal goals are, in fact, class-dependent.5 Merton’s theory, then, is an attempt to account for the distribution of deviant behavior within a social system and for differences in the distribution and rates of deviant behavior among people by functions or system properties (i.e., the ways in which cultural goals and opportunities for realizing them are distributed).6 This theory has been applied to drug use and abuse,7 but never successfully. While the original article, which hardly mentions drug addiction or alcohol, is considered a classic of its kind, and is “probably the single most cited article in the entire sociological literature,” a number of researchers consider the theory inadequate and irrelevant when applied to etiology or causality of drug use, and therefore the theory is not given much attention.8 With the 1960s came growing signs of dissatisfaction with both the definition of deviance and the explanatory variables. The main thrust of this criticism was that the theory failed to “regard deviance as a process [by which] persons become labeled deviant and a concern with organizational responses or adaptation to deviance.”9 Perhaps the most serious attempts to redefine the study of deviance came

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from Erving Goffman (1963) and Howard Becker (1963).10 An example of the shift in thought is found in Becker’s definition of deviance, that “social groups create deviance by making the rules whose infractions constitute deviance, and by applying those rules to particular people and labeling them as outsiders.”11 Deviance, then, is not so much a matter of the act a person commits, but rather concerns how those who make the rules—and can enforce them—view the act and/or the person or class of persons who committed it. While the theories of Merton, Goffman, and Becker contribute in part to understanding deviant behavior in the context of drug use, their explanations fail to include the role of personality and its interface with other forces that shape attitudes and behavior that are defined as outside the acceptable social order. From the 1940’s to the 1960’s, most of the ethnographic studies in the drug field shifted the emphasis from asking why people used drugs to asking how they went about getting involved in drug use and how they remained involved. Rather than looking for underlying causes, ethnographers began to search for etiological influences in the social world rather than the internal world of experimenters. This period constituted the first major shift away from psychoanalytic theory and a medical model of addiction to a more sociological perspective. . . . Building on the work of Hughes (1959) who introduced the study of occupations into sociology, Becker (1963) took the career model and applied it to deviant careers in general and drug users specifically. This conceptual shift has broad implications and was the basis for what came to be viewed as a new sociological movement called the “labeling theory.”12

SOCIAL FORCES: PHYSICAL ENVIRONMENT, VALUES, AND MORALS From research conducted as early as the 1920s in the United States, it has been shown that the environment in which a person lives can be an influential factor in the use and abuse of drugs. An environment that is deteriorating and poverty stricken serves as a breeding ground for such behavior. Living in this type of setting are people from the lower end of the social hierarchy who are usually beset with a huge assortment of personal and family problems. These people, in order to exist, adopt norms and values that are different from those prescribed through explicit and implicit social policies, rules of governance, and methods of enforcement. The norms and values that they adopt enable them to achieve goals that are readily attainable and less abstract.13 In two recently published and acclaimed books analyzing the drug problem and policy, The Fix by Michael Massing (1998) and Drug Crazy by Mike Gray (1998), both authors provide descriptions of drug-affected people from Spanish Harlem, New York, and Chicago, their lifestyles, and the patterns of interaction and existence—addicts as well as those engaged in law enforcement. El Barrio, as it was called . . . had the unmistakable feel of the ghetto. On almost every social index, from unemployment and single-parent families to HIV transmission and infant mortality, Spanish Harlem ranked near the bottom of New York neighborhoods, and the

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level of drug abuse was correspondingly high. . . . Here, on the block between Lexington and Third—a bustling crossroads that included a U.S. post office, a public library, a supermarket . . . —two or three dozen dealers would always be out: flush-faced, glassy-eyed men offering [all types of drugs,] Valium and methadone, cocaine and, especially, heroin. The dope sold on 110th Street was among the best in the city, and people would come as far away as Connecticut and Pennsylvania to buy it. Every day, an estimated 5,000 to 7,000 bags of heroin were sold here, generating revenues of up to $25 million a year. The dealers were so brazen that they would actually shout out brand names, the labels proudly advertising the toxic nature of their product: Poison, Tyson, DOA, Hot City, Natural Born Killers.14 Their target this morning was an enclave known as “K-Town” . . . the area around the Marconi Grammar School was flooded with crack. . . . A car pulls up, a couple of guys get out, each one with a dozen “sixty-packs”—sixty little vials of crack, about a fifth of a gram in each. These guys are wholesalers. They round up their street dealers and front each one a single sixty-pack. When the street dealer sells out his supply at ten bucks a pop, he keeps one hundred dollars, turns the other five hundred over to the wholesaler, and gets another sixty-pack. . . . The street dealers, of course, are all quite young. . . . In Illinois . . . the maximum you can give a juvenile is thirty days [the buyers, you name it]. . . . The impact of this kind of activity on an otherwise peaceful neighborhood is beyond belief. When the dealers move in, the most significant change, of course, is the guns.15

In one of the major examinations of structure theory, Miller (1958) contends that deviant behavior is the product of goals and means that are prescribed by, and common to, members of the lower classes.16 Conflicts between the middle and lower classes are considered irrelevant, since most of the lower classes have little interest in either the goals or methods of the middle class. Miller argues that people at the bottom of the social hierarchy are inured to the cultural and economic deprivations they have to endure, and that they have little expectation of reforming their society or bettering their position in it. To gain a sense of personal worth and satisfaction, lower-class people need to build their culture around values that can be more readily sustained than those of the middle class. The result is a destructive pattern of goals and practices, one that can be endorsed by deprived people despite the opposition of those in society supporting the normative order.17 Based on this theory, drug use may be considered a natural consequence of adherence to a lower-class normative structure and the associated values and morals. Cohen (1955) suggests that lower-class individuals with behavior such as drug use adopt their own system of values and morals in order to maintain self-respect and status while being confronted by the omnipotent judgments of others. Cohen contends that people in institutional settings are constantly being evaluated (e.g., in the school, on the job, or under the law) by representatives of the middle class. Therefore, poor and minority members face handicaps and frustrations when their teachers and other institutional officials discriminate against them and fail to recognize the problems with which they are confronted. Furthermore, Cohen has written that understanding and equal treatment are difficult, especially for institutional workers having middle-class values, middle-class language, and middle-class stereotypes alleging the inferiority of the lower classes. In the case of a drug offender, characteristics such as family status, place of residence, skin color,

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ethnic affiliation, and the language and habits acquired in early socialization may be perceived (by those judging the offender) as symbols of weakness, immorality, and deviance.18 The issue of access and opportunity is another perspective of why certain people adhere to a deviant set of values and morals. Cloward and Ohlin (1960) maintain that legitimate and illegitimate methods of achieving social objectives are differentially distributed among the various groups and classes of a society, so that some have access primarily to legitimate means, others to illegitimate ones, and still others to both methods of attaining their goals. This theory focuses on the disparity between what lower-class people are led to want and what is actually available to them. The authors believe that this issue is one of the major factors contributing to problem attitudes and adjustment.19 Through their theory, Cloward and Ohlin attempted to portray several delinquent subcultures, one of which was the “retreatist” subculture of addicts, which was based on a theoretical category developed by Merton, Cloward’s mentor. The only empirical study that provided actual descriptions of addict behavior and supported this perspective was Finestone’s short description in “Cats, Kicks and Color.” It became the sole basis of support for a theory that was soon to achieve national prominence [in the United States]. . . . Because of the importance of the Cloward and Ohlin opportunity theory and its use as the underpinning . . . [for delinquency and antipoverty programs], their mini-theory of addicts as double failures within a retreatist subculture became a persistent theme.20

While issues such as lower-class values and morals and the disproportionate amount of crime and drug problems found among the poor have been widely covered by sociological research and literature, studies have shown that such problem behavior is also indigenous to the middle and upper classes. For example, Schur (1969) discusses the point that there is much more actual problem behavior than is officially recorded. An implication of “hidden crime” is that “in the main it [is] lower-class crime that [is] officially dealt with and middle- and upper-class offenses that [remain] hidden.”21 This becomes clear through self-reports of crime and drug problems taken from samples of the general population. Consistent with this, Short and Nye (1957) found that problem behavior was distributed more evenly throughout the socioeconomic structure of society.22 Basically, those studies that focus on the problem of middle- and upper-class deviance point out that reliance on the theories of drug use being a lower-class phenomenon requires closer scrutiny.23 This has been evidenced by the widely publicized Hollywood movie “Traffic,” with its “disturbing images of middle-class teenage addiction.”24 By no means does this review of physical environment, values, and morals imply that drug use is a social class phenomenon. Facts and statistics reveal that drug use and abuse are a problem that transverses all social classes. They are also a problem, however, that tends to be more easily rooted among poor people in conditions that are consistent with poverty and social degradation and the “social reality” defined by politicians, law enforcement officials, police, and other decision makers.

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INTERPERSONAL RELATIONS The Family The role of the family is often referred to as a major causal factor in shaping the personality and behavior of children. The family serves as a reference group on personal and normative levels. Ideally, the child should receive sustenance, recognition, approval and appreciation from family members for participation in those goals held in common. As a normative reference or “bonding” group, members of the family serve as agents of a culture, transmitting norms, attitudes, and values to the child. How long the family remains a reference group for the child may depend on how well it serves his needs.25 “It is the family which is a major transmission belt for the diffusion of cultural standards to the oncoming generation. But what has until lately been overlooked is that the family largely transmits that portion of the culture accessible to the social stratum and groups in which the parents find themselves. It is, therefore, a mechanism for disciplining the child in terms of the cultural goals and mores characteristic of this narrow range of groups. . . . Quite apart from direct admonitions, rewards and punishments, the child is exposed to social prototypes in the witnessed daily behavior and casual conversations of parents.”26 Parents train their children to conform or not to conform to particular moral standards through the examples they provide by their own behavior. For example, research indicates a greater amount of socially deviant behavior (e.g., drug use, alcoholism, and criminality) in the parents of problematic youth than in the parents of law-abiding children. It has also been found that “the mother’s conformity to socially approved modes of conduct [seems] to be a stronger influence for a child’s good conduct than the father’s behavior; a combination of two socially deviant parents produced the highest crime rates in the children.”27 Investigators of families with a drug-abusing member have identified some consistent patterns related to adolescent drug use, including the theme of a dominant mother who is overindulgent, overprotective, and manipulative, and a father who is far more subordinate, being viewed as weak, inept, and uninvolved.28 Since Paul Goodman’s Growing Up Absurd was published in 1960, it has been common to trace the long series of societal changes which have narrowed down a household to a nuclear unit, then sent mothers into the labor force, and lastly, with increasing divorce rates, further limited a child’s opportunity for receiving parenting.29 In discussing the transition of youth to adulthood, the report of the Panel on Youth of the President’s Science Advisory Committee (1973), for example, mentions that throughout the nineteenth century in America households provided a variety of people from whom the child could draw support and with whom he could identify. During that time, the family was dominant and young persons were introduced as quickly as possible to a work situation to aid the economy of the family. Knowledge, skills, and values acquisition came primarily from the family and church.30

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In the traditional folk society, the norms were generally simple. There was a limited range of possibilities for human action, so the rules necessary were also limited. Too, the norms tended to be tied together in a “neater” package. Family life, educational life, and economic life were so closely related that they were difficult to separate. The norms that governed a father and son in a field were, at the same time, familiarly, educationally, and economically important. If the son violated a norm, the negative sanction, i.e., punishment, for this violation would be immediate and certain. The specific deviant act by the son, however, would be considered in terms of his “whole” personality, his total actions, past and present. His behavior would be seen as “bad,” but the son would not likely be considered a deviant person because of such an isolated action.31

With industrialization and the growth of a technological and urbanized society, family structures and functions have experienced great change. “The family . . . may no longer be the major socializing influence. Rather, that responsibility is shared today with other societal institutions and with peer groups.”32 Broken homes, a mother present/father absent or father-weak household structure, inconsistent discipline, abuse, threats, verbal attacks, and other negative familial characteristics have been linked to drug use and dependence.33 Additionally, research shows that parental divorce, arrest, a lack of closeness between parents and children, parent and sibling drug use, family disorganization, father unemployed, one or both parents missing, a perceived lack of parental support, lack of identification with a positive male figure, family emphasis on independence instead of self-discipline and community responsibility, and mental illness all correlate with alcohol and drug abuse among young people in the family.34 The quality of the parent-child relationship, the quality and consistency of family management, family structure, attachment, communication within the family, modeling of substance use, approval and tolerance of substance use involvement, absence of closeness of parents, low educational aspirations for the children, lack of parental involvement in the child’s activities, weak parental control and discipline, death or absence of a parent, and emotional, physical, or sexual abuse are other factors that have been associated with drug use.35 Additional research has shown that babies born to mothers suffering alcoholism and depression had poor developmental outcomes; fathers with alcohol addiction have a negative impact on their child’s development; childhood physical and sexual trauma is associated with severity of later drug use; and early onset of alcoholism appears to be driven most clearly by family history.36 In a study of the family role in fostering or mitigating substance abuse, it has been found that parent-youth relationships influence a young person’s use of alcohol and other drugs. Nonusers felt closer to their parents, considered it important to get along with them, and wanted to be like them. The parents of nonusers set more limits, provided more praise and encouragement, and were less likely to use substances themselves.37 It has been found that drug addiction is associated with parental rejections, a lack of emotional warmth in the family, and overprotection.38 Other studies have found that family influence is one of the strongest sources of risk and protection of adolescent substance use; perceptions of conflict in parent-child relations constitute a risk factor for poor child adjustment and the experi-

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ence of alcohol-related consequences; and women may be more influenced than men by family background factors in terms of their problems with alcohol, drugs, and violence.39 Regarding addicts, the role of the father has been found to be a predictor of narcotic addiction among boys. “The degree of attachment at ages 12–14 to one’s father is a major determinant of how strong a young person’s resistance will be to the temptations offered by addiction in neighborhoods where high levels of drug abuse are prevalent. . . . A positive home atmosphere and a strong parental commitment is similarly a strong predictor of the addiction history of young people. . . . [I]n one study, approximately 40% of the subjects came from families without natural parents in the household and the addict subject perceived his father in a negative fashion.”40 Peers Peer relations is a factor often linked to drug use and dependence. Such behavior may be learned through association and interaction with others who are already involved with drugs. A person’s relationship with peers may serve as a means of providing the individual with an escape from other interpersonal dealings that he wishes to avoid, such as family, school, or work. Interaction with peers may also be a means by which a person can receive emotional gratification, recognition, reinforcement, security, self-protection, and defense for his deviant behavior.41 Studies have found “peer drug use and peer attitudes are among the key influences on marijuana use among young people. . . . [T]he likelihood of young people using marijuana during the past year was 39 times higher among those who had at least a few close friends who tried or used marijuana”; students who perceived a higher degree of drug use among their friends and who received more information about drugs from their friends used drugs more frequently; substances are widely used by youth as a means of excitement, consolation, belonging to a referent group, rebellion, a symbol of social and sexual maturity and independence; peer pressure is an essential cause of adolescent substance use and abuse; the relationship between peer pressure and drug use tends to be stronger among girls than boys, and also among adolescents in families without fathers and step-fathers; those spending unsupervised time with peers tend to have higher levels of aggression, delinquency, substance use and susceptibility to peer pressure and lower levels of parental monitoring than did adolescents at home with parents; early substance users are likely to have weaker decision-making skills, more susceptibility to peer pressure, more negative perceptions of school, less confidence in their skills, and an increased likelihood of being male; and peers emerged as the most consistent social influence on health-risk behavior and may be better predictors of such behavior than parental social influences among young adolescents.42 Despite much earlier research that points in the direction of peer influences being most prevalent among lower-class persons,43 Erickson and Empey (1969) believe that their data does not support the notion that peer standards have more importance for the lower classes than they do for the middle class.44 In fact, their findings lead them to hypothesize that because they (i.e., the youth) are departing

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perhaps even further from the expectations of their parents than lower-class children, middle-class drug users have a greater need for peer support than lower-class offenders. In either case, however, the friends of a drug user and commitment to peer values appear to be far more predictive of such problematic behavior than social class. Studies reveal that a high level of adolescent peer activity predicts marijuana use; the more that adolescents are isolated and alienated from the parental subculture and the more involved they are with the teenage peer subculture, the greater the likelihood that they will experiment with and use drugs; and that users tend to be friends of users and the selective peer-group interaction and socialization therefore constitute probably the single-most powerful influence related to drug use among young people.45 A study of drug consumption (i.e., marijuana, amphetamines, and tranquilizers) among young adults showed this type of behavior related to those who share an apartment (flat) with friends and who are in disagreement with their parental upbringing.46 Regarding the patterns of substance use, there tends to be a progression of roughly four stages: (1) beer or wine; (2) cigarettes or hard liquors; (3) marijuana; and (4) other illegal drugs. “Adolescents rarely skip stages; thus drinking alcohol is necessary to smoking marijuana, just as marijuana use is necessary to moving on to more dangerous drugs such as cocaine and heroin.”47 In another study using a four-variable simplex model to prove the progression theory of substance use, it was found that alcohol use predicted marijuana use, and marijuana use predicted hard drug use.48 Regarding drug abuse patients in treatment in the United States, it was found that onset of heroin addiction for males commonly began as a peer-group recreational activity at an early age (14–18 years); for females onset usually started with their addicted boyfriends.49 In sum, it may be concluded that “association with substance-using peers . . . is among the strongest predictors of . . . substance use. Peer influence, approval and/or tolerance of substance use, and modeling have been identified as salient variables. Strong bonds to family and school, however, usually decrease the influence of antisocial peers.”50 Education The school is a major agent of status definition in society and has established a critical role in the socialization process of people; consequently, it is an important facet of the drug problem. As a social transmission agency, the school is an institution that labels youth as winners or losers and by doing so frequently determines the directions they take in conducting their lives. The school system and its personnel may be perceived as an organization that produces, in the course of its activities, a wide variety of careers [including those of an asocial, deviant, and problematic nature]. Within the organizational setting of the school, the day-to-day activities of adolescents and personnel define, classify, and process a wide range of “routine” and “problem” behaviors. Because the school occupies a strategic position as a coordinating agency between the activities of the family, the police, and the peer group vis-a-vis adoles-

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cents, it serves as a “clearinghouse” that receives and releases information from and to other agencies concerning adolescents.51

Many studies have shown the relationship between a negative school experience and drug use to be strong. For example, negative attitudes toward school, low academic aspirations and educational achievement, and disciplinary problems in school often precede the onset of drug use and/or dropping out of school. Furthermore, teenage pregnancies and frequency of school absenteeism are associated with increasing levels of drug use.52 Prospective long-term studies have indicated that early cannabis use may significantly increase risks of subsequent poor school performance and, in particular, early drop out. Use of alcohol, cigarettes, and illicit drugs has been found to be strongly associated with truancy and perceived school performance. Key factors in determining whether teens are likely to drink, smoke, use weapons, have sex or think about suicide include how well they do in school and how they spend their free time. Early smokers have been found to be at higher risk for low academic achievement and behavioral problems at school, stealing and other delinquent behaviors and involvement with predatory and relational violence. Also, young smokers are at least three times more likely by grade 12 to regularly use tobacco and marijuana, use hard drugs, sell drugs, have multiple drug problems, drop out of school, and experience early pregnancy and parenthood.53 The educational process, the school, and school personnel are a potent force in shaping the attitudes and behavior of youth. Too often, however, the full impact of the school’s resource base is lost. Communications between teachers and parents, particularly in the areas of strengthening and reinforcing the learning processes of youth during nonschool hours, tend not to be emphasized. Also, school policy and program administrators normally take a system’s maintenance approach of the education process rather than one of a developmental nature that draws on available resources to address the broad spectrum of community needs in terms of programs especially during evenings, vacation periods, weekends, and summer months. Most important, the school is too often limited in its ability to prepare young people for a rewarding and happy life, one that serves as a major influence for helping young people come to grips with the conflicting normative structure found in their society. Media Since the 1920s when motion pictures became a major source of mass entertainment, the effects of the media have been subject to scientific inquiry and public concern.54 It has long been recognized that movies, television, and popular “hard rock” music portray an excessive amount of violence and illegal behavior. As early as 1954, a Gallup poll found that seven out of ten American adults attributed the postwar rise in problem behavior among youth at least in part to the high incidence of criminal acts shown in the media.55 Crime, as it is portrayed through certain aspects of the media, encourages and causes improper attitudes and behavior among

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some children. Testimony before a U.S. Senate subcommittee in 1955 reported that television was serving as a preparatory school for antisocial activity.56 Information presented by the media provides a young person with an awareness of the external world. Such information, however, if not qualified, can also enhance the likelihood that he will behave in an inappropriate and lawless manner. The causal connection between media and problem behavior has been the subject of over 1,000 studies, including a Surgeon General’s special report in 197257 and a National Institute of Mental Health report 10 years later.58 Regarding exposure to media, it has been reported that American children and adolescents spend an average of three to five hours per day with a variety of media, including television, radio, videos, video games, and the Internet. “Every day a typical U.S. preteen views three hours and 14 minutes of TV . . . [and] research [shows] that children glued to the TV for more than 10 hours each week are more likely to be overweight, aggressive, and slower to learn in school. For that reason, the American Academy of Pediatrics recommends no ‘screen time’ (whether TV, computers or video games) for children under 2 and a maximum of two hours a day for older kids.”59 In a survey of youth it was found that those who listened to more radio and watched more music, videos, cartoons, and soap opera were more likely to engage in behavior such as drinking alcohol, sex, and smoking cigarettes.60 In terms of societal beliefs, the mass media shape people’s ideas about what the real world is like,61 what people think about, and which issues they consider most important.62 From the perspective of individual behavior, a considerable amount of experimental studies show that media can teach specific acts of problem behavior even after controlling for the effects of socioeconomic class, education, and race.63 Also, there is a cumulative effect of the influence of media over an extended period of time.64 Behavior, such as drug use, in the media can have a lasting effect on children and youth if (1) the themes presented are repeated often enough and (2) the information imparted by the media is not clearly contradicted by significant others such as parents, peers, or teachers. In fact, lessons learned by children from the media may be supported, either explicitly or implicitly, by the statements and actions of parents. Adults do not always frown on immorality and the child may observe his parents occasionally approving illegal behavior, or hear them condoning someone’s violation of the law.65 While it may be true that television, movies, comic books, popular music, and so on will excite antisocial conduct from only a relatively small number of people, it can be said that the heavy dosage of [activity] in the media heightens the probability that someone in the audience will behave [that way] in a later situation.66 Research shows that a possible relationship exists between drug use and music style including rave music. Televised beer advertisements contribute to the quantity of alcohol consumed on drinking occasions which in turn contributes to the level of alcohol-related problems. The media have an influence on the primary socialization process and, in turn, drug use and deviance. The primary effects of media exposure (i.e., television, movies, rock music and music videos, advertising, video games, computers and the Internet) are increased violent and aggressive behavior, increased high-risk behaviors, including alcohol and tobacco use, and ac-

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celerated onset of sexual activity. Also, television is the main source of information about illicit drugs followed by young people, friends, and what is talked about in school.67 Despite widespread concern about the effects of the media, particularly violence through television, there has been relatively little empirical research on drinking and drug use. What is known is that there are four basic types of television content presenting substance-related stimuli: (1) TV commercials centrally feature positive portrayals of beer and wine drinking; (2) public service announcements typically warn against alcohol abuse, drunk driving, and cocaine use; (3) newscasts disseminate information about problematic outcomes of substance misuse, including reports of drunk-driving accidents, drug-related deaths and arrests, and health risks; and (4) entertainment programming, particularly dramas, movies, and comedy shows, frequently portray characters using alcohol and experiencing positive and/or negative consequences; occasional depictions of other drugs are also presented. While substance use and abuse are shaped by a variety of personality characteristics, family and peer influences, and sociodemographic factors, television is also considered to play an influential role.68 Many issues need to be examined and questions answered regarding the impact of the media on shaping drug behavior. Nevertheless, it is clear that to a large extent drug use has been popularized by the media. For young people needing only a slight stimulus to engage in drug use, many sources are to be found. LABELING/CRIMINALIZATION PROCESS Building on the work of Everett Hughes69 who introduced the study of occupations into sociology, Howard Becker70 took the career model and applied it to deviant careers in general and drug users specifically. This conceptual shift has broad implications and was the basis for what came to be viewed as a new sociological movement called the “labeling theory.” When applied to the field of addiction, it provided a different perspective that included an analysis of the individual drug users and of public policy, as well as a legal framework within which such activities took place. In this way, Becker’s concepts helped structure the way drug ethnographers began to collect and analyze data. The shift in concept was evident in [Becker’s] own study, “Becoming a Marijuana User” [published in 1953].71 The labeling process is a method that determines the fate of a person. It tends to reinforce problem behavior rather than ameliorate it. Essentially, labeling theories are less interested in the problem behavior of a person and his characteristics than in the criminalization process by which a community seeks out its law violators, stigmatizes them, and assigns them to a negative status. The following assumptions have been suggested by Schrag as best characterizing the labeling-criminalization process: (1) no act is intrinsically criminal. It is the law that makes an act a crime. Crimes therefore are defined by organized groups having sufficient political power to influence the legislative process; (2) criminal definitions are enforced in the interest of powerful groups by their official representatives, including the police, courts, correctional institutions, and other administrative bod-

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ies. While the law provides detailed guidelines in its substantive definitions and rules of procedure, the way the law is implemented may be determined by the decisions of local officials who depend on political and social leaders for financial support or other resources; (3) a person does not become a criminal by violating the law. Instead, he is designated a criminal by the reactions of authorities who confer upon him the status of an outcast and divest him of some of his social privileges; (4) only a few persons are caught in violation of the law, though many may be equally guilty. The ones who are caught may be singled out for specialized treatment; (5) criminal sanctions vary according to characteristics of the offender; for any given offense, they tend to be most frequent and severe among males, the young, the unemployed or underemployed, the poorly educated, members of the lower classes, members of minority groups, transients, and residents of deteriorated urban areas; (6) criminal justice is founded on a stereotyped conception of the offender (e.g., drug user) as a pariah—a willful wrongdoer who is morally bad and deserving of the community’s condemnation; and (7) confronted by public condemnation and the label of an evil man, it may be difficult for an offender to maintain a favorable image of himself or herself.72 In terms of drug use, a consistent pattern of events tends to take place resulting in a feedback cycle involving more deviations, more penalties, and still more deviations. Hostilities and resentment are built up, culminating in official reactions that label and stigmatize the addict, thereby justifying even greater penalties and restricting opportunities for the drug user to change his role. Often, the drug offender ultimately accepts his deviant status and develops a career of systematic norm violations. It may be concluded from the labeling/criminalization process, therefore, that the treatment of drug law violators often serves as a self-fulfilling prophecy. It forecloses the offenders’ non-criminal options and coerces them into a permanent state of drug use. [I]t is common for addicts themselves to believe the conventional wisdom of “once an addict, always an addict,” often expressed by them as having an “addictive personality,” or being a “hope to die dope fiend.” Such beliefs work to undermine users’ decisions to stop and weaken their ability to resist relapse. . . . A second obstacle to addicts who are trying to end their drug abuse is the absence of any role model or sub-cultural folklore to give them insight into how they might implement their resolution. The reason for this lack of information about successful, self-initiated termination is that addicts who are able to maintain their abstinence without having utilized some form of treatment generally cease to associate with those who remain addicted. Consequently, successfully abstaining ex-addicts who remove themselves from the drug scene are believed to have failed in their resolve and, perhaps, are assumed to be readdicted in another city, imprisoned, or dead.73

The roots of the labeling and criminalization process tend to go right to the heart of a major controversy regarding the drug scene—that is, the belief that the judicial and law enforcement decision-making process underlying the drug problem is racially biased.

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A team of American lawyers, clergy and drug experts, organized as the Campaign to End Race Discrimination in the War on Drugs, [asserts] that America’s criminal justice system has turned into an “apartheid-like” device. . . . The motivation behind America’s drug wars, its willingness to let the incarceration rate balloon to the highest in the world, was not race but “law and order” politics. Yet, the impact of the politics has become profoundly racist. . . . According to the Washington-based Sentencing Project, African-Americans are 13 percent of drug users but represent 35 percent of arrests for drug possession, 55 percent of convictions and 74 percent of prison sentences. . . . If you’re white middle-class and your kid is on drugs, you call the treatment center. In the inner city there’s no treatment. Your first port of call is the criminal justice system—and it escalates. . . . States fed these fires with their tough laws of recent years, and the federal government, if anything, is worse. Under federal law it takes only one-hundredth the amount of crack cocaine (generally more popular in black neighborhoods) to trigger the same mandatory minimum sentence as powder cocaine (more popular among affluent whites). . . . In many city neighborhoods, more than half of young black men spend time in prison . . . leading to “incapacitation of future generations . . . hopelessness and despair in the black community, says James Compton, President of the Chicago Urban League. . . . Drug prohibition has become a replacement system for segregation. . . . It has become a system of separating out, subjugating, imprisoning . . . substantial portions of a population based on skin color says Ira Glazer, director of the American Civil Liberties Union.74

BIOLOGICAL AND PSYCHOLOGICAL CHARACTERISTICS Biological “Biological theories are those that postulate innate, constitutional, physical mechanisms in specific individuals that impel them either to experiment with drugs, or to abuse them once they are exposed to them.”75 Research shows that certain individuals are predisposed toward drug and alcohol use because of their genetic makeup. Nondrinking sons, for example, have brain wave patterns similar to their alcoholic fathers.76 Studies show that sons of alcoholics turn up with drinking problems four to five times as often as sons of nonalcoholics77 and it appears that genetic loading in combination with environmental and personality factors could make for a significantly higher level of drug abuse or alcoholism in certain individuals or groups in the population.78 The National Institute of Drug Abuse reports, based on research of the patterns of marijuana and cocaine use by female twins, that genetic factors play a major role in the progression from drug use to abuse and dependence. . . . “[This] research supports other studies that indicate that family and social environmental factors are influential in determining whether an individual begins using these drugs. . . . [Also, the] findings suggest that the progression from the use of cocaine or marijuana to abuse or dependence was due largely to genetic factors.” It has been found that genetic influences are stronger for abuse of some drugs than for others. “[Evidence] suggests that genetic influences contribute to a common vulnerability for abusing marijuana, sedatives, stimulants, heroin or opiates, and psychedelics.” Studies involving male and female twins suggest that genetic factors from drug abuse are stronger in males than females. “For females, genetic influ-

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ences accounted for 47 percent of the differences between identical and fraternal twins in abuse, dependence, or both for any drug, compared with 79 percent for males.”79 Another theory postulates metabolic imbalance as a possible cause of drug abuse—specifically, narcotic addiction.80 While “no precise biological mechanism corresponding to metabolic imbalance has ever been located, the best that can be said about this theory is that the treatment program based on it, methadone maintenance, has helped a certain proportion of addicts.”81 Psychological Psychological theories associated with drug use and dependence may be categorized into two groups—those that emphasize the mechanism of reinforcement, and those that stress personality differences between people who use and are dependent on drugs and those who abstain.82 In terms of the first approach, research shows that drugs have addicting reinforcement properties, independent of personality factors. There are two different approaches to understanding reinforcement theory—positive and negative. Positive reinforcement occurs when the individual receives a pleasurable sensation and, because of this, is motivated to repeat what caused it.83 “The pleasure mechanism may . . . give rise to a strong fixation on repetitive behavior.”84 The euphoria-seeking addict gives up conventional activities and commitments for personal pleasure which often results in a pattern of deviant and criminal behavior.85 Negative reinforcement occurs when an individual does something to seek relief or to avoid pain, thereby being rewarded and, hence, motivated to repeat whatever it was that achieved relief or alleviated the pain. For example, “withdrawal symptoms as being due to the absence of opiates will generate a burning desire for the drug.”86 Addicts continue taking their drug of choice just to feel normal.87 Personality pathology, defect, or inadequacy is another theoretical approach. The inadequate personality approach points to problems of an emotional or psychic nature of certain individuals leading them to drug use. Drugs are used to escape from reality, to avoid problems, and to retreat into a state of indifference.88 The inadequate personality type lacks responsibility, independence, and the ability to defer pleasurable gratification for the sake of achieving long-range goals.89 There is a tendency to use narcotics and hypnotics in order to manage such emotions as rage, shame, jealousy, and anxiety; to use stimulants to alleviate depression and weakness; to use psychedelics against boredom and disillusionment; and to use alcohol against guilt, loneliness, and anxiety.90 This personality type also tends to have low self-esteem and feelings of self-derogation brought about by “peer rejection, parental neglect, high expectations for achievement, school failure, physical stigmata, [rejection by the peer group], impaired sex-role identity, ego deficiencies, low coping abilities, and coping mechanisms that are socially devalued and/or are otherwise self-defeating.”91 A focus on deviant or problem behavior reveals that those who use drugs, compared to non-drug users, tend to be “more rebellious, independent, open to new ex-

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periences, willing to take a wide range of risks, accepting of deviant behavior and transgressions of moral and cultural norms, receptive to uncertainty, pleasure-seeking, hedonistic, peer-oriented, nonconformist, and unconventional. They also tend to be less religious, less attached to parents and family, less achievement-oriented, less cautious” and have a higher level of sexual activity.92 CONCLUSION A number of theoretical approaches about drug use and dependence have been presented. What can be said about this information, beginning with the work of Dai (1937)93 and Lindesmith (1947),94 is that it has contributed to nearly 50 years of debate and inquiry on the major views of the phenomenon—drug addiction as crime and drug addiction as disease; to more recent descriptions of addicts and treatment programs.95 Many factors, either alone or in combination, influence or are associated with drug use and dependence.96 These include: (1) societal issues of normative structure, deviance definitions, and resources allocation; (2) sociological forces of the environment, values and morals, family, school, peers, and media, and the labeling/criminalization process; and (3) biological/psychological personality characteristics. Figure 2.1 represents these factors as separate entities and in connection with each other. NOTES 1. Join Together Online (JTO) (2001). Why do Sally and Johnny use drugs. Alan Leshner, Boston University School of Public Health, April 9. 2. Ball, J., Nurco, D., Clayton, R., Lerner, M., Hagan, T., and Groves, G. (1995). Etiology, epidemiology and natural history of heroin addiction: A social science approach. In L. Harris (ed.), Problems of Drug Dependence, 1994: Proceedings of the 56th Annual Meeting, The College on Problems of Drug Dependence, Inc., Vol. 1, pp. 74–78. 3. Merton, R. (1969). Social structure and anomie. In D. Cressey and D. Ward (eds.), Delinquency, Crime and Social Process. New York: Harper and Row, pp. 254–284. 4. Merton, R. (1957). Social Theory and Social Structure. New York: Free Press. 5. Ibid., p. 188. 6. Cohen, A. (1965). The sociology of the deviant act: Anomie theory and beyond. American Sociological Review, 30:5–14. 7. Cloward, R., and Ohlin, L. (1960). Delinquency and Opportunity. New York: Free Press; Palmer, S., and Linsky, A. (eds.) (1972). Rebellion and Retreat: Readings in the Forms and Processes of Deviance. Columbus, OH: Charles E. Merrill. 8. Lindesmith, A., and Gagnor, J. (1964). Anomie and drug addiction. In M. B. Clinard (ed.), Anomie and Deviant Behavior: A Discussion and Critique. New York: Free Press. Kandel, D. (1980). Drug and drinking behavior among youth. Annual Review of Sociology, 6:235–285; Goode, E. (1989). Drugs in American Society, Third Edition. New York: McGraw-Hill, p. 64. 9. Reiss, A. (1965). Schools in a Changing Society. New York: Free Press, p. 57. 10. Goffman, E. (1963). Stigma. Englewood Cliffs, NJ: Prentice-Hall; Becker, H. (1963). Outsiders: Studies in the Sociology of Deviance. New York: Free Press.

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Figure 2.1 Factors Associated with Drug Use and Dependence

SOCIOLOGICAL INSTIGATING FORCES

SOCIETAL ISSUES Normative Structure Deviance Definitions Resource Allocation

Environment Values and Morals Interpersonal Relations Family Peers School Media

LABELING/CRIMINALIZATION

BIOLOGICAL/PSYCHOLOGICAL PERSONALITY CHARACTERISTICS

DRUG USE AND DEPENDENCE

11. Becker, p. 9. 12. Feldman, H., and Aldrich, M. (1990). The role of ethnography in substance abuse research and public policy: Historical precedent and future prospects. In Elizabeth Lambert (ed.), The Collection and Interpretation of Data and Hidden Populations, Monograph 98, Rockville, MD: National Institute on Drug Abuse (NIDA), p. 19. 13. Shaw, C., and McKay, H. (1931). Social Factors in Juvenile Delinquency: Report on the Causes of Crimes. Washington, DC: National Commission on Law Observance and Enforcement, pp. 2–13; Shaw, C., and McKay, H. (1942). Juvenile Delinquency in Urban

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Areas. Chicago: University of Chicago Press; Lander, B. (1954). Towards an Understanding of Juvenile Delinquency. New York: Columbia University Press; Berkowitz, L. (1962). Aggression: A Social Psychological Analysis. New York: McGraw-Hill; Johnston, L., O’Malley, P., and Bachman, J. (1989). Drug Use, Drinking and Smoking: National Survey Results from High School, College and Young Adult Populations, 1975–1988. DHHS Pub. No. (ADM) 89-1638. Washington, DC: U.S. Government Printing Office; Lorion, R., Bussell, D., and Goldberg, R. (1991). Identification of youth at high risk for alcohol or other drug problems. In E. Goplerud (ed.), Preventing Adolescent Drug Use: From Theory to Practice. DHHS Pub. No. (ADM) 91-1725. Washington, DC: U.S. Government Printing Office, p. 71; Kvaraceus, W., and Miller, W. (1969). Norm-violating behavior and lower-class culture. In R. Caven (ed.), Readings in Juvenile Delinquency. Philadelphia: J. B. Lippincott. 14. Massing, M. (1998). The Fix. Berkeley: University of California Press, pp. 21–22. 15. Gray, M. (1998). Drug Crazy. New York: Random House, pp. 4–5. 16. Miller, W. (1958). Lower class culture as a generating milieu of gang delinquency. Journal of Social Issues, 14(3):5–19. 17. Miller, pp. 5–19; Schrag, C. (1973). Crime and Justice: American Style. Rockville, MD: National Institute of Mental Health, pp. 71–80; Flay B., and Petraitis, J. (1991). Methodological issues in drug use prevention and research. In C. Leukefeld and W. Bukoski (eds.), Drug Abuse Prevention Intervention Research: Methodological Issues. NIDA, DHHS Pub. No. (ADM) 91-1761. Washington, DC: U.S. Government Printing Office, p. 86. 18. Schrag; Cohen, A. (1955). Delinquent Boys. New York: Free Press. 19. Cloward and Ohlin. 20. Feldman, H., and Aldrich, M. (1990). The role of ethnography in substance abuse research and public policy: Historical precedent and future prospects. In E. Lambert (ed.), The Collection and Interpretation of Data and Hidden Populations, Monograph 98, Rockville, MD: NIDA, p. 20. 21. Schur, E. (1969). Our Criminal Society. Englewood Cliffs, NJ: Prentice-Hall, pp. 37–38. 22. Short, J., and Nye, I. (1957). Reported behavior as a criterion of deviant behavior. Social Problems 36(Fall):207–213. 23. Clark, J., and Wenninger, E. (1970). Social class and delinquency. In M. Wolfgang, L. Savitz, and N. Johnston (eds.), The Sociology of Crime and Delinquency. New York: John Wiley and Sons; Scott, J., and Vaz, E. (1969). A perspective on middle-class delinquency. In Ruth Caven (ed.), Readings in Juvenile Delinquency. Philadelphia: J. B. Lippincott. 24. New York Times (2001). Adjusting drug policy, Editorial, February 27, p. A22. 25. Kelley, H. (1952). Two functions of reference groups. In G. Swanson and T. Newcomb (eds.), Readings in Social Psychology. New York: Henry Holt; Wilson, W. (1987). The Truly Disadvantaged: The Inner City, the Underclass and Public Policy. Chicago: University of Chicago Press; Flay and Petraitis, p. 86. 26. Merton, p. 282. 27. Berkowitz, p. 216. 28. Glynn, T., and Haenlein, M. (1988). Family theory and research on adolescent drug use: A review. Journal of Chemical Dependency Treatment, 1(2):39–56. 29. Goodman, P. (1960). Growing Up Absurd. New York: Random House.

Theoretical Considerations and Risk Factors

43

30. U.S. Office of Science and Technology (1973). Youth: Transition to Adulthood. Report to the Panel on Youth of the President’s Science Advisory Committee. Chicago: University of Chicago Press. 31. Dinitz, S., Dynes, R., and Clark, A. (1975). Deviance: Studies in Definition, Management and Treatment. New York: Oxford University Press, p. 4. 32. Searcy, E., Harrell, A., and Grotberg, E. (1973). Toward Interagency Coordination: An Overview of Federal Research and Development Activities Relating to Adolescence. Washington, DC: Social Research Group, George Washington University, p. 27. 33. Whiting, J. (1971). An anthropological investigation of child-rearing practices and adult personality. In J. Segal (ed.), The Mental Health of the Child. Rockville, MD: National Institute of Mental Health; McCord, W., McCord, J., and Howard, A. (1961). Familial correlates of aggression in non-delinquent male children. Journal of Abnormal Social Psychology, 62:79–93; Elder, G. (1968). Adolescent socialization and development. In E. Borgotta and W. Lambert (eds.), Handbook of Personality, Theory and Research. Chicago: Rand McNally; Bandura, A., and Walters, R. (1959). Adolescent Aggression: A Study of the Influences of Child Training Practices and Family Inter-Relationships. New York: Ronald Press; Goode, Drugs in American Society, pp. 62–67. 34. Robins, L., Davis, D., and Wish, E. (1977). Detecting predictors of rare events: Demographic, family and personal deviances as predictors of stages in progression toward narcotic addiction. In J. Strauss, H. Babigian, and M. Ross (eds.), The Origins and Course of Psychopathology: Methods to Longitudinal Research. New York: Plenum; Kandel, D. (1975). Adolescent marijuana use: Role of parents and peers. Science, 181:1067–1070; Kandel, D., Kessler, R., and Margulies, R. (1978). Antecedents of adolescent initiation into stages of drug use: A developmental analysis. Journal of Youth and Adolescence, 7(1):13–40; Cooper, D., Olson, D., and Fournier, D. (1977). Adolescent drug use related to family support, self-esteem, and school behavior. Center Quarterly Focus, Spring:121–134; Harbin, H., and Maziar, H. (1975). The families of drug abusers: A literature review. Family Process, 14(3):411–431; Norem-Hebeisen, A., and Hedin, D. (1983). Influence on adolescent problem behavior: causes, connections and contexts. In R. Isralowitz and M. Singer (eds.), Adolescent Substance Abuse. New York: Haworth; Needle, R. (1986). Interpersonal influences in adolescent drug use: The role of older siblings, parents and peers. The International Journal of the Addictions, 21(7):739–766; Simcha-Fagan, O., and Gersten, J. (1986). Early precursors and concurrent correlates of PG items of illicit drug use in adolescence. Journal of Drug Issues, 60(1):7–28; Lorion, et al., pp. 75–76. 35. Copeland, J., and Howard, J. (1997). Substance abuse and juvenile crime, in A. Borowski and I. O’Connor (eds.), Juvenile Crime, Justice and Corrections. South Melbourne, Australia: Addison Wesley Longman, pp. 172–173. 36. JTO (2001). Alcoholic fathers impact child development, August 17; Marcenko, M., Kemp, S., and Larson, N. (2000). Childhood experiences of abuse, later substance use, and parenting outcomes among low-income mothers. American Journal of Orthopsychiatry, 70(3):316–326; Dawson, D. (2000). The link between family history and early onset alcoholism: Earlier initaition of drinking or more rapid development of dependence? Journal of Studies of Alcohol, 61(5): 637–646. 37. Coombs, R., and Paulson, M. (1988). Contrasting family patterns of adolescent drug users and nonusers. Journal of Chemical Dependency Treatment, 1(2):59–72. 38. Emmelkamp, P., and Heeres, H. (1988). Drug addiction and parental rearing style: A controlled study. International Journal of the Addictions, 23(2):207–216.

44

Drug Use, Policy, and Management

39. Turner, A., Larimer, M., and Sarason, I. (2000). Evidence exists that women may be more influenced than men by family background factors in terms of their adult problems with alcohol, drugs and violence. Journal of Studies on Alcohol, 61(6): 818–826; Chermack, S., Stoltenberg, S., Fuller, B., and Blow, F. G. (2000). Gender differences in the development of substance-related problems: The impact of family history and childhood conduct problems. Journal of Studies on Alcohol, 61(6):845–852; Kuperman, S., Schlosser, S., Kramer, J., Bucholz K., Hesselbrock, V., Reich, T., and Reich, W. (2001). Risk domains associated with adolescent alcohol dependence diagnosis. Addiction, 96(4):629–636; Vakalahi, H. (2001). Adolescent substance use and family-based risk and protective factors: A literature review, Journal of Drug Addiction, 31(1):29–46. 40. Ball, J., Nurco, D., Clayton, R., Lerner, M., Hagan, T., and Groves, G. (1995). Etiology, epidemiology and natural history of heroin addiction: A social science approach. In L. Harris (ed.), Problems of Drug Dependence, 1994: Proceedings of the 56th Annual Scientific Meeting. The College on Problems of Drug Dependence Inc., Vol. 1, pp. 74–78. 41. Yablonsky, L. (1969). The classification of gangs. In R. Caven (ed.), Readings in Juvenile Delinquency. Philadelphia: J. B. Lippincott; Goode, Drugs in American Society; Elliot, D., Huizinga, D., and Ageton, S. (1985). Explaining Delinquency and Drug Use. Beverly Hills, CA: Sage Publications; Lubben, I., Kitano, J., and Harry, H. (1989). Differences in drinking behavior among three Asian American groups. Journal of Studies on Alcohol, 50(1):15–23; Lubben, I., Kitano, J. and Harry, H. (1988). Heavy drinking among young adult Asian males. International Social Work, 31(3):219–229; Austin, G., Prendergast, M., and Lee, H. (1989). Substance abuse among Asian American youth. Prevention Research Update No. 5. Portland, OR: Northwest Regional Education Laboratory, Winter, pp. 1–13. 42. JTO (2001). Predictors of youth drug use identified, March 8; Pruitt, B., Kingery, P., Mirzaee, E., Heuberger, G., and Hurley, R. (1991). Peer influence and drug use among adolescents in rural areas. Journal of Drug Education, 21(1):1–11; Segal, B., and Stewart, J. (1996). Substance use and abuse in adolescence: An overview. Child Psychiatry and Human Development, 26(4):193; Farrell, A., and White, K. (1998). Peer influences and drug use among urban adolescents: Family structure and parent-adolescent relationship as protective factors, Journal of Consulting and Clinical Psychology, 66(2):248–258; Flannery, D., Williams, L., and Vazsonyi, A. (1999). Who are they with and what are they doing? Delinquent behavior, substance use, and early adolescents’ after school time. American Journal of Orthopsychiatry, 69(2):247–253; Sobeck, J., Abbey, A., Agius, E., Clinton, M., and Harrison, K. (2000). Predicting early adolescent substance use: Do risk factors differ depending on age of onset? Journal of Substance Abuse, 11(1):89–102; Beal, A., Ausiello, J., and Perrin, J. (2001). Social influences on health-risk behaviors among minority middle school students. Journal of Adolescent Health, 28(6): 474–480. 43. Cohen, A. (1955). Delinquent Boys: The Culture of the Gang. New York: Free Press. 44. Erickson, M., and Empey, L. (1969). Class position, peers and delinquency. In D. Cressey and D. Ward (eds.), Delinquency, Crime and Social Process. New York: Harper and Row, p. 417. 45. Kandel, D. (1980). Drug and drinking behavior among youth. Annual Review of Sociology, 6:235–285; Kandel, D. (1974). Inter- and intragenerational influences on adolescent marijuana use. Journal of Social Issues, 30(2):107–135; Johnson, B. (1973). Marijuana Users and Drug Subcultures. New York: John Wiley and Sons; Goode, E. (1969). Multiple drug use among marijuana smokers. Social Problems, 17(Summer):48–64; Goode, Drugs in American Society; Needle; Lorion et al., pp. 76–77.

Theoretical Considerations and Risk Factors

45

46. Queipo, D., Alvarez, F., and Velasco, A. (1988). Drug consumption among university students in Spain. British Journal of Addiction, 83(1):91–98. 47. Kandel, D. (1980). Development states in adolescent drug involvement. In D. Lettieri, M. Sayers, and H. Pearson (eds.), Theories on Drug Abuse: Selected Contemporary Perspectives. Rockville, MD: NIDA, pp. 120–121. 48. Windle, M., Barnes, G., and Welte, J. (1989). Causal models of adolescent substance use: An examination of gender differences using distribution free estimators. Journal of Personality and Social Psychology, 56(1):132–142. 49. Ball, pp. 74–78. 50. Copeland and Howard, p. 172; Dielman, T., Butchart, A., Shope, J., and Miller, M. (1991). Environmental correlates of adolescent substance use and misuse: implications for prevention programs. International Journal of the Addictions, 25, (7A and 8A):855–880; Farrell, A. (1993). Risk factors for drug use in urban adolescents: A three-wave longitudinal study, Journal of Drug Issues, 23(3):443–462; Hoffmann, J. (1993). Exploring the direct and indirect family effects on adolescent drug use. Journal of Drug Issues, 23(3):535–557; Kandel, D., and Yamaguchi, K. (1985). Developmental patterns of the use of legal, illegal and medically prescribed psychotropic drugs from adolescence to young adulthood. In Etiology of Drug Abuse (NIDA Research Monograph 56). Washington, DC: Department of Health and Human Services, pp. 193–235. 51. Cicourel, A., and Kitsuse, J. (1965). The social organization of high schools and deviant adolescent careers. In A. Reiss, Jr. (ed.), Schools in a Changing Society. New York: Free Press, p. 31. 52. Ahlgren, A., Norem-Hebeisen, A., Hochhauser, M., and Garvin, J. (1980). Antecedents of smoking among pre-adolescents. Unpublished paper; Smith, G., and Fogg, C. (1978). Psychological predictors of early use, late use, and non-use of marijuana among teenage students. In D. Kandel (ed.), Longitudinal Research on Drug Use: Empirical Findings and Methodological Issues. Washington, DC: Halstead-Wiley; Patan, S., Kessler, R., and Kandel, D. (1977). Depressive mood and adolescent illicit drug use: A longitudinal analysis. Journal of Genetic Psychology, 131(2):267–289; Jessor, R., and Jessor, S. (1977). Problem Behavior and Psychological Development: A Longitudinal Study of Youth. New York: Academic Press; Bachman, J., O’Malley, P., and Johnston, D. (1978). Adolescence to Adulthood: Change and Stability in Lives of Young Men. Ann Arbor, MI: Survey Research Center; Millman, D., and Wen-Huey, S. (1973). Patterns of illicit drug use among secondary school students. Journal of Pediatrics, 83(2):314–320; Smith, G. (1975). Teenage drug use: A search for cause and consequences. In D. Lettieri (ed.), Predicting Adolescent Drug Use: A Review of Issues, Methods and Correlates. DHEW Pub. No. (ADM) 276–299, Washington, DC: NIDA; Newcomb, M., and Bentler, P. (1989). Substance use and abuse among children and teenagers. American Psychologist, 44(2):242–248; Hawkins, J., Lishner, D., Catalano, R., and Howard, M. (1985). Childhood predictors of adolescent substance abuse: Toward an empirically grounded theory. Journal of Children in Contemporary Society, 18(1–2):11–48. 53. Lynskey, M. (2000). The effects of adolescent cannabis use on educational attainment review. Addiction, 95(11):1621–1630; Miller, P., and Plant, M. (1999). Key factors in determining whether teens are likely to drink, smoke, use weapons, have sex or think about suicide include how well the child does in school and how they spend their free time. Alcohol, 34(6):886–893; Blum, R., Beuhring, T., Shew, M., Bearinger, L., Sieving, R., and Resnick, M. (2000). The effects of race/ethnicity, income, and family structure on adolescent risk behaviors. American Journal of Public Health, 90:1879–1884; Ellickson, P.,

46

Drug Use, Policy, and Management

Tucker, J., and Klein, D. (2001). High risk behaviors associated with early smoking: Results from a 5 year follow-up. Journal of Adolescent Health, 28(6):465–473. 54. Schooler, C., and Flora, J. (1996). Pervasive media violence. Annual Review of Public Health, 17:275. 55. Klapper, J. (1960). The Effects of Mass Communication. New York: Free Press. 56. Banay, R. (1955). Hearings Before the United States Senate Subcommittee to Investigate Juvenile Delinquency. U.S. Senate Committee on the Judiciary, Television Programs and Juvenile Delinquency, 84th Congress, First Sessions, pp. 81–83. Washington, DC: U.S. Government Printing Office. 57. Behavior USGSACoTaS. (1972). Television and Growing Up: The Impact of Televised Violence: Report of the Surgeon General, US Public Health Service. Washington, DC: U.S. Government Printing Office. 58. Pearl, D., Bouthilet, L., and Lazar, J. (1982). Television and Behavior: Ten years of Scientific Progress and Implications for the Eighties. Washington, DC: U.S. Government Printing Office. 59. Strasburger, V., and Donnerstein, F. (2000). Children, adolescents and the media in the 21st century. Adolescent Medicine, 11(1):51–68; Springen, K. (2001). Unplugged America. Newsweek, August 20:37. 60. Christenson, P., and Roberts, D. (1990). Popular Music in Early Adolecence. Washington, DC: Carnegie Council on Adolescent Development; Klein, J. Brown, J., Childers, K., Oliveri, J., Porter, C., and Dykers, C. (1993). Adolescents’ risky behavior and mass media use. Pediatrics, 92:24–31. 61. Gerbner, G., and Gross, L. (1976). Living with television: The violence profile. Journal of Communication, 27:171–180. 62. Cohen, B. (1963). The Press and Foreign Policy. Princeton, NJ: Princeton University Press. 63. Heath, L., Bresolin, L., and Rinaldi, R. (1989). Effects of media violence on children. Archives of General Psychiatry, 43:376–379. 64. Singer, J., Singer, D., and Rapaczynski, W. (1984). Family patterns as predictors of children’s beliefs and aggression. Journal of Communication, 34:73–89; Singer, J., and Singer, D. (1981). Television, Imagination, and Aggression: A Study of Preschoolers. Hilldale, NJ: Erlbaum. 65. Berkowitz, p. 244. 66. Ibid., p. 255. 67. Forsyth, A., Barnard, M., and McKeganey, N. (1997). Musical preference as an indicator of adolescent drug use. Addiction, 92(10):1317–1325; Wyllie, A., Zhang, J., and Casswell, S. (1998). Responses to televised alcohol advertisements associate with drinking behaviour of 10–17 year olds. Addiction, 93(3):361–371; Oetting, E., Donnermeyer, J., and Deffenbacher, J. (1998). Primary socialization theory: The influence of the community on drug use and deviance. Substance Abuse and Misuse, 33(8):1629–1665; Villani, S. (2001). Impact of media on children and adolescents: A 10 year review of the research. Journal of the American Academy of Child and Adolescent Psychiatry, 40(4):392–401; Wright, J., and Pearl, L. E. (2000). Addiction, experience and knowledge of young people regarding illicit drug use, 1969–99. Addiction, 95(8):1225–1235. 68. Atkin, C. (1990). Effects of televised alcohol messages on teenage drinking patterns. Journal of Adolescent Health Care, 11(1):10–24. 69. Hughes, E. (1959). The study of occupations. The Sociological Eye: Selected Papers. New Brunswick, NJ: Transaction Books, 1984, pp. 283–297.

Theoretical Considerations and Risk Factors

47

70. Becker, H. (1963). Outsiders: Studies in the Sociology of Deviance. Glencoe, IL: Free Press, 1963. 71. Becker, H. (1953). Becoming a marijuana user. American Journal of Sociology, 59:235–242. Feldman, H., and Aldrich, M. (1990). The role of ethnography in substance abuse research and public policy: Historical precedent and future prospects. In E. Lambert (ed.), The Collection and Interpretion of Data for Hidden Populations. Monograph Series 98, Rockville, MD: NIDA, U.S. Department of Health and Human Services, p. 19. 72. Schrag, pp. 89–92. 73. Biernacki, P. (1990). Recovery from opiate addiction without treatment: A summary. In Elizabeth Lambert (ed.), The Collection and Interpretation of Data from Hidden Populations, NIDA Research Monograph 98, Rockville, MD: NIDA, U.S. Department of Health and Human Services, pp. 113–119. 74. Peirce, N. (2001). America’s war on drugs looks unfairly warped. International Herald Tribune, August 22:6; Belenko, S. (1993). Crack and the Evolution of Anti-Drug Policy. Westport, CT: Greenwood, pp. 115–154; Gray, M. (1998). Drug Crazy. New York: Random House, pp. 106–108. 75. Goode (1989), p. 55. 76. Kolata, G. (1987). Alcoholism: Genetic links grow clearer. New York Times, November 10, pp. C1, C2; Kumpfer, K. (1988). Prevention of substance abuse: A critical review of risk factors and prevention strategies. In D. Shaffer and I. Phillips (eds.), Project Prevention. Washington, DC: American Academy of Child and Adolescent Psychiatry. 77. Goodwin, D. (1971). Is alcoholism hereditary? Archives of General Psychiatry, 25:545–549; Goodwin, D (1979). Alcoholism and heredity: A review and hypothesis. Archives of General Psychiatry, 36:57–61; Goodwin, D. (1984). Studies of familial alcoholism: A review. Journal of Chemical Psychiatry, 45(2):14–17. 78. Schucket, M. (1980). A theory of alcohol and drug abuse: A genetic approach. In D. Lettieri, M. Sayers, and H. Pearson (eds.), Theories on Drug Abuse: Selected Contemporary Perspectives. Rockville, MD: NIDA; McCord, J. (1988). Alcoholism: Toward understanding genetic and social factors. Psychiatry, 51(2):131–141; Dawson, D. (2000). The link between family history and early onset alcoholism: Earlier initiation of drinking or more rapid development of dependence? Journal of Studies on Alcohol, 61(5): 637–656. 79. Zikler, P. (1999). Twin studies help define the role of genes in vulnerability to drug abuse. NIDA Note, 14(4):1; Kendler, K., and Prescott, C. (1998). Cannabis use, abuse, and dependence in a population-based sample of female twins. America Journal of Psychiatry, 155(8):1016–1022; Kendler, K., and Prescott, C. (1998). Cocaine use, abuse, and dependence in a population-based sample of female twins. British Journal of Psychiatry, 173:345–350; Van den Bree, M., Johnson, E., Neale, M., and Pickens, B. (1998). Genetic and environmental influences on drug use and abuse/dependence in male and female twins. Drug and Alcohol Dependence, 52(3):231–241. 80. Dole, V., and Nyswander, M. (1965). A medical treatment for diacetylmorphine (heroin) addiction. Journal of the American Medical Association, 193 (August):646–650; Dole, V., and Nyswander, M. (1980). Methadone maintenance: A theoretical perspective. In D. Lettieri, M. Sayers, and H. Pearson (eds.), Theories on Drug Abuse: Selected Contemporary Perspectives. Rockville, MD: NIDA; Dole, V. (1980). Addictive behavior. Scientific American, 243(December):138–154. 81. Goode, Drugs in American Society, p. 57. 82. Ibid. 83. Ibid., pp. 57–58.

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84. Bejerot, N. (1980). Addition to pleasure: A biological and social-psychological theory of addiction. In D. Lettieri, M. Sayers, and H. Pearson (eds.), Theories on Drug Abuse: Selected Contemporary Perspectives. Rockville, MD: NIDA, p. 253. 85. Goode, Drugs in American Society, p. 60. 86. Sutter, A. (1966). The world of the righteous dope fiend. Issues in Criminology, 2 (Fall):195. 87. Goode, Drugs in American Society, pp. 58–59. 88. Ibid., p. 60. 89. Ausubel, D. (1980). An interactionist approach to narcotic addiction. In D. Lettieri, M. Sayers, and H. Pearson (eds.), Theories on Drug Abuse: Selected Contemporary Perspectives. Rockville, MD: NIDA, pp. 4–5. 90. Wurmser, L. (1980). Drug use as a protective system. In D. Lettieri, M. Sayers, and H. Pearson (eds.), Theories on Drug Abuse: Selected Contemporary Perspectives. Rockville, MD: NIDA. 91. Kaplan, H. (1980). Self-esteem and self-derogation theory of drug abuse. In D. Lettieri, M. Sayers, and H. Pearson (eds.), Theories on Drug Abuse: Selected Contemporary Perspectives. Rockville, MD: NIDA, p. 129; Galaif, E., Nyamathi, A., and Stein, J. (1999). Psychological predictors of current drug use, drug problems, and physical drug dependence in homeless women. Addictive Behaviors, 24(6):801–814; Petraitis J., Flay, B., Miller, T., Torpy, E., and Greiner, B. (1998). Illicit substance use among adolescents: A matrix of prospective predictors. Substance Use and Misuse, 33(13):2561–2604. 92. Goode (1989). Drugs in American Society, p. 62.; Wagner, M. (2000). Behavioral characteristics related to substance abuse and risk taking, sensation-seeking, anxiety sensitivity and self-reinforcement. Addictive Behaviors, 26(1):115–120. 93. Dai, B. (1937). Opium Addiction in Chicago. Shanghai: Commercial Press. (Reprint, Montclair, NJ: Patterson Smith, 1970.) 94. Lindsmith, A. (1947). Opiate Addiction. Bloomington, IN: Principia Press; 2nd ed. Addiction and Opiates. Chicago: Aldine, 1968. 95. Hanson, B., Besschner, G., Walters, J., and Bovelle, E. (1985). Life with Heroin: Voices from the Inner City. Lexington, MA: Lexington Books; Biernacki, P. (1986). Pathways from Heroin Addiction: Recovery without Treatment. Philadelphia: Temple University Press. 96. Conroy, R. (1988). The many facets of adolescent drinking. Bulletin of the Menninger Clinic, 152(3):229–245; Smart, R. (1986). Solvent use in North America: Aspects of epidemiology, prevention and treatment. Journal of Psychoactive Drugs, 18(2):87–96; Flay and Petraitis, pp. 81–109; Lorion, et al., pp. 53–89.

Chapter 3

Heroin: The “King” of Illegal Drugs

HISTORICAL PERSPECTIVE If one substance were to be labeled the “king” of illegal drugs most people would say it is heroin. Since the turn of the century when it was created, heroin has virtually defined the drug problem.1 [H]eroin addicts are the most stigmatized of all drug users. [Heroin] is the epitome of the illicit street drug. Its association in the public mind with street crime, in spite of strong competition from crack, is stronger than for any other drug. The stereotype of the “junkie” is that he or she is by nature a lowlife, an outcast, a dweller in the underworld, an unsavory, untrustworthy character to be avoided at almost any cost.2

Heroin is chemically derived from morphine, which in turn comes from the opium poppy grown primarily in the Golden Crescent which creates a border between Afghanistan, Pakistan, and Iran, the Golden Triangle located in parts of Thailand, Laos, and Burma (now Myanmar), the Middle East, most notably Lebanon, and Latin American countries including Colombia and Mexico. Opium is the product of the poppy plant, Papaver somniferum, an annual plant growing three to four feet high, with a long-stemmed, large (four to five inches in diameter) flower that is usually either purple, red, pink, white, or scarlet, depending on the species. The plant grows in mountainous areas, although not at very high altitudes. Once the flower opens, the bulb is slashed or punctured with a three-pronged knife and the flowing juice, once dried by the wind, is collected. This dried substance is then boiled until it becomes a mass of raw opium called “black.” Black is then refined to a morphine base, which is later transformed into heroin. Each successive step re-

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quires more sophisticated laboratory techniques, although the first steps can be made directly in the fields where a good part of the opium is consumed, often eaten by natives in the areas where the plant is grown. The word “opium” is derived from the Greek word for juice and literary critics have suggested that the sailors who accompanied Ulysses in the Odyssey, whom Homer described in the ninth century B.C. as eating lotus, were actually consuming opium; and, the Country of the Lotophagi would, according to this version, be located in the Far East. “The first historical reference to opium is on a wall plaque from 2000 B.C. found in Kurgia, Turkey. The four edges of the plaque are decorated with opium poppy pods. The first written description of the use of opium is on a papyrus called the Ibis papyrus, dated between 1550 and 1600 B.C. The papyrus points out some of the salient therapeutic uses of opium, even in those days, for pain and for constipation.”3 Opium and the opium poppy had been known to the Chinese well before the year 1000 when it was primarily used by a select, elite group. Over the years, the Chinese developed the habit of smoking tobacco and eating opium. Eventually, these two pleasures became one (that is, in the form of smoking) and opium became the substance of choice.4 Arab merchants trading in the Silk Route knew it as “amdak” and they introduced it to the West as a medicinal plant in the seventh and eighth centuries A.D. The Chinese name for the substance was “Chandu,” or “Yen” (this is the origin of the English word “yearn”), and it became “Akbari” when introduced to India. Opium preparations were part of the armamentarium of every self-respecting Arab doctor in a period when Arab medicine was probably the best in the world. Opium over time has been used against malaria, colitis, and pain.5 By 1729, the use of opium in China was so prevalent that a law was introduced mandating that opium shop owners were to be strangled. Once opium for nonmedical purposes was outlawed, it was necessary for the drug to be smuggled in from India, where poppy plantations were abundant.6 The economic stakes were high for those involved; smugglers included British adventurers and members of the East India Company. It has been noted that “the British had very little success with introducing alcohol either in India or the Far East. A certain percentage of the Asian population have enzyme systems that cause them to have severe side effects from the ingestion of alcohol. Thus, until recently, alcohol was not popular in [that region of the world]. The British decided to go into the opium business, and they were joined by all the other Western powers. They grew opium in India and exported it to China.”7 When an effort was made in 1839 to suppress the smuggling of opium into China, relations among nations and peoples became strained, resulting in the Opium War of 1839, which lasted for about two years. “As victors, the British were given the island of Hong Kong, broad trading rights, and $6 million to reimburse the merchants whose opium had been destroyed.”8 Not until 1906, through the British Parliament, was legislative action taken to stem the opium trade, but by that time problem behavior related to opium addiction was no secret, especially among those who provided the substance. “There were at the end of the Second World War, hundreds of thousands of opiate dependent individuals in the

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People’s Republic of China. These by and large disappeared from view, at least until very recently, when there has been a resurgence in opiate use.”9 In 1806, a young German scientist by the name of Frederich Sertürner published a report on his isolation of the primary active ingredient in opium—an ingredient 10 times more potent than opium itself. Sertürner named it “morphium” after Morpheus, the god of dreams. Two major developments during the nineteenth century promoted the widespread use of morphine. First, in 1853 the hypodermic syringe was perfected by Dr. Alexander Wood, making it possible to introduce morphine directly into the bloodstream or body tissue rather than the slower process of eating opium or morphine and waiting for it to be absorbed through the gastrointestinal tract. The second factor was the use of morphine as a pain relief agent for casualties of the American Civil War (1861–1865), the Prussian-Austrian War (1866), and the Franco-Prussian War (1870). The percentage of returning veterans from those wars addicted to morphine was so large that the illness was later called “soldier’s disease,” or the “army disease.”10 In 1874, a chemical bonding process for morphine was discovered that produced heroin—a substance about three times as potent as morphine. Heroin was initially marketed by Bayer Laboratories of Germany in 1898 as a nonaddictive substitute for codeine, derived from opium. It took nearly a decade of research before it was found that heroin was the most addictive of the opiates, able to affect brain functioning faster than anything yet known. Despite a growing problem of opiate dependence arising from unrestrained distribution of opium derivatives within the medical system in the United States, it was the street use of the opiates and cocaine that generated public and professional interest in their habit-forming properties. After the U.S. Civil War, it appears that a host of conditions arose that were to lead to various city, state, and federal legislation attempts to control the spread of drug use. Among these factors were: increased Chinese immigration on the West Coast that was linked to smoking opium, the possession of opium pipes and the maintenance of opium dens; the addicted Civil War soldiers; and the widespread use of patent medicines for the relief of aches, pains, and anxiety which contained alcohol and/or opiates such as opium or morphine, and which could be purchased legally at a store or through mail order firms like Sears Roebuck.11 Although estimates varied, it was generally believed that the total number of addicts never exceeded a quarter of a million, divided evenly between medical and street dependence. Increased awareness, brought about by crusades waged among law enforcement officials against the street use of opiates and cocaine, aroused public anxiety about a narcotics problem of major proportions. The movement for national alcohol prohibition further sensitized the public to a need for national drug prohibitions. This movement culminated in the passage of the Harrison Narcotics Act of 1914 in the United States.12 This act outlawed non-medical use of opiates, and Supreme Court decisions during the next 7 years further narrowed even the medical uses of opium products. With the Harrison Act, people who had become dependent on opiates had to seek alternative sources for drugs con-

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taining opiates. This elimination of the medical supply of opiates and the criminalization of opiate use shifted narcotic addiction from the medical arena to the legal arena. At the same time, this law precipitated the need for treatments to assist those who were addicted to opiates but could no longer obtain them from their physicians.13

Following the Second World War, anti-opium laws in many parts of Asia suppressed the availability of opium at the cost of stimulating the creation of domestic heroin industries and substantial increases in heroin use. A similar situation occurred in the United States when Congress banned opium imports in 1909.14 It has been noted that at the turn of the century despite the virtual absence of any controls on availability, the proportion of Americans addicted to opiates was only two to three times greater than today. . . . The typical addict was not a young black ghetto resident but a middle-class white Southern woman or a West Coast Chinese immigrant. The violence, death, disease, and crime that we today associate with drug use barely existed, and many medical authorities regarded opiate addiction as far less destructive than alcoholism (some doctors even prescribed the former as treatment for the latter). Many opiate addicts, perhaps most, managed to lead relatively normal lives and kept their addictions secret even from close friends and relatives. That they were able to do so was largely a function of the legal status of their drug use.15

With a ban on opiates, new forces entered the market, namely, the illegal organizations interested in making a quick profit. Those organizations succeeded in popularizing the opiates in the United States and Europe much faster than the British had succeeded in China. Until the mid-1960s, laboratory facilities to transform morphine base into heroin were available only in Europe and the United States. This meant that most of the product had to be transported to be refined, and the refining process put a great deal of money into Western hands. In the mid-1960s two apparently unrelated episodes changed the situation. On one hand, under American pressure, the Turkish government agreed to close most of the illegal fields in that country, reserving a small portion of the product for legal medicinal purposes. On the other hand, Hong Kong–based drug entrepreneurs succeeded in establishing a series of laboratories in the field along the Mekong River. They started refining the product locally. [It is rumored that] those organizations foresaw the massive American intervention in the Vietnam War and readied themselves to profit from the American soldiers coming to the area. Others claim that the Vietcong foresaw American intervention and assisted the Chinese in establishing the laboratories, so that heroin could be easily available in order to support the war effort. . . . Also, it is claimed that the political changes undergone by Vietnam at the time were related, at least partially, to the war for the domination of the heroin market. . . . President Diem, his brother Nhu who ran the opium traffic at that time, and Madame Nhu were deposed and assassinated. They were succeeded in the government by General Ky who was also deeply involved in the opium trade business. . . . At that time, the Laotian and Burmese armies were involved; the United States Central Intelligence Agency [is alleged to have] organized the traffic through a number of small airlines such as Air Laos Commercial (also known as “Air Opium”); and Kuomintang soldiers (Chinese nationalists)

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escorted the caravans transporting the raw material to Saigon, Bangkok and other places. The alleged reason for the CIA supporting the traffic was related to the American need to provide economic support for allied countries to prevent them from turning communist.16

Up to the early part of this decade, evidence revealed no significant rise in opiate and heroin addiction despite the general impression to the contrary.17 For example, about 1 percent of all Americans have tried heroin at least once in their lives18 and among all episodes of illegal drug use only 1 percent involve heroin.19 Presently, however, surveys reveal that illegal drug use is on the rise, especially among young people. According to the European Monitoring Center on Drugs and Drug Addiction, the most alarming trend is heroin use. “It has long been the biggest source of Europe’s drug-related crime and medical problems, including AIDS and hepatitis from shared needles. Now its availability and popularity are growing.”20 In the early 1990s the European addict population, estimated at between 500,000 and a million, seemed to stabilize. Now, in most places, heroin has gotten cheaper, purer, and easier to find than before. For example, the price has dropped to a level that is cheap enough to allow smoking or snorting the substance instead of injecting it, which makes it attractive for those who want to experiment. One reason for this is geopolitics. Since the end of the cold war, drugs have been financing some of the religious and ethnic conflicts. It has long been reported that the warlords have become the drug lords . . . the collapse of the Soviet Empire opened up new supply routes and spawned smuggling rings from Burma to Estonia. The opening of borders in the European Union afforded unprecedented access to a vast untapped market. Aggressive criminal gangs in Africa and South America have been quick to seize the initiative, too. Capitalizing on skills in dealing marijuana or cocaine, they have expanded their product lines to include heroin . . . with a significant amount being South America heroin which was virtually unknown five years ago. In 1994 it accounted for 32 percent of the heroin seized in America; [in 1995] it was up to a “staggering 62 percent.”21 Back in the late 1980’s, the market-savvy Colombians spotted an interesting dichotomy. The profit margin on heroin . . . was more than triple the return on cocaine. . . . The high Andes proved perfectly hospitable to opium poppies. . . . [W]ithin a couple of years they were flooding the market with [clean and cheap] heroin. The Colombian product turned out to be an astonishing 95 percent pure . . . so powerful you could sprinkle it on cigarette tobacco, and a few tokes later . . . not a care in the world. Since there were no ugly needles involved, kids got the impression it wasn’t dangerous. . . . The number of heroin-related emergency episodes doubled from 1990 to 1995.22 This new-style heroin abuser can become an addict as readily as someone using a needle. But smoking or sniffing is less likely to be instantly fatal: usually a user will nod out before absorbing lethal quantities of heroin. [An official of the New York office of the Drug Enforcement Administration—DEA] says that many cocaine and crack addicts have taken to using heroin as well. Heroin’s mellow euphoria is a counterpoint to what he calls the “hyperkinetic effects” of cocaine and crack. . . . According to the National Institute of Drug Abuse, the number of intravenous heroin users remained constant from 1982 [to 1991]: 492,000 addicts nationwide, with half of them located in New York. The numbers of her-

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oin-related cases in U.S. hospital emergency rooms—one of the standard barometers of the drug’s inroads—also changed little from 1988 to 1991. [Yet, it was predicted then by U.S. drug experts and law enforcement officials that there were ominous signs of a heroin comeback with improved purity at much lower cost.]23

TRENDS Have the predictions of increased heroin use and the problems associated with its abuse proven correct? For the most part, the answer is yes, based on epidemiological trends reported by the U.S. National Institute on Drug Abuse. The following are highlights drawn from government reports. In the Community Epidemiology Work Group (CEWG) areas included in Drug Abuse Warning Network (DAWN), heroin/morphine hospital emergency department (ED) mentions were stable in 10 CEWG areas, mixed in 8 and increased in 3. Indicators suggest that injection of heroin is on the rise. Heroin indicators are increasing among youth in many CEWG areas and there is a growing concern that, as they become more experienced with the drug, youth are turning to injecting for more efficient infusion of heroin. It has been reported that from 1998 heroin [is] starting to spread beyond the cities into the surrounding area with some dealers setting up shop in apartments in the suburbs and smaller towns . . . the use of heroin is going up said Alan Leshner, director of the National Institute on Drug Abuse. . . . Two trends in the heroin trade that have officials especially concerned are the increase in the purity of the drug and the substantial decline in the street price. With the increase in purity and the decrease in cost, new populations have been recruited. . . . [T]he number of hard-core heroin addicts in the U.S. rose by 25 percent in the past five years.24 About 2.4 million (1.1 percent) of the 218 million persons represented in the 1998 National Household Survey on Drug Abuse (NHSDA) reported heroin use (i.e., smoking, snorting or sniffing, or injecting) in their lifetime. A total of 253,000 persons (0.1 percent) reported use in the past year and 130,000 (0.1 percent) reported use in the past month. Between 1997 and 1998, no statistically significant differences were found for any age group for lifelong and past month heroin use. However, past year use among the total population did decrease from 0.3 percent in 1997 to 0.1 percent in 1998. . . . In the total population, males were more likely than females and blacks were more likely than whites and Hispanics to report lifetime use of heroin. Lifetime use also was higher among unemployed persons than those employed. . . . Those aged 12 to 25 were more likely to report past year heroin use than were those 26 or older.25 There were an estimated 81,000 new heroin users in 1997, not statistically different than the 149,000 new users in 1996. . . . [T]here was a statistically significant upward trend in the number of new heroin users from 1992 to 1996, a finding that is consistent with anecdotal reports of increasing numbers of new heroin users. The recent increases in new heroin use are comparable to the increases seen in the epidemic of the late 1960s and early 1970s. . . . Among recent initiates found in the 1997 and 1998, 87 percent were under age 26; and, 72 percent had never injected heroin. A similar analysis of new heroin users in the 1991 and 1992 showed that only 61 percent were younger than age 26 and only 46 percent

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had never injected.26 Heroin/morphine was the top-ranking drug among drug-related deaths reported to [the] Drug Abuse Warning Network (DAWN) in 14 metropolitan areas . . . in 1997. . . . Heroin/morphine was the most commonly mentioned drug among Hispanic (52 percent of episodes) and white (44 percent) decedents and the second most commonly mentioned drug among all drug decedents (43 percent) in 1997. . . . [It] was the most commonly mentioned drug among male decedents (48 percent of episodes) and ranked second among female decedents (32 percent) in 1997 . . . and was involved in at least 41 percent of deaths among decedents age 18 to 54, 29 percent of deaths among those age 55 and over, and 25 percent of deaths among age 6 to 17.27 Use Patterns: Approximately 1.3 percent of the respondents in the 1998 National Household Survey on Drug Abuse reported drug use (e.g., heroin) with needles in their lifetime. . . . Persons aged 18 or older were two to four times more likely than youths aged 12 to 17 to have used an illicit drug with a needle. Youths aged 12 to 17 were less likely than any other age group to have injected drugs, but there were no significant differences among the adult age groups. . . . Some gender differences were found in lifetime injection drug use. In the total population and among 18 to 25 year olds and those 35 or older, needle use was significantly more common among males than females. Among 12 to 17 year olds and 26 to 34 year olds, there were no gender differences in the rates of needle use. Lifetime needle use was not related to race/ethnicity, population density, region or education for the total population or any age group. Few differences in needle use by current employment were found: For the total population, needle use was higher among full-time than part-time workers and higher among the unemployed than part-time workers.28 [Throughout the United States the following “route of administration” has been reported:] Boston: Due to high purity, snorting is the common starting route of administration for new and younger users, but progression to injection is widely reported due to the increased effect from a given amount of heroin. . . . Chicago: Brown and black tar heroin are typically sought only by those who inject, although reports indicate that some users dissolve black tar heroin and drip the solution into their nostrils. . . . Texas: Heroin is still primarily injected, but there are reports of younger adults burning it in aluminum foil and inhaling the fumes “chasin the dragon,” or they are snorting the powder form. These alternative methods of using heroin are seen in the sex industry business and topless bars. . . . “Monkey water” and “shebanging” describe heroin nose drops. The drug is dissolved in water and then either sprayed up the nose using a squeeze bottle or squirted up the nose using a syringe. . . . Injecting remains the most common route of administration among heroin [addicts] in the majority of cities. . . . [However], intranasal use remains the majority choice in Chicago, Detroit, Newark, and New York. . . . Smoking [heroin] remains relatively rare, accounting for 1–3 percent of heroin admissions in most eastern and central sections of the country. . . . Route of administration often varies demographically. In New York, for example, intranasal users, compared with injectors, are more likely to be younger than 36 and Hispanic; by contrast, injectors are more likely to be white and to have started use before age 20. In Newark, females are more likely than males to use intranasally; among males, African-Americans [are more likely to use heroin intranasally] than Hispanics and whites.29 Multisubstance Use and Shifting Use Patterns: [In cities throughout the United States many heroin users use other drugs primarily alcohol and cocaine but also others including morphine, marijuana, benzodiazepines, sertraline (Zoloft)—a relatively new antidepressant that may be replacing benzodiazepines to moderate the effects of coming down from a heroin high and others.] Recent field reports especially from the South Side (Chicago) indicate an increased use of heroin/cocaine combinations “speedballs” and of taking clonidine (Catapres) or amitriptyline (elavil) immediately after injecting heroin (or methadone) to increase the “dope” effect. . . . In Denver, “chocolate rock” [is being used which is a] mixture

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Drug Use, Policy, and Management of crack and heroin that can be smoked. Street sources indicate that more users are mixing heroin and cocaine and smoking it. . . . Multisubstance use patterns are related to route of administration—for example in Baltimore, intanasal users are less likely to report use of other drugs than are heroin injectors. . . . [I]n New York, primary heroin injectors are more likely than intranasal users to report cocaine as a secondary drug of abuse. Demographics: (Age) Indicators suggest that heroin abuse is increasing among youth in the Community Epidemiology Work Group (CEWG) areas. There is growing concern that injection of heroin also may be increasing among youth as they become more experienced and knowledgeable and look for a more efficient infusion of the drug.30 A review for heroin ED [hospital emergency department mentions] from 1993 through 1997 shows generally steady declines in the 26–34 age group—possibly a cohort effect as that group has been transitioning into the next age bracket. The 35+ age group accounts for the highest percentages of admissions for primary heroin abuse [throughout the United States]. The 26–34 [age] group, however, is fairly well represented. . . . [In many areas there is evidence of increased heroin use among younger adults].31 (Gender) Males predominate in heroin mortality figures . . . [M]ales also outnumber females as a percentage of heroin emergency department mentions. . . . [A]mong primary heroin treatment admissions, males account for the majority [of clients]. Regarding female arrestees, opiate-positive rates have increased in the majority of CEWG reporting areas. . . . The highest percentages of adult female arrestees testing opiate-positive in 1999 were reported in Chicago (32.4 percent); New York City (21.1 percent); Seattle (20.3 percent); Detroit (16.4 percent); Philadelphia (14.2 percent); Phoenix (11.6 percent); and San Diego (10.9 percent). Female arrestees, as in prior years, continued to be more likely than males to test opiate positive.32 (Race/Ethnicity) Decedents were predominately white in most areas reporting heroin mortality. . . . Emergency department admissions show mixed racial demographics . . . and among heroin treatment admissions the results are mixed depending on the racial composition of the city (e.g., in New York, Hispanics are the largest group; in Los Angeles, the largest groups are whites and Hispanics; in Miami the largest group is whites; and in Detroit, blacks are the largest group of heroin addicts seeking treatment). Law Enforcement Data: (Availability) Four types of heroin are available in the United States. High quality heroin from Colombia, South America dominates the east coast market and has spread to cities in the central U.S. region. Lower quality Mexican black tar and brown heroin predominates in the U.S. West and Southwest but is available in the Midwest and has recently been increasing in purity. Southeast Asian (SEA) and Southwest Asian (SWA) heroin availability has been declining in recent years but is still reported in numerous cities.33 (Price and Purity) Boston—Heroin remains very cheap, pure, and available. A bag of heroin ranges in cost from $6 to $20; Detroit—According to the DEA, the price of heroin per pure milligram was $0.62 in 1999—a decrease of nearly 50 percent from 1998. Purity increased in 1999; Honolulu—Black tar heroin is readily available in all areas of the State; Miami—A “glut” of very pure South American heroin has resulted in a 50 percent reduction in the wholesale price; Minneapolis-St. Paul—Heroin is increasingly available at extremely high purity levels and at a low cost; San Diego—Data from the DEA’s Domestic Monitor Program show that San Diego [is one of the areas] with the lowest price for heroin and among the areas with the highest heroin purity level.34 Trafficking and Distribution: New York remains the main heroin distribution center in the Northeast. Its [South American] heroin is distributed via established cocaine trafficking routes. . . . New York dealers have stopped using brand names and are now packaging their heroin in unlabeled plastic bags in order to avoid police detection. . . . [There] informants report that dealers use young teens to transport their supply of heroin between sites. One street source says dealers believe that the police would not expect adolescents to walk

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around with so much heroin in their possession. . . . [In Philadelphia], dealers use brand names to maintain buyer affiliation, to indicate their willingness to maintain potency. . . . Among the 26 brand names on retail level heroin packaging [in 1998,] 22 were also mentioned [in 1999]. In Houston, a survey of addicts in and out of treatment found that many brands of heroin are available, including “DOA,” “bloody mary,” “China white,” “blue heroin,” and “redrum,” which is “murder reversed.” Ethnographic data from Washington, D.C. continue to show that . . . the ready availability of demand for heroin has lead to fierce competition among street dealers who have created a host of brand names to label their packages (e.g., “Jerry Springer,” “money talk,” “puf mama,” “puff daddy,” “heart beat,” “life,” “lynch mob,” . . . In Boston, most of the heroin is transported from New York, trafficking is dominated by Dominican nationals. . . . The Dominican lock on Boston trafficking, and the advent of cellular phone and beeper technology, are credited by police with helping to decrease drug-related crime. Turf wars are infrequent, and buys arranged by beeper are usually consummated off the street, sometimes in stores, malls, and supermarkets, as well as in cars and private homes.35

INTERNATIONAL PERSPECTIVES Worldwide, it is estimated that some 8 million people (0.14 percent annual prevalence) abuse opiates, mostly in South East and South West Asia. “In general, consumption affects less than 2 percent of the population in these regions; however, use can be more widespread in some of the opium cultivating areas. . . . Compared to a decade ago, heroin consumption is now far more widespread. The most dynamic growth in the 1990’s was in the Americas. While consumption in most western European countries stabilized over the 1995–1997 period (with a few exceptions), strong increases were reported from most of the countries in eastern Europe. Increases in abuse also were reported from the main immediate ‘transit countries’ of the opiates originating in Afghanistan, then Iran, Turkey, and even a number of countries in Central Asia. An even stronger growth in heroin addiction over the last decade occurred in Pakistan.”36 The following information is based on reports received through personal e-mail communication with a senior military official responsible for the U.N. Anti-Drug Project “Osh knot” in Osh, Kyrgyzstan during 1999. This edited description provides a unique inside perspective of the opium and heroin situation in Afghanistan and “transit countries” in Central Asia. Afghanistan and Beyond: The World Leader in Opium and Heroin Production Afghanistan, [is] a traditional opium producer and considered [to be] one of the main routes of the world’s narco-smuggling. The flow of drugs [has over time] gone through Iran to Turkey and then to Europe. In the middle of the 1980’s, Iran proclaimed a [“jihad” or holy war] against drugs. The country’s legislation was harden[ed], “Islamic anti-drug troops” were formed, and a huge stone wall was built along the state borders. [Nevertheless, criminal interests] invested big money into narco-business and the [loss] of profits was totally unacceptable. According to the Drug Enforcement Administration of United States every dollar, invested into narco-business, will gain $12,240. . . . [Illegal drug investors] looked for new roads to Europe for Afghan drugs. It was a time when the USSR collapsed and all the borders became “open.” The abrupt [breakdown] of the national economy, ethnic clashes and a

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lot of other political and social problems supported the explosive aggravation of narco-traffic through the Central Asian CIS countries. . . . Tadjikistan has 1200km of common border with Afghanistan, 800km of these in the Gorno-Badakhshan Region. That is why this republic was first and very actively involved in narco-traffic. The Gorno-Badakhshan Region became the main “narco-beachhead.” The Tadjik-Afghan border in 1991–93 became the line of narco-barter, one kilo of raw opium from there could be easily exchanged for one pair of soldier’s boots “made in USSR,” a pea-jacket or big iron pot. . . . From the Gorno-Badakhshan Region, via the mountain road to Khorog (a small city center of the Gorno-Badakhshan Region of Tadjikistan) to Osh (a regional center of southern Kyrgyzstan), drugs “made in Afghanistan” were smuggled to the Kyrghyz Republic, then to Uzbekistan, Kazakhstan, Russia, Baltic countries, and Europe. Drugs, through the “Osh corridor,” could be seized in Germany, Greece, Poland, and the Netherlands. In 1995, Osh was already well-known as a regional center of narco-transit. According to experts, the estimated [weekly amount of raw opium] was up to 100kg. The top [level] of narco-traffic via the “over-clouded route” of Osh-Khorog was reached in 1996. In that year, 726 kg of opium were [seized]. . . . The narco-situation in the region [rapidly deteriorated]. The [excessive] flow of drugs caused an increase of weapons; [counterfeit] dollars being used as a payment for drugs [and corruption throughout the region]. . . . Local government armed forces and domestic law enforcement agencies were unable to keep the situation under control. That is why the efforts of international agencies were involved, for example, International Anti-Drug UN Project “Osh knot,” aimed to strengthen the anti-drug law enforcement capacities of Uzbekistan, Kyrghyzstan and Tadjikistan. In order to close the “over-clouded route,” the police and customs operative units were supported by government military troops, special task forces and border troops. The tactics of narco-dealers immediately demonstrated their flexibility—numerous small side-roads along the whole distance of Kyrghyz-Tadjik “green” border became the new entrance gates for drugs, more than 800 km, guarded by no one. Heroin began to displace opium smuggling more and more. Uzbekistan and Turkmenistan fell down in the process of [being very active against] the narco-smuggling; [especially trying to guard] hundreds of kilometers of joint borders with Afghanistan. The [marketing] of heroin is expanding. Laboratories, producing “white death,” were moved from Iran and Pakistan borders to the borders with Tadjikistan and [toward] the Kyrghyz state borders according to some operatives. Opium production in Afghanistan was nearly 3,000 tons [in 1997]; sufficient to produce almost 300 tons of heroin. These figures [have been mentioned] by UN officials based on a report issued by the International Narcotics Control Board titled Taliban. [D]rugs are used as a monetary equivalent to pay for weapons and food. Talib’s emissaries reached the small Afghan Pamir—arduous mountain area, inhabited by 3,000 ethnic Kyrghyz who have been wandering there with cattle for years. They are forced to take heroin and opium for sale [in order to protect their] livestock. If you want to survive, sell drugs and [protect] your cattle. Meanwhile, Afghan narco-traffic [has been] seeking new ways into China. The present situation around the China-Afghanistan-Tadjikistan borders today is quite similar to “the wild barter” on Tadjik-Afghan border in Gorno-Badakhshan during 1991–1993. Last summer, Chinese frontier-guards arrested 10 smugglers-citizens from Tadjikistan and Kyrghyzstan and confiscated nearly 50kg of opium. [A considerable amount] of anxiety among Chinese authorities is caused not by drugs only, but also by the religious factor—the danger of “Mojaheddins” supplying weapons and instructors to [people] of the “explosive” Scin-Czyan-Uyghur Region of China. . . . [A]ccording to specialists, the international narco-mafia will get access to the

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[whole drug transport] territory of the China Kara-Korum Highway and its sea-ports on the Pacific Ocean; the way to Europe will become much easier and cheaper for Afghan drugs. There will be [considerable negative] consequences for Japan and United States. The region is suffering from a “drug fever.” [T]raditional hashish and marijuana addiction among a [growing] population of local abusers is rapidly being displaced by much more . . . dangerous heroin use. . . . The problem of drug-abuse, which always was a specific attribute of big cities, has now became a rural evil. The percentage of women involved with the narco-business is rapidly increasing: one of every three arrested narco-couriers is a woman. One of every 8–9 criminal cases, registered in Kyrghyzstan, is linked to drugs. During the civil war [in the region], opium in Tadjikistan became a kind of power measure for different armed groups. For example, in 1997, as a result of [a large-scale military operation] carried out by government forces . . . a huge amount of opium was revealed in the area. . . . The following figures illustrate [conditions] involving Russian border troops in Tadjikistan in 1998: 135 attempts of narco-smugglers to cross the state border were cut off; during 40 armed clashes 35 narco-couriers were killed, 7-wounded; and, even commanders of Russian frontier outposts and fortified zones were sentenced to death by narco-barons. Taking into consideration the tragic situation in the region, the decision was made to extend the UN Anti-Drug presence and to assign $8 million for the special Anti-Drug Program “The Security Belt around Afghanistan.” The Afghan [drug situation] has had a negative influence on narco-situation in Uzbekistan. Producing more than three thousand metric tons of raw opium annually, Afghanistan uses this country to smuggle drugs over its border road-transport, rail and water-ways. Last year, six armed and very well equipped organized groups of narco-smugglers were neutralized in Uzbekistan. The greatest [troubles] for Uzbek drug control authorities] is caused by Afghan heroin labs. In 1995–1998, Uzbek customs service [personnel] cut off attempts to smuggle 72 tons of [opium]. The number of drug-abusers in the country is rapidly increasing. Drug-addiction used to be a specific problem of town-dwellers, it is [now common in the rural areas with a serious effect on agriculture]. The real “opium war,” [that] started on the Afghan-Turkmen border [has caused a considerable amount of death and havoc]. “The train of death”—18 wagons loaded with mines, grenades and jet propulsion missiles were stopped in Osh as a result of joint national security and customs service operation. As a commentary to this information, the President of Kyrghyzstan Ascar Akaev in his December (1998) interview to “Komsomolskaya Pravda” alluded to [narco-mafia involvement]. The probable aim was to hasten the withdrawal of Russian border troops from the Afghan frontiers [resulting in greater freedom] for narco-smuggling to Europe. Narco-business “is a real force,” said Mr. President. He also stressed “the increasing flow of drugs from Afghanistan into his country and the huge amount of money involved. Answering a question, if narco-mafia has the influence and power to nominate presidents and dismiss governments, Ascar Akaev said: “We are the transit country for narco-couriers, and the situation is not that ‘deep’ to place or replace ‘a suitable government.’ Nevertheless, if we shall not critically combat the narco-business, the end, you spoke about, could become real.” . . . “For me combating drugs is the highest priority,” said the President. Meanwhile, new narco-routes are cutting through the region. A big load of drugs—750kg was seized in Termes a few days ago. Confiscated [were] heroin, opium, hashish. [T]hese drugs were seized on the way from Tadjikistan and were intended, obviously, for Russia. Narco-mafioso did not want to take a risk using the traditional Pamir route—too costly and too risky. . . . The Afghan-Turkmen border has become more and more attractive for narco-smugglers. A lot of Tadjik-Afghan caravans move through there. Through the desert

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they transport opium and heroin to the Caspian Sea-banks, then, by sea, to Iran or Azerbaijan, and, again through Iran—to Europe or Russian sea-ports—Makhachkala, Dherbent, and Astrakhan. The biggest load of heroin in the Russian history, confiscated by Astrakhan Customs Inspection in January (1998) was 220kg; the seizure came as a result of criminal investigation. The lasting civil war in Afghanistan is a great stimulus for narco-production. All fighting sides are involved. The biggest “dream mill” in the world, for example, equipped by the American narco-mafia, is the property of Mr. Khekmatiar—Leader of the Islamic Party of Afghanistan. According to the specialists, the annual income of Afghan-Pakistan narco-barons is estimated to be $10 billion. . . . More over, according to security services information, the area of poppy fields will be extended [threefold] in 1999, the value of the heroin production will reach 700 metric tons. . . . The internal armed conflict in Afghanistan is lasting. And, it is [wrong] to call this conflict “internal.” The whole world is involved. . . . In his report to the UN Security Council (January, 1998) the Special UN Resident-Representative in Afghanistan said that the presence and the activity of international humanitarian aid agencies cannot be restored in the country in the near future because of insufficient security. The military presence of Pakistani armed groups in the country, international terrorists, as well as Osama bin Laden, also aggravate the situation. The Special UN Representative marked the unwillingness of Talibs to cooperate. He expressed his disappointment with results from the efforts of the “six + two” group activity—(countries neighboring with Afghanistan + USA and Russia). This failure has ruined the hopes of the world community [for resolving the drug problem].

The following is a brief review of the heroin situation in a number of countries throughout the world.37 Australia: The Australian Bureau of Criminal Intelligence reports that 80 percent of the heroin in Australia is imported from the Golden Triangle. According to Australian Customs, the number of heroin seizures has decreased but the quantity of each seizure has increased. . . . The Queensland Police Service reports no significant changes in price, purity, and availability of heroin: one cap (0.1–0.3 gram) sells for $50; one-forth gram sells for $120; one-half gram sells for $250; and 1 “street” gram sells for $400–500. Purity ranges from between 56–86 percent. . . . Heroin is being used as a “party drug” by young people who are breaking with the traditional usage stereotypes. . . . Heroin continues to be a drug of high availability. Over the last few years, “street prices,” have fallen and the increase in purity since 1995–96 has been maintained. . . . Heroin deaths continue to increase at an alarming rate in Australia. . . . Drug agencies and treatment services clearly suggest [there is] an increase in the number of people seeking treatment and support for their problematic heroin use. . . . [Also there is evidence that] the average age of first time users is steadily declining to 14.7 years. . . . [T]here is a growing trend for heroin to be the first drug injected. . . . There are reports that highly dependent cannabis users are shifting directly to heroin injection (pp. 29–31). Canada: Overall the national rate of heroin use appears to be relatively low, the use of heroin represents a major health and social problem in several sites such as Toronto and Montreal, and it is reaching crisis proportions in Vancouver. In Montreal, heroin can be purchased for as little as $10 for a “quarter of a point,” the smallest quantity available on the street. . . . The proportion of treatment clients whose primary drug problem concerns heroin use varies . . . from 2 percent or less in most sites to approximately 10 percent in Vancouver. . . . By far, the highest number of heroin/opiate related deaths . . . occurs in

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Vancouver. . . . In addition to other serious social and health consequences, heroin users are particularly vulnerable to HIV and hepatitis infection (pp. 41–42). Europe: Although the prevalence of heroin use in the EU population is low, it is clearly the main illicit drug associated with serious health and social problems such as mortality, morbidity, and drug-related crime across most of the EU. The exception is some Scandinavian countries where amphetamines are important. The level of heavy opiate use or dependence (mainly heroin) appears to be relatively stable across the EU. The average age of known users (30 years, range = 24 to 33) continues to slowly increase; this may reflect partly the expansion of substitution treatment. The total number of “problematic opiate users” is estimated to be as high as 1.5 million people (4 per 1,000 population) in the EU; of these, about 1 million (2.7 per 1,000 population) probably meet the criteria for dependence. The number of people in the EU receiving substitution treatment, mainly methadone, is now estimated to be around 300,000; this suggests that up to 30 percent of the opiate-dependent population is currently reached by methadone treatment (p. 53). Mexico: Of the nearly 11,000 patients in government treatment centers during 1998, only 0.2 percent reported that heroin was their drug of onset; however, as the primary drug of abuse, heroin ranked fifth. . . . According to data gathered from non-government treatment centers in 1998, heroin was used mostly by males and the age of onset for heroin use was between 15 and 19. . . . Since 1994, reports of heroin as a drug of onset have been increasing (p. 61). South Africa: The average age of heroin users in treatment appears to be declining in certain sites throughout the country. . . . The proportion of females using heroin is greater than for many other drugs. . . . The average age of persons in treatment was 23–24. Heroin is mostly smoked . . . heroin purity is reportedly high and the drug is apparently being cut in South Africa before being exported to other countries. . . . The price of heroin is low in South Africa in comparison to other countries ($20–$58) per gram (p. 81).

THE HEROIN ADDICT: PERSONALITY CHARACTERISTICS There are many theories about why people use and abuse heroin and other harmful substances including those discussed in Chapter 2. In terms of inadequate personality, heroin addicts have been found to lack responsibility, independence, and the ability to defer gratification in order to achieve long-range goals.38 They are unable to face realities of life, to confront their problems, or meet the demands of society,39 and have difficulty controlling emotions such as rage, shame, jealousy, and anxiety.40 They tend to have low self-esteem,41 with feelings of “peer rejection, parental neglect, unrealistic expectations for achievement, school failure, physical stigmatism (e.g., devalued group memberships), impaired sex role identity, ego deficiencies, low coping abilities, and (generally) coping mechanisms that are socially devalued and/or are otherwise self-defeating.”42 Research on deviance and problem behavior has found that those who use and abuse drugs such as heroin tend to be more rebellious and are willing to take a wide range of risks that often involve socially unacceptable behavior transgressing moral and cultural norms.43 Such persons are receptive to uncertainty and are inclined to be pleasure-seeking and hedonistic, peer-oriented, and nonconformist, as well as unconventional.44 Other personality characteristics of users show that they

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tend to be less religious, less attached to parents and family, less achievement-oriented, and less cautious. This personality manifests itself in a wide range of problem behavior for the individual and society.45 Heroin users and addicts are closely associated with a life of crime46—especially that which is money making. Inciardi47 described the level of heroin-related crime as “astronomical.” Discounting drug offenses, there were more than 230 criminal offenses per year per user—from procuring and prostitution to armed robbery and assault. These drug users are more involved with crime than others who use illegal substances. What emerges from research is that the use of or addiction to narcotic drugs seems to intensify a tendency to be involved in criminal activity48 and consequently to increase an addict’s relation to the criminal justice system. Prison for such offenders is generally considered to be the option of last choice. It represents the inability or unwillingness of the family, service agencies, and/or the justice system (e.g., police and courts) to continue the support of the heroin addict in the community because of severe functional limitations and behavioral problems. Generally speaking, heroin addicts have many characteristics in common. Using a status model perspective, however, the question arises whether certain psychological factors differ based on the nature of treatment services received (e.g., heroin addicts imprisoned because of drug offenses and those self-referred to a community outpatient treatment program). The following factors were used to determine the differences: (1) attitude toward drug taking; (2) interpersonal relationships including those with parents, siblings, and peers; (3) self-concept in terms of the addict’s perception about his own abilities, success or failure in life, and happiness or unhappiness; (4) personal values on perspectives of human nature, the world, honesty, and dedication to society; (5) risk-taking tendency; (6) motivation; (7) rebelliousness against rules and regulations, social institutions, and authorities; and (8) pleasure-seeking. Findings show only two psychological characteristics significantly different among the prison and community-based addicts: attitudes toward using drugs and attitudes toward pleasure. For both characteristics, community-based heroin addicts reported a greater inclination toward illegal drug use and self-gratification. Additional results regarding the psychological factors of heroin addicts show that liberal attitudes toward illegal drug use were more common among those who had a lower self-concept, were more likely to take risks, were more rebellious, and were more pleasure seeking. Those with positive interpersonal relations were likely to have a positive self-concept, be less likely to be risk takers, and be more motivated. Positive self-concept was related to positive personal values and motivation. Positive personal values were linked to motivation and a lesser degree of rebelliousness. Risk-taking was found to be associated with those who were more rebellious and pleasure seeking. Those with a greater degree of motivation were less rebellious. Rebelliousness was linked to pleasure seeking.49 The status model of drug use among heroin addicts shows that the psychological characteristics of prisoners are no more (and in some cases even more positive) than those in a community-based treatment program. This finding is somewhat

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surprising considering the negative status associated with those assigned to prison, a placement of last resort, but understandable considering the controlling effect prison may have on the attitudes and behavior of addicts. Imprisoned addicts, more than those in a community-based treatment program, tend to attitudinally reject illegal drug use and pleasure-seeking experiences (e.g., altered state of consciousness).50 Female Heroin Addicts Considerable progress has been made toward understanding problems associated with heroin addiction. It is only recently, however, that research related to women has been recognized as being sorely neglected.51 From what limited research is available, particularly from the United States, it has been found that the number of female heroin addicts tended to be relatively stable during the past few years. For example, the Substance Abuse and Mental Health Services Administration’s National Household Survey on Drug Abuse reported in 1992 that among those 12 years of age or older, 0.6 percent (644,000) of women compared to 1.2 percent (1.2 million) of men ever used heroin.52 When asked about drug use during the past year (1991), statistics reveal 0.1 percent (88,000) of the female and 0.2 percent of the male (236,000) respondents used heroin. The 1997 survey of the Drug Abuse Warning Network (DAWN), a nationally representative probability sample of hospitals located throughout the United States, shows that 0.6 percent of females compared to 1.3 percent of males ever used heroin, and 0.2 percent of females compared to 0.4 percent males used heroin during the year prior to the survey. DAWN data for 1998 show that women account for 20 percent of all heroin/morphine mentions and about 26 percent of drug abuse deaths.53 From other nationally based research in the United States, it has been found that 6 percent of women ages 15 to 54 meet the criteria for lifelong drug dependence. Of women who had ever used illicit drugs, 13 percent meet the criteria for dependence, and of those who had used heroin, 25 percent meet the criteria for heroin dependence.54 Studies of chemical dependency show that women begin abusing substances later than males; are more likely than men to have a coexisting psychiatric problem, especially depression; report a greater history of suicide attempts; and are more likely to be victims of violence during pregnancy.55 A particularly stressful event is often cited by women as a reason for beginning substance use—for example, many report being victims of childhood physical and sexual abuse or having a history of sexual assault.56 They tend to have low self-esteem and lack assertiveness skills, making it difficult for them to manage the complex treatment and assistance network.57 Socioeconomic factors are viewed as related both directly or indirectly to substance abuse by women. In a study of Caucasian and African American women receiving treatment for heroin addiction, most of the clients lacked education and job experience.58 Additional studies of female addicts show that they are less likely than men to seek treatment for drug abuse; child care responsibilities often interfere with female addicts’ ability to attend treatment programs.59 Women who are addicted and in need of treatment tend

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to reflect problems related to codependency, incest, physical and sexual abuse, victimization, sexuality, and relations with significant others.60 It has been reported that AIDS is a leading cause of death for American women between the ages of 25 and 44. Women who inject drugs, such as heroin, and/or who have been the sexual partners of past and present injection users are at the greatest risk for HIV infection.61 Additionally, tuberculosis (TB), once considered eradicated, has surfaced as a health hazard, especially among those who have spent time in overcrowded prisons and mental institutions. It has been found that foreign-born women account for nearly one-third of the reported TB cases in the United States. Women with HIV infection and homeless women are at high risk for contracting TB. Also, female injection drug users have higher rates of TB whether they are HIV-positive or not.62 In terms of female immigrants and their drug use, little research exists.63 Generally, however, it is known that in addition to the psychosocial problems they have as addicts, immigrants experience a variety of emotional and cognitive adjustments as well as conflicts related to the realities of life in their new country. These stress factors place them at high risk for continuing their troubled life characterized by risk-taking behavior including initiation, maintenance, and relapse into illegal drug use.64 CROSS-CULTURAL PERSPECTIVES OF HEROIN ADDICTS: THE RUSSIAN CRISIS From a cross-cultural perspective, a question that arises is to what extent addicts from different countries have common background characteristics and attitudes toward the use and abuse of heroin. To answer such a question, an adequate study cohort must be organized and economic, political, cultural, and other relevant factors, need to be taken into account. While drug use has seldom been systematically studied in a cross-national or cross-cultural manner, it should be recognized that considerable exploratory work is needed and there can be no guarantee that the most rigorous research will provide definitive results. With this in mind, research was conducted to compare native-born and Russian-speaking immigrant heroin addicts in Israel. Native-Born and Russian-Speaking Immigrant Heroin Addicts in Israel At the end of the 1980s, the tightly controlled emigration policies of the former Soviet Union were liberalized, providing massive numbers of people with the opportunity to leave that part of the world. This situation allowed millions of people, most notably those who were Jewish, claimed to be Jewish, or related to a Jewish person, to relocate principally to Israel, the United States, and Germany. In the case of Israel, a country that imposes an ethno-religious test of fitness for naturalization, only Jewish people are acceptable for automatic naturalization under Israel’s law of return.65

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65

The extent of immigration to that country was so overwhelming that government authorities could barely manage the detailed inspection of those who met acceptance criteria based on religious grounds, let alone examine the mental and physical health, criminal experience or addiction to illegal substances of the immigrants. During the one-year period of 1990–1991, the number of persons who immigrated to Israel was approximately 370,000, reaching nearly the number of Russian-speaking immigrants who had settled in the country over the entire previous 40 years.66 Since the initial influx of immigrants from the former Soviet republics in 1989, the population of Israel has increased by more than 850,000, which represents nearly 13 percent of the current residents of the country. The illegal drug scene in Israel, prior to the immigration that began in 1989, was made up of about 95 percent Jewish people of Mediterranean and Middle Eastern decent primarily from Morocco and Tunisia who prefer smoking heroin. Among these addicts, most are between the ages of 18 and 30, poorly educated, and of low socioeconomic status.67 Female addicts accounted for about 18 percent of the country’s addicts. Soon after 1990, the profile of the nation’s heroin addict population changed, and the reason is attributed to immigrants, primarily intravenous users, from the former Soviet republics. Presently, it is estimated that 25 percent of the country’s 25,000 addicts68 came to the country after 1989 from Russia, the Ukraine, Georgia, Azerbaijan, and the Caucasus region near the Caspian Sea including numerous small republics. Among the Russian-speaking addicts, about 20 percent are female. The Israel Ministry of Health and the Ministry of Labor and Social Affairs, both with responsibilities for addressing the drug problem, have expressed concern about Russian-speaking addicts; however, little documentation exists about their psychosocial profile, patterns of substance use, and how they compare with native-born addicts. To better understand the needs of Russian-speaking heroin addicts in the country, a study was conducted using a data collection instrument adapted from research of illegal and legal drug use in Israel and elsewhere.69 The instrument consists of 68 items including: (1) predisposition (e.g., sociodemographic status including gender, marital status, place of birth, year of immigration to Israel, education, and the impact of immigration on family relations); (2) prison and psychiatric institution experience; (3) physical and sexual abuse as a child and while in an institutional setting such as prison; (4) licit and illicit drug use/abuse including age of first use, the type and amount used, the use of substances by parents and other family members, patterns of abuse prior to immigration, and substance use while receiving treatment; and (5) self-image. Males Background Characteristics Among the entire group of male heroin addicts interviewed, 55 percent (114) were immigrants mostly from Russia and the Ukraine and 45 percent (93) were born in Israel (see Table 3.1). In terms of marital status, 43 percent (86) were single, 6 percent (12) married without children, 29 percent (56) married with children,

Table 3.1 Immigrant and Native-Born Male Heroin Addicts: Background Characteristics Variable

Immigrant (N=114)

Native Born (N=93)

Total (N=207)

X2

n.s.

% (N) Background Characteristics Marital Status Single Married (no children) Married (with children) Divorced Widow/Widower

48 (54) 8 (9) 25 (28) 16 (18) 3 (3)

37 (32) 3 (3) 33 (28) 26 (22) 1 (1)

43 (86) 6 (12) 29 (56) 20 (40) 2 (4)

Education < high school high school vocational school college

24 (27) 46 (52) 18 (20) 12 (14)

67 (59) 21 (18) 12 (11) 0 (0)

43 (86) 35 (70) 15 (31) 7 (14)

49.2***

Satisfactory Relations (affirmative response) mother 96 (97) father 89 (66) brother(s) 88 (37) sister(s) 93 (38) spouse 83 (33)

91 (64) 84 (47) 92 (67) 88 (60) 90 (56)

94 (161) 87 (113) 90 (104) 90 (98) 87 (89)

n s. n.s. n.s. n.s. n.s.

Institution Experience (affirmative response) prison 51 (58) psychiatric institution 17 (19)

80 (66) 13 (11)

63 (124) 15 (30)

17*** n.s.

Abused as a Child (affirmative response) physically 36 (39) sexually 5 (5)

31 (26) 15 (11)

33 (65) 9 (16)

n.s. 5.8*

Parental Substance Use (affirmative) Father alcohol use (always or often) illicit drug use (yes only)

13 (33) 5 (5)

44 (34) 7 (5)

37 (67) 6 (10)

13.4* n.s.

Mother alcohol use (always or often) illicit drug use (yes only)

11 (12) 3 (3)

5 (4) 1 (1)

8 (16) 2 (4)

* p < 0.05; ** p < 0.01; *** p < 0.001

n.s. n.s.

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20 percent (40) divorced, and 2 percent (4) widowed. Regarding education, 57 percent (115) reported completing high school, trade school, or some form of higher education, and 43 percent (86) did not complete high school. Among all subjects, 23 percent said they were using heroin while in treatment; 19 percent were using heroin with alcohol while in treatment, and 28 percent reported being clean of heroin but using alcohol and other drugs while in treatment. The majority (98 percent) of the addicts reported that they wish to stop heroin addiction, and 82 percent believed it was possible to stop. The main reason for trying to stop, expressed by 43 percent of the addicts, was concern about health. In terms of institution experience, 63 percent reported being in prison and 15 percent spent time in a psychiatric facility. Among those interviewed, 33 percent (65) reported being physically abused as a child and 9 percent reported being sexually abused. Chi square analysis was used to determine whether a relation existed between the background characteristics, attitudes, and behavior of the addicts and their group status (i.e., native-born or immigrant). Results show that few differences exist between the native-born and immigrant groups. Among the significant factors that differentiate the two groups are: education—immigrant men have more years of formal schooling; sexual abuse—native-born men were more likely to have experienced it; and father’s alcohol use—native-born men have fathers who are more inclined to drink frequently or often. Licit and Illicit Substance Use; Self-Esteem and Other Factors Regarding age of first use, significant differences were found for hashish with native-born addicts beginning its use earlier; and sedatives—Russian-speaking addicts beginning at a younger age (see Tables 3.2 and 3.3). While receiving treatment, Russian-speaking addicts were more inclined to use addictive substances. No difference was found among immigrant and native-born addicts regarding the number of times spent in a mental institution. Native-born addicts, however, were sent more often to prison. Native-born addicts expressed a greater concern for their health as a reason for stopping drug use. Finally, Russian-speaking immigrants reported a higher personal assessment of self-esteem. Females Background Characteristics Among the total group of female addicts surveyed, 46 percent (53) were immigrants from the former Soviet Union (i.e., the majority from Russia and the Ukraine) and 54 percent (61) were born in Israel (see Table 3.4). The findings show that 30 percent (34) were single, 9 percent (10) married without children, 18 percent (21) married with children, 38 percent (43) divorced, and 5 percent (6) widowed. Regarding education, 63 percent (72) reported finishing high school, trade school, or some other form of education, 26 percent (30) did not finish high school, and 11 percent (12) had no formal education. In terms of religious status, 78 percent of the study group reported being Jewish and the population of non-Jewish women were all from the former Soviet Union. Non-Jewish women

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Table 3.2 Immigrant and Native-Born Male Heroin Addicts: Age of First Time Use of Substance, Self-Esteem, and Institution Experience Variable

Immigrant (N=114)

Native Born (N=93)

ANOVA (df)

Mean Score (S.D.) Age of First Use Cigarettes

14.7 (8.4)

14.2 (9.9)

0.42 (193) n.s.

Alcohol

15.6 (3.9)

15.4 (2.6)

0.19 (115) n.s.

Marijuana

16.1 (2.7)

17.6 (7.1)

-1.44 (95) n.s.

Hashish

16.6 (3.4)

14.8 (3.7)

3.12 (145) **

Opiates

18.9 (4.0)

17.5 (7.2)

1.40 (93) n.s.

Heroin

22.0 (5.9)

21.2 (5.4)

0.90 (161) n.s.

Methadone

27.7 (6.0)

26.0 (6.4)

1.20 (84) n.s.

Sedatives

20.5 (5.1)

23.7 (7.8)

-2.00 (74) *

Jailed (Total Times)

2.4 (1.9)

4.8 (3.9)

-3.92 (108) ***

Mental Institution (Total Times)

2.8 (2.9)

1.9 (1.6)

0.90 (24) n.s.

Self-Esteem

3.4 (0.6)

2.9 (0.6)

6.13 (192) ***

Other Factors

* p < 0.05; ** p < 0.01; *** p < 0.001

represent 47 percent of the immigrant cohort. Regarding alcohol use among parents, 36 percent of the addicts reported that their fathers were heavy users of alcohol compared to 9 percent of their mothers. Illicit drug use among fathers was 7 percent and mothers 6 percent. At the time of being interviewed, 29 percent said they were using heroin at the time of the interview and the majority of these women (56 percent) were using the substance with alcohol; 30 percent of the addicts reported they were clean of heroin but were using alcohol or other drugs. The majority of study participants (86 percent; 98) reported they would like to stop using drugs; however, only 68 percent (77) believed it was possible. The main reasons for trying to stop were to regain custody of their child(ren) (57 percent; 65) and to improve health (45 percent; 51). In terms of institution experience, 32 percent (37) reported being in prison and 26 percent (30) spent time in a psychiatric hospital. Among those interviewed, 42 percent (48) reported being physically abused as a child and 32 percent (36) reported being sexually abused. Again, as in the case of male addicts, chi square analysis was used to determine whether a relation existed between the background characteristics, attitudes, and

Table 3.3 Immigrant and Native-Born Male Heroin Addicts: Patterns of Substance Use While in Treatment and Attitudes Variable

X2

Immigrant (N=114) Native Born (N=93) Total (N=207)

%(N) Patterns of Substance Use Heroin Use While in Treatment

33 (37)

10 (8)

23 (45)

Heroin Use with Alcohol While in Treatment 17.50***

29 (31)

5 (4)

19 (35)

Clean of Heroin but Using Alcohol and Other Drugs While in Treatment 14.90***

38 (41)

13 (9)

28 (50)

Wish to Stop Heroin Addiction

96 (99)

100 (73)

98 (172)

n.s.

Believes Can Stop Addiction

86 (84)

75 (35)

82 (119)

n.s.

Concern About Health (main reason to stop drug use)

34 (37)

57 (41)

43 (78)

64.11***

17.73***

Attitudes

* p < 0.05; ** p < 0.01; *** p < 0.001

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Table 3.4 Background Characteristics of Immigrant and Native-Born Female Heroin Addicts Variable

Immigrant (N=53)

Native Born (N=61)

Total (N=114)

X2

% (N) Background Characteristics Marital Status Single Married (no children) Married (with children) Divorced Widow/Widower

23 (12) 13 (7) 23 (12) 35 (19) 6 (3)

36 (22) 5 (3) 15 (9) 39 (24) 5 (3)

30 9 18 38 5

(34) (10) (21) (43) (6)

12 (6) 43 (23) 31 (17) 14 (7)

59 26 15 0

(36) (16) (9) (0)

37 34 23 6

(42) (39) (26) (7)

83 77 73 80 84

(51) (47) (45) (49) (51)

81 73 80 80 84

(92) (83) (92) (91) (96)

n.s. n.s. n.s. n.s. n.s.

36 (22) 28 (17)

32 (37) 26 (30)

n.s. n.s.

45 (24) 25 (13)

39 (24) 37 (23)

42 (48) 32 (36)

n.s. n.s.

45 (24) 4 (2)

23 (14) 9 (5)

33 (38) 7 (7)

23.74*** n.s.

14 (7) 4 (8)

2 (4)

n.s.

Education < high school high school vocational school college

35.83***

Satisfactory Relations (affirmative response) mother father brother(s) sister(s) spouse

77 (41) 67 (36) 89 (47) 80 (42) 85 (45)

Institution Experience (affirmative response) prison psychiatric institution

28 (15) 25 (13)

Abused as a Child (affirmative response) physically sexually

Parental Substance Use (affirmative) Father alcohol use (always or often) illicit drug use (yes only)

Mother alcohol use (always or often) illicit drug use (yes only)

5

(3)

9 (10) 6 (6)

n.s. n.s.

* p < 0.05; ** p < 0.01; *** p < 0.001

behavior of the female addicts and their group status (i.e., native-born or immigrant). Similar to the comparative results for men, few differences were found between the native-born and immigrant groups. Among the factors that did differentiate the two groups are: education—immigrant women have more years of formal schooling; father’s alcohol use—immigrant women have fathers who are more inclined to drink frequently or often; a wish to stop addiction—immigrant women have a stronger desire to quit drug use; concern about health—immigrant women are more likely to want to stop drug use in order to improve their

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health status; and to retain their children—immigrant women are more inclined to believe this condition is desirable. Licit and Illicit Substance Use; Self-Esteem and Other Factors Generally, immigrant women began using substances at an earlier age (see Tables 3.5 and 3.6). Closer examination reveals, however, that the only statistically significant difference is for sedatives. While receiving treatment for addiction, immigrant, more than native-born, women reported they were using heroin or heroin with alcohol or alcohol and other drugs while clean of heroin. Regarding self-esteem, the two subgroups did not differ. No difference was found among immigrant and native-born addicts regarding the number of times spent in a mental institution; however, native-born addicts were referred more often to prison. Study Limitations First, it is clear that the interrelationships between substance use and native-born/immigrant status are undoubtedly complex. The data presented here, and from other research, suggest that high-risk behaviors may cluster and therefore multivariate analyses are needed to delineate the nature of these interrelationships. Second, the interviews of male and female participants were collected at one point in time and from those receiving some form of treatment for their addiction. From a study of Israeli addicts, it was found that less than 20 percent find their way to detoxification and treatment programs;70 therefore, caution must be exercised in terms of generalizing the results of this prospective study. Policy and Treatment Services Considerations Scant research exists on the impact of migration on substance use among Russian-speaking immigrants.71 Generally, however, it is known that the process of leaving behind a familiar language, culture, community, and social system contributes to increased risk of psychosocial problems, adjustment failure, risk-taking behavior, and drug use.72 In Israel, policy and program decision makers talk about the need for special services to Russian-speaking addicts as well as separate treatment services for women. For the most part, little has been done to address either issue in the country. From this study, few factors differentiate male native-born and immigrant heroin addicts; however, some factors exist differentiating female native-born and Russian-speaking heroin addicts (e.g., education level, fathers’ alcohol use, patterns of drug use while in treatment, and the desire and reasons to stop drug use). Such differences, however, do not appear to justify a separate treatment program based on group status; however, special services within the existing treatment structure do appear warranted. According to Sullivan et al. (1997),73 researchers have not confirmed that separate programs for special populations are superior to mainstream efforts with respect to outcomes, and it has been noted that experts question the cost-effectiveness of such special programs and their applicability to heteroge-

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Table 3.5 Immigrant and Native-Born Female Heroin Addicts: Age of First Time Use of Substance, Self-Esteem, and Institution Experience Variable

Immigrant (N=53)

Native Born (N=61)

ANOVA (df)

Mean Score (S.D.)

Age of First Use Cigarettes

15.1 (3.3)

14.7 (2.7)

0.45 (104) n.s.

Alcohol

15.5 (3.3)

17.6 (6.4)

-1.69 (99) n.s.

Marijuana

17.2 (5.2)

18 0 (5.4)

-0.64 (65) n.s.

Hashish

17.1 (4.5)

17.9 (6.7)

-0.48 (49) n.s.

Opiates

19.5 (5.0)

19.7 (7.2)

-0.16 (46) n.s.

Heroin

22.4 (7.0)

22.3 (7.2)

0.15 (91) n.s.

Methadone

28.0 (6.7)

27.3 (7.7)

0.80 (63) n.s.

Sedatives

18.7 (5.1)

24.9 (9.1)

-2.70 (42) **

Jailed (Total Times)

1.2 (0.3)

2.3 (1.9)

-2.14 (30) *

Mental Institution (Total Times)

1.6 (0.8)

2.5 (1.9)

-1.57 (23) n.s.

Self-Esteem

3.3 (0.7)

3.4 (0.6)

-1.40 (103) n.s.

Other Factors

* p < 0.05; ** p < 0.01; *** p < 0.001

neous groups with overlapping characteristics. Furthermore, it has been found (at least in one study) that even effort focused on specific problem histories of female drug addicts (i.e., physical and sexual abuse) does not improve the long-term effectiveness of drug treatment or the lives of those who have been subject to such conditions.74 Nonetheless, some experts contend, based on clinical observations, that “treatment of special populations may be enhanced if their particular needs are considered and met.”75 This prospective study provides insight, albeit limited, about male and female heroin addicts and group status in Israel. For treatment policy and services and decision-making purposes, much more research needs to be conducted to understand the impact of migration on Russian-speaking addicts, their substance use, attitudes, and behavior. Also, further study of a long-term nature is needed to determine whether special services may be justified for reasons other than humanistic purposes.

Table 3.6 Immigrant and Native-Born Female Heroin Addicts: Patterns of Substance Use While in Treatment and Attitudes Variable

Immigrant (N=53)

Native Born (N=61)

Total (N=114)

X2

% (N) Patterns of Substance Use Heroin Use While in Treatment

40 (21)

19 (11)

29 (32)

7.73*

Heroin Use with Alcohol While in Treatment

28 (15)

5 (3)

16 (18)

11.38**

Clean of Heroin but Using Alcohol and Other Drugs While in Treatment

46 (23)

15 (8)

30 (31)

12.42***

Wish to Stop Heroin Addiction

93 (49)

80 (49)

86 (98)

4.07*

Believes Can Stop Addiction

68 (36)

68 (41)

68 (77)

n.s.

Concern About Health (main reason to stop drug use)

67 (35)

27 (16)

45 (51)

30.63**

Desire to Retain Child(ren)

74 (39)

43 (26)

57 (65)

5.28*

Attitudes

* p < 0.05; ** p < 0.01; *** p < 0.001

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Interviews: Russian-Speaking Heroin Addicts in Israel The following interviews of Russian-speaking heroin addicts in Israel provide insight of their personal history prior to immigration as well as the stressful living conditions they have had to cope with in their new country. The interviews were conducted by a Russian-speaking physician expert in the field of substance abuse treatment.76 The Case of Vladimir Vladimir was 41 years old when interviewed. He immigrated to Israel in 1991 with his parents and brother. He was divorced and worked as a classical musician in the concert hall in Odessa as well as playing in restaurants, weddings, and special occasions prior to his immigration. How was your childhood? I had a normal childhood. We were an ordinary Jewish family in which the parents worked to support us, and the children went to school and were involved in music and sports. After my birth my mother stopped working and stayed at home to take care of the children. The relations in the family were always very calm and normal. My relationship with my parents was normal as well. When I graduated from school, I was accepted to a music college. When was the first time you tried using drugs? After I graduated from high school, at the age of 18. I never drank alcohol but started smoking hashish and later on using pills. I began using drugs because of curiosity. When was the first time you started using more serious drugs? A year later. I guess it was partially curiosity, but mostly it was my need to prove to myself and others that I was no different than anyone else in my neighborhood. At first I didn’t use I/V because in the summer I could cut down the poppy plants, but later on I started using “the kitchen laboratory.” That’s when I started using I/V. I didn’t feel or was not ready to admit that I was addicted. I liked it. What exactly did you like? First of all, I liked the feeling that I got during the use. It was a feeling of pleasure. At that time, it felt just like a fresh, tasty piece of cake. Did it cause you any problems at work? At that time it wasn’t such a big problem. Were you living alone? No, I was living with my parents; but they didn’t see it, or maybe just didn’t want to see it. They didn’t want to admit that their son could be an addict. When did it start bothering you? I mean, you must have needed quite a sum of money for it. The sums of money I needed weren’t that big. It was possible to bring the “material” from nearby villages. In addition, I was working in several places. Actually it didn’t start bothering me until the time I arrived to Israel. Didn’t you think that you were becoming dependent and there is something wrong about it? I realized that I was dependent, but it didn’t really bother me. Did you have any problems with the law? Yes, I did. But I saw it as a game of “cops and robbers.” It was an amusing, fun game. How much did you need to consume per day? My doses were quite serious, in addition I was using pills, tranquilizers.

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Were you ever in treatment due to your problem? Yes, I was forced to receive treatment in a psychiatric hospital. The first time I was hospitalized I wasn’t even addicted yet. It happened because I was arrested with my friend who was carrying hashish. The second time was quite similar to the first actually. The hospitalization didn’t cause me any emotional damage. My parents were shocked, but they were hoping that from that moment on I would understand what’s going on and stop using. Did you ever spend time in prison? Yes, I was sent to prison three times. The first time for a year and a half; the second for 2 years; and, the third time for 3 years. How did you respond to your time in prison? During my first arrest I was in shock. But I had to survive. I don’t think there is a person who did time in prison without getting involved in a fight in order to find his own place inside. I had to fight, whether I wanted it or not. I fought to survive. While you were in prison, did you have the opportunity to use drugs? I didn’t have the opportunity, but I had the desire. I was living for the chance that once I got out, I would be able to start using again. I learned the unwritten rules of prison that changed my perception of life though my personality didn’t suffer a drastic change. Do you have any tattoos? No, I didn’t do any tattoos while I was in prison because I realized that sooner or later I will go out and I didn’t want people to know I did time. Tattoos can be a symbol of pride only in certain places. Whose decision was it to immigrate to Israel? It was a family decision. My last release from prison was about half a year before my move to Israel. My release was not related to my immigration to Israel. Did you suffer from anti-semitism in prison? No, I didn’t. In prison it doesn’t really matter what’s your religion, it’s more important who you are as a person. How did the immigration affect your relationship with your family? It made it worse. We were all living together until my mother’s death. After that, things just fell apart. You came to Israel without knowing the language, how did you find a pusher? It’s not a hard thing to do when you know how to use body language. The pusher was an Arab. How long has it been until you realized that you have a serious problem? Since the moment of my arrival to Israel, 4 years. That was when I realized I needed medical and social help. I’ve been clean for about 4 years now. How do you feel about yourself as an individual? I don’t consider myself to be worse than anyone else. In a way maybe I’m better than people who don’t know what drugs are about. I try to understand and relate to my situation in a correct way; If I think that I’m relating to the situation better than others, I’m not telling myself that I’m wrong. What are your hopes for the future? I hope to study, progress and most of all I hope that I won’t spend the rest of my life as an instructor in the drug detoxification center. Perhaps I will get into the business world someday. I think that I owe the 4 years of being clean to myself and only to myself. Do you think that treatment facilities with a Russian-speaking staff would help in resolving the problem of Russian drug addicts in Israel? Yes, of course. Russian addicts in Israel are a very serious problem, which becomes more serious every year. I think that it would be very useful, because a very important part of treating a drug addict is the issue of mentality. I believe that there would be better results.

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The Case of Galina Galina was 36 years old at the time of the interview. A Jewish woman, she immigrated to Israel in 1995 from Moscow where she worked as a costume designer and model. A well-educated woman, she had worked in a theater in Moscow but declined to say which one. Why did you immigrate to Israel? Due to personal reasons, after divorcing my husband, I was depressed. He was working in the same theater as I was. He was involved with one of the actresses. I was living with my mother and daughter. My parents were divorced. It was difficult to survive financially. The situation was too difficult for me to handle, so I decided to immigrate. I immigrated alone, my mother and daughter stayed in Moscow. I thought I would start a new life, and bring both of them to Israel once I established myself here in the country. What could you tell me about your life in Russia? My childhood was normal, just like the childhood any Russian child has: school, camp, et cetera. My family lived in a small apartment. When I was 14 years old, my father left us, 6 months later I found out my parents got divorced, and that my father had a new family. I took it very hard. My mother helped me with my feelings about the situation. I was always a good student. Ever since I was a child I liked painting, and I always wanted to be a costume designer. After high school I got into the university and to the faculty I wanted. While I was in the university I was happy because I was doing what I wanted to do. My years in the university were the happiest years of my life. I was living with my mother. I got married quite young, and kept fearing that the same thing that happened to my mother might happen to me. Unfortunately it did. How is your relationship with your parents? I have a very good relationship with my mother. I’ve lost contact with my father, though. More correctly, he lost contact with us. It was a big shock for me, because we always had a good relationship. Later, my mother told me that he had always had other women, she also said she never knew about it until the moment he got up and left her. That was when he told her that he had always had other women. I always had a very good relationship with my mother and like I already mentioned, she helped me through it all. I can’t say that I wasn’t angry with her for a while after he left, I thought that she didn’t try to hold on to him hard enough, I thought that she was supposed to fight for him and hated her for her weakness. Later on, I understood that her main concern was for me. When you decided to come to Israel, you must have known how hard it is for an immigrant to get through life? Of course I did. But I thought that I was young enough to get through anything. I was sure that I would quickly learn the language. I also knew English and was positive that it will help me. How did your life here begin and how did you end up using drugs? When I came here, I was all alone. I had no friends or family. The money I got from the Ministry of Absorption wasn’t enough and I had to look for a roommate. The Ministry of Absorption recommended a young woman, such as myself. Together we rented a flat in Dalet neighborhood, because it was the only thing we could afford. The flat, the neighborhood and Beer Sheva in whole, made an awful impression on me, especially after Moscow. I ended up being even more depressed than before. Our neighbor turned out to be a drug addict; I never thought about it and there was no way for me to tell because I’ve never seen a drug

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addict before. Also, I never assumed that there could be drug addicts in Israel, since all the Jews I’ve known in Moscow were with a high level of education and culture. Our neighbor was showing us attention, tried to help us, something we highly appreciated since being left alone without a man’s help was very difficult. We became very close, I told him about my life and depression and he offered something to help me with it. I was not aware that it was drugs [heroin], but I liked it a lot. Did you know what drugs are, I mean, you were working in the theater, you must have seen it there? Of course I knew what it was, but in the theater if anyone did use anything, it was either hashish or alcohol. Alcohol was the worst. At first, I didn’t even realize that my neighbor was an addict, because to me an addict is someone who looks awful. He was well dressed and looked good. He told me about his problems, about his wife. Our communication was quite limited due to the language. How did you feel after the first use? I felt incredibly light, as though all my problems were left far away. My new life is beginning, everything is ahead of me. It was like recovering after a long illness. I tried it again and again, and all of a sudden I realized that I couldn’t live without it. My roommate also started using. All of a sudden I found myself in bed with that man. The situation was becoming awful, I needed more and more drugs. For a while he was getting it for me, suddenly our relationship changed, he told me that it costs money and that he wouldn’t mind if I had sex with someone else for money or drugs. My roommate was doing that for money at that time. I tried to stop using, but with no luck. I started feeling guilty before my daughter and mother, and I decided I need to get them near me, and get treatment. I was convinced that their presence would help me to get out of this mess. They did come, we rented a new flat, but I realized that it wasn’t enough and that I still needed drugs. I was in Israel for about 8 months at that time. My mother saw that there was something wrong with me, at first it was hard for me to tell her, but eventually I told her everything. Did you continue seeing him? At first I stopped seeing him, but when my mother and daughter came, he used to come and help us, so I started seeing him again. Naturally, the relationship was accompanied with drugs. In order to get the money, I started working as a cleaning woman. It was hard for me for two reasons: physically, because I wasn’t used to it and because I was using drugs; and mentally because I realized how low I had gone. I loved my job [the one in Russia], but I realized that this profession is not needed here. I stopped working, and we were living on my mother’s pension and my welfare. I saw that my daughter was suffering because I became a completely different person. I talked to my mother and I went into treatment. I tried to stop using myself a couple of times, but with no success. I heard about a treatment center, went to a social worker and started treatment again. Did your relationship with your mother and daughter change in any way? At first, it was greatly damaged. When I told my mother I was using drugs, she didn’t understand me. But when I started the treatment process, the social worker called my mother, and after talking to her, my mother understood that I won’t be able to deal with it without her help. How long have you been clean and what do you think of this treatment program? I have been clean for a month. It was very hard for me in the inpatient clinic, but the medications and the fact that there were Russian-speaking workers there made it easier on me. I hope that I will be able to stay clean, though now I understand the size of this problem.

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Do you ever regret moving to Israel? At first, I did. I wanted to go back. Now I can’t really answer that. How do you see yourself as an individual and how do you see your future? My past was much better than my present. I was satisfied with my job, I had many friends, the atmosphere in the theater was very special, it’s a different world, a world that I miss. I think that’s the reason things were so difficult for me in the first place; and, one of the reasons of my psychological breakdown. I realize that I will never be the person I was there, but I would like to believe that I will find a place where I belong in life. I can’t answer this question definitely. Maybe, I just don’t want to think about the future. Or maybe, I’m just not ready to forget the past just yet. My only hope now is that I will be able to break out [of my problem situation] for the sake of my daughter. Do you think anyone is to blame for what had happened to you? No, I think the only one to blame is myself.

The Case of Ludmilla Ludmilla was 37 years old at the time of the interview. She is a non-Jewish single parent with one child, received vocational training in Russia, and immigrated to Israel in 1998. How was your childhood? I lived with my mother, I never knew my father. My mother was an alcoholic. We always had a group of my mother’s alcoholic friends in our house. The people often changed, there was fighting, cursing, et cetera. My mother changed lovers very often. When I was 7 years old, one of my mother’s boyfriends raped me. My mother was so drunk, she lost consciousness. Soon after that she became paralyzed and was hospitalized. I went to live with my old aunt. Compared to my life with my mother, it was heaven for me: it was quiet, nobody beat me and no one made me drink. When I was 10 years old, my mother died and the government “took care” of me. I was living in an orphanage; life there wasn’t easy. Just like when I was 7 years old, I was the victim of constant rape, abuse and beating. When I left that place I was feeling sick and broken. I had nowhere to go; I tried committing suicide and got sent to the psychiatric hospital. I spent a couple of years there and when I got released I was on pills. I wanted to have a profession. I learned how to do repairs and went to work on a construction site. By that time I was 20 years old, I was alone, had no one to rely on, so I went to live in the dorms. Did you have a separate room? Of course not, there were always a couple of other people in the room. At first, we were 4 people in the room. There was one very strong woman there that took me under her protection and even managed to get us a room for 2 people. Everything was going great until the time she explained to me that a favor requires another favor, she meant that she wanted me to sleep with her. I started living with her. After all I’ve been through I couldn’t even think about men. But you do have a child. How’s that? We wanted to have a family with my girlfriend. Like I said, I couldn’t think about men, but she brought someone over, he gave me something, it was actually the first time I tried drugs, we had sex and I got pregnant. What did you feel when you first tried drugs? For the first time in my entire life I was feeling light and free. I remembered that feeling.

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What happened next? I got pregnant and gave birth. We finally had a real family, but the feeling of lightness and carelessness I felt when I tried drugs was unforgettable. We were bothered a lot because lesbian affairs were against the social laws in Russia. My girlfriend went through a lot too and knew how to stand up for both of us. Six months after I gave birth I was suffering from severe depression, I wanted to commit suicide again and was very afraid of ending up in the hospital again. That was when I asked my girlfriend to find the man who gave me the drugs. That’s how it all began. Did you use I/V? Yes, I did. Everyone used I/V there. Drugs cost money. Where did you get the money from? In order to have money, you need to work a lot and on a construction site you can’t make a lot of money. I had to sell my body. It was hard, because I hated men. In order to be unconscious I drank. Alcohol was cheaper. I started hating myself even more and wanted to die. The only escape was when I was injecting. Did you ever try to stop using? Yes. I got arrested and spent 3 years in prison. In prison I stayed clean, because there were no drugs there. My child was in an orphanage, and the thought was killing me. Also, my girlfriend was angry with me. I suffered from great depression. Did you experience physical or sexual abuse in prison? Yes, just like everywhere else. I don’t want to go into details about what I’ve been through in prison. What happened after you were released? I was waiting for that day, because I wanted to get my son back. But when I got out, I realized I had nowhere to go and no money to live on. My aunt died and I got her old house. My girlfriend was with someone else by that time and didn’t want to help me. I didn’t know how to take care of my not so small child. I started using drugs again. History was repeating itself. It bothered me a lot. Two years later I was arrested again. I spent 2 more years in prison and left there clean again, determined never to start using [drugs] again. My son was growing up and I decided to try to give him a better life. Why did you decide to move to Israel? I didn’t see any other way to give my son a new life. Having connections in the criminal world, it’s very easy to get any kind of document. My ex-girlfriend helped me get a document saying I was Jewish. So we came to Israel. I guess she loved me after all. What happened in Israel? As you know, it’s very hard for a single mother to get by in Israel. Besides, I had no profession and no education. I met a man that seemed to care about me, but when I needed to sleep with him, I couldn’t do it without drugs. He supplied it to me with great pleasure. History repeated itself again. When did you realize you needed treatment? I thought about it constantly. Unfortunately I am naturally weak. My son found out that there was an inpatient treatment clinic. He worked for a few months and made enough money to send me there. He’s a very kind, loving boy. He was afraid he would be taken away from me. We have no one here except each other. How old is your son? He is 13 years old. Do you believe that you will be able to start a new life? I believe it, but I’m not sure I’ll do it by myself. I rely on my son and believe we can overcome everything together. I’m sorry, but I would like to stop the interview. I can’t continue.

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The Case of Alexander Alexander was 36 years old at the time of the interview. A Jewish widower with one child, he came to Israel in 1996 with his son and mother. How was your childhood? I was born in a small Siberian town, most of the time I was living with my mother, because my father was constantly in jail. He rarely showed up and when he did it was for a short while. It wasn’t a very happy time for me because his friends constantly showed up and once in a while the police would come over to arrest him. In our neighborhood it was very common for people to get arrested. Most of the children in my class came from families such as mine. We formed a gang and everyone in school had to be afraid of us. We felt that we were being respected. Did you get in trouble with your teachers? Of course I did. My principal often asked my mother to come to school. It was mostly formal though because both sides realized there was nothing they could do in order to change the situation. Some of the kids even threatened the teachers that once their fathers got out of prison, they’ll be punished. We stole, sold the theft, got into fights, and even were brought into custody. When I was 15 years old I was brought to a juvenile prison. I needed to learn my place there, that was where I started my criminal career. I was good with my hands. I drew well and it was good for the tattoo business. I was a clever boy; I was really good playing cards and knew many card tricks—my father taught me them. There were always people who owed me. This way I could live a good life. I was 19 years old when I got out of prison. I graduated school there with a profession. Naturally, I wasn’t planning on working when I got out. Some of the people who owed me were already released, others were close to being released. By that time, I was already well known in the criminal world since the last 2 years I spent in a regular prison. When I got out, I was living with my mother. My father was back home by that time and he introduced me to his criminal friends. I was smarter than my father though, that’s why I didn’t end up in prison as often as he did. I always had money. When I was 24 years old, I got married. A few years later my son was born. My problems began when I got into the drug business. While I was just selling it, everything was fine. The real trouble began when I tried using it. It hurt my ability to concentrate; I was less cautious and was sent off to prison. When I was 27 years old, I got arrested again. I got 5 years. Everything went smoothly in there because I still had a good reputation. Did you ever take part in murders? No, I never killed. You moved to Israel without your wife. What happened to her? She died from cancer while I was in prison. When I got out of prison my son was already 4 years old. We had to get to know each other all over again because neither one of us really remembered the other. I got really tied to him. But because I was on drugs again, I wasn’t that good in my “profession,” and got arrested again. This time I got 3 years. My son was with my mother. You had a son, did you want him to have the same kind of life you did? Did you ever think there was something wrong with the way you were living your life? Unlike me, my son had everything in life. I was making a lot of money and could provide him with everything. But his parents weren’t there for him? I didn’t think of that at that time. When did you decide to immigrate to Israel? My friend told me that while we were in prison that some of our friends immigrated to Israel. We figured we could make a nice business there. I then remembered my mother was Jewish, and realized I would have no problems

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doing that. A year before I was supposed to be released, I asked my mother to start preparing the documents. She was happy about it because I told her I wanted to start a new life there. A year after I was released, we immigrated to Israel. Did you find your friends here? Of course I did. They were settled in quite well. We got a government apartment in Dimona. I was back in “business.” The only problem was that I was using drugs. I decided to get treatment and went to methadone at first. I was shocked that some fucking social worker was interfering with my life, trying to take my son away from me. She also told me that my mother couldn’t be my son’s legal guardian because she was an elderly woman. I had a girlfriend. Is she still your girlfriend and is she using drugs? Yes, we’re still together. She is a wonderful person; she never used drugs and has no connection to the criminal world. I guess you want to know what is she doing with me. I guess it’s because I know how to treat women. My nickname is “intelligent.” I’m always well dressed, well mannered and women are always very sympathetic towards me. They always think I got into all the problems because of bad luck or poor faith. They always want to help me. My girlfriend helped me to get into the inpatient treatment clinic; she even paid for it. It’s your third time in the inpatient clinic. Did she pay for it every time? Yes. If I ask her to, she’ll pay for it over and over again. What happened to your son? He’s with my mother. I hope that this time I’ll really put an end to this drug story. What do you plan on doing next? I do not give it too much thought. The most important thing for me now is to stay clean so that they won’t take my son away from me. I can always get money.

NOTES 1. Kaplan, J. (1983). The Hardest Drug: Heroin and Public Policy. Chicago, IL: University of Chicago Press; Goode, E. (1989). Drugs in American Society, Third Edition. New York: McGraw-Hill. 2. Goode, p. 226. 3. Harris, L. (1993). Opiates: a History of Opiates and Their Use in Treatment. In C. Hartel (ed.), Biomedical Approaches in Illicit Drug Demand Reduction. Rockville, MD: National Institute on Drug Abuse (NIDA), p. 85. 4. Ray, O., and Ksir, C. (1990). Drugs, Society and Human Behavior. St. Louis, MO: Times Mirror/Mosby, p. 274. 5. Telias, D. (1991). The World of ‘H’. Tel Aviv: Freund Publishing House, Ltd. 6. Scott, J. (1969). The White Poppy: A History of Opium. New York: Funk and Wagnalls. 7. Harris, p. 89. 8. Ray and Ksir, p. 275. 9. Harris, p. 90. 10. Lindesmith, A. (1965). The Addict and the Law. Bloomington: Indiana University Press; Ray and Ksir, p. 278; Weisberger, B. (1993). The Chinese must go. American Heritage, (March):24–26.

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11. Musto, D. (1973). The American Disease: Origins of Narcotic Control. New Haven, CT: Yale University Press; Nadelmann, E. (1993). Should we legalize drugs? History answers. American Heritage, (March):41–48. 12. Ray and Ksir, p. 280. 13. McCann, M., Rawson, R., Obert, J., and Hasson, A. (1994). Treatment of Opiate Addiction with Methadone. Rockville, MD: U.S. Department of Health and Human Services, p. 2. 14. Nadelmann, p. 45. 15. Ibid. 16. Telias, p. 6. 17. Johnston, L., O’Malley, P., and Bachman, J. (1987). National Trends in Drug Use and Related Factors among American High School Students and Young Adults, 1975–1986. Rockville, MD: NIDA; Martz, L. (1990). A dirty drug secret. Newsweek, February 19, p. 44. 18. NIDA (1986). Highlights of the 1985 National Household Survey on Drug Abuse. Rockville, MD: NIDA. 19. Goode, p. 228. 20. Dickey, C., and Underhill, W. (1996). The drug threat. Newsweek, October 14, pp. 41–47. 21. Ibid., p. 43. 22. Gray, M. (1998). Drug Crazy. New York: Random House, pp. 143–144. 23. Liu, M. (1991). The curse of china white. Newsweek, October 14, pp. 10–16. 24. NIDA (2000). Epidemiologic Trends in Drug Abuse, Advance Report. June, Rockville, MD: U.S. Department of Health and Human Services, p. 4; Join Together Online (JTO). (2001). Report: Heroin use on rise in U.S., Boston University School of Public Health, March 7. 25. Substance Abuse and Mental Health Services Administration (SAMHSA) (2000). National Household Survey on Drug Abuse Main Findings 1998. DHHS Pub. No. (SMA: 00-3381), Rockville, MD, pp. 61–62. 26. SAMHSA (1999). Summary of Findings from the 1998 National Household Survey on Drug Abuse. DHHS Pub. No. (SMA: 99-3328), Rockville, MD, p. 26. 27. SAMHSA (2000). Drug Abuse Warning Network Annual Medical Examiner Data 1997. DHHS Pub. No. (SMA: 00-3377), Rockville, MD, p. xii. 28. SAMHSA (2000). National Household Survey on Drug Abuse Main Findings 1998. DHHS Pub. No. (SMA: 00-3381), Rockville, MD, pp. 142–143. 29. NIDA (1999). Epidemiologic Trends in Drug Abuse, Vol. 1: Proceedings of the Community Epidemiology Work Group. Rockville, MD: U.S. Department of Health and Human Services, pp. 35–37. 30. NIDA, Advanced Report, p. 8. 31. NIDA, Vol. 1: Proceedings, pp. 40–41. 32. NIDA, Advanced Report, p. 8. 33. NIDA, Vol. 1: Proceedings, p. 44. 34. NIDA, Advanced Report, p. 9. 35. NIDA, Vol. 1: Proceedings, pp. 46–48. 36. U.S. National Institutes of Health, NIDA (1999). Epidemiologic Trends in Drug Abuse, Vol. II: Proceedings of the International Epidemiology Work Group on Drug Abuse. Bethesda, MD: National Institutes of Health. 37. U.S. National Institutes of Health, NIDA, Epidemiologic Trends, pp. 136–137.

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38. Ausubel, D. (1980). An interactionist approach to narcotic addiction. In D. Lettieri, M. Sayers, and H. Pearson (eds.), Theories on Drug Abuse: Selected Contemporary Perspectives. Rockville, MD: NIDA, pp. 4–7. 39. Scher, J. (1970). Patterns and profiles of addiction and drug abuse. In J. McGrath and F. Scarpitti (eds.), Youth and Drugs. Glenview, IL: Scott, Foresman, pp. 25–29. 40. Wurmser, L. (1980). Drug use as a protective system. In D. Lettieri, M. Sayers, and H. Pearson (eds.), Theories on Drug Abuse: Selected Contemporary Perspectives. Rockville, MD: NIDA, pp. 71–74. 41. Fieldman, N., Woolfolk, R., and Allen, L. (1995). Dimensions of self-concept: A comparison of heroin and cocaine addicts. American Journal of Drug and Alcohol Abuse, 21(3):315–326; Jurich, A., and Polson, C. (1984). Reasons for drug use: Comparison of drug users and abusers. Psychological Reports, 55:371–378; Smart, R., and Whitehead, P. (1974). The uses of an epidemiology of drug use: The Canadian scene. The International Journal of the Addictions, 9:373–388. 42. Knight, D., Broome, K., Cross, D., and Simpson, D. (1998). Antisocial tendency among drug-addicted adults: Potential long-term effects of parental absence, support and conflict during childhood. American Journal of Drug and Alcohol Abuse, 24(3):361–375; Kaplan, H. (1980). Self-esteem and self-derogation theory of drug abuse. In D. Lettieri, M. Sayers, and H. Pearson (eds.), Theories on Drug Abuse: Selected Contemporary Perspectives. Rockville, MD: NIDA, pp. 128–131. 43. Lukoff, I. (1974). Issues in the evaluation of heroin treatment. In E. Josephson and E. Carroll (eds.), Drug Use: Epidemiological and Sociological Approaches. New York: Wiley, pp. 129–157; Jessor, R., and Jessor, S. (1977). Problem Behavior and Psychosocial Development: A Longitudinal Study of Youth. New York: Academic Press; Kandel, D. (1973). Adolescent marijuana use: Role of parents and peers. Science, 181(September 14):1067–1070. 44. Gainey, R., Catalano, R., Haggerty, K., and Hope, M. (1997). Deviance among the children of heroin addicts in treatment: Impact of parents and peers. Deviant Behavior, 18 (2):143–159; Jessor, R., and S. Jessor (1980). A social-psychological framework for studying drug use. In D. Lettieri, M. Sayers, and H. Pearson (eds.), Theories on Drug Abuse: Selected Contemporary Perspectives. Rockville, MD: NIDA, pp. 102–109. 45. Goode, p. 62. 46. Ibid., p. 235. 47. Inciardi, J. (1979). Heroin use and street crime. Crime and Delinquency, 25 (July):335–346; Inciardi, J. (1986). The War on Drugs: Heroin, Cocaine, Crime and Public Policy. Palo Alto, CA: Mayfield, pp. 122–132. 48. Sahni, S. (1992). Heroin addiction and criminality. Journal of Personality and Clinical Studies, 8(1–2):35–38; Inciardi, pp. 130–140; Goode, p. 236. 49. Isralowitz, R., Telias, D., and Zighelbaum, Y. (1992). Heroin addiction in Israel: A comparison of addicts in prison, community-based facilities, and non-drug users based on selected psychological factors. International Journal of Offender Therapy and Comparative Criminology, 36(1):70. 50. Ibid. 51. Leshner, A. (1998). Foreword, in C. Wetherington and A. Roman (eds.), Drug Addiction Research and the Health of Women, NIH Publication No. 98-4289, Rockville, MD: NIDA, iii. 52. U.S. Department of Health and Human Services (1992). SAMHSA, National Household Survey on Drug Abuse Population Estimates 1992, 104.

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53. U.S. Department of Health and Human Services (2000). SAMHSA, Drug Abuse Warning Network Annual Medical Examiner Data, 1998, DHHS Pub. No. (SMA) 00-3408. 54. Kandel, D. (1998). Epidemiology of drug use and abuse among women. In C. Wetherington and A. Roman (eds.), Drug Addiction Research and the Health of Women, NIH Publication No. 98-4289, Rockville, MD: NIDA, pp. 24–28. 55. Moras, K. (1998). Psychosocial and behavioral treatments for women. In C. Wetherington and A. Roman (eds.), Drug Addiction Research and the Health of Women, NIH Publication No. 98-4289, Rockville, MD: NIDA, pp. 49–52; Crowe, A., and Reeves, R. (1994). Treatment for Alcohol and Other Drug Abuse. DHHS Publication No. (SMA) 94-2075; Roth, P. (1991). Alcohol and Drugs are Women’s Issues: Vol. 1. A Review of the Issues. Metuchen, NJ: Scarecrow Press; Amaro, H., Fried, L., Cabral, H., and Zuckerman, B. (1990). Violence during pregnancy and substance use. American Journal of Public Health, 80(5):575–579. 56. Fiorentine, R., Pilati, M., and Hillhouse, M. (1999). Drug treatment outcomes: Investigating the long term effects of sexual and physical abuse histories, Journal of Psychoactive Drugs, 31(4):363–372; Bernstein, D., Stein, J., and Handelsman, L. (1998). Predicting personality pathology among adult patients with substance use disorders: Effects of childhood maltreatment. Addictive Behavior, November–December; 23(6):855–868; Dansky, B., Brady, K., Saladin, M., Killeen, T., Becker, S., and Roitzsch, J. (1996). Victimization and PTSD in individuals with substance abuse disorder: Gender and racial differences. American Journal of Drug and Alcohol Abuse, February 22(1):75–93; Gil-Rivas, V., Fiorentine, R., and Anglin, M. (1996). Sexual abuse, physical abuse, and post traumatic stress disorder among women participating in outpatient drug abuse treatment. Journal of Psychoactive Drugs, 28(1):95–102; Wellisch, J., Anglin, M., and Prendergast, M. (1993). Numbers and characteristics of drug using women in the criminal justice system: Implications for treatment. Journal of Drug Issues, 23(1):6–30. Swett, C., Cohen, C., Surrey, J., Compaine, A., and Chavez, R. (1991). High rates of alcohol use and history of physical and sexual abuse among women outpatients. American Journal of Alcohol Abuse, 17(1):49–60. 57. Mitchell, J. (1993). Pregnant, Substance-Using Women (Treatment Improvement Protocol Series 2). Rockville, MD: Center for Substance Abuse Treatment. 58. Moise, R., Kovach, J., Reed, B., and Bellows, N. (1982). A comparison of black and white women entering drug abuse treatment programs. The International Journal of Addictions, 17(1):46–47. 59. Moras, K. (1998). Psychosocial and behavioral treatments for women. In C. Wetherington and A. Roman, (eds.), Drug Addiction Research and the Health of Women, NIH Publication No. 98-4289, Rockville, MD: NIDA, pp. 49–52. 60. Bryant, V., Eliach, J., and Green, S. (1990). Adapting the traditional EAP model to effectively serve battered women in the workplace. Employee Assistance Quarterly, 6(2): 1–10; Hurley, D. (1991). Women, alcohol and incest: Analytical review. Journal of Studies on Alcohol, 52(3):253–268. 61. U.S. Department of Health and Human Services (1995). SAMHSA. Practical Approaches in the Treatment of Women Who Abuse Alcohol and Other Drugs. DHHS Publication No. (SMA) 94-3006; NIDA (1995). Women’s HIV Risk and Protective Behaviors. NIH Guide, Vol. 24, No. 30, August 18. 62. U.S. Public Health Service (1994). Morbidity and Mortality Weekly Report. May 27, 43(20), Centers for Disease Control, Atlanta, GA; Migliori, G., and Ambrosetti, M. (1998). Epidemiology of tuberculosis in Europe. Mondali Archives of Chest Diseases, 53(6):681–687.

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63. Isralowitz, R., Afifi, M., and and Rawson, R. (eds.) (2002). Drug Problems: Cross-Cultural Policy and Program Development. Westport, CT: Auburn House; Isralowitz, R. (2001). Toward an Understanding of Russian-Speaking Heroin Addicts and Drug Treatment Services. Journal of Social Work Practice in the Addictions, 1(2):33–44. 64. Grunberg, N. (1998). Smoking, eating, stress, and drug use: Sex differences. In C. Wetherington and A. Roman, (eds.), Drug Addiction Research and the Health of Women, NIH Publication No. 98-4289, Rockville, MD: NIDA, pp. 39–42; James, D. (1997). Coping with a new society: The unique psychosocial problems of immigrant youth. Journal of School Health, 67:3, 98–102; Goodenow, C., and Espin, O. (1993). Identity choices in immigrant adolescent females. Adolescence, 28:109, 173–184. 65. Light, I., and Isralowitz, R. (1997). Immigrant Entrepreneurs and Immigrant Absorption in the United States and Israel. Aldershot, England: Ashgate. 66. Goldscheider, C. (1992) Demographic transformations in Israel: Emerging themes in comparative context. In C. Goldscheider (ed.), Population and Social Change in Israel. Boulder, CO: Westview Press, pp. 1–38. 67. Isralowitz, R., Telias, D., and Abu Saad, I. (1994). Psychological characteristics of heroin addicts and non-drug users in Israel: A status model comparison. Journal of Social Psychology, 134(3):399–401. 68. Elisha, D. (1998). Israel Ministry of Health, Substance Abuse Treatment Unit: An overview. In Isralowitz, R. (ed.), Palestinian and Israeli People against Drug Use: Problems, Policies and Programs. A Cooperative Effort to Address the Problem through Communication, Cooperation and Coordination. Conference Proceedings, Economic Cooperation Foundation, Tel Aviv. 69. Isralowitz, R., Abu Saad, I., and Telias, D. (1996). Work values among heroin addicts: A status model perspective. Journal of Offender Rehabilitation, 24(1/2):141–154; Isralowitz,Telias, and Abu Saad, Psychological characteristics of heroin addicts. 70. Isralowitz, Abu Saad, and Telias, Work values among heroin addicts. 71. Isralowitz, Afifi, and Rawson. 72. Brindis, C., Wolfe, A., McCarter, V., Ball, S., and Starbuck Morales, S. (1995). The association between immigrant status and risk-behavior patterns of Latino adolescents. Journal of Adolescent Health, 17(2):99–105; Velez, C., and Ungemack, J. (1989). Drug use among Puerto Rican youth: An exploration of generational status differences. Social Science Medicine, 29(6):779–789; James, D. (1997). Coping with a new society: The unique psychosocial problems of immigrant youth. Journal of School Health, 67(3):98–102; Goodenow, C., and Espin, O. (1993). Identity choices in immigrant adolescent females. Adolescence, 28(109):173–184; Ishiyama, F. (1989). Understanding foreign adolescents’ difficulties in cross-cultural adjustment: A self-validation model. Canadian Journal of School Psychology, 5:41–56; Arredondo, P. (1981). Personal loss and grief as a results of immigration. Personal and Guidance Journal, 59(6):376–378. 73. Sullivan, E., and Fleming, M. (1997). A Guide to Substance Abuse for Primary Care Clinicians. DHHS Publication (SMA), 97-3139, Rockville, MD: SAMHSA. 74. Fiorentine, R., Pilati, M., and Hillhouse, M. (1999). Drug treatment outcomes: Investigating the long term effects of sexual and physical abuse histories. Journal of Psychoactive Drugs, 31(4):363–372. 75. Sullivan and Fleming; Landry, M. (1996). Overview of Addiction Treatment Effectiveness. DHHS Publication (SMA), 96-3081, Rockville, MD: SAMHSA, 59–70; American Psychiatric Association (1995). Practice Guide for Treatment of Patients with Substance Use Disorders: Alcohol, Cocaine, Opioids. Washington, DC: American Psychi-

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atric Association; Kauffman, J., and Woody, G. (1995). Matching Treatment to Patient Needs in Opiod Substitution Therapy. DHHS Publication No. (SMA) 95-3049, Rockville, MD: SAMHSA; Institute of Medicine (1990). Broadening the Base of Treatment for Alcohol Problems. Washington, DC: National Academy Press. 76. Dr. S. Borkin, a Russian-speaking physician, immigrated to Israel in 1990. Certified as a drug treatment specialist, she also served as regional inspector for drug treatment services in the Negev for the Israel Ministry of Health.

Chapter 4

Alcohol and the Alcoholic

Many substances are used to experience special physical sensations, but alcohol is the most prominent over time. Alcohol is a drug in precisely the same sense that heroin, cocaine, and LSD are—they are all psychoactive. Alcohol is addictive, and in this sense definitions regarding dependence and abuse presented in Chapter 1 are relevant. It generates severe withdrawal symptoms including depression, blackouts, and liver disease when the heavy, long-term drinker discontinues its use. Some individuals who are dependent on the substance may continue to use alcohol to relieve the symptoms of withdrawal despite adverse consequences including cirrhosis of the liver, which is one of the leading causes of mortality in the United States. According to the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association (1994), “a substantial minority of individuals who have Alcohol Dependence never experience clinically relevant levels of Alcohol Withdrawal, and only about 5% of individuals with Alcohol Dependence ever experience severe complications of withdrawal (e.g., delirium and grand mal seizures).”1 Alcohol . . . [lowers] interpersonal inhibitions and anxiety. . . . A person under the influence of larger amounts of alcohol usually exhibits an unsteady gait, blurred vision, and slurred speech. Vomiting may precede loss of consciousness . . . memory lapses during prolonged bouts of heavy drinking, known as blackouts, can also occur. During a blackout, the drinker is functioning, conscious, and alert, yet once the alcohol has passed through the system, he or she does not recall events or experiences that transpired. . . . Chronic alcohol abuse results in organ damage . . . [including] liver diseases, pancreatitis, brain damage, . . . heart disease, and vascular disorders (hypertension and stroke) [as well as] increases the risk of developing . . . cancers of the esophagus, pharynx, and

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mouth. . . . People under the influence of alcohol have diminished coordination, judgment, reaction time, and motor skills.2

A person who abuses alcohol is likely to find that school and job performance suffers; child care or household responsibilities are ignored, and social and interpersonal relations are affected by arguments, violence, and physical and sexual abuse of spouse and children. When such “problems are accompanied by evidence of tolerance, withdrawal, or compulsive behavior related to alcohol use, a diagnosis of Alcohol Dependence, rather than Alcohol Abuse, should be considered.”3 After tobacco, alcohol abuse and dependence are by far the most common form of drug addiction. In the United States, it has been estimated that there are 20 alcoholics to every one heroin addict.4 Alcohol abuse is a major cause of premature death and illness in the United States. HISTORICAL PERSPECTIVE Although it is not known exactly when alcohol and its effects on human behavior were discovered, paleontologists say that the four basic ingredients needed by man to produce the substance (sugar, water, yeast, and heat) existed as long as 200 million years and in almost all geographic locations and cultures. [There is] ample testimony from Ancient Egyptians, Hebrews, Greeks, and Romans that intoxicating beverages, both wines and stronger drinks, were well known within their cultures. . . . We know humans have been drinking alcoholic beverages since 6400 B.C., when beer and berry wine were discovered. Grape wines date from 300 to 400 B.C. . . . The drinking custom is probably even older than that. Some experts believe that mead, an alcoholic beverage made of honey, was used about 8000 B.C. . . . One of the oldest temperance [accounts] was written in Egypt, about 3,000 years ago under the title of the “Wisdom of Ani” stating “Take not upon thyself to drink a jug of beer. Thou speakest and an unintelligible utterance issueth from my mouth. If thou fallest down and thy limbs break there is none to hold out a hand to thee.” Reference to alcoholism is in the Bible (Chapter 1 of the First Book of Samuel). . . . Hannah was childless and extremely unhappy on account of it. At the annual family pilgrimage to the shrine in Shiloh she . . . went off by herself [to pray] to God to grant her a son. [Praying] silently, only her lips [moved]. Eli, the high priest, noticed her odd behavior and mistook [her] for a hallucinating drunkard, advising that an alcoholic must give up drink.5 Leaders throughout history have encouraged moderation. King Solomon warned the ancient Hebrews to beware of alcohol. Plato and other Greek philosophers urged their followers likewise. In ancient times, an intoxicated person was often shunned and condemned. . . . In China, wine drinking prohibitions were enacted and repealed 40 times between 1100 B.C. and 1400 A.D.6

Early use of alcohol seems to have been worldwide; for example, beer was drunk by the American Indians encountered by Columbus.7 Wine drinking was common in medieval Britain and consumption was high. When William of Orange became King of England in 1688, he encouraged the production of gin by issuing charters to divert the surplus of English grain for its production. In 1690, a further

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step to ensure the sale of English grain was taken when import of foreign spirits was prohibited. In Queen Anne’s time, the monopoly of the Worshipful Company of Distillers was canceled, leading to unlimited gin production, mostly of poor quality, which was sold in the streets and hawked from door to door at one penny per pint.8 Ale has been drunk in England since Celtic times, and hopped beer since the fifteenth century.9 The tragedy of drunkenness was summed up in the eighteenth century when it was said “some of the most dreadful mischiefs that afflict mankind proceed from wine. It is the cause of disease, quarrels, sedition, idleness, aversion to labor, and every species of domestic disorder.”10 In the “new continent,” what American colonists considered normal drinking would be defined as deviant and intemperate from a contemporary viewpoint. “The colonists’ views toward alcoholics were reflective of their basic philosophic assumptions regarding free will and moral depravity of human beings, and of their class bias.”11 Levine (1978) notes that between 1785 and 1835 considerable concern about drinking by the poor was being expressed among an economic and social elite.12 In the United States, the year was 1784 when Benjamin Rush, a physician and signer of the Declaration of Independence, described in his work “An Inquiry into the Effects of Ardent Spirits upon the Human Body and Mind” that drunkenness was a disease resembling certain hereditary, family, and contagious diseases.13 In nineteenth-century America, a temperance movement that demonized alcohol became an important social force and a rallying point for the expanding middle class; thus the liquor problem became a focus of attention for a broader sector of American society14 that would bring social, political, and religious activism together, culminating in Prohibition. In the United States, an amendment to the Constitution in 1919 made it illegal to manufacture or sell any alcoholic beverage. This amendment remained in effect until 1933 and had a significant impact on the nation’s social patterns, economy, and underground life during those years and after.15 The end of Prohibition, it has been suggested, was the result not so much of an overwhelming American popular desire for legitimate sources of alcohol but of corporate interests, who saw the restoration of liquor taxes as a means of lowering personal and business taxes.16 Moreover, at a time when social and economic pressures and protests due to the Great Depression were building, popular disregard of Prohibition was also viewed as another aspect of disregard for law and order.17 Once Prohibition was repealed, the windfall from taxes on alcohol was used to fund depression-relief projects.18 No record of alcohol sales was kept in the United States from 1920 to 1933; nevertheless, there is a general perception that alcohol consumption rose during this period and that Prohibition was a failure. Contrary to this belief, death by cirrhosis of the liver which is very closely correlated with alcohol consumption decreased during Prohibition, and increased once alcohol use was legal again.19 The number of people arrested and jailed on charges of public drunkenness and the number of automobile fatalities, another factor strongly related to the consumption of alcohol, declined.20 Exaggeration, myths, and the media probably account more for the misunderstanding of Prohibition’s effect on people’s drinking behavior than any

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other factors. For the most part, it has been noted that most Americans did not drink during the Prohibition years, and those who did drank less and less often than before or after the period.21 Over time, the detrimental results of alcohol use have been subject to a macabre array of remedies to address the problem. For example, Pliny the elder, in his Historia Naturalis (xxxii, 49), written in the first century, suggested putting a roach or worm or other disgusting creature (e.g., screech-owl’s eggs) into the drink of a drunkard to stop excessive use of wine. In 1601, a book was published in England recommending the use of a tonic wine in which eels or green frogs have been suffocated to wean the uncontrolled drinker. The Chinese used both human cerumen (ear wax) and the head of a rat ashed in the first moon as medicaments for the treatment of alcoholism. In more recent times, the Ruthenians, a group of Ukrainians living in Ruthenia and eastern Czechoslovakia, believed that the problem of excessive alcohol use could be dealt with by pouring the drunkard’s own urine back into his mouth, while the Magyars believed the problem could be cured by secretly mixing sparrow’s dung into the drunkard’s brandy. Also, the Ruthenians believed that alcoholism could be cured by placing a piece of pork secretly into a Jew’s bed and keeping it there for nine days, then pulverizing it and feeding it secretly to the drunkard. This was done on the belief that the drunkard will abhor alcoholic drink as a Jew abhors pork. Throughout the nineteenth century, the notion of secretly mixing special substances into the drink or even coffee of alcoholics was a popular way to cure the problem. In places like Brazil such a practice continues. And it has been reported that Dr. Benjamin Rush once tempted a patient who was habitually fond of ardent spirits to drink some rum in which he had put a few grains of tartar emetic. The tartar sickened and caused the patient to vomit believing that he had been poisoned. Dr. Rush was gratified by observing that the patient could not bear the sight or smell of alcohol for two years afterward. One hundred and fifty years later, Doctor Walter Voegtlin, who had not read Rush but had read Pavlov, was to develop the same idea into a systematic method using emetine to induce vomiting in association with alcohol. This treatment helped several thousand alcoholic patients to become total abstainers. Doctor Rush himself, never having heard of Pavlov, credited the idea to no less an authority than Moses when, he writes, Moses compelled the children of Israel to drink the solution of the golden calf (which they had idolized) in water. This solution, if made as it probably was, by means of what is called hepar sulphuris, was extremely bitter, and nauseous, and could never be recollected afterwards, without bringing into equal detestation, the sin which subjected them to the necessity of drinking it.22

THE ALCOHOLIC: THEORIES AND PERSONALITY CHARACTERISTICS Alcoholism is the most common form of addiction and the typical drug addict is an alcoholic, not a street junkie.23 Like most addictive substances, no single factor and no combination of factors have been presented that allow us to predict which individuals will become alcohol abusers or dependent on the substance.24 “Studying the factors that influence drinking is important in understanding how al-

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cohol use and alcohol problems develop. Investigation of factors associated with drinking behavior can also shed light on the ways in which alcohol-related problems may be prevented and controlled.”25 The following information is a selective overview of theories and research associated with alcohol.26 One major category used to understand the use and abuse of alcohol includes psychological theories. A popular perspective relates drinking to tension reduction.27 This theory suggests that alcohol is used to relieve tension caused by stressful life events. “The purported effect of alcohol on tension as it might relate to alcoholism can be broken down into two parts: the first consists of the hypothesis that alcoholics, when compared to [nonalcoholics], may have different baseline levels of anxiety, and the second part relates the possible effects that alcohol might have in differentially decreasing levels of tension for alcoholics.”28 While many individuals think that alcohol helps them relax after a stressful day, there is little evidence that the use of alcohol in this manner causes alcoholism. In spite of a lack of evidence linking this theory to alcoholism, it is still a useful approach toward understanding the reasons for alcohol use, abuse, and dependence. Other psychological approaches that address issues of reinforcement and explain why people begin drinking, drink abusively, or remain alcoholics include receiving peer approval, enhancing or altering social interactions, changing levels of consciousness, decreasing the pressures of work, providing the opportunity to feel powerful and independent, and blotting out unhappy memories or stress response dampening.29 Transactional theories are another approach used to explain the problem. Generally, it is assumed that poor communications may be responsible for initiating alcohol use and the progression to alcoholism, and that levels of communication become more disordered as alcohol intake increases. It has been noted that alcoholism is the result of interaction in which the individual and the family use drunkenness and helplessness as an excuse for such behavior.30 The psychodynamic approach implies that alcohol is a reinforcing agent that helps the alcoholic fulfill some need such as decreasing self-centered, narcissistic drives,31 fulfilling a need for self-destructive punishment,32 or addressing latent homosexuality.33 Other theories under this rubric view alcohol use as a defense mechanism or protection against low self-esteem,34 a means contributing to the achievement of power, and/or a way of generating care and dependence.35 Personality theories tend to reflect no one personality type specific to the development of alcoholism and that the range of personality types of alcoholics is no different from that found in the general population,36 but even for this statement an exception can be found. Antisocial personality disorder, for example, has been frequently associated with alcoholism. It has been “hypothesized that heavy drinking occurs not as alcoholism but as part of the antisocial picture, just as drug abuse, a high rate of divorce, accidents, and death by homicide can be seen in individuals with an antisocial picture.”37 Other psychological factors commonly associated with alcoholism include high levels of anxiety in interpersonal relations, emotional immaturity, ambivalence toward authority, low frustration tolerance, low self-esteem, feelings of isolation, perfectionism, guilt, compulsiveness, angry overdependency,

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sex-role confusion, an inability to express angry feelings adequately, narcissism, defiance, grandiosity, and resentment.38 A second major category of theories relates to sociocultural factors that have been used to study the historical aspects of alcohol abuse, compare how different societies view and respond to alcohol problems, and observe adaptive strategies used by individuals who have alcohol-related problems, or to consider drinking in the context of interpersonal relations.39 Such factors are “typically defined as the impact of the environment, where environment is broadly interpreted to include not only the physical and social setting, but also the interpersonal behavior of others, including peers and family members. [The influence] can take many forms, and as with psychological processes, different factors have different effects on different people at different times. Also like psychological processes, social processes do not occur in isolation from other influences that motivate drinking.”40 It has been noted that “sociocultural theories can relate to drinking practices, drinking problems, or alcoholism. . . . [They] serve as an impetus for theory formation and research but rarely, if ever, definitively answer questions.”41 Group norms, peer influences,42 and expectancies about the effects of alcohol43 shape drinking behavior. The effects of the home environment, including the influences of the family, on drinking behavior and the development of alcohol dependency including childhood adjustment problems to later alcoholism have been perhaps the most frequently studied social influence.44 Cultural theories relate to the alcohol use attitudes and behavior of a particular society or subgroups within a society.45 Issues of parental child rearing practices,46 social mobility, and access to opportunities (e.g., jobs and income),47 as well as sex and work role expectations particularly for women48 all fall into this category. Biological factors show that “alcoholics have many body-functioning abnormalities, [a finding that is] not surprising considering the ubiquitous effects of alcohol on the body and the damage done through chronic alcohol intake and dietary neglect.”49 Issues of biochemical effects including sugar and carbohydrate metabolism dysfunction, food allergy, and other similar approaches to explaining alcoholism are under investigation and speculative.50 One factor, however, that has been receiving considerable investigation is that of genetics, which reveals the familial nature of alcoholism.51 “Evidence of genetically transmitted vulnerability for alcoholism exists. Much of the evidence has arisen from adoption studies, but additional support for potential genetic contributions is found in research on markers of inherited susceptibility. . . . [T]win studies suggest that the interaction between genetic and environmental influences is implicated in certain drinking behaviors.”52 Finally, it has been noted that “of all the variables studied, genetic factors were the easiest to investigate and have yielded findings of importance in establishing one element in particular of the many responsible for the final alcoholic picture.”53 TRENDS The magnitude of alcohol use and problems associated with its use has been overshadowed in recent years by the preoccupation with the widespread use of il-

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licit drugs including heroin, cocaine crack, and ecstasy, as well as the threat of AIDS. It needs to be recognized, however, that if one takes “the deaths from every other abused drug . . . [and adds] them together, . . . they still don’t equal the deaths or the cost to society of alcohol alone.”54 In the United States alone, alcoholism claims tens of thousands of lives each year, ruins untold numbers of families, and costs from $85.8 billion55 to $117 billion56 a year in everything from medical bills to lost workdays. The indirect cost in 1995 has been estimated to be $166.5 billion, which translated to $177.3 billion in 1997. The total cost to society of this substance is on order of 30 times what the nation spends on its treatment—about $6.4 billion in 1997.57 Alcohol use has been targeted as the cause for nearly half of all driving fatalities in the Unted States58 and is the major factor in adult drownings.59 It has been seriously implicated in millions of injuries and thousands of deaths resulting from industrial accidents and a substantial proportion of general (noncommercial) aviation crashes and boating accidents. The vast majority of all fire fatalities and fire burns involve alcohol use at the time of the accident—cigarette smoking is a major cause of fires, and a direct association exists between drinking and smoking in the general population. Alcohol has been found to be involved in up to 70 percent of all deaths and 63 percent of all injuries from falls. Suicide is a major cause of death in the United States, and about 30 percent of those who commit suicide are alcoholics.60 Alcoholics are far more likely than nonalcoholics to attempt and commit suicide while drinking, and alcohol’s mood-changing properties have been seen as a possible link to suicidal actions. Child abuse, neglect, molestation, and marital violence are prevalent types of aggression in the family, and alcohol use is a precipitating factor of these problems as well.61 A Department of Justice survey estimates that nearly a third of the nation’s state prison inmates drank heavily before committing rape, burglaries, and assaults. As many as 45 percent of the country’s homeless, estimated to be about 700,000 on any given night, are alcoholics.62 In the 1989 Bureau of Justice Statistics’ survey of inmates in local jails throughout the United States, offenders charged with or convicted of driving while intoxicated were more than 1 in every 11 inmates. Among convicted inmates, 86 percent of those serving a sentence for driving while intoxicated had been sentenced in the past. Almost a third of the DWI inmates had served three or more previous sentences in jail or prison. Regarding those who are arrested for driving while impaired, persons in jail for DWI are more likely to be the serious offenders in terms of the nature of criminal activity.63 In 1997, roughly 1.7 million drivers were arrested for driving under the influence of alcohol or narcotics.64 The use of alcohol in the United States has risen steadily since the end of Prohibition to 1978. Since the early 1980s, however, there has been a downward trend—a behavior pattern that appears in consonance with the use of most psychoactive substances, including cocaine. The number of new regular users, defined by the U.S. Public Health Service as people who drink alcohol once a month or more, peaked at 3.4 million in 1977, and since the 1980s the number has remained at over 2 million new regular drinkers each year. Other factors characterizing the down-

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ward trend of alcohol use during the past decade include: a decline in sales, self-reported alcohol consumption for all ages, and fewer young people ever drinking.65 Alcohol-related traffic fatalities dropped from 25,165 in 1982, 17,858 in 1992, and 16,068 in 2000.66 Another important indicator of excessive alcohol use is cirrhosis (liver disease) deaths. Since 1970, death rates have dropped 26 percent.67 An overview of drinking patterns reveals that alcohol use in the lifetime, past year, and past month is generally more prevalent among males than females, except among the adolescent age group (i.e., those aged 12 to 17) where there tends to be no significant difference.68 Men at all ages are more likely than women to drink and report current heavy alcohol use. Drinking rates for females tend to be more closely related to the rates for males in the 18–29 age groups, with gender difference becoming more pronounced with increasing age, and rates in younger cohorts in general exceed rates for older cohorts.69 Among all of the adult age groups, whites tend to be more likely than blacks and Hispanics to report lifetime, past year, and past month alcohol use. Among adolescents, whites and Hispanics are more likely than blacks to report lifetime, past year, and past month use. Adults who attend or graduate from college report greater lifetime, past year, and past month use than adults who had not attended college, but this is not the case for heavy alcohol use as noted below. Rates of alcohol use vary across employment categories—use is most prevalent among persons employed full time. Young adults aged 18–25 are the most likely to report heavy alcohol use which is defined as drinking five or more drinks per day on each of five or more days in the last 30 days. Overall, those with a high school education or less and those with some college were more likely than college graduates to report heavy alcohol use.70 Drinking five or more drinks on the same occasion on at least one day in the past 30 days is defined as binge drinking. Approximately 15 percent of the total population of household residents aged 12 or older reported at least one episode of binge drinking in the past 30 days. Young adults aged 18 to 25 (31 percent) were more likely than all other age groups to have engaged in binge drinking, and the rate of binge drinking increased significantly between 1997 and 1998 among this age group. Close to half of males aged 18 to 25 (42 percent) reported at least one episode of binge drinking in the past month.71 Regarding adolescents, alcohol tends to be the drug used most often among high school seniors. “Although most high school seniors cannot legally buy alcoholic beverages, 90 percent of them had tried alcohol, compared with 64 percent who had tried cigarettes and fewer still who had tried other drugs.”72 The rate of alcohol use is likely to be higher among dropouts, and dropout rates differ among racial and ethnic groups. For example, dropout rates are higher than average among Native Americans and Hispanics, and lower than average for Asian Americans. Dropout rates for blacks and whites are comparable.73 In a comprehensive study of alcohol and other substance use among American secondary school students, college students, and young adults from 1975 to 1991 it was found that despite the fact that it is illegal for virtually all high school students and most college students to purchase alcoholic beverages, experience with alcohol is almost universal among the 88 percent of the high school seniors who have tried it and active use is wide-

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spread. Based on national results of adolescent drug use in 2000, Johnston et al. (2001) report [the] proportions of 8th, 10th and 12th graders who admitted drinking an alcoholic beverage in the 30 day period prior to the survey were 22%, 41% and 50% respectively. . . . [R]egarding episodic heavy drinking, or what is called “binge drinking” measured by having five or more drinks in a row during the prior two week interval (Note: The definition of “binge drinking” differs according to the study referenced), [this behavior appears to have] reached its peak at about the time that overall illicit drug use did, in 1979. It held steady for a couple of years and then declined substantially from 41% in 1983 to a low of 28% in 1992 (also the low point for any illicit drug use). This was an important improvement—a drop of almost one-third in binge drinking. Although illicit drug use rose considerably in the ’90’s in proportional terms, binge drinking rose only by a small fraction—about four percentage points among the 12th graders—between 1992 and 1998. At 8th grade there was some upward drift between 1991 (12.9%) and 1996 (15.6%), as was true at 10th grade between 1992 (21.1%) and 1997 (25.1%). Use has been level over the past three years in all three grades. One point to note from the findings is that there is no evidence of any “displacement effect” in the aggregate between alcohol and marijuana—a hypothesis frequently heard. The two drugs have moved much more in parallel over the years than in opposite directions.74

In sum, based on the National Household Survey on Drug Abuse (1998), 178 million (81 percent) of the 218 million people aged 12 or older reported alcohol use in their lifetime. An estimated 140 million persons (64 percent) reported use in the past year; and 113 million persons (52 percent) reported current use (in the past month). The percentage of persons reporting alcohol use has remained relatively stable. This said, however, the high prevalence of use among the young adults aged 18 to 20 suggests that laws prohibiting the purchase, possession, and use of alcohol by young people in this range may not be very effective. The high prevalence of use among youths aged 12 to 17 supports this conclusion (NHSDA, 1998:89).75 Finally, in terms of youth, young adult populations as well as women, the alcohol industry and soft drink companies (e.g., Coca-Cola and Pepsi) have been actively marketing new alcohol and alcohol-related products. As in the cigarette industry, effort is being made to address the psychology of these groups in terms of promoting their use of alcohol. Alcoholic beverages mixed with juices and sweet liquids; malt lemonades, and caffeine-loaded “energy” drinks (e.g., Red Bull, KMX, and Adrenaline Rush) used with alcohol are examples of a strategy to enlarge the drinking population and increase sales.76 University Student Alcohol Use: Patterns and Problems The college or university is more than an institutional mechanism that provides opportunities for higher education, career development, and personal advancement; it is one of the primary means a society has to transmit cultural values and behavior through social interaction.77 Research has been conducted to understand drinking among collegiate populations, document its frequency, and identify the

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consequences of negative drinking patterns, such as disruptions in personal relationships, problems with authority figures, impaired academic performance, fighting, and physical or property damage.78 Most studies have been done, however, with divergent theoretical and operational definitions that tend to obfuscate understanding the extent of the problem. For example, the reported prevalence of students abusing alcohol ranges from such extremes as 6 to 72 percent.79 Studies have reported at least occasional alcohol use by over 90 percent of the college students in the United States,80 with consumption rates for the majority of student alcohol users ranging from one to ten drinking occasions per month and one to five drinks per occasion.81 Confronted with such a range of numbers and facts, one can understand why policy and program personnel involved with prevention and treatment of alcohol-related problem behaviors have difficulty addressing the issue. From information available, it is clear that no single factor explains why a college student uses and/or abuses alcohol. Reasons that are commonly cited include the need to socialize, peer group pressure, escape from negative feelings or emotions, or simply getting drunk for the “fun of it.”82 It has been found that while most students drink to amplify positive affective conditions, problem drinkers also seek to escape negative ones, or to use intoxication as an opportunity to express socially inappropriate behavior.83 Attitudinal and personality characteristics often found associated with problem drinking include lowered impulse control, greater proneness to deviant problem behavior, lower expectations of academic success, and greater value placed on independence than on academic achievement.84 According to Jessor and Jessor (1975),85 a combination of personality characteristics and environmental and behavioral factors appears to best explain problem drinking. “Within this model, alcohol abuse is viewed as a behavioral pattern of problem-prone individuals likely to engage in other forms of deviant behavior as well. . . . Thus, the research on personality points to the importance of non-alcohol factors in understanding problem drinking. Furthermore, these factors, termed ‘commonalities’ are thought to underlie other forms of substance abuse as well.”86 The social context of peers, family, and environment is another important factor in considering drinking among college students. Studies have shown that the influence of social context is stronger than that of personality factors in predicting the initiation of, and involvement in, problem-drinking behavior patterns.87 Moreover, from a review of relevant literature, it has been concluded that “among social context variables, peer influences have outweighed the effects of family and environment. . . . Young problem drinkers appear to have weaker ties to parents and are more oriented to peers, who provide influential models for their heavier alcohol use. In a study of a college population, [it has been demonstrated] that the influence of peers upon heavy drinking [is] far greater than that of other environmental and family characteristics.”88 Factors that reflect current drinking habits and problems among college students include: binge drinking on college campuses increased by 14 percent between 1993 and 1999—among the contributing factors are the traditions of heavy alcohol consumption by fraternities, sororities, and athletes as well as the

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high-volume supply of inexpensive alcohol and drink specials promoted at bars. Nearly half of the college student population binge drink (five or more drinks at a time for men, four or more at a time for women). On campuses where more than 70 percent of the student body binge drinks, 87 percent of the students report experiencing problems such as physical assault, sexual harassment, and impaired sleep and study time. Among college drinkers, 28 percent have reported being drunk three or more times in the past month compared to 23 percent in 1993. Nonbinge drinkers represent 57 percent of the college population and consume only 9 percent of the alcohol. As many as 360,000 of the nation’s 12 million undergraduates will eventually die from alcohol-related problems, many of which began in college. Alcohol on college campuses is a factor in 40 percent of all academic problems and 28 percent of all dropouts. Each year, college students spend $5.5 billion on alcohol (mostly beer) which is more than they spend on books, soda, coffee, juice, and milk combined. College athletes drink more than their peers who are not involved in sports activities, suggesting that the team atmosphere may promote heavy drinking behaviors.89 ALCOHOL USE AND CULTURE: AN INTERNATIONAL PERSPECTIVE Alcohol is a cultural artifact; the form and meanings of drinking alcoholic beverages are culturally defined, as are the uses of any other major artifact. The form is usually explicitly stipulated, including the kind of drink that can be used, the amount and rate of intake, the time and place of drinking, the accompanying ritual, the sex and age of the drinker, the role involved in drinking, and the role behavior proper to drinking. How a society socializes drunkenness is as important as how it socializes drinking.90 Each culture can be regarded as having a range of behavior which is integral to the culture.91 In attempting to explain social organization and its relation to alcohol use, Bales used four attitudes to describe the use of alcohol. In some cases, societies exist that show an almost pure form. Combination of attitudes within a society also exist, and there are also a number of societies which, as a part of the process of social change, are in a state of transition between one attitude, or combination of attitudes, and another. The first is an attitude which calls for complete abstinence. For one reason or another, usually religious in nature, the use of alcohol as a beverage is not permitted for any purpose. The second might be called a ritual attitude toward drinking. This is also religious in nature, but it requires that alcoholic beverages, sometimes a particular one, should be used in the performance of religious ceremonies. Typically the beverage is regarded as sacred, it is consecrated to that end, and the partaking of it [is] a ritual act of communion with the sacred. . . . The third can be called a convivial attitude toward drinking. Drinking is a “social” rather than a religious ritual, performed both because it symbolizes social unity or solidarity and because it actually loosens up emotions which make for social ease and good will. This is what is often called “social drinking.” The fourth type seems best described as a utilitarian attitude toward drinking. This includes medicinal drinking and other types calculated to fur-

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ther self-interest or personal satisfaction. It is often “solitary” drinking, but not necessarily so.92

Utilitarian attitude, essentially self-oriented, has been used to describe the patterns of alcohol use and abuse among the Irish, specifically in terms of everyday use, to get rid of a hangover, to quiet hunger, and to release sexual and aggressive tensions.93 The ritual attitude defines the acceptable use of alcohol as largely restricted to religious functions. Jewish drinking and sobriety have been used as an example.94 The third type of attitude to drinking, the convivial, is a mixture of the first two: it includes some ritual components which symbolize social solidarity such as standing “shouts” or exchanging cups of sake, and some utilitarian components such as the expectation of “good feeling” as a result of drinking. Bales (1959) considered that wherever convivial drinking “is found highly developed it seems to be in danger of breaking down toward purely utilitarian drinking.”95 In general, “cultural attitudes predominately ritual or abstinent seem to be associated with a form of drinking highly intergrated with other cultural characteristics and consistent throughout a given culture. Utilitarian attitudes, on the other hand, seem to be found mainly in modern, complex societies, in which both attitudes and drinking behavior are pluralistic and at times inconsistent. Convivial attitudes manifest themselves in a wide range of forms. In some cases they seem to be predominately integrative and associated with a low rate of alcoholism.”96 Perspective: Alcohol Use among Jewish People It has been widely thought that the rate of alcohol abuse and alcoholism among Jewish people, in comparison to other ethnic and national groups, is low. Most of the studies upon which this assumption is based “have been done in an attempt to understand the pattern of moderate drinking amongst Jews in the Diaspora (i.e., countries other than Israel), within the framework of a generally permissive attitude towards alcoholic beverages.”97 Research during the past decade suggests, however, that drinking patterns and problems tend to change as individuals interact with people of other religious or cultural backgrounds that stress different drinking norms.98 Thus, in a study of alcohol use among undergraduate college students at 72 colleges in the United States in 1984 and 1985,99 little difference was found between Jewish students and others in terms of alcohol-related attitudes and behavior. The study points to the significant degree of assimilation among Jewish people as a possible factor for the finding. Historically, alcohol-related problems among Jews were unknown in Palestine during the British mandate period prior to the establishment of the state of Israel in 1948.100 Factors such as the shared sense of mission to establish the state, a high level of motivation and pioneering spirit, and austerity provided controls on excessive alcohol-drinking behavior. “Social drinking habits, which were brought from countries of exile, were neglected or diminished within the context of the conscious change in the lifestyle of the immigrants.”101 This pattern of behavior ap-

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pears to have held throughout the 1950s and up to the 1960s, when the controls mentioned above became less influential. During the various waves of immigration to Israel, certain groups, especially from North Africa and Middle-Eastern countries, brought with them social drinking habits acquired in their countries of origin. Adaptation difficulties due to the breakage of patriarchism during the adjustment to the new modern country, sometimes turned a formerly moderate drinking habit into pathologically excessive drinking. A change of status due to a redefinition of the socioeconomic status of the head of the family, who had to compete in a society having a far different educational, social and economic level than that of his original society in his country of origin, causes economic difficulties. In addition to these, the tension of day to day life in Israel, under pressure from outside the country, from hostile states as well as from within [in terms of] Israel’s highly competitive society, has hastened the tendency for [people] to fall back on drink as an escape mechanism.102

In addition to this group of Jewish people, excessive alcohol users existed among survivors of the Holocaust, who drank to cope with problems of adjustment and to escape from loneliness and the horrors of the past and its memories.103 During the 1970s, a different pattern of alcohol-related behavior emerged in Israel, a movement away from moderation and a generally pejorative attitude to one reflecting a greater acceptance of alcohol as a substance affecting the interaction of people on an individual and group basis. Drinking became a “status symbol” and a “trademark of being worldly.”104 Several other factors also directly contributed to a spread of “hedonistic alcohol use” that promoted problems of abuse and alcoholism in the country. After the Six-Day War in 1967, there was a rise in the country’s standard of living, and large numbers of volunteer workers from Western countries, who viewed alcohol as a means of pleasure and fun, influenced other young people in the country with whom they sought companionship. During the 1970s, a gradual change in values and norms developed in Israel. Personal motivation became dominant at the expense of human values, and Israeli society tried to be a society “like all societies.” In the process of transition, it became difficult to maintain the moderate level of alcohol use that characterized the isolated Jewish community in the Diaspora and in the period of the establishment of the state.105 Israel, to a major extent, has adopted Western culture and values, including its attitudes and behavior toward alcohol use. Since 1990, for example, the number of pubs throughout the country has increased from 100 to 2,000 in response to the growing demand for alcohol among veteran citizens, particularly the young, and from immigrants from the former Soviet Union. Another indicator of the rise of alcohol use in Israel is driving behavior. In 1992, the country’s Highway Safety Administration of the Ministry of Transportation reported that 4 to 5 percent of road accidents were caused by drunk drivers, as compared to less than 2 percent during the previous year. Government officials cite the influx of Russian immigrants, a people with high levels of alcohol use and alcoholism, as a major factor in this growing problem, but they also point out that young Israelis are “emulating Western habits and are taking to the bottle. This, together with a lack of experience behind the wheel and a show of ‘macho bravado’, appears to be contributing to an

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increase in fatal accidents.”106 This situation resulted in a law enacted in 1991 banning young people from driving between 1 A.M. and 5 A.M.; however, the legislation was repealed a year later as ineffective.107 NOTES 1. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Washington, DC: American Psychiatric Association, pp. 195–196. 2. Falkowski, C. (2000). Dangerous Drugs. Center City, MN: Hazelden, pp. 96–97. 3. American Psychiatric Association, p. 196. 4. Goode, E. (1989). Drugs in American Society, Third Edition. New York: McGraw-Hill, p. 16. 5. Keller, M. (1986). The old and the new in the treatment of alcoholism. In D. Strug, S. Priyadarsini, and M. Hyman (eds.), Alcohol Interventions. New York: Haworth Press, pp. 23–40. 6. Hafen, B. (1977). Alcohol: The Crutch that Cripples. St. Paul, MN: West Publishing, pp. 1–2. 7. Ray, O., and Ksir, C. (1990). Drugs, Society and Human Behavior. St. Louis, MO: Times Mirror/Mosby, p. 151. 8. Spring, J., and Buss, D. (1979). Three centuries of alcohol in Britain. In D. Robinson (ed.), Alcohol Problems. London: Macmillan Press, p. 25. 9. Wilson, C. (1973). Food and Drink in Britain. London: Constable Press. 10. Alcohol and Alcoholism: Problems, Programs and Progress (1972). Bethesda, MD: National Institute of Mental Health, National Institute on Alcohol Abuse and Alcoholism, PHS Publication No. (HSM) 72-9127, p. 1. 11. Strug, D., Pryadarsini, S., and Hyman, M. (eds.) (1986). Alcohol Interventions: Historical and Sociocultural Approaches. New York: Haworth Press, p. 1. 12. Levine, H. (1978). The discovery of addiction: Changing conceptions of habitual drunkenness in America. Journal of Studies on Alcohol, 39(1):143–174. 13. Keller, p. 27; Alcohol and Health (1990). Rockville, MD: U.S. Department of Health and Human Services, p. 3. 14. Strug, Pryadarsini, and Hyman, p. 3. 15. Hafen, pp. 1–2. 16. Levine, H. (1984). The alcohol problem in America: From temperance to alcoholism. British Journal of Addiction, 79:109–119. 17. Strug, Pryadarsini, and Hyman, p. 4. 18. Lender, M., and Martin, J. (1987). Drinking in America. London: Macmillan. 19. Grant, B., Noble, J., and Malin, H. (1986). Decline in liver cirrhosis mortality and components of change. Alcohol Health and Research World, 10(Spring):66–69; Goode, p. 127. 20. Burgess, L. (1973). Alcohol and Your Health. Los Angeles: Charles Publishing. 21. Goode, pp. 123–124. 22. Keller, pp. 26–28. 23. Goode, p. 108. 24. Ray and Ksir, p. 156; Vaillant, G. (1983). The Natural History of Alcoholism, Cambridge, MA: Harvard University Press; Schuckit, M. (1986). Etiologic theories on alcohol-

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ism. In N. Estes, and M. Heinemann (eds.), Alcoholism: Development Consquences and Interventions. St. Louis, MO: Times Mirror/Mosby, pp. 15–30. 25. Alcohol and Health, p. 129. 26. Schuckit. 27. Conger, J. (1956). Alcoholism: Theory, problem and challenge: II. Reinforcement theory and the dynamics of alcoholism. Quarterly Journal of Studies on Alcohol, 17:296–305. Cappell, H., and Herman, C. (1972). Alcohol and tension reduction: A review. Quarterly Journal of Studies on Alcohol, 33:33–64. 28. Schuckit, p. 16. 29. Ibid., p. 17. 30. Steiner, C. (1971). Games Alcoholics Play. New York: Grower Press. 31. Conger. 32. Ward, R., and Faillace, L. (1970). The alcoholic and his helpers: A system view. Quarterly Journal of Studies on Alcohol, 31:684–691. 33. Schuckit, p. 18. 34. McCord, J. (1972). Etiological factors in alcoholism: Family and personal characteristics. Quarterly Journal of Studies on Alcohol, 33:1020–1027. 35. Schuckit, M., Morrison, C., and Gold, E. (1983). Alcoholism in women: Some clinical and social perspectives. In M. Greenblatt and M. Schuckit (eds.) Alcoholism Problems in Women and Children. New York: Grune and Stratton. 36. Schuckit, M. (1984). Drug and Alcohol Abuse: A Clinical Guide to Diagnosis and Treatment. New York: Plenum Publishing Corp. 37. Robins, L. (1978). Study childhood predictors of adult antisocial behaviour: Replications from longitudinal studies. Psychiatric Medicine, 8:611–622. 38. Denzin, N. (1987). The Alcoholic Self. Newbury Park, CA: Sage Publications, p. 31. 39. Heath, D. (1976). Anthropological perspectives on the social biology of alcohol: An introduction to the literature. In B. Kissim and H. Begleiter (eds.), The Biology of Alcoholism, Vol. 4. New York: Plenum Press. 40. Alcohol and Health, p. 136. 41. Schuckit, p. 20. 42. Jessor, R., and Jessor, S. (1975). Adolescent development and the onset of drinking: A longitudinal study. Journal of Studies on Alcohol, 36:27–51; Zucker, R., and Noll, R. (1982). Precursors and developmental influences on drinking and alcoholism: Etiology from a longitudinal perspective. In Alcohol Consumption and Related Problems. National Institute on Alcohol Abuse and Alcoholism. Alcohol and Health Monograph No. 1. DHHS Pub. No. (ADM) 82-1190. Washington, DC: Superintedent of Documents, U.S. Government Printing Office, pp. 289–327. 43. Marlatt, G., Demming, B., and Reid, J. (1973). Loss of control drinking in alcoholics, an experimental analogue. Journal of Abnormal Psychology, 81(3):233–241; Zinberg, N. (1984). Drug, Set, Setting: The Basis for Controlled Intoxicant Use. New Haven, CT: Yale University Press; Goldman, M., Brown, S., and Christiansen, B. (1987). Expectancy theory: Thinking about drinking. In H. Blane, and K. Leonard (eds.), Psychological Theories of Drinking and Alcoholism. New York: Guilford, pp. 181–226. 44. McCord, J. (1988). Identifying developmental paradigms leading to alcoholism. Journal of Studies on Alcohol, 49:357–362; Werner, E. (1986). Resilient offspring of alcoholics: A longitudinal study from birth to age 18. Journal of Studies on Alcohol, 47 (1):34–40; Drake, R., and Vaillant, G. (1988). Predicting alcoholism and personality disorder in a 33-year longitudinal study of children of alcoholics. British Journal of Addictions,

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83:917–927; Zucker, R., and Gomberg, E. (1986). Etiology of alcoholism reconsidered: The case for a bio-psychosocial process. American Psychology, 41(7):783–793; Barnes, G. (1990). Impact of the family on adolescent drinking patterns. In R. Collins, K. Leonard, and J. Searles (eds.), Alcohol and the Family: Research and Clinical Perspectives. New York: Guilford Press. pp. 137–161; U.S. Department of Health and Human Services (1990). Alcohol and Health. ADM-90-1656. Washington, DC: Superintendent of Documents, U.S. Government Printing Office, pp. 4–6. 45. Roebuck, J., and Kessler, R. (1972). The Etiology of Alcoholism: Constitutional, Psychological, and Sociological Approaches. Springfield, IL: Charles C. Thomas, Publisher. 46. Bacon, M. (1974). The dependency-conflict hypothesis and the frequency of drunkenness. Quarterly Journal of Studies on Alcohol, 35:863–876. 47. Morrison, C., and Schuckit, M. (1978). Locus of control in young men with alcoholic relatives and controls. Journal of Clinical Psychiatry, 44:306–307. 48. Schuckit, M., and Morrissey, E. (1976). Alcoholism in women: Some clinical and social perspectives. In M. Greenblatt, and M. Schuckit (eds.), Alcoholism Problems in Women and Children. New York: Grune and Stratton. 49. Schuckit, p. 21. 50. Alcohol and Health, pp. 147–159. 51. Ibid., pp. 61–77; Cotton, N. (1979). The familial incidence of alcoholism. Journal of Studies on Alcohol, 40:89–116; Schuckit, p. 21. 52. Cloninger, C., Bohman, M., and Sigvardsson, S. (1981). Inheritance of alcohol abuse. Archives of General Psychiatry, 38:861–868; Goodwin, D., Schulsinger, F., Hermansen, L., Guze, S., and Winokur, G. (1973). Alcohol problems in adoptees raised apart from alcoholic biological parents. Archives of General Psychiatry, 28:238–243; Alcohol and Health, p. 5; Zickler, P. (1999). Twin Studies Help Define the Role of Genes in Vulnerability to Drug Abuse. NIDA Notes, Vol. 14, No. 4. 53. Schuckit, p. 27. 54. Desmond, E. (1987). Out in the open: Changing attitudes and new research give fresh hope to alcoholics. Time Magazine, November 30, p. 29. 55. U.S. Department of Health and Human Services (1993). Alcohol and Health. DHHS Pub. No. ADM-281-91-0003; Washington, DC: Superintendent of Documents, U.S. Government Printing Office, p. xxix. 56. Harwood, H., Kristiansen, P., and Rachal, J. (1985). Social and Economic Costs of Alcohol Abuse and Alcoholism. Issue Report No. 2. Research Triangle Park, NC: Research Triangle Institute. 57. Coffey, R. (2001). National Estimates of Expenditures for Substance Abuse Treatment. Washington, DC: U.S. Department of Health and Human Services, SMA 01-3511, p. 37. 58. U.S. Department of Health and Human Services (1993). Alcohol and Health. DHHS Pub. No. ADM-281-91-0003; Washington, DC: Superintendent of Documents, U.S. Government Printing Office, p. 238. 59. Dietz, P., and Baker, S. (1974). Drowning: Epidemiology and prevention. America Journal of Public Health 64(4):303–312; Patetta, M., and Biddinger, P. (1988). Characteristics of drowning deaths in North Carolina. Public Health Report 103(4):406–411; Plueckhahn, V. (1982). Alcohol consumption and death by drowning in adults. Journal of Studies on Alcohol, 43(5):445–452. 60. Goodman, R., Istre, G., Jordan, F., Herndon, J., and Kelaghan, J. (1991). Alcohol and fatal injuries in Oklahoma. Journal of Studies on Alcohol, 52(2):156–161. Smith, S., Good-

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man, R., Thacker, S., Burton, A., Parsons, J., and Hudson, P. (1989). Alcohol and fatal injuries: Temporal patterns. American Journal of Preventive Medicine, 5(5):296–302. 61. Noble, E. (1978). Alcohol and Health. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism; DeLuca, J. (ed.) (1981). Alcohol and Health. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism; Crum, R., Muntaner, C., Eaton, W., and Anthony, J. (1995). Occupational stress and the risk of alcohol abuse and dependence. Alcohol Clinical Experimental Research, 19:647–655; Zobeck, T., Grant, B., Stinson, F., and Bertolucci, D. (1994). Alcohol involvement in fatal traffic crashes in the United States: 1979–1990. Addiction, 89:227–233; Leigh, J. (1995). Dangerous jobs and heavy alcohol use in two national probability samples. Alcohol and Alcoholism, 30:71–86; Lahelma, E., Kangas, R., and Manderbacka, K. (1995). Drinking and unemployment: contrasting patterns among men and women. Drug and Alcohol Dependency, 37:71–82. 62. Desmond, pp. 29–30; National Law Center on Homelessness and Poverty (1997). Homeless in America: Unabated and Increasing. Washington, DC: National Coalition for the Homeless. 63. Cohen, R. (1992). Drunk Driving: 1989 Survey of Inmates of Local Jails. Washington, DC: Bureau of Justice Statistics Special Report. 64. Falkowski, p. 97. 65. Lender and Martin, p. 206; Gallup, G. (1980). The Gallup Poll: Public Opinion 1979; (1986). The Gallup Poll: Public Opinion 1985; (1987). The Gallup Poll: Public Opinion 1986. Wilmington, DE: Scholarly Resources; Fishburne, P., Abelson, H., and Cisin, I. (1980). National Survey on Drug Abuse: Main Findings, 1986. Rockville, MD: National Institute on Drug Abuse (NIDA); Johnson, L., O’Malley, P., and Bachman, J. (1987). Drug Use among American High School Students, College Students, and Other Young Adults: National Trends through 1985. Rockville, MD: NIDA. Goode, pp. 123–125; Barringer, F. (1991). With teens and alcohol, it’s just say when. New York Times, June 23, p. 1. 66. U.S. Department of Transportation, National Highway Traffic Safety Administration (2001). Traffic Safety Facts 1999. Washington, DC: U.S. Department of Transportation. 67. Horgan, C. (2001). Substance Abuse: The Nation’s Number One Health Problem, Princeton, NJ: Robert Wood Johnson Foundation, p. 50. 68. U.S. Department of Health and Human Services (2000). National Household Survey on Drug Abuse Main Findings, 1998. Washington, DC: Substance Abuse Mental Health Services Administration (SAMHSA), DHHS Publication No. (SMA) 00-3381, p. 90. 69. Grant, B., Harford, T., Chou, P., Pickering, R., Dawson, D., Stinson,F., and Noble, J. (1991). Epidemiologic Bulletin No. 27: Prevalence of DSM-III-R alcohol abuse and dependence: United States, 1988. Alcohol Health Research World, 15(1):91–96. 70. Rouse, B. (ed.) (1995). Substance Abuse and Mental Health Statistics Sourcebook. DHHS Publication No. (SMA) 95-3064, Washington, DC: Superintendent of Documents, U.S. Government Printing Office. 71. U.S. Department of Health and Human Services, National Household Survey, pp. 90–91. 72. U.S. Department of Health and Human Services, Alcohol and Health, p. 21. 73. Bachman, J., Wallace, J., O’Malley, P., Johnston, L., Kurth, C., and Neighbors, H. (1991). Racial/ethnic differences in smoking, drinking, and illicit drug use among American high school seniors, 1976–89. American Journal of Public Health, 81(3):372–377. 74. Johnston, L., O’Malley, P., and Backman, J. (2001). Monitoring the Future, Overview of Key Findings. NIH Publication No. 01-4923, p. 30. 75. U. S. Department of Health and Human Services, Alcohol and Health, p. 89.

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76. Join Together Online (JTO) (2000). Hard lemonade becomes popular worldwide, Boston School of Public Health, Boston University, October 4; JTO, (2000). Teens being lured by sweet, fruity alcohol drinks. May 11; Cowley, G., and Underwood, A. (2001). Soda pop that packs a punch. Newsweek, February 19, p. 57. 77. Wechsler, H. (1996). Alcohol and the American college campus. Change, July–August: 20–26; Gfroerer, J., Greenblatt, J., and Wright, D. (1997). Substance use in the US college-age population: Differences according to educational status and living arrangement. American Journal of Public Health, 87(1):62–65. 78. Berkowitz, A., and Perkins, W. (1986). Problem drinking among college students: A review of recent research. Journal of American College Health, 35:21–28; Wechsler, H., and McFadden, M. (1979). Drinking among college students in New England. Journal of Studies on Alcohol, 40:969–996. 79. Wright, L. (1983). Correlates of reported drinking problems among male and female college students. Journal of Alcohol and Drug Education, 28:47–57. 80. Kozicki, Z. (1982). The measurement of drinking problems among college students at a midwestern university. Journal of Alcohol and Drug Education, 27:61–72. 81. Hughes, S., and Dodder, R. (1983). Alcohol consumption patterns among college populations, Journal of College Student Personnel, 24:257–264; Wechsler and McFadden; Maddox, G. (ed.) (1970). The Domesticated Drug: Drinking among Collegians. New Haven, CT: College and University Press. 82. Wechsler and McFadden; Maddox; Straus, R., and Bacon, S. (1953). Drinking in College. New Haven, CT: Yale University Press; Berkowitz, A., and Perkins, W. (1985). Gender differences in collegiate drinking: Longitudinal trends and development patterns. Paper presented at the Annual Meeting of the American College Personnel Association, Boston, MA; Friend, K., and Koushki, P. (1984). Student substance use: Stability and change across college years. International Journal of Addiction, 19:571–575; Engs, R. (1977). Drinking patterns and drinking problems of college students. Journal of Studies on Alcohol, 38:2144–2156. 83. Berkowitz and Perkins, p. 23; Ratliff, K., and Burkhart, B. (1984). Sex differences in motivation for and effects of drinking among college students. Journal of Student Alcohol, 45:26–32. 84. Berkowitz and Perkins, pp. 23–24; Donovan, J., and Jessor, R. (1978). Adolescent problem drinking: Psychosocial correlates in a national sample study. Journal of Studies in Alcohol, 39:1506–1524. Donovan, J., Jessor, R., and Jessor, S. (1983). Problem drinking in adolescence and young adulthood: A follow-up study. Journal of Studies on Alcohol, 44:109–137. 85. Jessor and Jessor. 86. Berkowitz and Perkins, p. 24; Levinson, P., Gerstein, D., and Maloff, D. (eds.) (1983). Commonalities in Substance Abuse and Habitual Behavior. Lexington, MA: Lexington Books. 87. Berkowitz and Perkins, p. 24; Kandel, D. (1980). Drug and drinking behavior among youth. Annual Review of Sociology, 6:235–285; Zucker, R., and Noll, R. (1982). Precusors and developmental influences on drinking and alcoholism: Etiology from a longitudinal perspective. In Alcohol and Health Monograph #1: Alcohol Consumption and Related Problems. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism. 88. Perkins, W. (1985). Religious traditions, parents, and peers as determinants of alcohol and drug use among college students. Review of Religious Research, 27:15–31.

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89. Wechsler, H., Davenport, A., Dowdall. G., Moeykens, B., and Castillo, S. (1994). Health and behavioral consequences of binge drinking in college. Journal of the American Medical Association, 272(21):1672–1677; JTO (2000). Binge drinking increases; so does abstinence, March 16; Eigan, L. (1991). Alcohol Practices, Policies and Potentials of American Colleges and Universities. An OSAP White Paper, Office for Substance Abuse Prevention. Rockville, MD, February; Anderson, D. (1994). Breaking the tradition on college campuses: Reducing drug and alcohol misuse. George Mason University, Fairfax, VA; JTO (2001). College athletes drink more than non-athletes, January 26. 90. Mandelbaum, D. (1979). Alcohol and culture. In D. Robinson (ed.), Alcohol Problems. London: Macmillan Press, pp. 15–21. Heath, D. (1975). A critical review of ethnographic studies of alcohol use. In R. Gibbons et al., Research Advances in Alcohol and Drug Problems, Vol. 2. New York: Wiley; Vailliant, G. (1983). The Natural History of Alcoholism, Cambridge, MA: Harvard University Press, pp. 58–63. 91. Benedict, R. (1935). Patterns of Culture. London: Methuen; Sargent, M. (1973). Alcoholism as a Social Problem. St. Lucia, Queensland: University of Queensland Press, p. 35. 92. Bales, R. (1959). The cultural differences in rates of alcoholism. In R. McCarthy (ed.), Drinking and Intoxification. Glencoe, IL: Free Press, p. 267. 93. Bales, R. (1962). Attitudes toward drinking in the Irish culture. In D. Pittman, and C. Snyder (eds.), Society, Culture and Drinking Patterns. New York: Wiley, pp. 157–187. 94. Snyder, C. (1962). Culture and Jewish sobriety: The ingroup-outgroup factor. In D. Pittman and C. Snyder (eds.), Society, Culture and Drinking Patterns. New York: Wiley, pp. 188–225. 95. Bales, R. (1959). Cultural differences in rates of alcoholism. In R. McCarthy (ed.), Drinking and Intoxification. Glencoe, IL: Free Press, pp. 263–277. 96. Lollo, G., Serianni, E., Golder, G., and Luzzatto-Fegiz, L. (1958). Alcohol in Italian Culture. Food and Wine in Relation to Sobriety among Italian Americans. Monographs of Rutgers University Centre of Alcohol Studies, No. 3. New Haven, CT: Free Press; Sargent, p. 39. 97. Weiss, S., and Eldar, P. (1987). Alcohol and alcohol problems research 14. Israel. British Journal of Addiction, 82:227. 98. Greeley, A., McGready, W., and Theisem, G. (1980). Ethnic Drinking Subcultures. New York: Praeger; Engs, R., Hanson, D., and Isralowitz, R. (1988). Drinking problems among Jewish college students in the United States and Israel. Journal of Social Psychology, 128(3):415–417. 99. Engs, R., and Hanson, D. (1985). The drinking patterns and problems of college students. Journal of Alcohol and Drug Education, 31(1):65–83. 100. King, A. (1961). The alcohol problem in Israel. Quarterly Journal of Studies on Alcohol, 22:321–328. 101. Weiss and Eldar, p. 229; Shuval, R., and Kraslowsky, D. (1963). A study of hospitalized male alcoholics. Israel Annals of Psychiatry and Related Disciplines, 1:277–292. 102. Weiss and Eldar, p. 229 103. Shuval and Kraslowsky; Weiss and Eldar, p. 229. 104. Weiss and Eldar, p. 229. 105. Ibid. 106. Sudilovsky, J. (1992). Teenage drinking, Jerusalem Post, October 1, p. 1B. 107. Marcus, R. (1993). Drunken driving accelerates throughout the country. Jerusalem Post, January 1, p. 9.

Chapter 5

Cocaine and Crack

HISTORICAL PERSPECTIVE Sherlock Holmes “took his bottle . . . and hypodermic syringe and thrust the sharp point home, pressed down the tiny piston . . . with a sigh of satisfaction. . . . ‘Which is it today,’ he was asked, ‘morphine or cocaine?’ . . . ‘It is cocaine . . . care to try it?’ ”1 “Poverty-stricken and with few ordinary physician’s patients, [Sigmund Freud] . . . took a dose of 50 milligrams of 40 percent cocaine powder and found that it made him cheerful and feel that he had dined comfortably, had nothing to worry about and that all was well with the world. Additionally, and almost significantly, while there were no worries, there was also no loss of energy and no disincentive for physical and mental effort. . . . Under the influence . . . [he] wrote a long essay which reads as if written in a drug induced euphoria; it was also a hasty, unprofessional piece of work for a 28 year old physician.”2 In 1884, Freud wrote that he used very small doses of cocaine regularly against depression and against indigestion with considerable success.3 He recommended cocaine as a local anesthetic, an aphrodisiac, and as a means of treating depression, alcoholism, and morphine addiction.4 Freud used cocaine for three years during which time he supplied it to patients, fellow doctors, and medical students. “Cocaine was, at that time, . . . neither illegal nor proscribed. As with laudanum or morphine or even heroin, cocaine was freely available over the counter at pharmacies in almost every country . . . and there was no restraint on the use of any of what we would now call ‘illegal substances.’ ”5 By 1887, Freud had changed his mind on the merits of cocaine and wrote an article in which he said that cocaine was much more dangerous for public health than morphine.6

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Categorized as a stimulant, cocaine dates back more than 2,000 years to the Andes Mountains in South America. Evidence of the use of coca leaves has been found in a grave in Peru dating from about 500 A.D., and by 1000 A.D. the coca shrub was extensively cultivated in Peru.7 Despite efforts by Spanish invaders in the sixteenth century to stamp out its use, the coca leaf found its way to Europe, where its effects were studied by scientists and physicians.8 The Indians from the region (now Colombia, Peru, and Bolivia) still chew the leaves, which contain about 1 percent cocaine, to ward off fatigue and hunger enabling them to work long hours without stopping. The bushes have reddish-brown bark and light green leaves, which should be picked as carefully as tea leaves and selected for their apparent alkaloid value. . . . [Good] dried leaves are uncurled. The culture of the coca bushes is critical and is something about which no addict will have much knowledge. Bad leaves may produce cocaine concentrate that may suit the drug market but will give chewers of such leaves little sense of well-being, temporary or permanent.9

Isolated from coca leaves in about 1860 (the exact date is uncertain), cocaine became popular through Angelo Mariani, a French chemist, who developed and marketed in 1884 a concoction consisting of quality coca leaves steeped in good red wine known as “Mariani’s Coca Wine,” which won praise from popes, kings, and others including Queen Victoria and U.S. Presidents Grant and McKinley.10 During that time, in 1885, the Parke-Davis Pharmaceutical Company (now part of the Pfizer pharmaceutical conglomerate) started to market cocaine as a promising tonic, noting that it “can supply the place of food and make the coward brave,” and called it a “wonder drug.”11 There were many competitors to Mariani’s cocaine-laced wine; however, none were more famous than that of an Atlanta pharmacist, John Pemberton: Atlanta banned the sale of alcohol in 1885 under local option. John Pemberton (and many other pharmacists) sought to replace alcohol by non-alcoholic drinks that gave the consumer the same initial lift and kick that alcohol does. For his backyard product, Pemberton mixed sugar, caramel, caffeine, phosphoric acid, essence of coca leaves, fig juice and (probably) cinnamon, nutmeg, vanilla and glycerin and later, ground kola nut.12 . . . The [beverage was marketed as a valuable tonic and nerve stimulant that] makes not only a delicious, exhilarating, refreshing and invigorating beverage . . . but [also is] a valuable brain tonic, and a cure for all nervous affections.13

In the first five years, Pemberton only sold 160 gallons of the syrup and soon the drink was taken over by Asa Griggs Candler, a pharmacist who made history with Coca-Cola. The manufacturer believed [the] product should not only be strongly associated with cocaine by the product name but also by the product package. Thus, the unique shape of the Coca-Cola bottle was originally intended to resemble the shape of the coca bean. In reality, the bottle shape resembles a cocoa bean because the production artists mistakenly used a co-

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coa bean, instead of a coca bean, as the model for the bottle design. In 1903, soon after the dangers of cocaine were publicized, the manufacturer of Coca-Cola removed cocaine from its formulation.14 . . . In 1909, the FDA (Food and Drug Administration) seized a supply of Coca-Cola syrup and made two charges against the company. One that it was misbranded because it contained “no coca and little if any cola” and second, it contained an added poisonous ingredient, caffeine. . . . In 1916 the Supreme Court of the United States upheld [a] lower court [ruling] rejecting the charge of misbranding.15

Available in a large number of products for drinking, snorting, or injection, all the elements needed to insure cocaine’s outlaw status were present by the first years of the twentieth century: it had become widely used as a pleasure drug and doctors warned of the dangers attendant on indiscriminate sale and use; it had become identified with despised or poorly regarded groups—black, lower-class whites, and criminals; it had not been long enough established in the culture to ensure its survival; and, it had not, though used by them, become identified with the elite, thus losing what little chance it had for weathering the storm of criticism.16

The regulatory actions against the manufacture, sale, distribution, and use of cocaine eventually taken by the United States were at variance with the drug’s wide acceptability. When the Harrison Narcotic Act (1914) was used as a means of controlling drug addiction during the Prohibition era of the 1920s in the United States, cocaine became less available and more expensive. During this period [c]ocaine was soon accepted by musicians, songwriters, singers, and the smart film/theatre set generally; cocaine became indelibly connected in the public mind with jazzier elements in every branch of show-biz including the brand new radio scene. . . . In Europe, during the late 1920’s, cocaine [had] strong connections [with] sex, jazz, night clubs, and high-class prostitution.17

Cocaine’s use further declined in the 1930s with the introduction of inexpensive and easily available amphetamine substances, and did not increase again until the end of the 1960s, when amphetamines became harder to obtain.18 Three factors have been pointed to as contributing to an increase of demand. They include: (1) there was a law-enforcement initiative against American-made amphetamines. This had an immediate effect on demand for the more natural imported product, cocaine; (2) jet aircraft revolutionized travel between the Southern states in the United States and the Caribbean and Latin America. The five years 1970–75 saw twenty times the passenger-traffic into the U.S. from the South compared with the five years 1950–55; and (3) there was a strong revolt in the 1960s against any suggestion that government had the right to prescribe what people should or should not consume.19 During the early 1980s, cocaine abuse in the United States maintained epidemic status. Estimates from the National Household Survey on Drug Abuse indicate that in 1994 there were 1.4 million active cocaine users in the United States. European countries, in comparison, did not experience dramatic increases in cocaine abuse,

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but in the last few years there has been a progressive increase in the number of crack abusers.20 According to a study released by the White House of national drug control policy, European nations led by Spain, Germany, and Italy consumed between 194 and 207 tons of cocaine in 1999. That marks an increase from 1996 consumption reports of beween 104 and 110 tons.21 Crack Until the late 1970s, the usual form of cocaine available on the street was cocaine hydrochloride, a salt form of cocaine that is usually sniffed (snorted) nasally or injected intravenously when mixed with water. Since the hydrochloride salt is quickly destroyed at high temperatures, it cannot be smoked unless it is in a freebase alkaloid form. Freebase cocaine is generally prepared by one of two ways. One method is to mix the hydrochloride salt with buffered ammonia, then the extract alkaloidal cocaine from the solution using ether, and then evaporate the ether to yield cocaine crystals. When heated, the crystals make a popping sound, and this characteristic sound is the origin of the term “crack.” This form of cocaine is very pure and is generally called “freebase” on the street. The other method of producing freebase cocaine is to combine cocaine hydrochloride and sodium bicarbonate (baking soda) and heat the solution until a solid forms. The resultant pieces of the solid, also called “rock,” when heated release vaporized cocaine.22 Since the mid-1980s, this has been the preferred method of production for smokable cocaine because it is simpler and safer than the ether extraction method. Today, most of the available crack cocaine in the United States has been produced in this manner.23 For the last decade or so a lump, or rock, of crack cost about $10, which made it available to the poor.24 Market factors in cocaine distribution were responsible in part for the development and merchandising of crack. A glut in raw cocaine in the early 1980’s led to a substantial drop in wholesale powdered cocaine prices. . . . The discovery that smokable cocaine could be simply manufactured using safe and readily available substances and relatively low quality cocaine was a marketing breakthrough. For several dollars, an intense smokable cocaine high could be obtained. . . . [From its initial start] crack began to [find] its way to the poor minority neighborhoods [such as] New York and Detroit . . . and by the end of 1986, it was available in twenty-eight states.25

Cocaine and crack have become synonymous with the so-called “War on Drugs.” In 1982, the U.S. government allocated $200 million for a major initiative it thought would mark a turning point in the battle against drug violations and crime. Only seven years later, the government was promising $2.2 billion to finance its “war.” Newspapers and magazine articles at that time reported the crack situation as follows: Gangs that run the crack business, more fiercely armed and violence-prone than traditional racketeers, intimidate whole communities. In city after city, police report a startling rise in shootings of innocents struck by stray bullets . . . the criminal justice system, struggling to

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cope with crack-related crime, lacks energy and resources for everything else. And the numbing cost of more police, courts and especially prisons sucks away funds from education, health, housing and infrastructure. . . . [P]romiscuous sex in crack houses has become a powerful factor in the spread of AIDS. Overdoses, injuries and other health emergencies related to crack increased ten-fold from 1985 to 1987. The burden has pushed many urban clinics and hospitals to the brink, threatening all patients. The popularity of crack among women drags children into the drug problem on a scale never seen before. Intensive care for damaged babies born to crack-addicted women already costs $2.5 billion a year. Florida estimates it must spend $700 million to get the 17,500 crack babies born in 1987 ready for kindergarten. Everywhere, crack has generated an ugly wave of child abuse whose victims will lay heavy claim to social services the rest of their lives.26

In 1990, it was noted that at least 375,000, or 11 percent of all newborns in the United States had been exposed to drugs in utero. Crack cocaine was the primary addiction of pregnant women. Many of these babies start their lives with serious handicaps. . . . [T]hey are likely to be born prematurely . . . more likely to have hydrocephaly (water on the brain), poor brain growth, kidney problems and apnea (when babies suddenly stop breathing). . . . [T]hey are also more likely to have suffered an infarct of the brain—similar to a stroke. . . . [As these children develop they have been found to be] either extremely irritable or very lethargic, have poor sucking abilities that hamper feeding and irregular sleep patterns . . . they may be hyperactive, slow in learning to talk and have trouble relating to other people.27 Unlike heroin, crack is popular with women. When they abuse it, they devastate their children as well as themselves. Such a child has been described as “a mere patch of flesh with a tangerine-sized head and limbs like splinters. Intensive hospital care for each crack baby costs about $90,000. That translates to $190 million a year in New York. For the nation, the figure is $2.5 billion.”28

The crack baby situation appeared to be the “mother-lode of all drug problems” stretched to the limit by an imaginative media force. It has been noted: In 1987 . . . [p]eople began bracing for the arrival of a permanent subhuman biological underclass [of cocaine babies]. . . . But . . . the expected tidal wave . . . failed to materialize. . . . [The facts were] that a jittery preemie born to a malnourished, abused woman who drinks and smokes could hardly be laid at the feet of cocaine. Women who use cocaine while pregnant also drink more booze, smoke more cigarettes, and dip into more kinds of other drugs. They have poorer nutrition and health and are more often exposed to violence. Rather than cocaine . . . those children were “victims of gross neglect.”29 According to an analysis of data from 36 studies on prenatal cocaine use that appears in the Journal of the American Medical Association, the “crack baby” is a myth. It is now suggested that poverty and use of tobacco, alcohol and other drugs while pregnant are at least as likely as cocaine to cause developmental problems in young children.30

By best estimates, 2.4 million Americans have tried crack, but contrary to the myth of instant and total addiction, less than half a million now use it once a month

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or more. And even among the current users, there are more occasional smokers than chronic abusers.31 The irony of this situation is that it is somewhat parallel to an earlier cycle of cocaine use that occurred around the turn of the century: early acceptance as benign, a growing awareness of its dangers and side effects, and finally, regulatory measures taken to control it. It has been suggested that the public is now in the second stage of this recurring cycle.32 Furthermore, it has been noted that: although crack is a relatively serious drug, easy and cheap to manufacture and distribute with high addiction potential, the reaction of policy makers to its emergence was too overreaching and not in balance with the prevalence of crack use or its real effects on overall crime rates. . . . What are the reasons for the harsh and immediate response to crack? First, crack emerged in the midst of an evolving concern about violent crime. . . . Second, crack first emerged among minority residents of the inner cities, the source of most people’s fears about crime. Third, intense media coverage of crack and its effects generated great concern. Fourth, crack emerged in the midst of a 1986 political campaign that was already gearing up to be strongly anti-drug. Finally, the same dynamics that drove previous drug epidemics and consequent public and media focus drove the response to crack—on a lesser scale, the newspaper stories about crack could have appeared earlier, with the name of the drug changed to heroin (1960s), LSD (early 1970s), PCP (late 1970s), powdered cocaine (early 1980s), or even marijuana (1930s).33

The last sentence of this quote is also relevant to the attention being given to methamphetamine (late 1990s) and ecstasy use now. TRENDS United States Cocaine use is a public health problem. Among the physical health problems linked to its use are strokes and heart attacks as well as thinking and memory disorders.34 Cocaine has also been liked to high-risk behaviors including those of a sexual nature.35 After marijuana, cocaine is the second most commonly used illegal substance in the United States. In 1998, 23 million individuals or 11 percent of the country’s population over the age of 12 years reported cocaine use sometime in their life. Additionally, it has been reported that more than 4 million or 2 percent reported crack use in their lifetime.36 In many population centers throughout the United States the number of cocaine users appears to be stable or on the decline especially in terms of cocaine related deaths and toxicology mentions. A comparison of the estimated number of hospital emergency department (ED) cocaine/crack mentions in the first half of 1999 compared to the first half of 1998 show significant decreases in 7 out of the 20 community epidemiology work group (CEWG) sites.37 Nevertheless, cocaine and crack continue to account for sizable proportions of total ED mentions. In most cities, cocaine (and crack) remains a major—if not the most commonly reported—il-

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legal drug dealt with in emergency situations by medical personnel. As much as 20 percent or more of the cases treated are caused by cocaine and crack use. Drug Abuse Warning Network (DAWN): Drug abuse deaths most frequently involve drug overdoses, but they also include death in which drug usage was a contributing factor. The United States Office of Applied Studies (OAS) in the Substance Abuse Mental Health Services Administration (SAMHSA) is responsible for the operation of DAWN which provides information on the consequences of drug use in selected areas of the United States “as manifested by drug-induced or drug-related deaths reported by participating medical examiners and coroners.” . . . DAWN is an ongoing drug abuse data collection system. The major objectives of the system are: to identify substances associated with drug abuse episodes that are reported by DAWN-affiliated facilities; to monitor drug abuse patterns and trends and to detect new drugs of abuse and new combinations; to assess health hazards associated with drug abuse; and to provide data for national, state and local drug abuse policy and program planners.38 Among the DAWN findings reported (1997) are: cocaine was the drug most frequently reported by medical examiners participating in DAWN. It was mentioned in 45 percent of all cases; cocaine was ranked first among decedents age 18 to 25, 26 to 34, and 35 and over; cocaine ranked first among black and Hispanic decedents; in cases of accidental or unexpected death, heroin/morphine was the most frequently mentioned drug (54 percent).39 National Household Survey on Drug Abuse 1998 Findings:40 The National Household Survey on Drug Abuse is an annual survey conducted by SAMHSA. The survey is based on a nationally representative sample of the civilian, noninstitutionalized population in the United States age 12 years and older. Among the significant cocaine-related findings for 1998 are: an estimated 1.8 million (0.8 percent) Americans age 12 and older were current users. Cocaine use reached a peak of 5.7 million or 3 percent of the population in 1985; there were an estimated 595,000 (0.3 percent of the population) frequent cocaine users in 1998. Frequent use defined as use on 51 or more days during the past year, was not different than in 1997; the estimated number of occasional cocaine users (people who used in the past year but on fewer than 12 days) was 2.4 million. The number of users decreased from 1985 (7.1 million); the estimated number of current crack users was about 437,000 in 1998 and there have been no changes since 1988. The highest rate of current cocaine use was for those age 18–25 (2.0 percent); rates of current cocaine use were 1.3 percent for blacks, 1.3 percent for Hispanics, and 0.7 percent for whites in 1998. Men have a higher rate of current cocaine use than women (1.1 percent and 0.5 percent, respectively); and, current cocaine use rates were strongly related to educational status. Among adults age 18 and older, those who had not completed high school had a current use rate of 1.4 percent. The rate was 0.8 percent among those with a high school education, 0.7 percent among those with some college, and 0.5 percent among college graduates. The rate of cocaine use was highest among the unemployed, as 3.4 percent of unemployed adults (age 18 and older) were current cocaine users in 1998, compared with only 0.9 percent of full-time employed adults and 0.5 percent of part-time employed adults.

The following are highlights of the cocaine situation in the United States as reported by the National Institute on Drug Abuse.41

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Use Patterns: Smoking, typically crack, is the dominant route of administration—by far—among primary cocaine treatment admissions [throughout the United States]. . . . In Boston needle exchange workers continue to see some injecting drug users (IDUs) dissolving crack cocaine in vinegar or lemon juice, to be used most often in combination with heroin (“speedballing”). . . . In Washington, D.C., injection is also becoming a mode of crack administration (either alone or mixed with heroin in the form of a speedball), particularly when cocaine HCL is not available. . . . In Chicago, imposed drug paraphernalia laws to eliminate the sale of crack pipes have caused crack (rock) users to improvise using cans or bottles to smoke the drug . . . smokers commonly use a car antenna and a piece of scouring pad, as a screen, to smoke rock. The smoking of crack with metal “straight shooters,” which are usually car antennas, may cause problems with the lungs due to the metal alloys from the antennas. . . . Route of administration varies by social and demographic characteristics of the treatment population. For example, in Newark, smoking was reported by 78 percent of the black cocaine treatment admissions, 39 percent of the whites, and 46 percent of Hispanics. In New York, crack smokers, compared with cocaine inhalers or snorters are more likely to be female and Afro-American. Multisubstance Use: As in previous years, alcohol and marijuana generally remained the most frequently reported secondary and tertiary drugs of abuse among primary cocaine treatment administrations. Crack/marijuana combinations are reported in some areas. In Chicago, for example, drug users prepare “diablitos” or “primos” according to individual preferences rather than buy them on the streets; they are known as “turbos” in Philadelphia; in Miami, “geek joints” are a declining fad among young people. A “bazooka” in Chicago is crack and tobacco in a joint. Crack users in Philadelphia frequently use marijuana, alprazolam (Xanax), or diazepam. In Austin, some users dip crack in formaldehyde to produce a more intense high. Demographics: (Age) New youthful cocaine users are not—for the most part—showing up in standard indicators. Mortality demographics continue to reflect an older cocaine-using population. . . . Likewise, DAWN data continue to suggest an aging cohort of cocaine users, with a few exceptions that bear watching. Since the early 1990’s, the 35+ age group has accounted for a growing percentage of cocaine [hospital emergency department mentions]. Between 1995 and 1997, that older group’s representation increased by 5 or more percentage points in nine cities. . . . By 1997, the 35+ age group constituted 50 percent or more of cocaine mentions in 11 cities and the second largest age group among cocaine mentions in all the other cities. . . . Correspondingly, in almost every instance, all the younger age groups have been declining as a percentage of cocaine ED mentions. . . . ADAM arrestee urinalysis data in most CEWG cities similarly suggest that younger users are not being recruited into cocaine use at rates high enough to replace current older users. (Gender) Life time, past year and past month cocaine use is more common among males than females, but when broken down by age, gender differences are not always found. Overall, 1998 results show that males were about twice as likely as females to be past year and past month cocaine users. While female cocaine users account for between 17 and 30 percent of the mortality demographics in major cities, males account for the majority of deaths, emergency department mentions and cocaine treatment admissions . . . in all locations throughout the United States. (Race/Ethnicity) Whites generally predominate in available cocaine mortality

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data. . . . African Americans account for the majority of cocaine ED mentions. . . . Overall, and for those age 12–25 and 26–34, whites have a higher lifetime use of cocaine than blacks and Hispanics. Also, there appear to be no differences by race/ethnicity for past year use, but past month use tends to be higher among blacks and Hispanics than whites. (Educational Attainment and Current Employment) In the total population, past year and past month use were more likely, based on 1998 information, among those with less than a high school education than [among] those who had attended or graduated from college. Unemployed adults used cocaine at higher rates than employed adults. Approximately 19 percent of unemployed adults reported that they used cocaine at least once in their lives; 6 percent had used it in the past year, and 3 percent were currently using cocaine. Law Enforcement Data: (Availability, Price, and Purity) Crack and cocaine hydrochloride (HCL) prices and purity have increased [or at least remained stable in most major population centers]. [In certain locations such as Chicago and Seattle] stiff competition . . . has resulted in marketing schemes such as “2-for-1” sales and free-sample giveaways. . . . Vials for packaging crack are increasingly being replaced by cellophane wrappers in New York City and by small plastic bags (known as “CDs”) in Philadelphia. (Crime and Violence). . . . Ethnographic data [from Atlanta, Minneapolis, and Denver] show an increase of crack sales and abuse as well as drive-by shootings, and car jackings among members of several gangs, which results in an increase of random violence and deaths. Drug-related homicides . . . in areas where crack is sold . . . continue to involve handguns and gang activity. Crack Cocaine Use: An estimated 4.5 million Americans ages 12 or older had used crack in their lifetime, and an estimated 1 million used it in the past year (1997). Those age 26 to 34 were most likely to have used crack cocaine in their lifetime (4 percent) and those age 12 to 17 least likely to have done so. Males, more than females, use crack and its use is more common among blacks than either whites or Hispanics. In the total population, those living in the West are more likely to report past year use than those in the Northeast and North Central regions. In general, less education was associated with a greater likelihood of crack use. Past year crack use also was more common among unemployed persons than among those employed.

International Worldwide, it is estimated that some 13 million people abuse cocaine. The highest prevalence exists in the United States while a large number of Latin American countries also have considerable numbers of people who abuse cocaine and “bazuco” (coca paste). “Trend data suggest that the spread of cocaine abuse was strong in the Americas in the mid-1980’s, lost momentum in the early 1990’s and started to rise again in the middle of the 1990’s, notably in and around the coca leaf producing countries. The main trends over the period of 1995 to 1997 have been a stabilization of cocaine abuse in the main markets of North America, and strong increases in the Andean and neighboring countries, and along the trafficking routes to North America and Europe. The strongest spread, however, was observed in Europe although the increase was less significant than the increase in [synthetic]

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amphetamine-type stimulants abused there.”42 The following description is a brief review of the cocaine and crack situation in a number of countries throughout the world (U.S. National Institutes of Health, NIDA, 1999).43 Australia: The Australian Bureau of Criminal Intelligence reports that, as a result of the stabilization of the United States cocaine market traffickers are seeking out alternative sites. This may account for the increase in cocaine use [principally in Sydney]. . . . Cocaine is cheapest [reflecting a drop in price in cities such as Sydney, Melbourne, and Adelaide] at $200 per gram. . . . Purity levels have generally increased . . . [reaching] 64 percent in 1998. . . . [A] disturbing trend has been observed in Sydney: heroin injectors have been increasing their injection of cocaine. . . . Cocaine use in other major centers such as Brisbane, Melbourne, and Adelaide remains very low. (pp. 33–34) Canada: The prevalence of cocaine/crack use is low in the general population. Based on [survey information], less than 2 percent of the Canadians use powder cocaine or crack cocaine. The prevalence of use among adolescent students ranges from 2 to 6 percent. . . . [T]he use of powder cocaine and crack is more common among particular segments of the population who are not easy to reach by conventional methods such as telephone and school surveys. Street youth in particular are at risk to cocaine/crack use. In Vancouver, 85 percent of the street youth reported having used cocaine, more than half reported frequent use, and 48 percent of the male and 32 percent of the female street youth reported injection use. Among street youth in Toronto, about 31 percent used powder cocaine and 31 percent used crack over the course of a year. In Montreal, about 32 percent and 18 percent of the street youth respectfully, used powder cocaine and crack in the month prior to the survey. (pp. 40–41) Europe: Surveys suggest that the prevalence of cocaine use (mostly sniffed on an occasional basis) is lower than the use of amphetamines or ecstasy but higher than heroin use. . . . Increases in seizures and other supply indicators, as well as falling prices over the 1990’s, suggest a continuing steady growth in the cocaine market across the [European Union]. While this trend is not reflected in survey data on use, indicators of problem cocaine use, such as treatment demand, show increases in several countries. . . . [T]he proportions of treatment demand involving cocaine as a primary drug are generally under 10 percent. Cocaine is more commonly recorded as a secondary drug in heroin addicts. (pp. 53–54) Mexico: [It has been reported that] cocaine users in 1998 were mostly males (89.2 percent); more than one-third (38.9 percent) were ages 15 to 19 . . . more than half (57 percent) were of middle-low socioeconomic status; 47.7 percent initiated cocaine use between ages 15 and 19; and more than one-third used cocaine once a week (38.9 percent) or daily (37.8 percent). Among patients [of government treatment centers] cocaine ranked fourth as the first drug used (13 percent) and first as the primary drug of abuse (41 percent). (pp. 60–61) South Africa: Cocaine powder is primarily snorted, whereas crack is smoked. Across [locations], prices of cocaine range from $29 to $49 per gram. [There is] extensive use and marketing of crack by sex workers . . . often in combination with Mandrax to come down from a “crack high.” (pp. 79–80)

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THE COCAINE USER: PERSONALITY AND OTHER CHARACTERISTICS Many users of illicit drugs experience psychological dependence, physical dependence, and drug addiction as a result of the harmful substances they use. Cocaine is not addictive in the same way that heroin and other opiates are, but its potential for creating psychological dependence nevertheless may be high, especially in the form of crack. The symptoms of heavy opiate use (especially of heroin) give rise to the concept of drug addiction. In some ways the symptoms of cocaine use mimic those of heroin use, but in other ways they do not. Frequent cocaine users are clearly characterized by compulsive use and psychological dependence. They are not characterized by the physical dependence of heavy opiate use. The distress associated with cocaine withdrawal is suggested to be more psychological than physiological.44 Different drugs are used in different ways. For example, the effects related to drug use are slowest for swallowing and sniffing and fastest for smoking and injection. Intravenous injection deposits drugs directly into the brain. Drugs inhaled in smoke are absorbed by blood vessels in the lungs and carried to the brain. The physical effects of cocaine are felt within 30 seconds after intravenous injection. The high from smoking cocaine begins within 8 seconds and is more intense and short-lived than the high from other modes of use. While cocaine can be sniffed or snorted, smoked, swallowed, or injected, it has been found that about 90 percent of those who use cocaine sniff or snort the substance, 30 percent tend toward smoking it, and 10 percent swallow the drug.45 Among the total household population age 12 or older who have used an illegal substance, 33 percent used marijuana and/or hashish in their lifetimes; cocaine is the second most common substance tried. About 12 percent of the illicit drug users have tried cocaine and about 2 percent have tried crack. These figures compare with the less than 2 percent who have ever used heroin.46 In terms of the amount of money spent on illegal drugs, even with the decreased pattern of use currently reported, cocaine ranks first. In 1990, the Office of National Drug Control estimated that drug consumers in the United States spent $18 billion for cocaine compared to $12 billion for heroin, $9 billion for marijuana, and $2 billion for other drugs.47 COCAINE: THE LATIN AMERICAN PLAGUE The primary location for coca leaf, the source for cocaine hydrochloride and crack, is Peru’s Upper Huallaga Valley. In terms of total production, it has been estimated that Peru produces 63 percent, Bolivia 26 percent, and Colombia 10 percent of the coca which was about 1,000 tons of net production (less local consumption and seizure) in 1991, according to the U.S. State Department’s annual International Narcotics Control Strategy Report. “In Peru, Bolivia and Colombia, an estimated 1 million people, including farmers and laborers, grow coca leaves and process and export cocaine products; in Peru, as many as 60,000 families are thought to depend on coca growing for their livelihood; and in Bolivia, an estimated 350,000 to 400,000 people, 5–6 percent of the population, are directly

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employed in the cocaine industry.”48 At the growing and harvesting stage, those involved are simple farmers and rural laborers who are out to earn an income by growing a crop long consumed without great danger. “They know full well they are breaking the law, but that is unfortunately common in societies with large informal sectors that have been forced by government rules to operate outside the law.”49 The income from the cocaine industry grew in the late 1970s and early 1980s. Such a rise was associated with the deep economic troubles of Bolivia and Peru in terms of government deficits and rampant inflation. A vicious cycle was created for these two countries when the price for coca leaf soared while the legal economy was in a state of decline. In order to temporarily hide conditions, the Bolivian and Peruvian governments created massive overemployment in the government and in loss-making state-owned enterprises. With the major population centers no longer able to absorb migrants from the overcrowded and resource poor highlands, “it could be argued that [poor people] from the highlands had little choice but to move to the coca-growing regions, greatly increasing the labor available to grow coca.”50 Cocaine production has proven to be a profitable undertaking for the farmer and trafficker; nevertheless, it has had serious negative effects on Latin American societies. Among the problems include: direct economic costs—governments have been forced to spend more of their scarce resources on the police, courts, and military; indirect economic costs—legal industry has been displaced, there has been a loss of control over economic policy, and governments’ inability to tax the cocaine industry has forced them to tax legal industries more heavily; social costs—while less prevalent than in the United States, cocaine consumption in Latin America is on the rise, causing an increase in social problems; ecological costs—poisonous chemicals are used in the production of cocaine and vast quantities are dumped into rivers. For example, turning coca leaves into coca paste requires the use of kerosene, sulfuric acid and sodium bicarbonate; making a cocaine base out of a coca paste requires sulfuric acid, potassium permanganate, and ammonia hydrochloride; and turning the cocaine base to powered cocaine necessitates the use of ethyl ether, acetone, and hydrochloric acid. Of course other substitute chemicals can be used in the process. For each kilogram of cocaine, between 65 and 130 gallons of kerosene and smaller amounts of the other chemicals are required.51 Also, the growing of coca on steep slopes causes erosion and destruction of forests; and political costs—the cocaine industry undermines fragile social democracies and weakens the ability to maintain law and order as well as to curb corruption and terrorism.52 The need to bring cocaine to its principal market, the United States, has generated a considerable amount of ingenious illegal import activity. One courier had a half pound of cocaine surgically implanted under the skin of each of his thighs. The cocaine was divided into four one-square-inch packages of one-quarter pound each. Cocaine has been carried across the border in Arizona on the backs of mules or horses or on foot. Variable amounts of cocaine have been containerized and shipped out of Ecuador with such products as shrimp, cacao, and bananas. Tons of cocaine have been shipped from Venezuela to Miami inside concrete fencing

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posts; in false-bottomed metal boxes labeled as toilet seats and bathroom sinks; in counterfeit bottles of Pony Malta de Bavaria; in 55-gallon drums of guava pulp with the cocaine in plastic packets inside the fruit; in cardboard boxes packed with canned fruit stuffed with cocaine; in anchovy cans shipped from Argentina; in stuffed teddy bears, Peruvian handicrafts, and cans marked asparagus. Panamanian cocaine smugglers have developed a new technology that combines cocaine with vinyl to produce a material that has been used in making luggage and sneakers. The cocaine is separated from the vinyl after reaching its destination. Cocaine has been smuggled in suitcases hidden behind interior panels of airplanes; hidden in a secret tank within the fuel tank of a cabin cruiser; and packed in 1 kilogram lots and placed inside a plastic pipe which was bolted to the bottom of a banana boat docked in Bridgeport, Connecticut Harbor. It has been sewn into the interior roof of a family station-wagon and transported during a family vacation; transported in a false compartment in the floor of a mobile home; and concealed in the gas tank of a car equipped with a baffle which made the left side a separate compartment.53 With the disintegration of the former Soviet Union in the late 1980s came opportunities to expand the network of Russian-speaking drug operations throughout the world. This development, including the Russian mafia-like organization in the United States was documented in an article that appeared in the New Yorker magazine titled “Land of the Stupid: When You Need a Used Russian Submarine Call Tarzan.” The following describes, in part, an ingenious scheme to transport cocaine (as well as other drugs). Until recently, the No.1 Russian crime figure in Miami was Ludwig Fainberg. . . . [He] was in the midst of executing the most audacious caper yet: the purchase of a hundred-million dollar Soviet-era diesel-powered submarine for the “people associated with the late Pablo Escobar.” [Escobar had been hunted down and killed by Colombian authorities in December 1993.] . . . Fainberg [was] taken to the front gate of Kronstadt, a sprawling naval base in the Baltic, where numerous abandoned diesel submarines bobbed on their sides, leaking oil, fluid, and battery acid into the harbor. Richard Palmer, who was a C.I.A. station chief in the former Soviet Union, [said] that at such bases “anything is available—the Soviet Fleet is rotting, and the sailors haven’t been paid for months. . . . Initially, the Miamians wanted to buy a huge attack submarine for Escobar’s East Coast drug trade. But a retired Russian submarine captain whom Fainberg nicknamed the Admiral suggested that they operate on the West Coast, where America’s anti-submarine net was less active. According to the D.E.A., a Russian active-duty officer suggested that Fainberg and his associates buy a small, diesel-powered Piranha-class submarine. Made of titanium and much quieter than other models, the Piranhas are used to plant saboteurs, troops, and spies behind enemy lines. But the Colombians considered the Piranha too expensive, and they wanted a submarine with greater range. . . . They finally agreed on a three-hundred foot long Foxtrot-class submarine, a model manufactured between 1958 and 1984 with a range of several thousand miles. It could disappear for days at a time and resurface, when required to deliver drugs. Drug lords calculated that it could carry up to forty tons of cocaine.54

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COCAINE HIGHLIGHTS Numerous stories, editorials, and other public reports relating to the cocaine and crack cocaine problem reveal interesting perspectives of the substance. The following highlights, chronicled, have been collected over the last 15 years from respected newspapers and magazines (the New York Times, International Edition of the Herald-Tribune, Newsweek, and others). Then: 1986–1993 Kids and Cocaine [C]ocaine abuse is the fastest-growing drug problem in America for adults and school-age children alike. . . . The new coke . . . is smoked, not snorted, and the resulting intoxication is far more intense than that of snorted cocaine—much quicker, much more addictive . . . there is no such thing as the “recreational use” of crack. . . . Crack is simply a variant on “freebasing,” which is the conversion of sniffable cocaine crystals into a smokable “base” form of the drug . . . the process is so simple it can be performed in any kitchen. Dealers make crack by mixing cocaine with common baking soda and water, creating a paste that is usually at least 75 percent cocaine. The paste hardens and is cut into chips that resemble soap or whitish gravel. A small piece, sometimes called “a quarter rock,” produces a 20 to 30 minute high. It is usually smoked in water pipes. . . . [A] single dose [of crack] sells for as little as $10 to $15. . . . Like fast food, it’s a quick-sale product. [Because] it transforms the occasional user into an addictive user, it is much more likely to yield a repeat customer. . . . Big city ghettos [are] infested with rock houses: also known as crack houses or base houses, they are the centers of the new cocaine trade. . . . In many respects, crack houses are the modern-day equivalent of opium dens—and the clientele includes young people from the suburbs as well as the city and from virtually every level of society. (T. Morganthau, Newsweek, March 32, 1986, pp. 40–45)

Getting Tough on Cocaine: The U.S. Is Losing the War America’s struggle against cocaine is much more like the war in Vietnam. As in Vietnam, the United States is fighting an adversary that is adept as concealing itself among the civilian population and operating from safe havens across international borders. As in Vietnam, the United States has misspent billions, botched both strategy and tactics, and consistently underestimated the enemy. And as in Vietnam, America is slowly losing the war. There is one vital difference, of course: this time the United States cannot pull out. Cocaine and crack are among the most addictive substances . . . [that] will not disappear—and probably will not decline significantly—as long as supplies are abundant and prices are low. [M]any critics . . . believe that the solution to America’s cocaine problem will ultimately be found on the “demand side”—by some combination of prevention, treatment and deterrence aimed at the cocaine-consuming public. That hope . . . will almost certainly prove illusory. . . . Prevention . . . works—but only up to a point. . . . [L]egalization is an enormous social gamble—and it is a policy that is at least partly rooted in indifference toward the addicted. Opponents are unanimous in predicting that the increase in addiction, over time,

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would be very large [and costly]. . . . Prevention would be one of the least expensive items in a drug war strategy. . . . The only problem is that many [programs] aren’t doing it well enough. (T. Morganthau and M. Miller, Newsweek, November 28, 1988, pp. 41–43)

Hour by Hour: Crack The plague feeds on junkies and cops, hookers and babies—and all of us. It’s another nation in our midst, and the misery is getting worse. . . . [T]wo Americas. . . . In 1985 a jumbo crack vial cost $40 in New York, but only $15 today. . . . Drug crimes have filled America’s prisons. . . . Drug cases have inundated the justice system. . . . Among young adults, 6.7 percent have tried crack and 40 percent cocaine. (J. Adler, et al., Newsweek, November 28, 1988, pp. 34–40)

The Newest Drug War Drug rings in Eastern cities are supplying small town contacts with increasing quantities of cocaine and crack. . . . For the first time, violent crime and other big-city problems have come to some corners of rural America. . . . Crack exploded onto the drug scene in the big Eastern cities in 1985, and just a year later it showed up in many Southern towns. (J. Baker and P. King, Newsweek, April 3, 1989, pp. 36–37)

Back in the High Life The American public no longer needs convincing that cocaine can destroy its users. . . . The barons’ rise to prominence is a classic ’80s success story. They displayed an uncanny ability to read the market and resorted to price discounting and easy credit—“inventory” was advanced to U.S.-based wholesalers, a low risk proposition since nonpayment meant death. . . . The drug lords had help from high places. A succession of governments was neutralized by payoffs—Panama, the Bahamas, Nicaragua, Colombia . . . big bucks, coupled with [the U.S.] national appetite for getting wasted, suggest a long war. Middle-class drug consumption may be down, but the arrival of crack has created an even larger pool of interested customers. (R. Rivard, Newsweek, May 22, 1989, pp. 52)

Cocaine Manufacturing Is No Longer Just a Colombian Monopoly [R]ural Peru is . . . the heart of the world’s biggest coca growing area . . . the business of refining and exporting cocaine [was] spreading beyond Colombia to other countries in South America . . . modern laboratories [were] turning up in Bolivia, another country previously known mainly as a source of coca leaves and coca paste and in the remote jungles of Brazil and Venezuela; ports in Argentina, Brazil, Venezuela and Suriname [became] smuggling outlets and money laundering [was] on the rise in Ecuador and Uruguay. . . . A business that has been confined largely to three countries [blossomed] in at least nine . . . [the] problem [was] virtually out of control. (J. Treaster, New York Times, June 30, 1991, p. 5)

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20 Years of War on Drugs, and No Victory Yet Standing on a bleak corner in the South Bronx [New York City] littered with old heroin syringes and empty crack vials, it [was] hard to imagine that the United States [poured] nearly $70 billion into fighting drugs in the last 20 years. . . . Each president since Mr. Nixon [threw] more money into the battle. But the problem [persisted]. (J. Treaster, New York Times, June 14, 1992, p. 7)

Why There’s No Methadone for Crack Since crack was invented, sending robbery and murder rates soaring again, politicians and drug experts have wondered aloud where the methadone equivalent for it is. . . . [B]ut nothing on the shelf that chemically resembles cocaine . . . has helped cocaine addicts in studies. The main reason is that heroin is a narcotic while cocaine is a stimulant. The cravings are different. A heroin addict takes his drug, gets calm, then waits a few hours before he wants it again . . . cocaine addicts tend to go on binges. . . . Heroin fits into a receptor meant to receive endorphines, the body’s natural painkillers. (D. McNeil, Jr., New York Times, June 14, 1992, p. 7)

Cocaine Comes Home On Friday the 13th in March 1992, emergency rooms in western Caracas confronted an unprecedented horror. Scores of patients streamed in around midnight, their faces blue, their breathing labored. Within hours many lay dead. . . . There [were] a group of jibaros—drug dealers—[who] had mixed heroin with cocaine in one-gram straws. Sold . . . for $12 and taken with alcohol, it became what Venezuelans called “the cocktail of death.” . . . Drug abuse [had not] reached the levels of the United States, where almost 10 percent of the population [used] illegal substances. Still [in Latin America] the rates of increase [were] greater than anyone was prepared for. . . . Before the [U.S. invasion that ousted General Manuel Antonio Noriega], cocaine cost $50 per gram. [In 1993] it [was] $3; crack [was] 50 cents per rock. Usage [was] so heavy that the drug paraphernalia business [was not able to] keep pace. Addicts [resorted] to crafting home made crack pipes from automobile antennas. . . . Venezuela and Panama [enjoyed] a flood of foreign investment since 1990, but real wages and jobs [dropped]. High times at the top and despair at the bottom have helped stoke drug abuse. (T. Padgett, Newsweek, March 29, 1993, pp. 23–26)

Recent Past and Now Heroin Is Proving a Growth Industry for Colombia As the number of cocaine users in the United States has declined, from an estimated 6 million a decade ago to 2.1 million currently, the number of heroin users has begun to increase. . . . While Colombia produces only 1.5 percent of the world’s heroin. . . . [Drug Enforcement Administration purchases] suggest that 91 percent of the heroin sold on the streets of New York, Newark, Philadelphia and Boston comes from South America, mainly from Colombia. (D. Schemo, New York Times, International Edition, March 30, 1997, p. 4)

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War on Crack Retreats, Still Taking Prisoners More people are behind bars for drug offenses in the United States—about 400,000—than are in prison for all crimes in England, France, Germany and Japan combined. . . . Some experts argue what might seem obvious: that high incarceration rates deserve the credit for falling crime rates. . . . What happened across the board is that police started going after small-time street dealers and users. . . . Crack never became a mainstream drug, but the fear of it changed perception and laws for virtually all illicit drugs. . . . For people convicted of a crack offense, the world of justice is unlike any other. Crack is simply cocaine processed so that it can be smoked. But Federal law equates 5 grams of crack with 500 grams of powder cocaine, a 1-to-100 ratio that no other country recognizes. Possessing 5 grams of crack is a felony with an automatic five year prison term, while 5 grams of the same drug in powder form is a misdemeanor likely to carry no jail time. One consequence of the disparity is that kingpins at the top of a drug network who sell pounds of powder cocaine for processing often serve less time than street-level dealers who sell grams of crack. A higher percentage of blacks use crack cocaine than whites or Hispanic people. But in absolute numbers, twice as many whites as blacks use crack, and three times as many whites as blacks use powder cocaine according to a national household survey. . . . The racial disparity would disappear if the law treated the powder and crack form of cocaine equally. . . . Harsh laws responding to crack have not reduced overall drug use. . . . [And] we can’t incarcerate our way out of this problem. . . . More than a quarter-million Americans in prison for drug offenses, could be better dealt with in treatment programs. (T. Egan, New York Times, February 28, 1999, p. 1)

War on Crack Changed U.S., But Did It Help Cut Drug Use? Every 20 seconds, someone in the United States is arrested for a drug violation. Every week, on average, a new jail or prison is built to lock up more people in the world’s largest penal system. . . . Ten years ago, half as many people were arrested for drug crimes, and the nation’s incarceration rate was closer to those of other democracies. But in the 1980’s, crack cocaine scared the country, and the criminal justice system has never been the same. . . . Now the violence of the crack trade has burned out, and murder rates have plunged. Yet crack left its mark. . . . Crack prompted the nation to rewrite its drug laws, lock up a record number of people and shift money from schools to prisons. It transformed police work, hospitals, parental rights, courts. . . . In an age of government downsizing, the federal corrections budget has grown more than tenfold in a decade to nearly $4 billion. . . . What the prison boom has not done, however, is reduce illicit drug use, national surveys show. . . . Crack probably had more impact on the entire criminal-justice system than it had on the communities and the drug users. (T. Egan, New York Times Service, International Herald-Tribune, March 1, 1999, p. 2)

Bolivia, at Risk of Some Unrest, Is Making Big Gains in Eradicating Coca Bolivia has been a sponge for more than $500 million in international money to fight the drug trade, mostly paid by American taxpayers . . . [and] even the most optimistic United States officials concede that the gains in Bolivia, and similar ones in Peru, have made little

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or no impact on the availability of cocaine or its price or use in the United States, in large part because growers in Colombia have filled the gap. . . . Bolivians still grow about 70,000 acres of coca and earn $300 million a year from the drug. . . . In the years past, coca growers who were paid to dig up their bushes and grow pineapples and bananas typically took the money, eradicated one coca field and then cultivated another deeper in the jungle. (C. Krauss, New York Times International, May 9, 1999, p. 6)

In States’ Anti-Drug Fight, a Renewal for Treatment A dozen years after the national alarm over crack speeded the discarding of drug treatment in favor of punitive laws that helped create the world’s largest prison system, drug policy is taking another turn. Treatment is making a comeback, driven largely by a grass-roots revolt. . . . But at least 40 states are giving judges and prosecutors discretion within existing laws to steer offenders toward treatment instead of jail through drug courts. . . . While not all addicts respond to treatment . . . it was nonsense . . . that crack addicts were untreatable. . . . Treatment is built around the person, not the drug. It involves rebuilding a life, in contrast to prison, where the concept of rehabilitation has been all but abandoned. . . . Prison should be for violent people and the recalcitrant. (T. Egan, New York Times, June 10, 1999, p. 1)

For Latin America, a Boomerang Effect on Illegal Drugs Consumption of illicit drugs in Latin America still does not approach the levels in the United States, which remains the world’s biggest consumer by far. But the percentage of drug users here is growing fast. . . . One report from Brazil estimates that the cost of medical care for drug addiction soared to $2.9 billion in 1997 from 902 million in 1993. At the same time, the percentage of AIDS cases from intravenous drug use rose 25 percent in 1998 from 2.5 percent in 1985. In Lima, bazuco, a derivative of coca paste smoked like crack cocaine, can be bought for 10 cents a dose—the lowest price in three years. . . . In Buenos Aires, cocaine powder sells for $5 to $20 a gram, about half its price in the 1980’s and a bargain compared with $80 to $150 on the streets of Washington. (A. Faiola, Washington Post Service, International Herald-Tribune, September 16, 1999, p. 2)

Shades of Vietnam: Heading for Trouble in Colombia Although President Clinton seems unaware of it, [the] $1.6 billion he is requesting to fight coca production in Colombia amounts to intervention in another country’s civil war. Neither the president nor the secretary of state has given the American people any coherent explanation of what is at stake in Colombia or how massive military assistance can do anything but make matters worse. . . . Although there is $145 million for crop substitution, the emphasis will continue to be an aerial spraying of herbicides to destroy the coca leaf. . . . It is curious that a government [i.e., the U.S.] as sophisticated as ours should cling to the naive belief that spraying the herbicides can do anything but drive the campesino cultivators deeper into the jungle. The campesinos grow coca not just because it commands bonanza prices but because the traffickers’ planes land nearby and pay cash on the barrelhead. (R. White, a former ambassador

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to El Salvador and Paraguay and president of the Center for International Policy in Washington, DC, Washington Post, February 8, 2000, p. A23)

Dangerous Plans for Colombia Colombia is Latin America’s most complex and troubled country. Its two overwhelming problems—a booming trade in cocaine and heroin, and a vicious, nearly 40-year old civil war—are threatening not just Colombia, but neighboring countries, including Venezuela, one of the largest suppliers of oil to the United States. Now the Clinton administration has unveiled a $1.3 billion plan to help Colombia, including $955 million in security assistance. . . . The plan reflects neither a realistic strategy to fight illegal drugs nor an effective long-term approach to establish peace and stability. Instead it risks dragging the United States into a costly counterinsurgency war. . . . Colombia produces 80 percent of the world’s cocaine and about two-thirds of the heroin consumed in the United States. Administration officials insist that the security assistance would be aimed primarily at fighting drug trafficking and not at counterinsurgency operations against leftist guerilla groups. But in many areas of Colombia the distinction is meaningless. (New York Times, Editorial, February 13, 2000, p. 16)

Crack Country Kids in the country are more likely to use illegal drugs than city kids. And not just slightly more likely, either. Thirty-four percent more likely to smoke dope. Fifty percent more likely to use cocaine. . . . [M]any people still don’t understand that rural America is poor America, and that country poor is different from city poor—different in a way that makes kids desperate for a psychedelic change of scenery. (W. Kirn, New York Times Magazine, February 13, 2000, pp. 15–16)

Cocaine Quietly Reclaims Its Hold as Good Times Return While a good many cocaine users and experts maintain that the drug never really went away, and national surveys and other numbers suggest that cocaine use is at least holding steady, there is strong anecdotal evidence to suggest that powder cocaine use is edging up as it undergoes a renaissance among the well-dressed and well-fed. . . . Cocaine is back for the 30- and 40-year olds. . . . Crack is considered to be highly addictive and synonymous with people down on their luck. Powder cocaine, due to its higher price, implies a certain social strata. It’s become the drug of choice for the so-called recreational user. . . . The rebound in cocaine use can be traced to two causes, and both of them have their roots in money. . . . The boom times on Wall Street have spurred the use of the drug, and so have falling cocaine prices. There is a worldwide glut in the cocaine market. (C. LeDuff, New York Times, August 21, 2000, p. B1)

Fights Rage over Colombian Drug Plan Even before it begins, the Colombian government’s U.S. backed anti-drug plan is changing lives in the heart of coca-growing country, plunging this frontier [region] into the worst season of armed conflict residents can remember. . . . The [Colombian] government plans to

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spend [millions but the] program has virtually no support in the [region]. Farmers here have asked for such improvements for decades to help get their yucca, plantain, rice, and other legal crops to market, and have seen little response. The most recent development, a nearby hearts of palm processing plant, sits unfinished and abandoned. (S. Wilson, Washington Post Service, International Herald-Tribune, October 16, 2000, p. 3)

Colombian Police Find Drug Sub Colombian police . . . discovered that a submarine was being built in a warehouse outside the capital of Bogota to smuggle cocaine . . . the sophisticated submarine was being built by Colombian drug traffickers with the help of American and Russian experts. The 100 foot submarine would have been able to cross an ocean, surface off coastal cities and secretly unload its cargo . . . up to 200 tons of cocaine. (Join Together Online (JTO), Boston University School of Public Health, September 15, 2000)

Colombia Anti-Drug Program Loses Major Supporter [C]hairman of the [U.S. Congress] House International Relations Committee has abruptly withdrawn his support from the decision to funnel $1.3 billion in mostly military aid to Colombia, arguing that the United States is on the brink of a “major mistake.” [In his letter] to the White House drug policy coordinator, General Barry McCaffery, [he] contended that the U.S. plan to increase the role of the Colombian military in the drug fight will end disastrously, because the military has undermined its political support after a history of corruption and human rights abuses. (C. Marquis, New York Times Service, International Herald-Tribune, November 18–19, 2000, p. 9)

Rebels Biggest Players in Narcotics Trade Marxist rebels in Colombia have become the dominant force in the narcotics trade and are the reason for Colombia’s increased cocaine production. . . . “They’ve got thousands of people with automatic weapons down there and it’s going to be tough going. . . . [T]here was little incentive for the [rebels] to put down [their] arms as long as it was bringing in an estimated $500 million to $1 billion a year in profits from production and trafficking in cocaine. . . . [There is likely to be] a giant increase in production [according to White House drug policy director Barry McCaffery]. (JTO, November 21, 2000)

How We Fight a Losing War Colombia is now taking full advantage of its resources and climate; there, too, [as in Mexico,] the war on drugs is being lost. . . . There are no winners. . . . What is the purpose of investing hundreds of millions of dollars in the fight against drugs, plunging countries into civil war, strengthening guerilla groups and unleashing enormous violence and corruption upon entire societies. . . . In the end, legalization of certain substances may be the only way to bring prices down, and doing so may be the only remedy to some of the worst aspects of the drug plague: violence, corruption and the collapse of the rule of law. . . . Using present tactics, the war on drugs is being lost; it is long past time to reassess a failed policy. (J.

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Castaneda, nominated Foreign Minister of Mexico, Newsweek, September 2, 2000 as reprinted from www.narconews.com, November 24, 2000)

Fox: U.S. Corruption Contributes to Drug Smuggling Mexican President Vicente Fox said corruption in the United States plays a major role in cross-border drug smuggling . . . “billions and billions of dollars generated by drug consumption comes from the United States. And those billions of dollars are used to bribe Mexican officials or Mexican policemen. Let’s face that we both have a problem, that each one of us has it, and let’s meet it together.” (JTO, November 28, 2000)

NOTES 1. Doyle, A. (1938). The sign of the four. In The Complete Sherlock Holmes. New York: Garden City Publishing, pp. 91–92. 2. Hobhouse, H. (1999). Seeds of Change. London: Papaermac, p. 299. 3. Taylor, N. (1949). Flight from Reality. New York: Duell, Sloan and Pearce, p. 17. 4. Freud, S. (1974). Uber coca. In R. Byck (ed.), Cocaine Papers. New York: Stonehill Publishers, pp. 49–73. 5. Hobhouse, p. 300. 6. Brain, P., and Coward, G. (1989) A review of the history, actions, and legitimate uses of cocaine. Journal of Substance Abuse, (1):431–451. 7. Antonil, C. (1978). Mama Coca. London: Hassle Free Press. 8. Goode, E. (1989). Drugs in American Society, Third Edition. New York: McGraw-Hill, p. 194. 9. Hobhouse, p. 294. 10. Andrews, G., and Solomon, D. (eds.) (1975). The Coca Leaf and Cocaine Papers. New York: Harcourt Brace Jovanovich; Hobhouse, p. 309. 11. Perry, C. (1972). The star-spangled powder. Rolling Stone, August 17, p. 26. 12. Hobhouse, pp. 309–310. 13. Ray, O., and Ksir, C. (1990). Drugs, Society and Human Behavior. St. Louis, MO: Times Mirror/Mosby, pp. 224–225; Huisking, C. (1968). Herbs to Hormones. Essex, CT: Pequot Press, p. 138. 14. Cornish, J., and O’Brien, C. (1996). Crack cocaine abuse: An epidemic with many public health consequences. Annual Review of Public Health, (17):260–261. 15. Ray and Ksir, pp. 225–226. 16. Ashley, R. (1975). Cocaine: Its History, Uses and Effects. New York: St. Martin’s. 17. Hobhouse, p. 338. 18. Ray and Ksir, p. 129. 19. Hobhouse, p. 342. 20. Cornish and O’Brien, pp. 262–263. 21. Join Together Online (JTO) (2000). Cocaine use increases in Europe. Boston University School of Public Health, Boston University, July 13. 22. Jaffe, J. (1990). Drug addiction and drug abuse. In A. Gilman, T. Rall, A. Nies, and P. Taylor, (eds.), The Pharmacological Basis of Therapeutics. New York: Pergamon, pp. 522–545. 23. Cornish and O’Brien, pp. 259–260.

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24. Ray and Ksir, pp. 134–135; Belenko, S. (1993). Crack and the Evolution of Anti-Drug Policy. Westport, CT: Greenwood Press, pp. 3–4. 25. Belenko, pp. 4–6. 26. New York Times (1989). Some war; meanwhile, crack undermines America. September 24, p. 6 (IE). 27. Kantrowitz, B. (1990). The crack children. Newsweek, February 12, pp. 50–51. 28. New York Times (1989). Crack: A disaster of historic dimension, still growing. Editorial, May 28, p. 6IE. 29. Gray, M. (1998). Drug Crazy. New York: Random House, pp. 108–110. 30. “Crack baby” term wrong, study says (2001). International Herald-Tribune, Wednesday, March 28, p. 3. 31. Martz, L. (1990). A dirty drug secret. Newsweek, February 19, pp. 44–45. 32. Ray and Ksir, pp. 135–136. 33. Belenko, p. 7. 34. Bolla, K., Cadet, J., and London, E. (1998). The neuropsychiatry of chronic cocaine abuse. Journal of Neuropsychiatry and Clinical Neurosciences, 10(3):280–289; Kaufman, M., Levin, J., Ross, M., Lange, N., Rose, S., Kukes, T., Mendelson, J., Lukas, S., Cohen, B., and Renshaw, P. (1998). Cocaine-induced cerebral vasoconstriction detected in humans with magnetic resonance angiography. Journal of the American Medical Association, 279(5):376–380; Mittleman, M., Mintzer, D., Maclure, M., Tofler, G., Sherwood, J., and Muller, J. (1999). Triggering of myocardial infraction by cocaine. Circulation, 99(21):2737–2741. 35. Durant, R., Krowchuk, D., Kreiter, S., Sinal, S., and Woods, C. (1999). Weapon carrying on school property among middle school students. Archives of Pediatrics and Adolescent Medicine, 153(1):21–26; Shrier, L., Emans, S., Woods, E., and Durant, R. (1997). The association of sexual risk behaviors and problem drug behaviors in high school students. Journal of Adolescent Health, 20(5):377–383; U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA) (1998). National Household Survey on Drug Abuse, Main Findings, 1998, DHHH Publication No. (SMA) 00-3381, pp. 47–58. 36. Office of Applied Studies, SAMHSA (1996). Preliminary Estimates from the 1995 National Household Survey on Drug Abuse (Advance Report No. 18, DHHS Publication No. SMA 96-3107). Rockville, MD: Author; U.S. Department of Health and Human Services, SAMHSA, National Household Survey on Drug Abuse, Main Findings, 1998, p. 47; National Institutes of Health and National Institute on Drug Abuse (NIDA) (1999). Epidemiological Trends in Drug Abuse, Vol. 1: Proceedings of the Community Epidemiology Work Group. Bethesda, MD: NIH Publication Number 00-4530, pp. 15–29. 37. National Institutes of Health and NIDA (2000). Epidemiological Trends in Drug Abuse, Advance Report, CEWG Publications, Rockville, MD: NIDA, p. 5. http://www.NIDA.NIH.gov/EWG/advancedRep/6. 38. Office of Applied Studies, Substance Abuse and Mental Health Services Administration (SAMHSA) (1999). Drug Abuse Warning Network Annual Medical Examiner Data, 1997, DHHS Publication No. (SMA) 00-3377. Rockville, MD: SAMHSA. 39. Office of Applied Studies, SAMHSA. 40. Office of Applied Studies, SAMHSA (1999). Summary of Findings from the 1998 National Household Survey on Drug Abuse, DHHH Publication No. (SMA) 99-3328, Rockville, MD: SAMHSA.

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41. NIDA (1996). Epidemiological Trends in Drug Use, Vol. 1. Rockville, MD: NIDA, pp. 13–14; U.S. Department of Health and Human Services, SAMHSA, National Household Survey on Drug Abuse, Main Findings, 1998, pp. 47–58; National Institutes of Health and NIDA (1999), Epidemiological Trends Vol. 1, pp. 15–29. 42. U.S. National Institutes of Health, NIDA (1999). Epidemiologic Trends in Drug Abuse, Vol. II: Proceedings of the International Epidemiology Work Group on Drug Abuse. Bethesda, MD: NIH Publication Number 00-4530, p. 136. 43. U.S. National Institutes of Health, NIDA, Epidemiologic Trends, Vol. II. 44. Bureau of Justice Statistics (1992). Drugs, Crime and the Justice System: A National Report. U.S. Department of Justice, Washington, DC, p. 21. 45. Ibid., p. 24. 46. Health and Human Services, SAMHSA, National Household Survey on Drug Abuse; Bureau of Justice Statistics, p. 27. 47. Bureau of Justice Statistics, p. 36. 48. Ibid. 49. United States Information Agency (1992), Consequences of Illegal Drug Trade: The Negative Economic, Political, and Social Effects of Cocaine in Latin America, p. 8. 50. Ibid., p. 9. 51. Drug Enforcement Agency (1991). Coca Cultivation and Cocaine Processing: An Overview. February, p. 8.; Bureau of Justice Statistics (1992), op. cit., p. 40. 52. United States Information Agency, pp. 2–3. 53. Bureau of Justice Statistics, p. 45. 54. Friedman, R. (2000). Land of the stupid: When you need a used Russian submarine call Tarzan. New Yorker, April 10, pp. 40–49.

Chapter 6

Marijuana: Is It Really a War of Values and Special Interests?

HISTORICAL PERSPECTIVE No illegal substance in the United States has generated more controversy and perhaps investigation in terms of impact on individual behavior and society than marijuana. The marijuana, cannabis, or hemp plant is one of the oldest psychoactive plants known to humanity. It . . . grows as weed and cultivated plant all over the world in a variety of climates and soils. The fiber has been used for cloth and paper for centuries and was the most important source of rope until the development of synthetic fibers. The seeds . . . have been used as bird feed and sometimes as human food. The oil contained in the seeds was once used for lighting and soap and is sometimes employed in the manufacture of varnish, linoleum, and artist paints. . . . The chemical compounds responsible for the intoxicating and medicinal effects are found mainly in a sticky golden resin excuded from the flowers on the female plants. . . . The plants highest in resin . . . grow in hot regions like Mexico, the Middle East, and India. . . . The three varieties are known as bhang, ganja, and charas. The least potent and cheapest preparation, bhang, is produced from the dried and crushed leaves, seeds, and stems. Ganja, prepared from the flowering tops of cultivated female plants, is two or three times as strong as bhang. . . . Charas is the pure resin, also known as hashish in the Middle East. Any of these preparations can be smoked, eaten or mixed in drinks.1

“Cannabis may have been cultivated as long as ten thousand years ago. It was grown in China by 4000 B.C. and in Turkestan by 3000 B.C. It also has long been used as a medicine in India, China, the Middle East, Southeast Asia, South Africa

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and South America.”2 The earliest reference to cannabis is in a pharmacy book written in 2737 B.C. by the Chinese emperor Shen Nung. Referring to the euphoric effects of the substance, he called it the “liberator of Sin.” There were some medical uses, among which included “female weakness, gout, rheumatism, malaria, beriberi, constipation and absent mindedness.”3 By 1000 A.D. the social use of the plant spread to the Moslem world and North Africa, and in the region of the Middle East its use was associated with a religious cult that committed murder for political reasons. The cult was called Hashishiyya, from which the word “assassin” developed. Stories related to the substance involving intrigue, sex, and murder spread throughout Europe for centuries. French soldiers with Napoleon’s campaign in Egypt used hashish as did many other Frenchmen who worked for the government or traveled in the Near East during the nineteenth century. Also, during that time, hashish was used by writers like Baudelaire, Gautier, and Dumas as well as impressionistic artists. Among the descriptions of the experience are: The intoxication will be nothing but one immense dream . . . at first, a certain absurd, irresistible hilarity overcomes you . . . after a few minutes the relation between ideas becomes so vague, and the thread of your thoughts grows so tenuous, that only your cohorts . . . can understand you . . . next your senses become extraordinarily keen and acute. Your sight is infinite. Your ear can discern the slightest perceptible sound, even through the shrillest of noises. . . . The strangest ambiguities, the most inexplicable transpositions of ideas take place. In sounds there is color; in color there is a music. . . . This fantasy goes on for an eternity. A lucid interval, and a great expenditure of effort, permit you to look at the clock. The eternity turns out to have been only a minute. . . . The third phase . . . is something beyond description. It is what Orientals call kef; it is complete happiness. There is nothing whirling and tumultuous about it. It is a calm and placid beatitude. Every difficult question that presents a point of contention . . . becomes clear. Every contradiction is reconciled. Man has surpassed the gods.4

A considerable amount of medical attention was given to cannabis from 1840 to 1900 recommending it for a variety of illnesses and discomforts. Among its recommended uses were as an analgesic (in the form of tincture of hemp—a solution of cannabis in alcohol taken orally); as a topical anesthetic for the mouth and tongue; and for problems and discomfort related to tetanus, neuralgia, dysmenorrhea (painful menstruation), convulsions, rheumatic and childbirth pain, asthma, postpartum psychosis, gonorrhea, chronic bronchitis, preventing migraine attacks, certain kinds of epilepsy, depression, asthma, rheumatism, gastric ulcer, and drug addiction, particularly of morphine and other opiate substances.5 By 1890, the medical use of cannabis was on the decline. Among the reasons were that the potency of the preparations was too variable, and that the invention of the hypodermic syringe in the 1850s made opiates more effective in pain relief since hemp products are insoluble in water and cannot be easily administered by injection. Also, synthetic drugs such as aspirin, chloral hydrate, and barbiturates which are chemically more stable became attractive for medicinal purposes in spite of their disadvantages.

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In the 1930s, marijuana received considerable negative attention—specifically, that the substance “would cause users to go crazy and become violent; men would rape and kill under the influence, and women would become promiscuous. Publications from the period had titles such as ‘Marijuana—Sex-Crazy Drug Menace,’ ‘Marijuana—The Weed of Madness,’ and ‘Marijuana: Assassin of Youth.’ Today these supposed effects receive no attention even in the most vigorous anti-marijuana polemics.”6 “Almost no observer argues that, in a single episode of use, marijuana generates psychosis, violence, or sexual ‘excess’ in the typical user. These issues are simply no longer the focus of controversy. . . . While the acute effects were emphasized in the 1930’s, it is the chronic effects that have become the center of attention today.”7 Generally speaking, little attention was given to marijuana during the early part of this century. There were references, however, linking the substance to Mexican Americans. “The prejudices and fears that greeted peasant immigrants also extended to their traditional means of intoxication—smoking marijuana.” Also, police officers in Texas claimed that marijuana incited violent crimes, aroused a “lust for blood,” and gave its users “superhuman strength.” Rumors spread that Mexicans were distributing the “killer weed” to unsuspecting American schoolchildren; and, sailors and West Indian immigrants were reported to have brought the practice of smoking marijuana to port cities along the Gulf of Mexico. In New Orleans, newspaper articles associated the drug with African-Americans, jazz musicians, prostitutes, and underworld whites. The ‘Marijuana Menace,’ as sketched by anti-drug campaigners, was personified by inferior races and social deviants.8

Curiously, in 1931, the Commissioner of Narcotics, Harry Anslinger, said that up to that year the Bureau of Narcotics had little on file about marijuana;9 yet, the Treasury Department stated that there was considerable public interest, mostly aroused by the newspaper articles, on the evils of marijuana abuse. This publicity magnified the issue spreading alarm about the improper use of the drug, when in reality the issue may not have been a significant problem.10 The early 1930s were a turning point for marijuana. In fact, it is reasonable to say that the war on marijuana began at that time with public opinion being shaped by Anslinger, who has been likened to J. Edgar Hoover in terms of having conservative, staunchly anticommunist, law-and-order values and idiosyncrasies that were strongly imposed on their federal bureaucracies and personnel. Anslinger did not believe in a public-health approach to drug addiction; he dismissed treatment clinics as “morphine feeding stations” and barrooms for addicts. In his view, strict enforcement of the law was the only proper response to illegal drug use; he urged judges to “jail offenders, then throw away the key.” [It is interesting to note that] in his memoir, The Murderers, Anslinger confessed to having arranged a regular supply of morphine for “one of the influential members of Congress,” who had become an addict. Anslinger’s biographer believes that addict was Senator Joseph R. McCarthy.11

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By 1935 there were 36 states with laws regulating the use, sale, and/or possession of marijuana and by the end of 1936 all 48 states had similar laws. In 1937, Congressional hearings were held and Anslinger stated that “traffic in marijuana is increasing to such an extent that it has come to be the cause for the greatest national concern.”12 This position was precipitated by police reports, newspapers and popular literature linking marijuana to violent crime, psychosis, and mental deterioration.13 Among the statements were that marijuana makes the smoker vicious, with a desire to fight and kill, and that marijuana smokers are key suspects in horrible crime and perversion.14 In spite of articles that contradicted this position (e.g., the chief psychiatrist at Bellevue Hospital in New York City stated that the probable cause for the assaults was alcohol and not marijuana),15 Anslinger pressed on and the film Reefer Madness, made as part of his campaign, was regarded as a serious attempt to influence public opinion and to shape policy.16 Indeed it did and evidence reveals it was done based on hearsay, little or no experimentation or reference to scientific undertakings, myth and distortion of reality.17 Why? Among the reasons were that the Great Depression made people sensitive and wary of any new and particularly foreign influences; lower-class Mexican Americans and African Americans who had initiated use of the drug made the drug even more dangerous to the white middle-class; and the substance was associated with crime and murders committed by the cult Assassins.18 This campaign led to acceptance of the Marijuana Tax Act of 1937 that “did not outlaw cannabis or its preparations; it just taxed the grower, distributor, seller, and buyer and made it, administratively, almost impossible to have anything to do with [the substance].”19 Once in place, the Marijuana Tax Act was credited with the immediate dramatic reduction of violent crimes committed under the influence of marijuana and the price of a marijuana cigarette, over a few years, increased 6 to 12 times to about a dollar.20 After the passage of the legislation, a number of significant events took place that contribute to further understanding the dynamics at play regarding marijuana use. Among the most significant were the findings by the New York Academy of Medicine in 1944 that marijuana impairs intellectual and physical functioning of an individual but does not affect the basic personality of the person and over time those who have been smoking marijuana show no mental or physical deterioration which may be attributed to the substance. Marijuana smoking did not lead to addiction in the medical sense of the term, nor was it a gateway to harder drugs. There was no evidence whatsoever that it was widespread in school yards or being used by children. And contrary to the belief that marijuana smokers were aggressive and belligerent, the investigators found the opposite. When one of the committee members visited a Harlem smoking den, he said the people seemed relaxed and “free from the anxieties and cares of the realities of life.” And finally, they found no significant relationship between marijuana and juvenile delinquency, and interviews with the police debased the idea that major crimes were inspired by smoking the weed. In summary, “the publicity concerning the catastrophic effects of marijuana in New York City is unfounded.”21 Strong reaction from the American Medical Association claimed that the New York study was too narrow and that sweeping and inadequate conclusions were

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drawn from an unscientific foundation that minimized the harm caused by marijuana use.22 Since the La Guardia Report (i.e., the New York Academy of Medicine’s study which resulted in a book called Marijuana Problems by [the] New York City Mayor’s Commission on Marijuana) is in substantial agreement with [other] comprehensive reports in the 1970’s by the governments of New Zealand, Canada, Great Britain, and the United States, in addition to the 1981 report to the World Health Organization and the 1982 report by the National Academy of Sciences to the Congress of the United States, it is likely that the conclusions of the La Guardia Report were and are for the most part valid.23

Using the threat “that the real menace to America was not communist troops but communist opium, [Anslinger] warned that the Red conspiracy was out to destroy the West not with force, but with needles. . . . The payoff was immediate. Congress opened the vaults, and the Bureau [of Narcotics]’s budget was doubled over the next five years. . . . [However], cash alone [was not] enough. Anslinger had been lobbying for tougher laws all along [so he added a new charge,] this time against the judicial system [claiming] the problem could be laid at the feet of lenient judges.”24 The 1950s were marked by a continuing rise in the fortunes of Anslinger with a groundswell of politicians (e.g., Congressman Hale Boggs of Louisiana and Senator and Governor Price Daniel of Texas) jumping on the antidrug bandwagon for their own gain.25 It was not until the John and Robert Kennedy leadership presence in the early 1960s that a decision was made to rein in Harry Anslinger and force his resignation or retirement, depending on one’s perspective. In many respects, a review of Anslinger and his followers reflects what can be achieved by manipulation of facts and appealing to the public by generating concern and fear about minority groups, work, sex, violence, and children. Anslinger molded drug policy, especially related to marijuana, by his mastery of public opinion—no doubt. In the 1970s, the antimarijuana forces appeared to be on the defensive especially since the drug had been decriminalized in 11 states making up a third of the nation’s population. Fearing a growing epidemic was taking place in the nation, Senator James Eastland conducted a series of Senate subcommittee hearings on the Marijuana-Hashish Epidemic and Its Impact on the United States Security.26 These hearings, in a manner similar to those used by Anslinger 40 years earlier, brought together witnesses and researchers who shared one factor in common, that they had something negative to say about marijuana. “Any researcher who had conducted a study showing that marijuana was not harmful was not invited to deliver testimony. [And Eastland stated,] ‘we make no apology . . . for the one-sided nature of our hearings—they were deliberately planned that way.’ ”27 The claims, most of which were not able to stand up to retest validation, concluded that marijuana caused brain damage, massive damage to the entire cellular process including chromosomal abnormalities, adverse effects on the reproductive process causing sterility and impotence, cancer, and a life of lethargy called the “amotivational syndrome.” Eastland’s response to the testimony and reports was

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that if the “cannabis epidemic continues to spread . . . we may find ourselves saddled with a large population of semi-zombies.”28 In contrast to the biased and mostly inaccurate information presented at the Eastland hearings, Sussman et al. (1996) provide a detailed analysis of the negative consequences of marijuana. The results show that the most well-confirmed danger from marijuana use is lung damage (and probably lung cancer). . . . A second potential negative consequence is that marijuana use appears to reduce the effectiveness of the immune system, although it may be a temporary reduction. . . . Third, it apparently impairs biosynthesis of nucleic acids and proteins which may disrupt selective attention and long term memory encoding if used over several years. . . . A fourth potential consequence includes pregnancy-related effects such as low birth weight and pre-maturity, although the data are equivocal. . . . Fifth, very high doses produce a toxic delirium, (especially if eaten) the symptoms of which include confusion, agitation, disorientation, loss of coordination, and hallucinations. . . . A sixth potential, but unconfirmed, consequence of chronic marijuana use is that it reduces one’s motivation to accomplish goals. . . . [Seventh, marijuana] has been found to be associated with a lower sperm count; however, this association may be temporary. . . . An eighth consequence is that adult users report subjective difficulties. These difficulties [may include], impairment of memory, concentration, motivation, self-esteem, interpersonal relationships, health, employment and finances, safety, and pregnancy. . . . Ninth, marijuana use also has been investigated as a stepping stone drug . . . to other hard drugs and their related negative consequences. . . . A tenth potential consequence is that marijuana may be addictive. Psychological dependence (e.g., conditioning effects) appears to be more important than physical dependence regarding withdrawal of use. . . . Finally, [the substance] effects coordination that may place users at risk for accidents. THC [trans-delta-tetrahydrocannabinol, which is the primary psychoactive agent in marijuana] is found in the blood of more than 30% of fatally injured drivers, and more than 50% of persons stopped for reckless driving show detectable levels of marijuana, or marijuana and another drug, tested in urine.29

A substantial amount of evidence has accumulated about the relatively benign consequences of marijuana use. Additionally, the significant benefits of marijuana use in the treatment process for cancer, AIDS, and other serious illnesses are widely acknowledged and are being addressed through such action as state legislation, for example, the overwhelmingly approved (California) Proposition 215—the Compassionate Use Act of 1996 which has made it possible for any “seriously ill” Californian to obtain marijuana upon the recommendation of a physician.30 In spite of the body of knowledge available about marijuana and state level actions being taken, federal opposition to marijuana use in any form has remained strong. In the wake of 215’s passage and the Arizona legislative initiative that allows doctors to prescribe any drug for legitimate medical purposes and mandates treatment, not incarceration, for those arrested for illegal drug possession,31 General Barry McCaffrey, director of the Clinton White House’s Office of National Drug Control Policy, began calling for “science not ideology” to settle the medical marijuana debate. McCaffrey ordered a comprehensive National Academy of Sciences review of the literature on the subject, but the timing of the study led many marijuana advocates to dismiss the measure as a tactic to delay any substantive re-

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form of the issue. Even so, McCaffrey’s call for more science was significant since it initiated a process drawing attention to facts about marijuana including its benefits. A similar review was conducted during the Carter administration lending support to the medical use of marijuana. This conclusion, however, was suppressed by government officials.32 Clearly, changes in policy are being made toward the use of marijuana, as evidenced in state referendums and laws, the nature of policing the problem, and judicial sentencing practices. Nevertheless, such policy and regulatory actions will be effective only to the extent to which those responsible for applying and enforcing laws are prepared to accept change. In California and Arizona, certain government officials provide ample evidence that they will ignore or find ways of subverting law, as the Narcotics Bureau under the U.S. Department of the Treasury did with the 1925 Supreme Court’s Linder v. U.S. decision that dealt with narcotics use for medical treatment purposes. In Europe the Netherlands, Belgium, and Switzerland are demonstrating that the time has come to no longer have the “made in America” problem their problem. MARIJUANA: THE FACTS—WHO AND WHAT TO BELIEVE? There is an abundance of information regarding the characteristics of marijuana. What is known about the substance tends to be presented in ways that are contradictory, supporting the special interests of those who advocate legal regulation of marijuana because of its alleged harmful effects or who advocate legalization because of its helpful and benign characteristics. The following comparison of government reports (G.R.) and Internet information sources (I.S.) including excerpts drawn from a 1999 report from the National Academy of Sciences (NAS) and the Marijuana Policy Project Foundation based in Washington, DC (www.mpp.org) provides an interesting analysis of what is communicated about marijuana.33 Comparison of Government Reports and Information Sources Is Marijuana More Potent Today Than in the Past? G.R.—Cannabis is a term that refers to marijuana and other drugs made of the same plant. Strong forms of cannabis include sinsemilla, hashish and hash oil. All forms of cannabis are mind-altering (psychoactive) drugs; they all contain THC (delta-9-tetrahydrocannabinol), the main active chemical in marijuana. They also contain more than 400 other chemicals. Marijuana’s effect on the user depends on the strength or potency of the THC it contains. THC potency has increased since the 1970’s but has been the same since the mid-1980’s. The strength of the drug is measured by the average amount of THC in test samples confiscated by law enforcement agencies. Most ordinary marijuana contains, on average, 3 percent THC. Sinsemilla (made from just the buds and flowering tops of female plants) contains, on average, 7.5 percent THC, with a range as high as 24 percent. Hashish (the sticky resin from the female plant’s flowers) has an average of 3.6 percent THC, with a

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range as high as 28 percent. Hash oil, a tar-like liquid distilled from hashish, has an average of 16 percent THC, with a range as high as 43 percent. I.S.—Contemporaneous, independent assays of unseized “street” marijuana from the early 1970s showed a potency equivalent to that of modern “street” marijuana. Actually, the most potent form of this drug that was generally available was sold legally in the 1920s and 1930s by the pharmaceutical company Smith-Klein under the name, “American Cannabis.”

Does Marijuana Lead to the Use of Other Drugs? G.R.—Long-term studies of high school students and their patterns of drug use show that very few young people use other illegal drugs without first trying marijuana. For example, the risk of using cocaine is 104 times greater for those who have tried marijuana than for those who have never tried it. Using marijuana puts children and teens in contact with people who are users and sellers of other drugs. So there is more of a risk that a marijuana user will be exposed to and urged to try more drugs. I.S.—The Dutch partially legalized marijuana in the 1970s. Since then, hard drug use—heroin and cocaine—have declined. . . . If marijuana really were a gateway drug, one would have expected use of hard drugs to have gone up, not down. This apparent “negative gateway” effect has also been observed in the United States. Studies done in the early 1970s showed a negative correlation between use of marijuana and use of alcohol. A 1993 Rand Corporation study compared drug use in states that had decriminalized marijuana versus those that had not. It was found that where marijuana was more available—the states that had decriminalized—hard drug abuse as measured by emergency room episodes decreased. From the National Academy of Sciences, Institute of Medicine’s 1999 report on marijuana, it has been noted that the substance “does not appear to be a gateway drug to the extent that it is the cause or even that it is the most significant predictor of serious drug abuse. This said, care must be taken not to attribute cause to association (p. 101). There is no evidence that marijuana serves as a stepping stone on the basis of its particular physiological effect (p. 99). A study, reported in the February, 2001 edition of the American Journal of Public Health, found that young people using marijuana are less likely to move on to hard drugs than once believed.” . . . Dire predictions of future hard drug abuse by youths who came of age in the 1990s may be greatly overstated.34

How Does Marijuana Affect Driving? G.R.—Marijuana has serious harmful effects on the skills required to drive safely: alertness, the ability to concentrate, coordination, and the ability to react quickly. These effects can last up to 24 hours after smoking marijuana. Marijuana can make it difficult to judge distance and react to signals and sounds on the road. . . . Marijuana may play a role in car accidents. In one study conducted in Memphis, TN, researchers found that, of 150 reckless drivers who were tested for drugs at the arrest scene, 33 percent tested positive for marijuana, and 12 percent tested positive for both marijuana and cocaine. Data have also shown that while smoking marijuana, people show the same lack of coordination on standard “drunk driver” tests as do people who have had too much to drink. I.S.—Marijuana . . . does impair performance in a manner similar to alcohol. . . . When a random sample of fatal accidents victims was studied, it was initially found that marijuana was associated with relatively as many accidents as alcohol. In other words, the

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number of accident victims intoxicated on marijuana relative to the number of marijuana users in society gave a ratio similar to that for accident victims intoxicated on alcohol relative to the total number of alcohol users. However, a closer examination of the victims revealed that around 85% of the people intoxicated on marijuana were also intoxicated on alcohol. For people only intoxicated on marijuana, the rate was much lower than for alcohol alone. This finding has been supported by other research using completely different methods. For example, an economic analysis of the effects of decriminalization on marijuana usage found that states that had reduced penalties for marijuana possession experienced a rise in marijuana use and a decline in alcohol use with the result that fatal highway accidents decreased.

Does Marijuana Cause Brain Damage? G.R.—Smoking marijuana causes some changes in the brain that are like those caused by cocaine, heroin, and alcohol. . . . It may be that marijuana kills brain cells. In laboratory research, scientists found that high doses of THC given to young rats caused a loss of brain cells such as that seen with [the process of] aging. At 11 or 12 months of age (about half their normal life span), the rats’ brains looked like those of animals in old age. It is not known whether a similar effect occurs in humans. I.S.—Studies of human populations of marijuana users have shown no evidence of brain damage. For example, two studies from 1977, published in the Journal of the American Medical Association (JAMA) showed no evidence of brain damage in heavy users of marijuana. The same year, the American Medical Association (AMA) officially came out in favor of decriminalizing marijuana. That’s not the sort of thing you’d expect if the AMA thought marijuana damaged the brain. . . . The 1999 marijuana study of the National Academy of Sciences report that “[e]arlier studies purporting to show structural changes in the brains of heavy marijuana users have not been replicated with more sophisticated techniques.” (p. 106)

Does Marijuana Damage the Reproductive System? G.R.—Findings so far show that regular use of marijuana or THC may play a role in some kinds of cancer and in problems with respiratory, immune, and reproductive systems. . . . It’s hard to know for sure whether regular marijuana use causes cancer. But it is known that marijuana contains some of the same, and sometimes even more, of the cancer-causing chemicals found in tobacco smoke. Studies show that someone who smokes five joints per week may be taking in as many cancer-causing chemicals as someone who smokes a full pack of cigarettes every day. I.S.—Studies of actual human populations have failed to demonstrate that marijuana adversely affects the reproductive system.

Does Marijuana Suppress the Immune System? G.R.—Our immune system protects the body from many agents that cause disease. It is not certain whether marijuana damages the immune system of people. But both animal and human studies have shown that marijuana impairs the ability of t-cells in the lungs’ immune defense system to fight off some infections. People with HIV and others whose immune system is impaired should avoid marijuana use. . . . Animal studies have found that THC can damage the cells and tissues in the body that help protect people from disease. When the immune cells are weakened, you are more likely to get sick.

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I.S.—Like the studies claiming to show damage to the reproductive system, this myth is based on studies where animals were given extremely high—in many cases, near-lethal—doses of cannabinoids. These results have never been duplicated in human beings. The National Academy of Sciences reports that “the short term immunosuppressive effects are not well established; if they exist at all, they are probably not great enough to preclude a legitimate medical use. The acute side effects of marijuana are within the risks tolerated by many medications.” (p. 126)

Other Medically Related Facts about Marijuana (National Academy of Sciences, 1999) What Conditions Can Marijuana Treat? The accumulated data indicate a potential therapeutic value for cannabinoid drugs, particularly for symptoms such as pain relief, control of nausea and vomiting, and appetite stimulation (p. 3). . . . For patients such as those with AIDS or who are undergoing chemotherapy and who suffer from severe pain, nausea, and appetite loss, cannabinoid drugs might offer broad-spectrum relief not found in any other single medication (p. 177). . . . The most encouraging clinical data on the effects of cannabinoids on chronic pain are from three studies of cancer pain. (p. 142)

What about Marinol, the Major Active Ingredient in Marijuana in Pill Form? It is well recognized that Marinol’s oral route of administration hampers its effectiveness because of slow absorption and patient’s desire for more control over dosing. (pp. 205–206)

Isn’t Marijuana Too Dangerous to Be Used as a Medicine? [E]xcept for the harms associated with smoking, the adverse effects of marijuana are within the range of effects tolerated for other medications (p. 5). . . . Terminal cancer patients pose different issues. For those patients the medical harm associated with smoking is of little consequence. For terminal patients suffering debilitating pain or nausea and for whom all indicated medications have failed to provide relief, the medical benefits of smoked marijuana might outweigh the harm. (p. 159)

Doesn’t the Medical Marijuana Debate Send Children the Wrong Message about Marijuana? In summary, there is no evidence that the medical marijuana debate has altered adolescents’ perceptions of the risks associate with marijuana use. (p. 104)

Isn’t Marijuana Too Addictive to Be Used as a Medicine? Some controlled substances that are approved medications produce dependence after long-term use; this, however, is a normal part of patient management and does not generally

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present undue risk to the patient (p. 98). . . . Animal research has shown that the potential for cannabinoid dependence exists, and cannabinoid withdrawal symptoms can be observed. However, both appear to be mild compared to dependence and withdrawal seen with other drugs (p. 35). . . . A distinctive marijuana and THC withdrawal syndrome has been identified, but it is mild and subtle compared with the profound physical syndrome of alcohol and heroin withdrawal (pp. 89–90). . . . In summary, although few marijuana users develop dependence, some do. But they appear to be less likely to do so than users of other drugs (including alcohol and nicotine), and marijuana dependence appears to be less severe than dependence on other drugs. (p. 98)

Marijuana Facts and Perspectives (“Marijuana Prohibition Facts—2001,” Marijuana Policy Protection Foundation) General Very few Americans have ever heard about marijuana when it was first federally prohibited in 1937. Today, nearly 70 million Americans admit to having tried it. . . . According to government funded researchers, the perceived availability of marijuana among high school seniors has remained high and steady despite decades of a nationwide drug war. With little variation, every year about 85% consider marijuana “fairly easy” or “very easy” to obtain.

Legal and Policy Perspectives There have been more than 12 million marijuana arrests in the United States since 1970, including a record 704,812 arrests in 1999. About 88% of all marijuana arrests are for possession—not manufacture or distribution. . . . Cultivation of even one marijuana plant is a federal felony. . . . Lengthy mandatory minimum sentences apply to a myriad of offenses. For example, a person must serve a five-year mandatory sentence if federally convicted of cultivating 100 marijuana plants. This is longer than the average sentences for auto theft and manslaughter. . . . Approximately 60,000 marijuana offenders are in prison or jail (June, 1999). . . . Civil forfeiture laws allow police to seize the money and property of suspected marijuana offenders—charges need not even be filed. The claim is against property, not the defendant. The property owner must then prove that the property is “innocent”—and indigents have no right to appointed legal counsel. Enforcement abuses stemming from forfeiture laws abound. . . . [It is] estimated that the war on marijuana consumers costs taxpayers more than $9 billion annually. . . . “Decriminalization” involves the removal of criminal penalties for possession of marijuana for personal use. Small fines may be issued (similar to traffic tickets) but there is no arrest, incarceration, or criminal record. Marijuana use is presently decriminalized in 10 states—California, Colorado, Maine, Minnesota, Mississippi, Nebraska, New York, North Carolina, Ohio, and Oregon. In these states, cultivation and distribution remain criminal offenses. . . . Decriminalization saves a tremendous amount in enforcement costs. California saves $100 million per year.

Medical Organizations that have endorsed medical access to marijuana include the AIDS Action Council, American Academy of Family Physicians, American Public Health Association,

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California Medical Association, California Society of Addiction Medicine, Lymphoma Foundation of America, National Association of People with AIDS, National Nurses Society on Addictions, the New England Journal of Medicine and others. . . . A few of the many editorial boards that have endorsed medical access to marijuana include: Boston Globe, Chicago Tribune, Miami Herald, New York Times, and USA Today.

SOCIAL, POLITICAL, AND ECONOMIC FACTORS LEADING TO POLICY FORMATION The social, political, and economic factors associated with marijuana, including those related to the passage of the Marijuana Tax Act of 1937 and the Eastland Congressional Hearings in 1974, raise a number of interesting and somewhat puzzling questions. Among them is the dramatic shift of attitude of narcotic and government officials, including Anslinger, toward marijuana use in a very short period of time. Such a turnaround was certainly not based on well documented and researched information. Regarding the link made between Mexicans and marijuana, themes of racism and national security may have been used to curb the influx of unwanted cheap labor. Since the early 1920s, Mexican immigration into the United States increased considerably especially to the states bordering Mexico. Mexican people were a cheap source of labor and were sought to develop large-scale agriculture in the South. Consequently, under pressure of both the Mexican government and large-scale farmers, Mexicans were not included in quota regulations.35 Nevertheless, “led by patriotic organizations [like the] American Legion, small farmers and labor unions, a passionate and racist campaign started against Mexicans.”36 In an environment wary from the Great Depression and being driven toward unionism, the connection of Mexican people and other minority groups and violence and marijuana became an effective strategy to promote legislation and regulatory actions that dealt not only with marijuana (e.g., Marijuana Tax Act of 1937) but also with immigration and migrant farm workers.37 In 1920, the Volstead Act brought about a total national prohibition on the sale of alcohol. The Volstead Act was passed because abstinence was identified with a prestigious and powerful group in American society. Prohibition failed because it was the powerful, prestigious middle class that abandoned abstinence as a legitimate and respectable way of life. Temperance ceased to be necessary to a respectable life; its symbolic connection with respectability was served. And lastly, the Depression loomed before the American public and the government, and relegalizing alcohol manufacture and sale brought with it the prospect of jobs and tax revenue.38

Marijuana was associated with an underclass, with marginalized populations labeled a threat to white middle-class safety and law and order. Nevertheless, marijuana may have been seen as a potential source of competition for profits to be reaped by the alcohol industry and state and federal governments. Now that it is known how far the tobacco industry would go to protect its interests, the question

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that arises is, to what extent may the alcohol industry have influenced government officials such as Anslinger, Eastland, and others, as well as law enforcement personnel, to protect its interests and profits by restricting the availability of marijuana in America? At the turn of the century numerous reports and personal experiences by physicians surfaced regarding the positive effects of marijuana for a range of illnesses. Parke-Davis and Company, a leader in pharmaceuticals, recognized the importance of marijuana. In spite of its practical applications and benefits, however, the substance was removed from the public scene once it was labeled an illegal drug. With a cheap and relatively effective medicine out of the way, drug companies were compelled to research and develop synthetic substances to address the needs of America’s unending appetite for pain remedies. In the process, drug companies acquired profits as well as a considerable degree of influence over the health care industry including perhaps medical associations (e.g., the California Medical Association that had failed to support Proposition 215). It appears that much was to be gained by the health care industry to have a useful, inexpensive drug like marijuana strictly regulated and, in fact, banished to the ranks of illegality. Drug producers and dealers, too, may be thought of as an interest group with something to lose if a soft policy toward marijuana use prevailed. With government controls to limit production and accessibility, the cost of the substance to the user would rise, creating greater profit for those involved with its sale. “If increased drug prices are seen as a success story, then the increase in marijuana prices is the greatest success”39—not only for government applying this criterion as a successful outcome of its efforts, but also for those seeking higher profits from growing and selling the substance. Any of the above-mentioned descriptions of self-interest may have played a role in the formation of marijuana policy and, more importantly, the ways in which regulations have been interpreted by police and the judiciary. One additional factor is surely worth consideration. That factor involves the process of problem creation and elements of legitimization to control and preserve the resources, status, and power of individuals and their followers. The creation of a problem put before the public may have begun in the 1920s with scare tactics that marijuana use caused violent behavior, its spread was a threat to national security, and it had infiltrated the schools putting the well-being of young people at risk. There was no well-documented evidence of these conditions as noted in testimony before the House Ways and Means Committee regarding the Marijuana Act of 1937. Dr. W. C. Woodward, a physician-lawyer serving as a legislative counsel for the American Medical Association, argued “for less restrictive legislation on the ground that future investigators might discover substantial medical uses for cannabis” and that there was little evidence to support the contention that marijuana was harmful.40 In his testimony, Woodward stated that newspaper accounts were not based on “competent primary evidence,” that the Bureau of Prisons had no evidence to show on the number of prisoners found addicted to marijuana, that contrary to statements that school children were the greatest users of marijuana cigarettes no evidence had been presented by the Children’s Bureau to show the nature and extent of the

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habit among children, and that inquiry of the Children’s Bureau showed it had no reason to investigate the issue. A similar response was presented concerning the position of the Office of Education.41 “His (i.e., Dr. Woodward’s) objections to the quality and sources of the evidence against cannabis did not endear him to the legislators.”42 Marijuana use came to be associated with people considered to be marginal to society, and Mexican Americans and African Americans became targeted as scapegoats for the problem. Also, there is much evidence that by government officials manipulated information for use by the media—“saying bad things [by the press] about drugs is never questioned, and disconfirming information never requires revision of original claims.”43 Other means used to strengthen the government’s policy toward marijuana included controlled congressional testimonies; denouncement of reports such as those produced in New York for Mayor La Guardia, as well as other professionally prepared studies on marijuana; the subjective application of law in terms of adjudication procedures such as minimum mandatory sentencing and the application of civil forfeiture statutes passed by Congress in the 1980s;44 and the “strong-arm” tactics used by supporters of government-sponsored anti-drug programs against those who questioned and challenged the effectiveness of efforts such as the Drug Abuse Resistance Education program (DARE).45 In sum, the process of problem and people manipulation regarding marijuana use may have been used by Anslinger, Eastland, and others to promote their self-interests at a considerable expense to society and the suffering of many. TRENDS Generally, patterns of marijuana use over the last 20 years or so do not indicate that government efforts have been successful in reducing or controlling the use of the substance. “The encouraging downturn in drug use of the early 1980’s halted in 1985 [not just among adolescents but among college students and young adults as well]. . . . The use of marijuana, for example, fell from 37% in 1978 to 25% in 1984, a one-third decline, and daily marijuana use fell proportionally even more over the same interval, from 11% in 1975 to 5%; however, both declines halted in 1985.”46 In 1992, “among youth 12–21 years of age, controlling for differences in age composition, 26.5 percent of adolescent current [cigarette] smokers reported marijuana use in the previous 30 days.”47 Since 1992, teenage marijuana use has grown considerably. By one measure it has doubled. “But that increase cannot be attributed to any slackening in the enforcement of the nation’s marijuana laws. In fact, the number of Americans arrested each year for marijuana offenses has increased by 43 percent since Clinton took office. There were roughly 600,000 marijuana-related arrests nationwide in 1995—an all-time record. More Americans are in prison today for marijuana offenses than at any other time in our history. And yet teenage marijuana use continues to grow.”48

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In 1995, a study conducted by the Partnership for a Drug-Free America tracked attitudes toward drugs in 1994 among 8,520 children and 822 parents across the United States. It was found that teenagers were more tolerant about marijuana, and this trend was attributed, in part, to a glamorization of drugs in pop music, movies, and television shows and to an absence of national and community leadership in discouraging experimentation with drugs. Teenagers were found less likely to consider drug use harmful and risky and more likely to believe that drug use is widespread and tolerated and to feel more pressure to try illegal drugs than teens did just two years prior to the study. In response, an expert (Dr. Lloyd Johnston) described the resurgence as a case of “inter-generational forgetting” as adolescents who learned the dangers of drugs grew up and moved on. “Each new generation needs to learn the same lessons about drugs if they’re going to be protected from them.”49 In another study conducted on substance use in the United States, it was found that the highest rates of past-month marijuana use were found among high school dropouts, particularly those living with parents, and college students not living with parents. Also, it was found that college students were not more likely than high school graduates to use marijuana.50 From the prevailing evidence, the culture of cannabis has grown. Among the reasons are more efficient agriculture, including new methods of harvesting and producing marijuana plants—the substance has been reported to be more potent than what was on the streets in the 1960s and 1970s; the generation that laughed through “Reefer Madness” may be ignoring new findings about the nature of addiction and the effect marijuana has on memory, the lungs, and the immune system; and perhaps because earlier messages about the dangers of marijuana were so overheated and hyperbolic that serious research of recent years has not received attention or acceptance.51 Drawing from the National Institute on Drug Abuse report Epidemiologic Trends in Drug Abuse, (1986, 1999)52 the following information relates to the patterns and problems associated with marijuana use: Emergency and Treatment Data: “Its use among adolescents is common, approaching that of cigarettes among older students. . . . [C]annabis is as available as alcohol via the loose-knit, informal buying networks at school and among friends. . . . [O]bservations by emergency department physicians suggest that marijuana is rarely the cause of a [hospital emergency department] visit, but it is frequently mentioned as a secondary drug.” [Excluding alcohol], marijuana accounted for the top percentage of total admissions [for treatment]. Use Patterns and Multisubstance Use: “Discussions with adult clients in treatment indicate a common drug use sequence, starting with alcohol, moving to marijuana, then to cocaine, and eventually heroin.” “Blunts (Vega)”—gutted cigars refilled with marijuana—remain entrenched in the culture of adolescents and young adults [throughout the United States]. . . . Marijuana tends to be used in combination with other substances, particularly alcohol and cocaine (usually crack) and, sometimes, phencyclidine (PCP). Some of the increase in adverse effects may be attributed to these other drugs. Nevertheless, a substantial proportion of marijuana ED [hospital emergency department] mentions involves marijuana alone (21 percent in 1994). Among primary marijuana

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treatment admissions, alcohol is generally the most common secondary drug of abuse . . . however, in many cities . . . a sizable portion of marijuana admissions do not report another drug of choice. . . . Blunt smoking is frequently accompanied by alcohol consumption. In Chicago, youth often combine smoking blunts with drinking malt liquor. Another common weekend evening purchase is a package of blunts [cigars], razor blades to slit them open, and champagne. . . . “Blunts” smoked sequentially—one laced with marijuana and the other with PCP are called the “dream team”. . . . Marijuana and PCP are frequently mixed with the combination called a “love boat” or “wets,” “lilies,” “wacky sticks,” or “donk” . . . marijuana-cocaine crack combinations are referred to as “geek joints,” “oolies,” “diablitos,” “primos,” “woolies,” and “turbo” [depending on the city] . . . [marijuana] with PCP plus formaldehyde is called “fry,” “amp,” or “water-water.” Demographics: (Age) Despite reports of increasing use among youth, marijuana ED [hospital emergency department] age distributions show greater increases between 1995 and 1997 in the oldest, rather than the youngest, age groups. The 18–25 age group accounts for the highest rate of marijuana ED mentions in most cities throughout the United States. Youth are increasingly dominating the marijuana treatment demographics. In most areas, primary marijuana users are generally younger than primary cocaine or heroin admissions. (Gender) Males outnumber females nationally among marijuana ED mentions. They account for 60 percent or more of the total. Treatment admissions are also more likely to be male than female. (Race/Ethnicity) Racial/ethnic distributions of primary marijuana treatment admissions vary across the country. Among 1997 marijuana mentions, whites and African-Americans each predominated in half of the CEWG cities in DAWN. Whites account for the largest proportions in seven areas (Baltimore, Boston, Minneapolis/St. Paul, Phoenix, St. Louis, and San Diego); African-Americans have the greatest representation in six areas (Chicago, Detroit, Newark, New Orleans, New York, and Washington, DC); and Hispanics constituted considerable proportions in only three cities: Los Angeles, New York, and Phoenix. . . . As is the case with ED mentions, no one racial/ethnic group dominates overall treatment admissions figures. Law Enforcement Data: (Arrestee Data) In 1998, marijuana was the most frequently detected drug among adult male arrestees in the majority of CEWG cities in the ADAM program. Juvenile offenders primarily choose marijuana rather than harder drugs, in part because they participate in the distribution network for harder drugs. The number of marijuana arrests continues to be high but there appears to be a trend downward because the substance is not the major concern with the heroin, cocaine, and methamphetamine problems that have developed. Nevertheless, a record number of marijuana arrests were recorded in New York in the first half of 1998. In Boston, marijuana arrests remained level, second only to cocaine arrests. A slight decrease was reported in Washington, DC, in the number of adults arrested for sale and/or possession of marijuana between 1997 and 1998. (Availability, Price, and Quality) Wide availability [and potency] continues to be reported [throughout the United States]. Generally, marijuana may be purchased for as little as $10 per ounce (e.g., in Los Angeles), where sinsemilla with a THC level of 25–30 percent continues to be common and as much as $400–600 for per ounce for high potency marijuana in Honolulu.

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(Cultivation, Seizures, and Trafficking) In most cities, marijuana continues to be imported mainly from Mexico, although Canadian marijuana [is being reported] in Washington State. Domestic cultivation, especially indoor hydroponics, continues to be reported in many areas. Mexico is the primary supplier of marijuana for the United States; however, it appears that there is a growing amount of indoor cultivation throughout the nation. Colorado remains one of the leading States for indoor cultivation, but a large amount is also smuggled from Mexico. Over time, large indoor operation seizures have occurred in such locations as a Colorado cave and a private home in Miami. Other reports related to cultivation and trafficking include: an increasing number of hydroponic farms have been seized in Miami private homes. . . . Some Latin American marijuana still enters Miami from Jamaica, the Bahamas, and other Caribbean transshipment points. . . . Trafficking patterns in Atlanta have shifted from coastal marine and air smuggling to complex indoor growing with hydroponics and domestic interstate shipments; however, Mexico remains a primary source, with Hispanic couriers and transporters being increasingly utilized. . . . At least 80 percent of the marijuana seized in the Seattle area is grown indoors. Many local growers are also reported in San Francisco. In Arizona, where marijuana is the most trafficked drug, foreign-grown marijuana is more prevalent in the southern and central areas, while domestically grown marijuana is more typically found in the higher elevations. . . . In Missouri, too, production is increasingly shifting to indoor operations, but many eradicated plants in Missouri are still grown in fields or on river banks. Much of the Missouri-grown marijuana is shipped out of state. . . . Intelligence in Texas suggests that previously active Colombian marijuana trafficking organizations are moving back into the marijuana market. Traffickers in Mexican marijuana in Texas are usually whites or Hispanics, while growers of domestic marijuana tend to be whites. A recent development shows that the annual marijuana crop grown in Kentucky comes in at an estimated $4 billion plus yield that flows illicitly to markets of the Northeast willing to pay street prices. “It’s kind of like the old moonshine days with neighbors making a living at it. . . . Everybody seems to know somebody who grows it, sells it, smokes it. . . . It’s the dirty little secret of Kentucky. . . . More than 200,000 pot plants, each worth about $1,000 in retail produce, are seized each year alone in the sprawling beauty of the [Daniel Boone National Forest]. . . . The planters use hydroponics, growing lamps and scientific pruning techniques to produce a crop every 89 days in basements, silos, closets and even underground bunkers, replete with booby traps and remote video monitoring.”53

International The following description is a brief review of the cannabis situation in a number of countries throughout the world (U.S. National Institutes of Health, NIDA, 1999).54 Australia: The Illicit Drug Reporting System (IDRS) suggests that cannabis is “easy to obtain” in all States [of Australia]. . . . Price varies according to THC content (e.g., leaf—$25/gram; head—$220/ounce bag or 28 grams; plant—$2,000). In many locations there has been an increase in the availability and purity of hydroponically grown cannabis, otherwise known as “skunk.” The Australian Bureau of Criminal Investigation reports that hydroponic cannabis cultivation is increasing. . . . Australian Customs reported that the quantity of cannabis seized has diminished. They believe that a

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readily-available, more potent local product, which is more difficult to detect by law enforcement authorities, has possibly reduced the demand for imported compressed heads or “Thai sticks.” Cultivation is increasing as market demand increases. There appears to be no shortage of cannabis on the market. . . . There continues to be a rapidly increasing number of cannabis-related presentations at the various treatment services across the country. A large number of these clients have psychosis and psychological problems associated with cannabis use. Cannabis remains the most popular and frequently used illicit drug. Canada: Cannabis is the most widely used illicit drug in Canada. Based on Canada’s Alcohol and Other Drugs Survey, 7.4 percent of Canada’s 15 to 19 year olds used cannabis at least once in the 12 months prior to the survey. Cannabis use among 15 to 19 year-olds is more than twice as frequent as in the general population. . . . Cannabis is rarely determined to be the cause of death . . . although cannabis [is] detected through toxicological testing in some cases. . . . In the past several years, law enforcement priorities concerning cannabis have shifted to addressing importation, trafficking, and production rather than possession. Europe: Cannabis is the most commonly used illicit drug across the EU. A tentative and probably conservative extrapolation from recent surveys suggests that over 40 million people in the EU have used cannabis (about 16 percent of the population age 15 to 64) and that at least 12 million used it in the past year (about 5 percent of the people age 15 to 64). . . . The proportions are higher among young people. On average, about 20 percent of adolescents age 15 to 16 report lifetime use of cannabis; by the time they reach their mid-twenties, the proportion is probably at least 30 percent. . . . There are considerable differences between countries in terms of the extent of cannabis use. . . . Some rise in treatment demand for cannabis is noted in several countries. Cannabis now accounts, on average, for about 10 percent of treatment demands, although demand is higher in new, younger clients. . . . It [seems] that cannabis may be a convenient label for a wider range of problems, since other drugs such as alcohol and/or amphetamine-type stimulants are often involved together with cannabis. . . . In most countries, cannabis is the main drug involved in arrests for drug offenses; most relate to cannabis use rather than trafficking. . . . Quantities of cannabis seized per year [and prices] are stable; although the number of seizures is steadily increasing. In much of the EU, cannabis use is not associated with any specific social or recreational context or with particular groups in the population. In many parts of the EU, it appears that cannabis use is increasingly perceived as normal or mundane rather than deviant. Mexico: Among those involved in government and non-government treatment centers as well as juvenile detention centers, cannabis is the most frequently reported drug of onset. . . . [M]ore than 90 percent of the users in these programs are male and tend to come from low socio-economic backgrounds with only a middle school education. . . . Among those seen by medical examiners, the main cause of death in the cases with marijuana involvement was wounding by a firearm (32 percent). The place of death was most likely at home (39 percent) or on the street (31 percent). South Africa: After alcohol, cannabis is the most common primary substance of abuse among patients seen in treatment facilities throughout the country. . . . Based on treatment center statistics, most cannabis users tend to be male and younger than users of other substances (excluding ecstasy).

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MARIJUANA USE: REFLECTIONS ON THE DUTCH EXPERIENCE No country has received more attention than the Netherlands in terms of addressing the use of marijuana through liberal policy. After a period of lenience that began in 1968 and lasted for about eight years, the national government of the Netherlands revised the Dutch Opium Act in 1976 and as a result the most significant and talked about aspect of the changes made has been the de facto decriminalization of cannabis in small amounts.55 Such de facto decriminalization, however, “was more the result of the absence of policy, and a response to already existing circumstances, than of any rational, well-considered action.”56 In this sense, the conditions underlying the formation of policy in the Netherlands and the United States tend to be similar. The results, however, have been very different—one a “self-willed,” lenient approach to soft drugs and the other a controlled, prohibitive way of managing the use of marijuana. Drawing from the research of Cohen (1995), a number of findings evidence the result of the liberal use of marijuana in the Netherlands, specifically in Amsterdam, between 1986 and 1994.57 In terms of substance use patterns, the results show that: (1) nearly 10 percent of the study population used the substance at least once during the past year; (2) 6 percent used marijuana during the last month; (3) 3 percent of the youth aged 12–15 used the substance and this rate was rather stable from year to year; (4) among the 20–24-year-olds, which is the age group that reflects the highest pattern of use, “ever use” increased slowly over the time period studied from just under 40 percent in 1987 to 50 percent in 1994 meaning that by the time young people in Amsterdam reached 24 years of age, half of them smoked a joint or pipe on at least one occasion; (5) in terms of last month use, the picture over the years is again very stable. Roughly 1 out of every 6 residents of Amsterdam in the 20–24 year group, the group with the most active night life in the city, smoked a joint or more; (6) among people older than 24 years, the rate of monthly marijuana tends to drop off. In Amsterdam, people over the 25–35-year age group show less enthusiasm for the substance and those in their fifties lose interest almost altogether. Based on the information collected it can be said with confidence that marijuana use, in contrast to alcohol use, is strongly bound to a phase of life. When used, it is chiefly something for the 16–35-year age group; (7) throughout the years of the study, about 20 to 25 percent of those who use marijuana do so on a continuous basis and 65 percent of this group use the substance at most twice per week. Smoking the substance more than 20 times a month was infrequent—only 4 percent of those who use it continuously. In comparison, 13 percent of the people who use alcohol on a continuous basis drink more than 20 times a month; (8) the average age of first marijuana use is not around 15 but 20, and the median age is 18; (9) the number of new marijuana users per year is very stable, about 1 percent of the population of 12 years or older; and, from the data (years 1990 and 1994) about 10 percent of all marijuana users quit each year and the average age of those people who stop marijuana use is 26; (10) the increase in marijuana availability in Amsterdam has not led to any intensification of use patterns; and (11) lifetime (marijuana) use in Amsterdam, in a climate of total decriminalization, is no higher than

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in the United States, where use of the substance is associated with a degree of criminalization. In his study, Cohen addresses the important issue of marijuana as a stepping stone to other drugs. According to the data collected, a portion of the marijuana users in Amsterdam has had experience with other drugs. But two-thirds to three-quarters (dependent on age group) of those who ever used marijuana never used any other illegal drug. In other words, in Amsterdam’s population there is a group of people who want to experience illegal drugs, but for the majority of these people marijuana use is sufficient. Furthermore, based on available data, marijuana users who take additional drugs are small in number and do so only very infrequently. In the Amsterdam population, “there is little evidence to support the stepping stone or gateway theory.”58 In sum, it can be said that after more than 20 years of liberal policy toward the use of marijuana two important observations can be made: (1) in the Netherlands the prevalence of marijuana use does not appear to be any higher than what exists in other countries where the use is still aggressively prosecuted and punished.59 The prevalence of marijuana use in the Netherlands even seems to decline, in spite of the absence of any form of public pressure or policies targeted against it; and (2) apparently marijuana has found its place in the Dutch variety of socially integrated drugs. “It can be assumed that rules and techniques have been generated in relatively easy going atmospheres that help regulate and control use.”60 Based, in part, on the Dutch experience with marijuana, a significant shift in attitude toward marijuana is occurring. For example, “a 1998 Belgian directive stipulated that the possession of cannabis products for personal use should be accorded the ‘lowest priority’ in criminal justice. Similarly, a June 1999 directive of the French Minister of Justice recommended prosecutors to deliver verbal warnings and cautions rather than imprisoning drug users—especially occasional users of cannabis—who had committed no other related offenses. In Germany, debate on the legal status of cannabis has intensified following the request of the Federal Constitutional Court in 1994 for uniform criteria for prosecuting or not personal use of cannabis. In March 2000, the UK government announced the start of scientific trials into cannabis prescription, the results of which are expected in 2002.”61 NOTES 1. Grinspoon, L., and Bakalar, J. (1993). Marijuana: The Forbidden Medicine. New Haven, CT: Yale University Press (and the Lindesmith Center), p. 1. 2. Ibid., p. 2. 3. Snyder, S. (1970). What have we forgotten about pot. New York Times Magazine, pp. 27, 121, 124, 130, December 13; Ray, O., and Ksir, C. (1990). Drugs, Society and Human Behavior. St. Louis, MO: Times Mirror/Mosby, p. 325. 4. Baudelaire, C. (1971). Artificial Paradises; on Hashish and Wine as Means of Expanding Individuality. Trans. E. Fox. New York: Herder and Herder; Ray and Ksir, p. 327. 5. Makuriya, T. (ed.) (1973). Marijuana: Medical Papers, 1839–1972. Oakland, CA: MediComp; Greenspoon and Bakalar, pp. 2–3.

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6. Nahas, G. (1975). Marijuana—Deceptive Weed. New York: Raven Press; Mann, P. (1985). Marijuana Alert. New York: McGraw-Hill. 7. Goode, E. (1989). Drugs in American Society. New York: McGraw-Hill, p. 145. 8. Schlosser, E. (1994). Reefer madness. Atlantic Monthly, August, p. 48. 9. Ray and Ksir, p. 327. 10. Snyder, p. 130; Ray and Ksir, p. 327. 11. Schlosser, p. 49. 12. Ibid. 13. Ray and Ksir, p. 328. 14. Grinspoon and Bakalar, p. 4. 15. Ray and Ksir, p. 328. 16. Grinspoon and Bakalar, p. 4. 17. Whitlock, L. (1970). Review: Marijuana. Crime and Delinquency Literature, 2(3):367; Ray and Ksir, p. 328. 18. Ray and Ksir, pp. 328–329. 19. Ibid., p. 329. 20. Ibid. 21. Sociological, medical, psychological and pharmacological studies by the mayor’s committee on marijuana (the La Guardia report). Reprinted in D. Solomon, The Marijuana Papers. New York: Signet, 1968, pp. 297, 307; Gray, M. (1998). Drug Crazy. New York: Random House, p. 83. 22. Solomon, D. (ed.) (1966). Mayor La Guardia’s Committee on Marijuana: The Marijuana Papers. New York: The New American Library; Ray and Ksir, p. 330. 23. Ray and Ksir, p. 330. 24. McWilliams, J. (1990). The Protectors: Harry J. Anslinger and the Federal Bureau of Narcotics, 1930–1962. Newark: University of Delaware Press, pp. 97–98, 107; Musto, D. (1987). The American Disease: Origins of Narcotic Control. New York: Oxford University Press, p. 222; Lindesmith, A. (1965). The Addict and the Law. Bloomington: Indiana University Press, p. 26; Gray, pp. 84–85 25. Gray, p. 86. 26. Eastland, J. (Chairman) (1974). Marijuana-Hashish Epidemic and Its Impact on United States Security. Washington, DC: U.S. Government Printing Office. 27. Ibid., p. xv. 28. Goode, p. 150. 29. Sussman, S., Stacy, A., Dent, C., Simon, T., and Johnson, C. (1996). Marijuana use: Current issues and new research directions. Journal of Drug Issues, 26(4):700–702. 30. Pollan, M. (1997). Living with medical marijuana. New York Times Magazine, July 20, p. 23. 31. Soros, G. (1997). It’s time to just say no to self-destructive prohibition. Washington Post, February 2, p. 2. 32. Pollan, p. 40. 33. U.S. Department of Health and Human Services, NIH Publication No. 98-4036 and NIH Publication No. 98-4037, 1998; “Marijuana Myths,” P. Hager, Hoosier Cannabis Relegalization Coalition, n.d. (www.cs.indiana.edu); Marijuana Policy Project (www.mpp.org); Institute of Medicine, National Academy of Sciences (1999). Marijuana and Medicine: Assessing the Science Base (http://bob.nap.edu/books/0309071550/html/). 34. Boston University School of Public Health (2001). Study: Gateway theory less applicable to today’s youth. Join Together Online (www.jointogether.org), March 9.

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35. Cohen, P. (1990). Cocaine and Cannabis: An Identical Policy for Different Groups. Amsterdam: Center of Drug Research, University of Amsterdam, p. 5. 36. Ibid., p. 6. 37. Ray and Ksir, pp. 328–329. 38. Gusfield, J. (1967). Symbolic Crusade: Status Politics and the American Temperance Movement. Urbana: University of Illinois Press; Goode, p. 122. 39. Rhodes, W., Hyatt, R., and Scheiman, P. (1994). The price of cocaine, heroin and marijuana, 1981–1993. The Journal of Drug Issues, 24(3):394–395. 40. Grinspoon and Bakalar, p. 5. 41. U.S. Congress, House Ways and Means Committee. Hearings on H.R. 6385: Taxation of Marijuana, 75th Congress, 1st session, April 27, 1937, 91–94. 42. Grinspoon and Bakalar, p. 5. 43. Peele, S. (1995). Assumptions about drugs and the marketing of drug policies. In W. Bickel and R. DeGrandpre (eds.), Drug Policy and Human Nature. New York: Plenum and the Lindesmith Center, p. 1. 44. Schlosser, E. (1997). More reefer madness. Atlantic Monthly, April, pp. 90–102. 45. Glass, S. (1997). Don’t you D.A.R.E. New Republic, March 3, pp. 18–28. 46. Johnston, L., O’Malley, P., and Bachman, J. (1987). Psychotherapeutic, licit, and illicit use of drugs among adolescents. Journal of Adolescent Health, 8:41. 47. Willard, J., and Schoenborn, C. (1995). Relationship between cigarette smoking and other unhealthy behaviors among our nation’s youth: United States, 1992. In Advance Data, 263, April 24, Washington, DC: National Center for Health Statistics, p. 4. 48. Schlosser, More reefer madness, p. 90. 49. Wren, C. (1996). Marijuana use by youths continues to rise. New York Times, February 20, p. A11. 50. Gfroerer, J., Greenblatt, J., and Wright, D. (1997). Substance use in the US college-age population: Differences according to educational status and living arrangement. American Journal of Public Health, 87(1):63. 51. Henneberger, M. (1994). “Pot” surges back, but its, like, a whole new world. New York Times, February 6, IE, p. 4. 52. National Institute on Drug Abuse (NIDA) (1996). Epidemiologic Trends in Drug Abuse, Vol. 1: Highlights and Executive Summary. Rockville, MD: National Institutes of Health; NIDA (1999). Epidemiologic Trends in Drug Abuse, Vol. 2: Proceedings of the International Epidemiology Work Group on Drug Abuse. Rockville, MD: National Institutes of Health. 53. Clines, F. (2001). Fighting Appalachia’s top cash crop, marijuana. New York Times, February 28, p. A10. 54. U.S. National Institutes of Health, NIDA, Epidemiologic Trends in Drug Abuse, Vol. II. 55. de Kort, M. (1994). The Dutch cannabis debate, 1968–1976. Journal of Drug Issues, 24(3):417–418. 56. de, Kort; Cohen, P. (1988). The Dutch experience: The place of Dutch drug policy in a general framework of social administration. Paper presented at the International CORA Conference on Anti-Prohibition, September 29, October 1. 57. Cohen, P. (1995). Cannabis users in Amsterdam. Paper presented at the National Conference on the Urban Soft Drugs Tolerance Policy, Utrecht, June 7, pp. 2–3. 58. Cohen, Cannabis users in Amsterdam, p. 7.

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59. Sijlbing, G. (1984). Het gebruik van drugs, alcohol en tabak. Amsterdam: Swoad, introduction. 60. Cohen, P. (1990). Cocaine and Cannabis: An Identical Policy for Different Drugs. University of Amsterdam, Centrum voor Drugsonderzoek, pp. 7–8. 61. European Ministry Centre for Drugs and Addiction (2000). Annual Report on the State of the Drugs Problem in the European Union. European Monitoring Centre for Drugs and Addiction, Belgium.

Chapter 7

Management: Elements of Drug Treatment Services Organization and Development

THE HUMAN SERVICES PERSPECTIVE Inevitably, every person voluntarily or involuntarily conducts transactions with a range of organizations whose explicit purpose is to shape, change, and control behavior as well as confirm or redefine social and personal status. The primary function of human service organizations is to enhance the well-being of a person through functions that are conducted on two levels, societal and individual.1 Within this context, human service organizations have three major functions. First, these organizations assume major responsibilities for the socialization of people into various roles they may occupy. Second, human service organizations serve as major social control agents by identifying individuals who fail to conform to their role prescriptions and by removing them, at least temporarily, from these role positions. Third, these organizations assume a social integration function by providing the means and resources for the individuals to become integrated in the various social units with which they affiliate. Through such mechanisms as resocialization, therapy, and counseling, human service organizations attempt to prevent social disintegration and promote the integration of the individual into society.2 A significant body of theoretical knowledge and empirical research exists regarding the organization and management of human services.3 In this context, theoretical approaches and tools such as operations research and management information systems have much to contribute to understanding and improving the provision of services.4 Theoretical approaches and tools tend to be based, however, on assumptions that often cannot be met. Even the fundamental organization development procedure of needs assessment and planning that includes such basic tasks as: (1) information gathering and problem definition; (2) setting objectives

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(or describing options) and prioritizing them; (3) choosing objectives (or options) and allocating resources; and (4) collecting data on program or service implementation and then interpreting the information to improve services provision, is many times ignored.5 DRUG TREATMENT SERVICES Human service organizations tend to provide a predominant type of service to a particular class of clients. For drug treatment organizations, the goal is to improve the well-being of addicts who are perceived to be malfunctioning. In this sense, these organizations may be characterized as people-changing mechanisms. They attempt to alter the attributes or behavior of their clients through various modification and treatment technologies.6 For the most part, drug addicts have identifiable social locations and social affiliations that cannot be ignored by the service organization. The social background of drug addicts serves as a critical indicator of the type treatment services required, their potential for change, and the desired outcomes. Also, affiliation and reference social groups (including family and peers) of the addict have considerable influence on that person’s motivation and behavioral patterns that need be considered by the organization in order to maximize the effectiveness of its interventions and to minimize the potential conflict between the services it provides and the ascribed affiliations and social status of the addict. Drug service organizations define their goals in relation to given tasks such as the detoxification of addicts, secondary and tertiary prevention activities, and so on.7 Within such a task environment, the organizations are often faced with addressing multiple, often conflicting, expectations and interests in terms of results. For example, in attempting to define goals, drug service organizations encounter diverse interest groups that influence their domains and mandates. Among these are (1) the police, concerned with the punishment and removal of the addicts from the community, especially since drug users are known to be the cause of much criminal activity. The National Institute of Justice, for example, estimates up to 80 percent of offenders, parolees, and probationers have some degree of substance abuse problem related to their criminal activity; more than half of the inmates in local jails report being under the influence of drugs or alcohol at the time of their offense8; (2) welfare departments, responsible for a range of social and related support services to families affected by the problem behavior and dysfunction of addicts; (3) local and regional government agencies, responsible for controlling and ameliorating the drug problem; (4) legislators, who see the police, courts, service agencies, and schools as the means to implement social control over drug use; and (5) parents, wives, children, and significant others, who rely on drug service organizations to resolve conflicts and address the needs of the addicts and their families. Oftentimes these diverse interest groups are in competition and conflict over defined responsibilities and limited resources that tend to weaken their ability or desire to communicate, cooperate, and coordinate services.

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Another factor affecting service provision may be dissonance among staff. Professional and paraprofessional personnel, differentiated by their organization location and work status, including factors such as academic background and personal experience with drugs, may have different ideologies of treatment and services to their clients. The greater the occupational, professional, and personal diversity in the drug service organization, the greater the difficulties in developing an internal consensus toward the goals of prevention and treatment of drug use, the control and supervision of staff, minimizing interpersonal conflict, and maintaining cooperation and coordination of efforts.9 Considerable energy and resources have been invested in controlling and preventing “war” efforts against drug use. In contrast, relatively little attention appears to have been given to the need for well organized and managed drug treatment services, including aftercare relapse prevention. Inclusive of this last point are issues of professional and paraprofessional manpower development through skills enhancement, career education, and in-service training opportunities; methods of consultation and technical assistance; supervision of management and direct service personnel; uniformity of information and data collection across locations and over time; and improved methods of needs assessment, evaluation, and research of the long-term effects of service provision. MANAGEMENT OF DRUG SERVICES Management The word “management” implies a very active and constructive development approach that involves the generation, utilization and possibly reshaping of resources. Management is considered to be an organization-related function that must be (1) concerned with the biopsychosocial distresses faced by addicts and their family and (2) responsive to those arrangements that must be made to address and, hopefully, relieve any or all of the distresses being experienced. Central to this approach is an emphasis on the following principles: (1) Drug-related distress, including the relapse or return to a drug-using state after detoxification, may be founded in social system deficiencies rather than physiological, metabolic, genetic, or intrapsychic disorders. Rather than focusing on diagnostic labels that obscure these social system elements, increased concern should be given to the daily “problems of living” adversely affecting addicts and their families. (2) The drug-related prevention and treatment activities given by caregivers have many qualities in common. Competence is the critical variable, and it transcends arbitrary distinctions of academic degree, discipline, and role status (e.g., manager/direct service provider or professional/paraprofessional) in the service provision process. (3) Accessibility of drug treatment and prevention services often is as important as their quality to clients seeking appropriate help. Accessibility must be viewed in terms of convenience (e.g., location and appropriate hours of service provision to permit clients to work) as well as psychological comfort (to the addict) involving competent and humanistically oriented staff. (4) Systems of service properly integrated to ensure continuity of care are more effective than single ser-

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vices functioning in isolation. The range of human problems associated with drug addiction is so broad that only in exceptional instances can a given organization, agency, or unit fully meet the total needs of an addict. Many drug services tend to reflect a “heap of parts” rather than an integrated network of activities working together. (5) Drug service providers are accountable to multiple constituencies, including clients. Determinations of program effectiveness must include the perspectives of the addicts and their families as well as those of the clinicians, administrators, and resource providers.10 Management implies more than being responsive to a central authority and loyal to established policies. Management should include actions that are development oriented, reflect the assertion of leadership, and demonstrate a certain amount of risk-taking if service provision is to improve. The idea of drug services management is a bidirectional dilemma that reflects issues of incremental improvements versus substantial reform. Are these two approaches congruent? In many instances certain actions can be taken immediately, within an existing structure, to improve the management of drug services. Such efforts (e.g., new and innovative activities to prevent the addict from relapse; in-service technical assistance to improve service provision; staff, volunteer, and paraprofessional training; and community leadership development training to combat drug use), however, must be planned as part of a larger, long-range strategy of service provision reform.11 Assessment of Drug Treatment Services Organization and Management At every level (i.e., national, regional, and local) and type of drug service provision (e.g., prevention and treatment), there should be a reasonably accurate assessment of the client’s needs. This is also true for the service provider, particularly where knowledgeable and experienced personnel, working with adequate resources, are in short supply. Long-range organization development is absolutely dependent on knowing the nature and scope of such needs. Because such needs change over time as a result of new policies and decisions, economic conditions, shifting population trends, and so on, such information gathering or needs assessment should be current.12 Assessment of drug treatment services provision is a complicated process because multiple dimensions must be taken into account, such as management needs and problems, organization development obstacles, manpower development and training, and research. Furthermore, assessment may fall into the realm of resistance among personnel involved or affected by the process, because service deficiencies may be interpreted as a shortcoming or failure of those involved with management and treatment. DRUG SERVICE AGENCIES: ORGANIZATION AND MANAGEMENT NEEDS AND PROBLEMS The system of service delivery for drug abuse treatment is made up of various private and public organizations, including those that address specialty treatment, physical and mental health care, social service, correctional care, and self-help.

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Though some progress has been made, the organization and management of treatment remains one of the least studied areas in drug abuse. Given the profound obstacles and changes that these organizations experience, there is a critical need for knowledge on how best to structure and manage service delivery to ensure positive client outcomes. This information must, however, build upon proven organization and management research findings across multiple disciplines.13 In the following portion of this chapter, discussion is given to drug treatment services organization and management issues based on a prospective study14 conducted, at one point in time and in one location. Among the issues examined were: (1) drug services development and managing services with scarce resources, (2) education and training, (3) out reach to critical target populations, (4) treatment and relapse prevention strategies, and (5) research and evaluation. Drug Services Development and Managing Services with Scarce Resources Is the existing structure of drug treatment services and personnel capable of doing more? The answer appears to be no, not without the infusion of funding resources to build up the capability of agencies to treat additional addicts. This includes increasing the number of trained treatment and prevention service personnel. It should be noted, however, that simply expanding the services structure is no guarantee that most addicts not connected with drug treatment and relapse prevention services will be motivated to come forward to receive assistance. Practically speaking, the population of addicts that seek treatment tends to be a small percentage of those who use illicit drugs on a regular, habitual basis. An even smaller number are motivated enough to stay off drugs for at least a few months or more. To talk about increasing the number of addicts for treatment services appears to be unrealistic unless strategies are found to increase outcome success. One possible way to achieve this may be the creation of a network of accessible, small community-based clinics or storefronts responsible for (1) prevention counseling and self help, (2) the distribution of methadone to heroin addicts, and (3) information dissemination and referral assistance to larger service facilities staffed with personnel experienced with multiple aspects of intervention and support. Treatment agency staff appear able, albeit with some difficulty, to handle their client caseloads. Caring staff do what they can with what resources are available. Without additional staff positions, however, doing more with less in terms of service provision will result in doing less with less. Clearly, some agencies based on performance are worthy of investment as “model treatment service centers” with “how to” knowledge and experience that can and should be replicated. Education and Training Drug service agency personnel need assistance, training, and education to (1) further develop the capacity to plan and provide treatment and prevention services,

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(2) improve staff supervision, (3) better manage case records, and (4) promote communication among professional and paraprofessional staff. A relatively stable work force of professional and paraprofessional drug service caseworkers and counselors, measured in terms of turnover and years of experience, tend to provide treatment and other services to addicts. A number of reasons may account for this. For example, the majority of staff are males, who are less likely to follow a wife or partner to another location for change of career purposes; staff tend to be affiliated and loyal to addressing the drug problem; and there is a limited range of mobility within drug treatment and prevention services enabling movement from job to job. Workforce stability among agencies may be considered a positive element of the drug services organization, justifying investment in training and education opportunities that will improve personnel work skills and promote career opportunities within drug services. Incentives, including time off from the job to pursue training and education, certification, promotion, salary increases, and a university degree, are important to motivate personnel and promote their development and attract new professionals and paraprofessionals to the field of drug services prevention and treatment. Opportunities for university education should be based on a flexible model of professional education that includes mechanisms for self-paced study, independent study, concentrated study, small-group and seminar-tutorial methods, project- or problem-centered study, practical or clinical experience, and work-study programs, off-campus study, and internships.15 These mechanisms should link professional and paraprofessional staff to education and training opportunities as much as possible. There should also be opportunities to address the unique characteristics of these two work/responsibility distinctions. Agency staff should be linked to university academic/clinical training departments (e.g., social work, medicine, nursing, occupational therapy, recreation, and education) to enhance intergroup learning among those involved or those who will be involved with drug services provision. An additional thought regarding drug training and education is the need for a “new careers movement” to respond to the limited availability of professionals and the high cost of their services. Less formally trained individuals, of a paraprofessional nature, should be developed to address drug prevention and treatment service needs, including outreach to addicts and their families in the community. Experimental and program research has shown that paraprofessionals may be quite successful in the delivery of specific services, particularly when they are under professional supervision. This suggests that there is a degree of generality in helping behavior. An individual who shows characteristics such as empathy, sensitivity, and a positive regard for others is likely to be an effective helper. Many community people with little or no formal training may be effective helpers.16 The trend toward the use of paraprofessionals has contributed to the belief that responsibility should depend on competence in the job to be done rather than on formal training in a particular professional discipline. In addition, the development of nontraditional community resources to deal with drug dependency and the general growth of self-help groups in other community problem areas have created doubt about the value of traditional professional jurisdictional privileges.17

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Although paraprofessionals lack formal training and the specific degrees of professionals, they have demonstrated competence as drug service workers on the basis of practical experience and generalist training.18 With this in mind, a paraprofessional drug specialist training program may prove to be a very worthwhile investment. Such a program should be tied to career development opportunities, including access to an education and training program with elements of community work, individual and family counseling, drug treatment and prevention, therapeutic recreation, job counseling and placement, occupational therapy, special education, and self-help services organization (e.g., Narcotics Anonymous). In addition to trained and educated professional and paraprofessional staff, the success of local drug treatment service provision, including community-based methadone maintenance clinics, may depend, in part, on the extent to which community leaders can be developed. Leadership at the local level that is capable of addressing the problem of drug use would seem to have two preconditions: (1) a person who has conceptual skills and good interpersonal relations, and (2) an environment responsive to, and perhaps even needing, change. Outreach: Critical Target Populations Three client populations appear to require special outreach and treatment services. They include (1) the majority of drug addicts who tend to have no contact with drug service agencies for treatment, aftercare, or other forms of intervention services, (2) female addicts, and (3) adolescent drug users. Drug Addicts in Need of Services Outreach efforts that encourage addicts to participate in a treatment program and the ability to provide successful treatment may both be grounded in the provision of services that relate to relapse prevention, education and vocational training, support of the family as part of the treatment milieu, work, community-based social and recreational activities, and suitable housing. Generally speaking, the vast majority of drug addicts do not receive treatment services. This group may therefore be a target for outreach activity that involves workers knowledgeable about the drug problem, skilled in talking to people, and capable of motivating addicts to turn their lives around. One of the important reasons for drug outreach service is to provide information, since many addicts are unaware of their rights for treatment, types of assistance available, and how to access help. For example, the outreach worker might make an appointment for a person at a community agency and he or she may talk to the agency in behalf of the addict and help set the stage for the addict’s entry into a treatment program. Also, the drug outreach worker may have an important role in helping the addict feel more at ease in using community services, since there is a tendency to be afraid or reluctant to talk about lifestyle, especially since it is likely to involve illegal drug use, crime, abuse, violence, and prostitution. Finally, the outreach worker can assist the community in learning about the people in need of drug service, particu-

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larly those who have not come to the attention of others.19 While many details need to be considered and developed further, especially in terms of the specific tasks to be undertaken by the outreach worker, the need to recruit ex-addicts, including women, who are familiar with the community for this role is important. Female Drug Addicts Generally, female addicts tend to be a minority, about 20 percent, of the population receiving treatment services.20 Among possible explanations is that women may be more able than men to sustain their addiction to drugs through illegal income-earning activities such as prostitution and/or their partners may be providing drugs or supplying the money necessary to purchase drugs. In either situation, there may be little need or interest to seek sources of support for their addiction or incentive to go through detoxification and treatment. Gender-specific treatment services, including individual and group counseling for female addicts, tend to be lacking. The world of drug addiction treatment appears to be a male domain; consequently, female addicts may feel (and rightly so) out of place in a treatment facility and may be reluctant to use the services provided if the facility and services are not gender-specific. In a study by the United States National Institute on Drug Abuse (NIDA, 1995) it has been found that at the end of 1994, 58,000 women were reported to be HIV-infected and 41 percent of these cases resulted from injection drug use. Indeed, women’s drug and sex risks for HIV frequently occur together. Women’s drug use often involves membership in a network with HIV-infected individuals where direct and indirect sharing of injection equipment and/or sexual liaisons are transacted and where the social context (e.g., shooting gallery) affects the likelihood of transmitting HIV. According to NIDA, drug dependent women are more likely than men to engage in high-risk sex, and women who inject drugs are more likely to acquire HIV sexually than men. Violence may be an additional risk factor. This is because women with abusive partners practice more HIV risk behaviors and are less likely to seek drug treatment or disclose their HIV status to their partners than nonabused women. Women’s unique HIV transmission context and behaviors, including the link between drug dependence and risky sex as well as the potential transmission to infants, have implications for the development of targeted, gender-specific risk-related interventions.21 While the proportion of HIV and female drug users is expected to vary from city to city and nation to nation, it is an issue that must be considered one of the most serious drug-related problems. Outreach activities targeted to female drug users and gender-specific treatment programs, including individual and group counseling as well as relapse prevention activities, must be given priority development status. Adolescent Drug Users According to Brown and Mills (1990) [w]ork in the field of prevention programming has emphasized the development of large-scale efforts designed to contain drug use throughout the adolescent population.

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Given the pernicious character of drug abuse, and its endemic nature in this country, it is not surprising that there has been an emphasis on providing educational experiences and prevention programs for a general adolescent population. But at the same time, it has been increasingly recognized that certain elements of the adolescent population are distinctly more at risk for substance abuse than others. Most notably, those living in communities in which there is widespread availability of illicit substances, and whose experiences more largely distance them from the larger society, can be viewed as at greater risk for substance abuse.22

Among the populations of young people that may be considered high at risk are delinquent youth, children of substance abusers, runaways, school dropouts, and those placed outside the home of their “natural parents” in foster care or an institutional setting. Using the children of substance abusers as an example, psychosocial studies have found that the offspring of alcoholics often exhibit cognitive and interpersonal problems as children and general psychiatric disturbances and alcoholism as adults. Also, it has been shown that parental and sibling illicit drug use increases the youth’s risk of alcoholism and drug abuse.23 The majority of clients in treatment for alcohol and drug abuse have had chemically dependent parents or relatives.24 Clearly, high-risk youth need special attention to prevent and if necessary treat their addiction to alcohol and/or drugs. Strategies must be developed for identifying those youngsters in need of drug abuse services and for coordinating the work of agencies treating substance abuse and other dysfunctional behaviors. Interventions may make use of existing staff at the community agencies treating the presenting problem or may involve referral to drug abuse treatment programs. In either case, innovative [programs] using skills training and/or other psycho-social strategies will need to be developed and evaluated, and agency staff will need to receive the training necessary [that contributes to the identification of drug abusers and promotes response(s) appropriate to their needs].25

TREATMENT AND RELAPSE PREVENTION STRATEGIES A range of intervention strategies has been discussed. What has been said and should be said again is that the treatment of drug addicts must go beyond detoxification and short-term intervention. A program of relapse prevention, including family, social, and recreational services as well as work opportunities (e.g., public facility repair jobs that offer a small financial incentive for a few hours of work each day in addition to welfare payments) should be made available as part of a total treatment program. In providing support to addicts, it must be realized they are not a homogeneous group. In other words, each addict has his or her unique personality and physical characteristics. Too often, human services clients receive only the services that are readily available to them. If a client does not match the available service(s), there is a good chance that the client will fall through the cracks between programs and not receive the service(s) that the client needs. Attention must be given to those addicts who are unique because of their physical (i.e., the handicapped or disabled) or

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mental (i.e., mentally retarded or mentally ill) characteristics. Appropriate diagnosis, planning, intervention and follow-up are vital to address the needs that are specific to these difficult subgroups within a difficult population. RESEARCH, EVALUATION, AND THE DISSEMINATION OF INFORMATION An important component of services organization and management is the application of information to shape policy and improve services provision. Numerous reasons exist, however, for the minimal application of usable knowledge. For example, “many suppliers and users of research, particularly of an applied social science nature, are dissatisfied, the former because they are not listened to, the latter because they do not hear much [of what] they want to listen to.”26 Other reasons include the existence of unsatisfactory personal relations between those responsible for gathering information and those responsible for the ongoing daily operations of a service agency27 and the difficulty social scientists and others have in presenting their knowledge in ways that promote understanding among those who can use it.28 It is not reasonable to expect drug researchers and information specialists to abandon professional standards in order to become more accessible to persons neither trained in research nor experienced in interpreting, modifying, and applying information that may be relevant to a particular situation or set of circumstances. Also, it cannot be expected that those involved with policy, regulations, administration, management, and services provision are able to sift through and apply relevant information without some assistance. People involved with providing drug services at all levels of responsibility need answers. It is important, therefore, that those responsible for research and information transfer be able to help others to identify issues that need to be addressed, perhaps through methods of assessment and evaluation, and by assisting them in locating, interpreting, and applying information. While many drug research and information centers are responsible for disseminating information, simply making information about resources available is not always enough to ensure that the resources will be used. Often it takes more than a report to encourage the adoption of new information and methods. It is a process that involves explanation, persuasion, motivation, interpersonal relations, and follow up carried out with an understanding of situation reality that includes values, culture, economics, and other factors. DRUG INFORMATION CENTER DEVELOPMENT: CASE EXAMPLE Regional Alcohol and Drug Abuse Resources (RADAR) is a program sponsored by the Substance Abuse Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services, designed to promote communication and dissemination of information about the prevention and treatment of drug use. RADAR centers exist throughout the United States and on an international level in countries where government, nongovernment, and univer-

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sity facilities serve as depositories for information published by U.S. government sources. In 1997, a RADAR center was established at Ben-Gurion University in Israel with few resources other than a small office, a few shelves, and access to standard office equipment including a telephone, fax, and computer. Because the RADAR materials that the center receives are in English, the center had few takers of information, since most Israeli drug professionals and paraprofessionals are inclined to speak and read Hebrew only. The Israel RADAR center has accomplished an exceptional record of information development and dissemination since its austere beginning by building a network of people from government and nongovernment agencies, foundations, and direct service agencies sharing common interests and concerns. The following describes the process generated through RADAR involving Palestinian and Israeli people against substance abuse (PIPASA).29 PIPASA involved a coalition of Israeli and Palestinian non-government agency personnel with substance abuse problem guidance provided by the Regional Alcohol and Drug Abuse Resources (RADAR) Center of Ben-Gurion University (BGU). Based on a meeting held in early 1997, it was decided that a workshop would be held on the issue of substance abuse. The objective of the workshop was to facilitate a meeting of professionals concerned with the problem from both societies and to gauge the extent of cooperation possible. It was agreed that the workshop would be held in Beer-Sheva (Israel), home base for Ben Gurion University, and that it was desirable to invite an international expert from the United States. With cooperation from the US Embassy in Tel Aviv, a foundation supportive of peace activities and a German philanthropist, the Co-Director of the University of California—Los Angeles, Drug Abuse Research Institute (now the UCLA Integrated Substance Abuse Program) was chosen to share his knowledge and experience. The agenda of the US based expert was widened to include a series of lectures in Gaza and the West Bank for Palestinian professionals, prior to the joint workshop in Beer Sheva. One of the main reasons for this was to ensure that his trip did not solely depend on the joint workshop that was in danger of being postponed due to a closure of the Israeli border crossings with Gaza and the West Bank. Having successfully completed the trips to the West Bank and the Gaza Strip, efforts were focused on the joint 2-day workshop entitled, “Palestinian and Israeli People against Substance Abuse: An Effort to Address the Problem Through Communication, Cooperation and Coordination.” As usual during that time period, travel permits for Palestinians to enter into Israel were a problem for the workshop, which was to be held November 4–5, 1997. Only two thirds of the Gaza workshop participants were granted permits. On the West Bank, two of the key participants were refused entry permits that prompted the frustrated 18-person West Bank delegation to threaten boycott of the event. Eventually, at the end of a long day of persistent negotiation by the staff of a non-government organization committed to the peace process and officials of the Israeli security establishment, permits were secured for all of the Palestinian West Bank participants. The permits, however, did not include sleepover permission for everyone causing those from the West Bank to arrive only on the second day of the workshop. Despite the workshop getting off to a difficult start as a result of the permit problems, the second day produced electrifying debate and it soon became apparent that the area of substance abuse encapsulated a world of its own for dialogue and cooperation. One of the major issues raised was the Palestinian claim that Israel deliberately encouraged the flow of drugs

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to Palestinian areas. This position was linked to two factors. The first was the association between some Palestinian criminal collaborators, often drug dealers and prostitutes, who had worked with the Israeli General Security Service as informants.30 A second factor contributing to this perception was that drug dealers holding Israeli identification cards, arrested for selling drugs in Palestinian areas, were soon seen on the streets after being transferred to the Israeli authorities. This situation was clarified by a senior representative of the Israeli Police who stated that Israeli authorities often had no choice but to release these people because they lacked the evidence to convict and that similar problems were being faced in Israel as a result of liberal arrest laws. The workshops provided a valuable framework to address these perceptions and enabled the participants to stress the importance of research including an assessment of Palestinian needs in the area of skills training. It is worth noting that the American expert played a central role in the Beer Sheva workshop and its discussions by providing a neutral third-party perspective, particularly at junctures when sensitive issues seemed to shift the focus of the workshop to a series of mutual recriminations. A stenographer recorded this and other workshop proceedings for publication and distribution.31 The initial Israeli-Palestinian substance abuse workshop served an important function. It provided participants with an opportunity to establish personal and professional contacts regarding substance abuse as well as to promote cooperation related to information sharing, research and training workshops. Furthermore, the event served to ensure that the process was practically oriented and that no one side imposed its will or agenda on the other. The forum also served as a means to dispel a number of misperceptions about the drug problem, reinforce the belief that the problem was of mutual concern, and humanize perceived adversaries. Building on the accomplishments of the first workshop, a second effort was organized with support from the US Information Agency (USIA) and the British Council in Tel Aviv. A consultant from the National Crime Prevention Council (NCPC) in the United States was recruited to lead “Prevention and Beyond: A Workshop on Community Based Initiatives,” held in Bethlehem on May 25–26, 1998. The workshop, with over 60 participants, was easier to organize since travel permits for participants from the West Bank were not required. A variety of new representatives from Israeli and Palestinian NGO’s and government ministries attended including those involved with youth, education, drug prevention and law enforcement (i.e., police) expanding the network of contacts. The participation of the government representatives was particularly significant at the time, considering that government-to-government contacts had tapered off due to the impasse in the peace process. In addition to the professional interactions, the evening saw the Israelis, who slept over in a Bethlehem hotel, visiting local coffee shops with the Palestinian participants. Again, as in the first workshop, Palestinians expressed the belief that Israel was “flooding” Palestinian streets with drugs, and again, these matters were discussed and diffused, this time by the police officers attending from both sides including the Deputy Director of the Palestinian Anti-Drug Authority. This interaction laid the foundation for future police-to-police workshops and cooperation. Following the second workshop, funding support was received from the Center for International Cooperation (MASHAV), Israel Ministry of Foreign Affairs for two substance abuse training programs for Palestinian professionals. These 40 hour training programs, organized by the BGU RADAR Center with its Palestinian partners, were held in Beer Sheva and at Al-Quds University in the West Bank. A third training workshop for Israelis and Palestinians was held in Beer Sheva immediately after completion of the Al-Quds University

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program. That workshop was led by Los Angeles–based Matrix Institute for the Treatment of Addictions personnel in the presence of a scientist of the Programme on Substance Abuse of the World Health Organization in Geneva who was invited to help promote Israeli and Palestinian involvement with WHO substance abuse research and evaluation activities. After this flurry of activity, plans were made to hold a fourth workshop to promote drug-related dialogue among Israeli and Palestinian law enforcement personnel including judges and police officers. This event was postponed twice because the Israeli participants were denied entry into Gaza. Finally, as a result of considerable persistence by the staff of the Israeli-based non-government organization committed to the peace process, the workshop was staged in the West Bank city of Ramallah on March 24 and 25, 1999. It was attended by officially sanctioned delegations of the Israeli and Palestinian police and legal experts of the Israel Ministry of Justice. Also, attending the workshop were the Deputy Director of the Israeli Anti-Drug Authority and his Palestinian counterpart resulting in improved relations between the two anti-drug authorities. Unfortunately, Palestinian judges from Gaza, including those affiliated with the supreme court, did not attend as a consequence of being detained at the border. During the workshop, the alleged role Israel had in supplying drugs surfaced as a major issue once again. Despite heated exchanges, the workshop proved to be a constructive forum for Israeli and Palestinian drug enforcement personnel, including police and legal authorities, to discuss common problems. While previous endeavors had created sufficient momentum for a variety of collaborative research and development projects, it is clear that these efforts were also instrumental in building the confidence and goodwill necessary for this “police to police” meeting. To a certain extent, high-ranking Israeli officers were suspicious of an NGO-driven process, arguing that the necessary structures for cooperation and coordination were already in place and that there was no real need for its personnel to meet with their Palestinian counterparts. In reality, however, poor relations prevailed between the Palestinian National Authority (PNA) and the government of Israel, reducing interactions to a bare “reactive” minimum. In April 1999, again with support from the U.S. Information Services, an expert from the University of Connecticut, Department of Community Medicine and Health Care visited the region to conduct training in Gaza and the West Bank. Also, he led a 2-day workshop in Beer Sheva (April 26 and 27, 1999) to promote a WHO substance abuse research initiative. In addition to the workshops and training described above, other programs and initiatives were generated. These included the development of Hebrew and Arabic versions of Matrix Institute drug treatment manuals for use in the West Bank, Gaza and Israel funded by the Palestinian-Netherlands Research Program which is administered by the Foreign Ministries of the Netherlands and Israel, and drug information center development in Gaza organized by the BGU RADAR Center with support from the Center for International Cooperation (MASHAV), Israel Ministry of Foreign Affairs. The “jewel in the crown” of these collective initiatives was the attendance of an Israeli and Palestinian delegation including the Deputy Director of the Palestine Anti-Drug Authority at an international meeting of the US Substance Abuse and Mental Health Services Administration RADAR Center Directors in Irvine, California—May 3–8, 1999. This event was followed by a research planning effort for the delegation with U.S. drug research partners in Los Angeles, supported by the Matrix and Friends Research Institutes. That effort led to the submission of a proposal to the US Agency for International Development (USAID/Middle East Regional Cooperation Program) for the development of improved methods of drug prevalence data collection and analysis in Israel, Gaza and the West Bank. The proposal received approval and efforts were initiated in 2001. Another positive outcome of the cooperation generated was the publica-

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tion of an edited book on the substance use problem in the Middle East that includes contributions from Palestinian and Israeli experts in the region, NIDA supported researchers, and experts affiliated with the World Health Organization.32

NOTES 1. Hasenfeld, Y., and English, R. (1978). Human Service Organization. Ann Arbor: University of Michigan Press, pp. 1–2. 2. Ibid.; Likert, R. (1967). The Human Organization. New York: McGraw-Hill; Moos, R. (1975). Evaluating Correctional and Community Settings. New York: Wiley; Patti, R., Poertner, J., and Rapp, C. (eds.) (1988). Managing for Services Effectiveness in Social Welfare Organizations. New York: Haworth. 3. Hasenfeld, Y. (ed.) (1992). Human Services as Complex Organizations. Newbury Park, CA: Sage; Hasenfeld and English; Sarri, R., and Hasenfeld, Y. (1978). The Management of Human Services. New York: Columbia University Press; Robbins, S. (1987). Organization Theory: Structure, Design, and Applications. Englewood Cliffs, NJ: Prentice-Hall International Editions; Burke, A., and Clapp, J. (1997). Ideology and social work practice in substance abuse settings. Social Work, 42(6):553. 4. Hasenfeld and English, p. 22. 5. Delahanty, D. (1980). The Comprehensive Plan: Strategies for Human Services. Louisville, KY: Human Services Coordination Alliance. 6. Hasenfeld and English, p. 6; Hasenfeld. 7. Moos; Patti, Poertner, and Rapp; DuPont, R. (1989). Stopping Alcohol and Other Drug Use Before It Starts: The Future of Prevention. AOSAP Prevention Monograph 1, Rockville, MD: U.S. Department of Health and Human Services, Office of Substance Abuse; Pickens, R., Leukefeld, C., and Schuster, C. (1991). Improving Drug Abuse Treatment, Research Monograph 106, Rockville, MD: U.S. Department of Health and Human Services, National Institute on Drug Abuse (NIDA). 8. Harlow, C. W. (1991). Drugs and Jail Inmates, 1989. Bureau of Justice Statistics, Special Report, Washington, DC: U.S. Department of Justice; Scheckel, L. (1993). Forging Links to Treat the Substance Abusing Offender. Washington, DC: Center for Substance Abuse Treatment, U.S. Department of Health and Human Services, Spring; Graham, M., and Reed, W. (1995). Searching for Answers. Annual evaluation report on drugs and crime: 1993–1994. Washington, DC: National Institute of Justice. 9. Hasenfeld and English, p. 7; Baron, R. (1986). Behavior in Organizations. Boston: Allyn and Bacon. 10. Demone, H. (1978). Stimulating Human Services Reform, Human Services Monograph Series. Project Share, Washington, DC: U.S. Department of Health, Education and Welfare. 11. Curtis, W. (1981). Managing Human Services with Less: New Strategies for Local Leaders. Project Share, Washington, DC: U.S. Department of Health, Education and Welfare. 12. Delahanty, D. (1978). The Community Profile. Louisville, KY: Human Services Coordination Alliance. 13. D’Aunno, T., and Vaughn, T. (1995). The organizational analysis of service patterns in outpatient drug abuse treatment units. Journal of Substance Abuse, 7: 27–42; D’Aunno, T., and Price, R. (1986). Linked systems: Drug abuse and mental health services. In W. R. Scott and B. L. Black (eds.), The Organization of Mental Health Services: Societal and

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Community Systems. Beverly Hills, CA: Sage Publications; Timko, C. (1995). Policies and services in residential substance abuse programs: Comparisons with psychiatric programs. Journal of Substance Abuse, 7:43; NIDA (1997). Organization and Management of Drug Abuse Treatment Services. NIH Guide, Vol. 26, No. 16, May 16. 14. Isralowitz, R., Telias, D., and Tabu, N. (1996 ). Drug Services in the Negev: A Study of Organization Problems and Needs, Staff Training and Treatment Issues: A report to the Negev Development Authority. Beer Sheva: Ben-Gurion University. 15. Burnford, F., and Chenault, J. (1978). The Current State of Human Services Professional Education. Project Share, Washington, DC: U.S. Department of Health, Education and Welfare. 16. Chenault, J., and Burnford, F. (1978). Human Services Professional Education. New York: McGraw-Hill; Cowen, E. (1973). Social and community interventions. In P. Mussen and M. Rosenzweig (eds.), Annual Review of Psychology. Palo Alto, CA: Annual Reviews, Inc.; Krebs, D. (1970). Altruism—An examination of the concept and a review of the literature. Psychological Bulletin, 73:258–302; Levine, M., and Graziano, A. (1972). Intervention programs in elementary schools. In S. E. Golann and C. Eisdorfer (eds.), Handbook of Community Mental Health. New York: Appleton. 17. Chenault and Burnford; Baker, F. (1977). The interface between professional and natural support systems. Clinical Social Work Journal, 5:139–148. 18. Iscoe, I. (1971). Professional and subprofessional training in community mental health as an aspect of community psychology. In Division 27 of the American Psychological Association. Issues in Community Psychology and Preventive Mental Health. New York: Behavioral Publications; Chenault and Burnford, p. 158. 19. Cushing, M., and Long, N. (1973). Reaching Out: Information and Referral Services. Washington, DC: U.S. Department of Health, Education and Welfare. 20. Isralowitz, R. (2001). Toward an understanding of Russian-speaking heroin addicts and drug treatment services in Israel. Journal of Social Work Practice in the Addictions, 1(2):33–44. 21. NIDA (1995). Women’s HIV Risk and Protective Behaviors, NIH Guide, Vol. 24, No. 30, August 18. 22. Brown, B., and Mills,A. (1990). Youth at Risk for Substance Abuse. Rockville, MD: U.S. Department of Health and Human Services, NIDA, p. vii. 23. Adler, R., and Raphael, B. (1983). Children of alcoholics. Australian and New Zealand Journal of Psychiatry, 17:3–8; Wilson, C. (1982). The impact of children. In J. Orford and J. Harwin (eds.), Alcohol and the Family. London: Croom Helm; Thorne, C., and DeBlassie, K. (1985). Adolescent substance abuse. Adolescence, 20(78):335–347; Kumpfer, K. (1986). Prevention Strategies for Children of Drug-Abusing Parents. Proceedings of the 34th Annual International Congress on Alcoholism and Drug Dependence, Calgary, Alberta. 24. Isralowitz, R., and Singer, M. (eds.) (1983). Adolescent Substance Abuse: A Guide to Prevention and Treatment. New York: Haworth; Cotton, N. (1979). The familial incidence of alcoholism. Journal of Studies on Alcohol, 40(1):89–116; Goodwin, D. (1971). Is alcoholism hereditary? A review and critique. Archives of General Psychiatry, 25:545–549. 25. Brown and Mills, p. 181. 26. Lindbloom, C., and Cohen, D. (1979). Usable Knowledge: Social Science and Social Problem Solving. New Haven, CT: Yale University Press. 27. Coulton, C. (1995) Riding the pendulum of the 1990s: Building a community context for social work research. Social Work, 40(4):437–440.

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28. Kirwin, P. (1994). The search for universal meanings: Issues in measurement. Social Work, 39(4):466–468. 29. Isralowitz, R., Sussman, G., Afifi, M., Rawson, R., Babor, T., and Monteiro, M. (2001). Substance abuse policy and peace in the Middle East: A Palestinian and Israeli partnership. Addiction, 96:973–980. 30. Robinson, G. (1997). Building a Palestinian State: The Incomplete Revolution. Bloomington: Indiana University Press. 31. Isralowitz, R. (ed.) (1998). Palestinian and Israeli people against substance abuse: A cooperative effort to address the problem through communication, cooperation and coordination. Workshop proceedings. Beer Sheva. November 4–5, 1997 (Tel Aviv and East Jerusalem: ECF and PCH); Isralowitz, R. (ed.) (1998). Palestinian and Israeli people against substance abuse: Prevention and beyond. Workshop proceedings. Bethlehem. May 25–26, 1998 (Tel Aviv and East Jerusalem: ECF and PCH); Isralowitz, R. (ed.) (1999). Palestinian and Israeli people against substance abuse: Legal and judicial aspects. Workshop proceedings. Ramallah. March 24–25, 1999 (Tel Aviv and East Jerusalem: ECF and PCH). 32. Isralowitz, R., Afifi, M., and Rawson, R. (eds.) (2002). Drug Problems: Cross-Cultural Policy and Program Development. Westport, CT: Auburn House.

Epilogue: The Final Straw—A Response to the War against Drugs

American society has a major drug problem on its hands. The condition is undesirable and it appears that policies must be changed and new programs instituted.1 This statement was made more than a decade ago and little has changed based on observations and reports regarding patterns of drug use and addicted behavior, criminal acts, emergency hospital visits, and violence. The opinions expressed by anti-drug leaders, a wide range of respected judicial and government officials, social scientists, and commentators on the social order tend to agree that national drug policy and the war on drugs is a “dismal failure,”2 “monumental error,” and “utter futility.”3 There are many ways of examining the “War on Drugs.” The following section overviews three perspectives: (1) public and expert opinion, (2) numbers on those effected, and (3) cost related to the problem. PERSPECTIVES: WHAT IS BEING SAID? It has been noted that [p]ublic opinion about the importance of drugs as a national problem runs a cyclical course. In the late 1980’s, it was the number one problem most cited by respondents in opinion polls, but in the early ’80s and early ’90s, it was cited much less frequently. Such variation raises the question of whether public opinion accurately reflects the severity of the problem or is instead determined by multiple causes, including greater media coverage. . . . More than 50 percent of those surveyed in a 1999 Gallup poll said that their concern about illicit drug use had grown in the past five years. . . . [Among the top concerns are adolescents drug use and crime].4

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In a survey by the Pew Research Center for the People and the Press (2001), it has been reported that the nation’s drug war is viewed as a failure by most Americans, and there is scant hope it will ever succeed. Nearly three-quarters of Americans say we are losing the drug war, just as many say that insatiable demand will perpetuate the nation’s drug habit. Yet this deep sense of futility has not generated more momentum for alternative anti-drug strategies, like establishing more treatment programs for drug users or decriminalizing the use of some drugs. The public still gives higher priority to traditional get-tough approaches, such as interdicting drugs at the border and arresting dealers in this country [in spite of declining numbers]. . . . [T]he public continues to rank drugs among the major problems facing both the nation and local communities, and concern about drug abuse potentially affecting a family member remains high. No less than 90% say drug abuse is a serious problem in the nation, with a quarter calling it a national crisis. Concern is particularly evident in the African-American community; more than four-in-ten blacks (43%) rate drug abuse as a national crisis, compared to 26% of whites. . . . In addition to being a top national concern, drug abuse is also a significant personal worry, and concern about drugs affecting a family member has, if anything, increased since the 1980’s. More than half of Americans say they are concerned about drugs causing problems in their family. . . . While Americans still mostly look to law enforcement to curb illegal drug use, a slim majority says that, in general, drug abuse should be treated as a disease rather than a crime. This may be the strongest evidence showing that Americans are open to alternative anti-drug strategies, although those strategies themselves have yet to win support.5

According to “Drug Wars,” a four-hour Frontline report aired on television by the Public Broadcast System (PBS), little has been accomplished over the past three decades to stem the use and availability of illegal drugs. Other reports and commentary show that the U.S. anti-drug campaign is waning; Americans are tired of wasting billions of dollars on a drug war that is not working, especially when clear, pragmatic alternatives exist. Wealthy businessmen have joined together to find ways of ending the drug war since their belief is that the federal government has proven incapable of reform, living in fear of the right-wing moralists.6 It has been pointed out in the Washington Post (2001) that “[d]uring the past three decades, the United States has invested billions in fighting the scourge of drugs, and more and more serious people are questioning its effectiveness. The critics range from Bill Buckley and New Mexico Gov. Gary Johnson to an array of liberals and they are having an impact on public opinion. While few argue with the editors of the influential British newspaper the Economist, which has laid out at length ‘the case for legalizing drugs,’ many more are expressing their doubts about current policies.”7 Other editorials appear in leading newspapers such as the New York Times, Washington Post, and the International Herald-Tribune critical of drug policy. “When the World Conference on Racism opens in Durban, South Africa (on August 31, 2001), the target will be America’s war on drugs in which black men are being imprisoned for drug offenses at 13 times the rate of white men. . . . The war on drugs is a war on civil liberties.”8 After five years as America’s “drug czar,” General Barry McCaffrey refers to the drug problem as a “can-

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cer,” not a war, calling for new drug courts, methadone, and access to insurance for drug abuse and mental health that McCaffrey believes will lower the level of spousal abuse and violence as well as save immense resources.9 NUMBERS: WHAT DO THEY SHOW? The most revealing evidence about the state of America’s drug policy and situation lies with the numbers of people involved and affected. An estimated 11 percent of the adult U.S. population suffers from substance abuse or dependence during the course of a year. About 13.7 million adults each year (based on 1992 data) abuse or are dependent on alcohol and about 5.3 million (based on 1996 estimates) abuse or are dependent on illicit drugs. The 1999 National Household Survey on Drug Abuse reveals that of the population 12 years of age and older, 6.7 percent used illicit drugs (at least once during the 30 days prior to the interview), 20.2 percent engaged in binge drinking (drinking five or more drinks on one occasion during the 30-day period), and 5.6 percent were heavy drinkers (drinking five or more drinks at a time during five or more occasions during the past 30 days).10 A report from the Robert Wood Johnson Foundation says: In 1997, more than 2.5 million arrests were made for alcohol offenses . . . and more than 1.5 million for drug offenses. . . . About half of the state prison inmates and 40 percent of the federal prisoners incarcerated for committing violent crimes report they were under the influence of alcohol and drugs at the time of their offence. . . . Alcohol is more likely to be involved in crimes against people [including homicides, rape, and sexual assaults]. . . . From 1985 to 1995, the proportion of drug offenders in state prisons increased from 9 percent to 23 percent . . . and the proportion of federal inmates sentenced for drug offenses grew from 34 percent to 60 percent. . . . In addition, more than one in three women in state prisons was serving a sentence for drug offenses in 1997, up from one in eight in 1986. These increases in incarcerated drug offenders are related, in part, to mandatory minimum sentencing laws for drug offenses, and are often cited as major reasons for prison overcrowding.11

Other relevant information shows that the number of hard-core users of cocaine has remained steady during the last decade at around 3.5 million. The number of hard-core heroin users, meanwhile, has risen from 600,000 in the early 1990s to 980,000 in 2001.12 In 1960, the U.S. inmate population (counting those locked up in long-term prisons, but not counting illegal immigrants and minors) stood at 333,000. During the next two decades it rose at a comparatively modest pace to 474,000. Then, from 1980 to 2000, the number of incarcerated quadrupled to 2 million. Regarding incarceration, 9.7 percent of black males in their twenties are imprisoned, compared with 2.9 percent of Hispanic men and 1.1 percent of white men in the same age group.13 According to the U.S. Department of Justice’s Bureau of Statistics, 38,288 drug offenders were referred to federal prosecutors in 1999, an increase from 11,854 in 1984. Furthermore, 84 percent of the 38,288 suspects were subsequently charged in a U.S. court and 90 percent of the drug offenders were convicted, the majority for drug trafficking. According to the report, however, one-third of federal drug of-

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fenders had never been previously arrested, and two out of three had no prior felony convictions. Of that minority of drug offenders with previous convictions, 32 percent had only prior drug convictions. Fewer than 10 percent of all drug offenders convicted in 1999 had previous felony convictions. Additionally, 90 percent of the people convicted on federal drug charges in 1999 were nonviolent offenders and two-thirds of those convicted were first felony offenders. Nine out of ten first-timers (92 percent) went to prison anyway.14 “Almost two million Americans are either in prison (after conviction) or jail (waiting for trial). Of every 100,000 Americans, 481 are in prison. By comparison, the incarceration rate for Britain is 125 per 100,000, for Canada 129, and for Japan 40. Only Russia, at 685, is quicker to lock ’em up.”15 In the United States, 1.5 million children have at least one parent in prison. The 1999 figures mean that 500,000 more children have a parent in prison compared to 1991. This is a 98 percent increase over the past eight years in the number of minors with a mother in prison. For the same period, the number of children with an imprisoned father increased 58 percent. Among the children with a parent in prison, 58 percent were younger than 10, with the average age being 8. “Fathers are most likely to be the imprisoned parent—representing 93 percent of all imprisoned parents—with the children generally living with their mothers. In addition . . . half of the parents in prison are African American, one quarter are white, and one-fifth are Hispanic.”16 Also, national estimates of the need for drug abuse treatment suggest that only two in five illicit drug abusers who need treatment for severe problems actually receive care. In 1996, about 5.3 million people with serious drug abuse problems needed treatment, while only about 2.0 million received it.17 MONEY: WHAT DOES ALL THIS COST? “The economic cost of substance abuse to the U.S. economy each year is staggering, and it is estimated at over $414 billion [in 1995]. . . . This cost includes productivity losses caused by premature death and the inability to perform usual activities as well as costs related to treatment, crime, destruction of property and other losses.” Alcohol abuse is the most costly ($166.5 billion) followed by smoking ($138 billion) and illicit drug abuse ($109.9).18 In 1992, the total cost to society for substance abuse (alcohol and drug alone) was $965 for every person in the United States; the per-person cost for illicit drug abuse alone was $383.19 The drug market in the United States was estimated to be at $150 billion a year in 1996. In 1996, the jails and prisons cost $20 billion a year; in 2001, the cost is in the area of $40 billion a year to construct and operate federal, state, and local prisons. The cost to taxpayers for the federal prison system alone, which cares for 150,000 prisoners (as of September 2001) will be “$4.66 billion in the next fiscal year, if the Bush administration’s prison budget passes.” This means that the annual cost per prisoner is $31,000. In 1986, when federal mandatory minimum sentences were enacted, the Bureau of Prisons budget was $0.7 billion according to the president of the Criminal Justice Policy Foundation. The annual federal

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anti-drug budget for law enforcement has grown from roughly $53 million in 1970 to about $10 billion in FY 1997. Since 1970, the United States has invested roughly $77 billion in domestic and foreign drug enforcement—$74 billion since 1981. In 1996, it was reported that America spends more than $3 billion a year on its overseas drug wars alone; in 2001, nearly $1.3 billion went to Colombia. According to a report by the National Research Council, the United States spends nearly $12 billion a year fighting the war on drugs; yet little evidence exists to determine the effectiveness of such spending. In a news release, the National Academy of Sciences stated that the nation’s ability to evaluate whether its drug policies work is no better now than it was 20 years ago, when drug-control efforts began to accelerate. According to an editorial by the New York Times, one month earlier, it was reported that “the bulk of the federal government’s annual drug fighting budget is still spent on interdiction and enforcement.” Also, it has been reported that “substance abuse and addiction will add at least $41 billion—10 percent—to the costs of elementary and secondary education in [2001], due to class disruption and violence, special education and tutoring, teacher turnover, truancy, children left behind, student assistance programs, property damage, injury and counseling.”20 A fundamental building block for an anti-drug strategy is treatment, yet “in the past decade, funds for treating drug addiction dropped from 25 percent of the federal drug budget—well before the cocaine epidemic created millions of new addicts—to only 14 percent. In the same period, arrests for drug crimes doubled, while violent crime jumped by more than a third. Half of all offenders arrested for homicide or aggravated assault in 1989 were using cocaine or heroin, as were three-quarters of those arrested for burglary or robbery. . . . Addicts today often face waits of six months or longer before they can get help. Treatment is even more scarce in the criminal justice system. The General Accounting Office reported in 1991 that only 364 of the 41,000 federal prison inmates who have drug problems are participating in intensive day treatment. More than three-quarters of all state prison inmates are drug users—at least 500,000 offenders—but only 10 to 20 percent receive any help. . . . [A]lthough addicts maintained on methadone will give up heroin and commit fewer crimes, such treatment is available to less than 20 percent of the nation’s heroin addicts.” Nearly 10 years later, it is reported that “fewer than 15 percent of people in prison receive substance abuse treatment, far less than the more than 70 percent in state prisons and the more than 30 percent in federal prisons estimated to need such treatment.”21 Simple cost facts do not appear to have had much influence on the way treatment policy has been formulated and resources allocated. A California study has shown, for example, that on average every dollar invested in treatment saves $7 in crime and health care costs.22 The National Association of State and Alcohol and Drug Abuse Directors estimated that the annual cost to incarcerate a drug offender is up to $50,000 per inmate compared to the annual cost of outpatient drug-free treatment at $2,300, methadone maintenance at $3,000 per patient, and residential drug-free treatment at $14,000.23

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From the supply-side drug strategy perspective, once again data appear to have had little influence on the formation of policy and intervention strategies. It has been noted: that even success in the [strategy] of significantly reducing overseas supply through force and coercion would fail to meet the larger political objective for which the war is being fought: raising the street price of drugs in the United States enough to reduce drug abuse and addiction. This is because the actual costs of growing and processing illegal drugs abroad are only a minimal part of the street price in the United States. At the point of export, the price of cocaine is still only 3 to 5 percent of the price a U.S. consumer will pay. Even smuggling costs—from Colombia to the United States—account for less than 5 percent of the retail price . . . [and putting the failure more simply] only four Boeing 747 cargo planes or thirteen trailer trucks could supply U.S. cocaine consumption for a year; the annual U.S. demand for heroin could be met by a twenty-square-mile field.24

In a Rand Corporation study of drug treatment spending by U.S. government agencies, a $1 billion overstatement was found. “While the Office of National Drug Control Policy (ONDCP) estimated that U.S. agencies spent $2.8 billion on drug treatment, authors of the Rand study said the actual amount was closer to $1.8 billion, or 36 percent less than reported.” In legislation introduced in Congress at the beginning of 2001, the Drug Abuse Treatment on Demand Assistance Act (S-160), a call was made to increase the Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration’s treatment funding to $6 billion by 2006 in annual incremental increases of $600 million. The bill also would authorize $625 million over five years in matching grants to states that provide treatment as an alternative to prison. In a New York Times editorial, February 27, 2001, President Bush was called on to keep his campaign pledge and “provide an additional $1 billion over 5 years for treatment to help close the gap between the 5 million Americans addicted to illegal drugs and the 2.1 million who currently receive treatment.”25 In spite of these conditions, government officials responsible for addressing the drug problem make declarations that “this is the country that mobilized itself to put a man on the moon in ten years, that built the interstate highway system and that won the [Persian] Gulf war in 30 days. We never fail. . . . Enough is enough. And, a strategy is in place providing the nation with a concise, action-oriented approach to drug prevention and drug treatment, law enforcement, local program implementation, and international/interdiction.” These remarks provide little solace, however, to those who know that the “high ground” has not been captured in the war against drugs and who have come realize that the “emperor’s drug war has no clothes.”26 PREVENTION AND TREATMENT In the war against drugs, a major battlefront involves prevention and treatment. At best, drug use prevention and treatment programs tend to reflect a mixed bag of results. It appears that a number of intervention strategies have demonstrated the

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ability to reduce or prevent drug use and drug-related crime. “They cover school and community-based education and prevention, various methods of treatment, drug testing and employee-assistance programs in the workplace, organized neighborhood action to drive out dealers, media campaigns and other efforts to change public attitudes and establish norms of conduct that rule out drug use, and grass-roots coalitions.”27 For the most part, drug prevention and treatment efforts have been fragmented, underfunded, less than comprehensive, and poorly planned and integrated for a variety of historical, political, and economic reasons including those that relate to the social construction of reality and social values discussed in Chapter 1. In spite of this, it has been found that better outcomes tend to exist when the treatment is individualized, promotes client motivation, and extends the amount of time the client is involved in the program.28 Furthermore, it “can be said with some certainty that (1) methadone maintenance programs can help clients who are highly motivated to end their drug abuse, and (2) a model program that provides counseling along with methadone has been able to help less well-motivated clients.”29 Drug addicts are not a homogeneous group and, in theory, the needs of each client should be matched,30 preferably to a service system characterized by rational, flexible, responsive, well defined, short- and long-term integrated service plans developed on dependable funding sources with on-going monitoring and evaluation.31 Such approaches are, however, for the most part absent in the United States. “Drug abuse treatment has waxed and waned over the past three decades under different administrations, under different funding priorities, and in response to changing patterns of drug use, drug availability, and perceived national threat.”32 Despite sporadic efforts by national commissions, policy advisory panels, and federal agencies to develop policies and plans to improve treatment—many of which have detailed the same or similar recommendations for what is needed—the development of drug treatment has more often than not been reactive rather than proactive, piecemeal rather than planned, and fragmented rather than integrated. . . . Current policy and practice isolate the drug abuser from the mainstream of health care; legislation and general policy, including funding priorities, have created often insurmountable barriers to treatment for many people with drug problems.33

Drug prevention efforts tend to reflect an equally muddled scene of policy and practice. Specifically, the government invests annually hundreds of millions of dollars in an anti-drug program known as DARE. In one evaluation of the program it was found that “the level of drug use among kids who had gone through DARE was virtually identical to the level among kids who had not . . . [and based on multiple outcome measures the conclusion was reached that] DARE exposure does not produce any long-term prevention efforts on adolescent drug use rates.”34 In a 1996 study published in Preventive Medicine it was found that any results from DARE were extremely short-lived and there was no evidence that the prevention program reduces drug use. In 1994, a National Institute of Justice–sponsored study concluded that “while DARE was loved by teachers and participants, it had no effect on drug use.” In response to this finding the Justice Department refused to re-

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lease the peer-reviewed study. The American Journal of Public Health, however, accepted it for publication.35 More recent, the mayor of Salt Lake City, Utah, called DARE “a fraud on the people of America . . . and we have frittered away opportunities to put in place in our schools programs that really work.”36 Also, a survey released by the National Center on Addiction and Substance Abuse (CASA) said that DARE presented “little evidence of any extended impact.”37 THE WAR: AND THE DEBATE GOES ON The National Review has stated that the time had come to revise the laws on drug trafficking. “[The National Review] deplores the [use of drugs] and we urge the stiffest sentences against anyone convicted of selling a drug to a minor. But that said, it is our judgment that the war on drugs has failed, that it is diverting intelligent energy away from how to deal with the problem of addiction, that it is wasting our resources, and that it is encouraging civil, judicial, and penal procedures associated with police states.”38 Based on a symposium of national experts sponsored by the magazine, the primary conclusions were: “(1) that the famous drug war is not working; (2) that crime and suffering have greatly increased as a result of prohibition; (3) that we have seen, and are countenancing, a creeping attrition of authentic civil liberties; and (4) that the direction in which to head is legalization.”39 Efforts to reverse drug prohibition face formidable obstacles40 such as anti-drug war lords’ control over the attitudes and behavior of those involved with all aspects of drug control, prevention, and treatment through the distribution of funding resources and the “bogeyman syndrome”—the need of people to use scapegoats to embody their fears and take blame for whatever ails them. . . . Just as anti-Communist propagandists once feared Moscow far beyond its actual influence and appeal, so today anti-drug proselytizers indict marijuana, cocaine, heroin and assorted hallucinogens far beyond their actual psychoactive effects and psychological appeal. . . . The evidence of history and of science is drowned out by today’s bogeymen. No rhetoric is too harsh, no penalty too severe.41

In spite of this situation and the fact that prospects for reevaluation and reform look dim,42 history shows that the legal and moral status of psychoactive drugs has kept changing. “During the seventeenth century the sale and use of tobacco were punished by death in much of Europe, Russia, China, and Japan. For centuries many of the same Muslim domains that forbade the sale and consumption of alcohol, at the same time, tolerated and even regulated the sale of opium and cannabis.”43 In the United States change is occurring especially at the state level as evidenced by initiatives to reduce penalties for marijuana use and legal challenges against the tobacco industry for compensation of health costs and reform. A broad-based coalition of respectable special interest groups and grass-roots organizations may prove to be the vanguard for moving drug policy and practices to a more rational and pragmatic level for addressing the problem. Certainly, if this expectation does not come to fruition, there is always the issue of economic realities and con-

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straints—“Americans are not keen on paying the rising costs of enforcing laws”44 especially when substantial tax revenues can be generated through different methods of control and regulation. The door is open for change in terms of how the problem of drug use is to be addressed; the only question is when and how that change will occur. Getting there will not be easy, and the effort should be taken incrementally. Such gradualism, which should begin with cannabis, would allow for a necessary shift in values so that more socially and economically pragmatic policies can be formulated and enacted.45 For some, such legislation may be a leap in the dark. Indeed, there will be unpredictable consequences as well as predictable ones. But that does not argue for doing nothing, or talking tougher with words that are empty in terms of action and outcomes. NOTES 1. Goode, E. (1989). Drugs in American Society. New York: McGraw-Hill, p. 261. 2. Russell, A. (1992). Making America drug free: A new vision of what works. Carnegie Quarterly, 37(3):1. 3. Sweet, R. (1996). The war on drugs is lost. National Review, February 12, p. 44. 4. Horgan, C. (2001). Substance Abuse: The Nation’s Number One Health Problem. Princeton, NJ: Robert Wood Johnson Foundation, p. 76. 5.The Pew Research Center for the People and the Press (2001). 74% say drug war being lost: Interdiction and incarceration still top remedies. March 21, http://www.people-press.org/drugs. 6. Join Together Online (JTO) (2000). Frontline says U.S. drug war fails. Boston University School of Public Health, October 6; JTO (2000). Public support grows for drug decriminalization, December 26; JTO, Trio of funders work to change US drug policy, November 2. 7. Broder, D. (2001). A debatable war on drugs. Washington Post Online, August 26, p. B07. 8. Peirce, N. (2001). America’s war on drugs looks unfairly warped. International Herald Tribune, August 22, p. 6. 9. Alter, J. (2001). A well-timed ‘Traffic’ signal. Newsweek, January 15, p. 21. 10. Coffey, R., Mark, T., King, E., Harwood, H., McKusick, D., Genuardi, J., Dilonardo, J., and Chalk, M. (2001). National Estimates of Expenditures for Substance Abuse Treatment. U.S. Department of Health and Human Services, DHHS Publication No. SMA 01-3511, Rockville, MD, p. 1. 11. Horgan, pp. 66–68. 12. International Herald-Tribune (2001). The demand for drugs. February 28, p. 8, editorial. 13. International Herald-Tribune (2001). Too many prisoners. August 22, p. 6, editorial. 14. JTO (2001). Drug cases, sentencing on rise. August 22; DRCNET (2001). Issue No. 200, August 24. 15. Murphy, C. (2001). Crime and punishment: Think that stuffing prisons with lawbreakers makes sense? Fortune, April 30 (reported in Harm Reduction Coalition, April 2). 16. United States Department of Justice (2000). Incarcerated parents and their children. Washington, DC: Bureau of Justice Statistics, NCJ 182335; JTO (2000). More children have parents in prison, September 7.

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17. Coffey et al., p. 1. 18. Horgan, p. 18. 19. Swan, N. (1998). Drug abuse cost to society set at $97.7 billion, continuing steady increase since 1975. NIDA Notes, NIH Publication No. 98-3478. 20. Sweet, p. 44; JTO (2001). U.S. prison spending quadruples, February 16; DRCNet (2001). Issue No. 182, April 20; Bertram, E., and Sharpe, K., (1996). The unwinnable drug war: What Clausewitz would tell us. World Policy Journal, (Winter):44; JTO (2001). US official says to expect costly Colombian drug war, April 6; NEWS, The National Academies (2001). Data sorely lacking on effectiveness of nation’s drug-enforcement programs, March 29; New York Times (2001). Adjusting drug policy. February 27, p. A22. 21. Falco, M. (1992). The Making of a Drug-free America: Programs That Work. New York: Times Books; Russell, pp. 5–6; Horgan, p. 106. 22. Gerstein, D., Johnson, R., Harwood, H., Fountain, D., Suter, N., and Malloy, K. (1994). Evaluating Recovery Services: The California Drug and Alcohol Treatment Assessment. Sacramento: California Department of Alcohol and Drug Programs. 23. National Institute of Justice (1993). Drug Use Forecasting: 1992 Annual Report: Drugs and Crime in America’s Cities. Washington, DC: National Institute of Justice, U.S. Department of Justice; Wellish, J., Prendergast, M., and Anglin, M. (1995). Toward a drug abuse treatment system. Journal of Drug Issues, 25(4):760–761. 24. Falco, p. 8. 25. JTO (2001). Study shows U.S. overstated drug treatment spending, January 24; JTO (2001). Senator Boxer proposes adding billions to federal treatment budget, January 26; JTO (2001). Editorial calls for Bush to invest in drug treatment, March 1. 26. Kitfield, J. (1996). Four-star general. National Journal, 4/13, p. 823; Brown, L. (1995). National Drug Control Strategy: Executive Summary. Washington, DC: Office of National Drug Control Policy, p. i; Bertram and Sharpe, p. 50. 27. Falco; Russell, p. 5; JTO (2001). Experts identify effective prevention measures, July 30; Horgan, p. 108. 28. Horgan, p. 108. 29. Apsler, R. (1994). Is drug abuse treatment effective? American Enterprise, (March/April): 53. 30. Cohen, A. (1986). A psychosocial typology of drug addicts and implications for treatment. International Journal of the Addictions, 21(2):147–154. 31. Downes, E., and Shaening, M. (1993). Linking state AOD and justice systems. Center for Substance Abuse Treatment TIE Communique (Spring):8–9; Wellish, Prendergast, and Anglin, p. 767. 32. Basteman, K. (1992). Federal leadership in building the national drug treatment system. In D. Gerstein and H. Harwood (eds.), Treating Drug Problems, Volume 2. Washington, DC: National Academy Press, pp. 63–88; Haaga, J., and McGlynn, E. (1990). The Drug Abuse Treatment Systems: Prospects for Reform. Santa Monica, CA: Drug Policy Research Center, RAND Corporation; Musto, D. (1987). The American Disease: Origins of Narcotic Control (2nd edition). New York: Oxford University Press; Wellisch, Prendergast, and Anglin, p. 765. 33. McAuliffe, W. (1990). Health care policy issues in the drug abuser treatment field. Journal of Health Politics, Policy and Law, 15(2):357–385; Schlesinger, M., and Dorwart, R. (1992). Falling between the cracks: Failing national strategies for the treatment of substance abuse. Daedalus, 121(3):195–237; Wellisch, Prendergast, and Anglin, p. 770. 34. Glass, S. (1997). Don’t you DARE. New Republic, March 3, p. 20.

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35. Clayton, R., Cattarello, A., and Johnstone, B. (1996). The effectiveness of Drug Abuse Resistance Education (project DARE): 5-year follow-up results. Preventive Medicine, May–June, 25(3):307–318. 36. JTO (2000). Mayor calls DARE program a fraud. June 28. 37. JTO (2001). CASA report calls DARE, Zero Tolerance ineffective, September 10. 38. National Review (1996). The war on drugs is lost. February 12, p. 34. 39. Buckley, W. (1996). 400 readers give their views. National Review, July 1, p. 32. 40. Nadelman, E. (1993). Should we legalize drugs? History answers. American Heritage, 44(1):42. 41. Nadelman, p. 47. 42. Bertram and Sharpe, p. 50. 43. Nadelman, p. 47. 44. Ibid. 45. The Economist (1997). Shopping for a drugs policy. August 15, p. 30.

Index

Abstinence, 97 Abuse, 3–4 Addiction, 1, 4–6, 40; and alcohol, 87; and new-style heroin abusers, 53 Addicts, 37, 49; before criminalization, 52; cross-cultural perspectives, 64–81; female, 63–64, 162; in need of services, 161–62; personality characteristics, 61–64; psychological theories, 39; social background of, 156 Advertising, 14–19 Afghanistan, and heroin, 57–60 AIDS, 93; and heroin, 53, 64; HIV-infected individuals, 162; and marijuana, 136 Alcohol, 2, 3, 6–7, 87–100; abstinence from, 97; binge drinking, 95–97; and crime, 93; historical perspective, 88–90; and holocaust survivors, 99; Jewish people’s use of, 98–100; Prohibition, 89–90, 142; psychological theories, 91; ritual drinking, 97–98; social drinking, 97–99; sociocultural factors, 92, 97–100; tax revenues from, 89, 142; and traffic fatalities, 94, 99–100; trends, 92–97; university student use of, 95–97; utilitarian drinking, 97–98; withdrawal, 87

Alcoholics, 88; biological factors, 92; personality characteristics of, 90–92 American Academy of Pediatrics, 35 American Civil War, 51 American Journal of Public Health, 178 American Medical Association, 4, 134–35 American Psychiatric Association, 1, 4, 5, 87 Amphetamine, 7, 109 Anslinger, Harry, 133–35 Anxiety, 91 Assassins, cult of, 132, 134 Australia: cocaine in, 116; heroin in, 60; marijuana in, 147–48 Bales, R., 97–98 Barbiturates, 9 Becker, Howard, 27, 36 Benzodiazepines, 9 Binge drinking, 95–97 Biological theories, 38–39, 92 Bolivia, 117, 123–24 Brain damage: and inhalants, 11; and marijuana, 139 Buckley, Bill, 172 Bureau of Narcotics, 133, 137

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Index

Bush, George W., 176 Caffeine, 4, 109 Campbell, William I., 17 Canada: cocaine in, 116; heroin in, 60–61; marijuana in, 148 Candler, Asa Griggs, 108 Cannabis, 2, 10, 131–32 Child abuse, 93 Children: and crack, 111, 120, 125; and marijuana, 143–44; media exposure, 35; and medical marijuana, 140; and parents, 30–32; and secondhand smoke, 14; and tobacco marketing, 16 Cigars, 14 Classes of drugs, 6–12 Classic addiction, 4–5 Clinton, Bill, 124 Cloward, R., 29 Club drugs, 9 Coca-Cola, 108–9 Cocaine, 2, 7, 107–27; in Australia, 116; in Canada, 116; demographics of, 114–15; ecological costs of, 118; economic costs of, 118; in Europe, 116; freebase, 110; with heroin, 53; historical perspective, 107–12; injection of, 107, 110; and Latin America, 117–20; and law enforcement, 115; and Marxist rebels, 126; medical use of, 107; in Mexico, 116; multisubstance use, 114, 117; political costs of, 118; production of, 118; in South Africa, 116; transport of, 118–19; trends, 112–16; use patterns, 114. See also Crack Cocaine users, 117 Codeine, 7 Cohen, A., 28 Cohen, P., 149–50 Colombia, 117, 119, 121–26 Compassionate Use Act of 1996, 136 Compton, James, 38 Costs, 118, 174–76 Crack, 7, 115; and children, 111, 120, 125; dependence on, 117; response to, 112; street dealers, 28; and the War on Drugs, 110, 120–24; and women, 111

Crime: and alcohol, 93; heroin-related, 62; hidden, 29; labeling process, 36–38; media portrayal of, 34–35 Criminalization, 36–38; addicts before, 52 Cultural theories, 92, 97–100 Dai, B., 40 DARE, 177–78 Date-rape drugs, 10 Decriminalization, 141, 149–50 Demographics: of cocaine use, 114–15; of heroin use, 56; of marijuana use, 146 Dependence, 1, 4–6 Deviant behavior, social and cultural sources of, 26–29 Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994), 1, 5, 87 Driving: and alcohol, 94, 99–100; and marijuana, 138–39 Drug Abuse Warning Network (DAWN), 54–55, 63, 113 Drug Crazy (Gray), 27–28 Drugs: addiction/dependence, 4–6; classes of, 6–12; cocaine, 2, 7, 107–27; date-rape, 10; deaths, 55, 122; hallucinogens, 10–11; heroin, 2, 7, 49–81; inhalants, 11–12; legalization of, 178; marijuana and hashish, 10, 131–50; multisubstance use, 53, 55–56, 114, 145–46; opiates, 7; and public opinion, 171–73; sedatives and hypnotics, 9–10; social context of, 1–21; stimulants, 7–9; street dealers, 28; tobacco, 12–20 Drug use, 3–4; biological theories, 38–39; cost of, 118, 174–76; and education, 33–34; environment, 27–29; and family, 30–32; and hidden crime, 29; and interpersonal relations, 30–36; labeling/criminalization process, 36–38; and the media, 34–36; numbers, 173–74; and peers, 32–33; prevention and treatment, 176–78; psychological theories, 39–40; and the social order, 26–29; theoretical considerations, 25–40

Index Eastland, James, 135–36 Ecological costs, 118 Ecstasy (methylenedioxymethamphetamine), 7–9 Education, 33–34, 159–61 Empey, L., 32–33 Employment, 15 Environment, 27–29 Erickson, M., 32–33 Europe: cocaine in, 116; heroin in, 61; marijuana in, 148 European Monitoring Center on Drugs and Drug Addiction, 53 European Union, cigarette smuggling into, 18 Family, 30–32, 62 The Fix (Massing), 27 Food and Drug Administration (FDA) 15–17, 109 Fox, Vicente, 127 Freud, Sigmund, 107 Gateway theory, 13 Geneva Convention, 2 GHB, 9, 10 Goffman, Erving, 27 Goode, E., 4 Goodman, Paul, 30 Gray, Mike, 27–28 Grinspoon, Lester, 8–9 Growing Up Absurd (Goodman), 30 Hallucinogens, 10–11 Harrison Narcotics Act of 1914, 51–52, 109 Hashish, 10, 132 Heart disease, 12–13 Heroin, 2, 7, 49–81; Afghanistan and beyond, 57–60; in Australia, 60; in Canada, 60–61; with cocaine and crack, 53; in Colombia, 122–23; and crime, 62; cross-cultural perspectives, 64–81; and deaths, 55; demographics of, 56; distribution of, 56–57; in Europe, 61; historical perspective, 49–54; injection of, 53–55; international perspectives, 57–61; in Israel, 64–81; law enforcement data, 56; in

185

Mexico, 61; multisubstance use, 53, 55–56; smoking of, 53; smuggling of, 57–60; in South Africa, 61; trends, 54–57; use patterns, 55 Hidden crime, 29 HIV-infected individuals, 162 Hughes, Everett, 27, 36 Immune system, 139–40 Inciardi, J., 62 Industrialization, 31 Inhalants, 11–12 Injecting: of cocaine, 107, 110; of heroin, 53–55; and HIV infection, 162 International Herald-Tribune, 172 Interpersonal relations, 30–36 Israel: alcohol use in, 98–100; heroin addicts in, 64–81; immigration to, 65; law of return of, 64 Jewish people, and alcohol use, 98–100 Johnson, Gary, 172 Johnston, James W., 17 Johnston, Lloyd, 145 Journal of the American Medical Association, 111 Kat, 2 Kennedy, John, 135 Kennedy, Robert, 135 Kessler, D., 15–16, 19–20 Ketamine, 9 Kingdon, John W., 20 Koop, C. Everett, 3 Labeling/criminalization process, 36–38 Laing, R. D., 8 Latin America, 117–26 Law enforcement: and cocaine, 115; and drug services, 156; and heroin, 56; and marijuana, 146–47 Legalization, 178 Legal systems, 2, 52; Israel’s law of return, 64; and marijuana, 141; and racial bias, 37–38 Leshner, Alan, 54 Levine, H., 89 Lindesmith, A., 40

186

Index

Lower classes, 27–29 LSD, 2, 9, 11 Lung cancer, 13–14 Management, 155–68; assessment of, 158; needs and problems of, 158–63 Mariani, Angelo, 108 Marijuana, 2, 131–50; and the alcohol industry, 143; in Australia, 147–48; and brain damage, 139; in Canada, 148; and children, 143–44; decriminalization of, 141, 149–50; demographics, 146; and driving, 138–39; the Dutch experience, 138, 149–50; emergency and treatment data, 145; in Europe, 148; historical perspective, 131–37; and the immune system, 139–40; legal and policy perspectives, 141, 146–47; Marinol, 140; medical use of, 132, 136–37, 140–43; in Mexico, 148; multisubstance use, 145–46; negative consequences of, 136; and other illegal drugs, 138; and the reproductive system, 139; and sexual activity, 132–35; in South Africa, 148; THC level, 10, 137–38; trends, 144–47 Marijuana Policy Project Foundation, 137 Marijuana Tax Act of 1937, 134, 143 Marketing of tobacco, 15–20 Marxist rebels, 126 Massing, Michael, 27 McCaffrey, Barry, 126, 136–37, 172–73 Media, 34–36 Medical use: of cocaine, 107; of marijuana, 132, 136–37, 140–43; of morphine, 2, 51 Merton, Robert, 26–27, 29 Mescaline and peyote, 9, 11 Methadone, 1–2; and crack, 122 Methamphetamine, 7–8 Methaqualone, 9 Mexico: cocaine in, 116; heroin in, 61; marijuana in, 148; and smuggling, 127 Middle and upper classes, 29; and peer support, 32–33 Miller, W., 28 Monitoring the Future (National Institute on Drug Abuse), 9 Morals, 27–29 Morphine, 7; medical use of, 2, 51

Multisubstance use, 53, 55–56, 114, 145–46 Music, 35 National Academy of Sciences, 137 National Cancer Institute, 17 National Commission on Marijuana and Drug Abuse, 4 National Household Survey on Drug Abuse (NHSDA), 54, 63, 95, 109, 113 National Institute on Drug Abuse (NIDA), 38, 54, 113, 145 National Institute of Justice, 156, 177 National Review, 178 Netherlands, and marijuana use, 149–50 New York Academy of Medicine, 134 Nicotine, 6, 13; manipulation of, 17 Nitrous oxide, 9 Nye, I., 29 Occupations, 27, 36 Ohlin, L., 29 Opiates, 7, 49–53 Opium, 49–52 Opium Wars, 20, 50 Oral cancer, 14 Overdose, 7; and smoking, 53 Oxycodone, 7 Palestinian and Israeli people against substance abuse (PIPASA), 165–68 Panel on Youth of the President’s Science Advisory Committee, 30 Paranoid behavior, 8 Parents, 30–32, 156 Partnership for a Drug-Free America, 145 Passive smoking, 14 PCP, 11 Peers, 32–33 Pemberton, John, 108 Personality characteristics: of alcoholics, 90–92; of cocaine users, 117; of heroin addicts, 61–64 Peru, 117, 121 Pew Research Center for the People of the Press, 172 Political costs, 118 Prohibition, 89–90, 142 Prostitution, 161

Index Psilocybin, 11 Psychological theories, 39–40, 91 Public Broadcast System (PBS), 172 Public opinion, 171–73 A Question of Intent: A Great American Battle with a Deadly Industry (Kessler), 19–20 Quindlen, Anna, 17 Racial bias, 37–38 Rand Corporation, 176 Regional Alcohol and Drug Abuse Resources (RADAR), 164–67 Relapse prevention, 163–64 Reproductive system, marijuana and, 139 Research, 164 Retreatism, 26, 29 Ritual drinking, 97–98 Robert Wood Johnson Foundation, 173 Rohypnol, 9, 10 Rush, Benjamin, 89–90 Russia: emigration policies of, 64; heroin in, 60; submarines of, 119 Russian-speaking immigrants, 64–81; interviews with, 74–81; policy and treatment services, 71–72 School experience, 33–34 Schur, E., 29 Second World War, 52 Sedatives and hypnotics, 9–10 Sertürner, Frederich, 51 Services, 155–68; assessment of, 158; drug information center development, 164–68; education and training, 160–61; management of, 157–58; needs and problems, 158–59; research, evaluation and dissemination of information, 164; resources, 159; target populations, 161–63; treatment and relapse prevention strategies, 163–64 Sexual activity, 32, 36; in crack houses, 111; and HIV risk, 162; and marijuana, 132–35 Short, J., 29 Smokeless tobacco, 14 Smoking, 6; arguments against, 12–13; and cancer, 13–14, 19; decline of, 17; and

187

drug use, 34; and heart disease, 12–13; and heroin, 53; and lung cancer, 13–14; passive, 14; and sudden infant death syndrome, 14 Smuggling: of cocaine, 118–19; and corruption, 127; of heroin, 57–60; with submarines, 119, 126; of tobacco, 18 Social context, 1–21, 92 Social drinking, 97–99 Social order, 26–29 South Africa: cocaine in, 116; heroin in, 61; marijuana in, 148 Stimulants, 7–9 Street dealers, 28 Structure theory, 28 Submarines, 119, 126 Substance Abuse Mental Health Services Administration (SAMHSA), 113, 164 Sudden infant death syndrome, 14 Suicide, 93 Surgeon General’s report (1964), 12, 17 Surgeon General’s report (1989), 13 Sussman, S., 136 Tax revenues: from alcohol, 89, 142; from marijuana, 134; from tobacco, 14 Television, 35–36 Temperance movement, 89 THC level, 10, 137–38 Theoretical considerations, 25–40 Tobacco, 3, 12–20; advertising and marketing of, 14–19; arguments against cigarette use, 12–13; cigars, 14; and employment, 15; gateway theory, 13; and lung cancer, 13–14, 19; “no limit” strategies, 20; and oral cancer, 14; smokeless, 14; smuggling of, 18; and tax revenues, 14; War on Drugs and, 20 Tobacco settlement, 16–19; funds from, 18–19 Tolerance, 5 Traffic fatalities, 94, 99–100 Treatment, 155–68; drug information center development, 164–68; goal of, 156; management of services, 157–63; and relapse prevention strategies, 163–64; and the War on Drugs, 176–78 Tuberculosis, 64

188

Index

University students, alcohol use, 95–97 Use, 2–3 Utilitarian drinking, 97–98 Values, 27–29 Venezuela, 118 Vietnam War, 52, 120 Voegtlin, Walter, 90 War on Drugs: “bogeyman syndrome,” 178; and crack, 110, 120–24; response to, 171–79; and tobacco industry, 20 Washington Post, 172

Welfare departments, 156 Withdrawal, 5, 87 Women: and crack, 111; heroin addicts, 63–64; HIV-infected, 162; and smoking, 14; and tobacco marketing, 15–17, 19 Wood, Alexander, 51 World Health Organization, 5–6, 17 Youth: and alcohol use, 94–95; education, 33–34; family, 30–32; high-risk, 162–63; media exposure, 35; peers, 32–33; street dealers, 28; and tobacco marketing, 16, 19–20

About the Author RICHARD ISRALOWITZ is Professor and Director, Israel Regional Alcohol and Drug Abuse Resources Center, Ben-Gurion University, Israel. He is the co-editor of Drug Problems: Cross-Cultural Policy and Program Development (Auburn House, 2002).