Drug abuse has been a major social problem in the United States for almost a century and we are now in the second decade of a continuing war on drugs. Drug abuse is a health and criminal justice problem that also has implications for nearly every facet of social life. It is a major element in the high cost of health care, a central reason for the United States’ extraordinarily high rate of incarceration, and a focus of intensive education and treatment efforts.
Substance abuse is an equal-opportunity problem that affects both high- and low-income persons, although its consequences are most often felt by those persons and communities that have the lowest social capital. Substance abuse, with its connotations of disapproval or wrong or harmful or dysfunctional usage of mood-modifying substances, is a term that was developed in the United States. The more neutral term, dependence, is often used in other countries. Addiction, which formerly communicated the development of tolerance after use and a physical withdrawal reaction after a drug became unavailable, has assumed less explicit meanings. Whatever terminology is employed, there is intense societal concern about the use of psychoactive mood altering substances that involve loss of control. This concern is manifest particularly for young people in the age group most likely to use such substances. Society is concerned that adolescents and young adults, who should be preparing themselves for crucial educational, vocational, and other significant life choices, are instead diverted by the use of controlled substances.
The United States has the highest rate of drug abuse of any industrialized country and, not surprisingly, spends more public money than any other country to enforce laws that regulate the use of psychoactive drugs. Its efforts to control drug abuse reach out across its borders. The United States also plays a critical role in developing knowledge about substance abuse; more than 85 percent of the world’s drug abuse research is supported by the National Institute on Drug Abuse.
Information on incidence and prevalence of drug use and abuse derives from a range of sources: surveys of samples of households and schools; hospital emergency room and coroners’ reports; urine testing of samples of arrestees; treatment programs; and ethnographic studies. Such epidemiological information enables us to assess drug abuse programs and decide on allocation of resources (Winick 1997).
Since World War II, the peak years for illicit drug use were in the late 1970s, when approximately 25 million persons used a proscribed substance in any thirty-day period. Overall illicit drug use has been declining since 1985. The yearly National Household Survey on Drug Abuse, which is the most influential source of epidemiology data, reported that in 1997 marijuana was used by 11.1 million persons or 80 percent of illicit drug users (Office of Applied Studies 1999). Sixty percent only used marijuana but 20 percent used it along with another illicit substance. During the 1990s, the rate of marijuana initiation among youths aged twelve to seventeen reached a new high, of approximately 2.5 million per year. The level of current use of this age group (9.4 percent) is substantially less than the rate in 1979 (14.2 percent).
Twenty percent of illicit drug users in 1997, ingested a substance other than marijuana in the month preceding the interviews. Some 1.5 million Americans, down from 5.7 million in 1985, used cocaine in the same period; the number of crack users, approximately 600,000, has remained nearly constant for the last ten years. At least 408,000 individuals used heroin in 1997, with the estimated number of new users at the highest level in thirty years.
Data on incidence and prevalence of use must be interpreted in terms of social structure. Thus, one out of five of the American troops in Vietnam were addicted to heroin, but follow-up studies one year after veterans had returned to the United States found that only 1 percent were addicted (Robins, Helzer, Hesselbrook et al. 1980). In Vietnam, heroin use was typically found among enlisted men and not among officers. Knowing such aspects of social setting and role can help in understanding the trends and can contribute to understanding the use of other substances in other situations. In any setting, the frequency of substance use, the length of time over which it was taken, the manner of ingestion, whether it was used by itself or with other substances, its relationship to criminal activity and other user characteristics (e.g., mental illness), the degree to which its use was out of control, the setting, and whether it was part of a group activity are also important.
Rates of use by subgroup can vary greatly. Thus, for example, prevalence rates of drug use are higher among males than females and highest among males in their late teens through their twenties. Over half the users of illicit drugs work full time. About one-third of homeless persons and more than one-fourth of the mentally ill are physically or psychologically dependent on illicit drugs. The first survey of mothers delivering liveborns, in 1993, found that 5.5 percent had used illicit drugs at some time during their pregnancy. A survey of college students reported that in the previous year, 26.4 percent had used marijuana and 5.2 percent had used cocaine. National Household Survey data indicate that use of illicit drugs by persons over thirty-five, which was 10.3 percent in 1979, jumped to 29.4 percent by 1991 and was 33.5 percent in 1997.
Rates of cigarette smoking are of interest because of their possible relationship to the use of other psychoactive substances. Approximately one eighth of cigarette smokers also use illicit drugs. In a typical month in 1997, 30 percent of Americans, or 64 million, had smoked cigarettes and one-fifth of youths between the ages of twelve and seventeen were current smokers. Almost half of all American adults who ever smoked have stopped smoking. Drug abusers may also be involved with alcohol.
A central contributor to current American policy toward mood-modifying drugs was the Harrison Act of 1914, which prevented physicians from dispensing narcotics to addicts (Musto 1987). The Marijuana Tax Act of 1937 and strict penalties for sale and possession of narcotics that were imposed by federal legislation in 1951 and 1966 expanded punitive strategies. An important change took place in 1971, when President Nixon—who had campaigned vigorously against drug use—established a national treatment network. Nixon was the only president to devote most of the federal drug budget to treatment; his successors have spent most of the budget on law enforcement.
In 1972, the Commission on Marijuana and Drug Abuse recommended a dual-focused policy that is both liberal and hard-line. The policy, which continues to the present, is liberal in that users who need help are encouraged to obtain treatment. But it is hard-line because it includes harsh criminal penalties for drug possession and sales. As a result, nearly two-thirds of the federal resources devoted to drug use are now spent by the criminal justice system to deter drug use and implement a zero-tolerance philosophy. President Carter’s 1977 unsuccessful attempt to decriminalize marijuana was the only effort by a national political leader to lessen harsh penalties for drug possession. Between 1981 and 1986, President Reagan doubled enforcement budgets to fight the ‘‘war on drugs.’’ Politicians generally have felt that the traditional hard-line policy served their own and the country’s best interests and here has been limited national support for legalization or decriminalization (Evans and Berent 1992).
Originating in several European countries, the policy of harm reduction has, during the last decade, generated growing interest in the United States as a politically viable alternative to legalization (Heather, Wodak, Nadelmann et al. 1998). It attempts to understand drug use nonevaluatively in the context of people’s lives and to urge that the policies that regulate drug use should not lead to more harm than the use of the substance itself causes. A representative harm-reduction initiative is the establishment of needle exchanges, for injecting users of heroin and other drugs, in order to minimize the possibility of HIV transmission resulting from the sharing of infected needles. The use of needles to inject illegal substances has been linked to one-third of the cumulative number of AIDS cases in the United States. In the United States, the use of federal government money for needle exchanges is prohibited, although there are approximately 1.3 million injecting drug users. Critics of these programs believe that such exchanges increase heroin use and send a latent message that it is acceptable to use drugs like heroin. Harm reductionists disagree and argue that needle exchanges lead to a decline in rates of HIV infection without encouraging use.
Another policy disagreement between America and other countries involves marijuana. In the United States many federal benefits, including student loans, are not available to those convicted of marijuana crimes. In contrast, marijuana has been decriminalized in a number of Western European countries, including Italy, Spain, and Holland. It is openly available in coffee houses in Holland, where officials believe that its use is relatively harmless and can deter young people from using heroin or cocaine. In America, marijuana is viewed by federal authorities as possibly hazardous and a potential ‘‘stepping stone’’ to heroin or cocaine use, and approximately 695,000 persons were arrested for its possession in 1997.
Other countries have experimented with ways to make drugs such as heroin legally available, albeit under control. Thus, in Switzerland, heroin addicts have been legally maintained. In England, methadone (a heroin substitute) can be obtained by prescription from a physician. In the United States, by contrast, an addict must enroll in a program to be able to receive methadone.
In the United States prevention of drug abuse has never been as important a policy dimension as treatment or law enforcement, in part because it requires legislators to commit resources in the present to solve a future problem. Prevention has, thus, accounted for less than one-seventh of the drug abuse budget. Because of the variety of prevention approaches and because of the American local approach to education, there are many viewpoints on how to conduct programs that will prevent young people from becoming drug users and abusers. An information-didactic approach, often with the assistance of law enforcement personnel, has been traditional. A role-training, peer-oriented, values-clarification, alternatives, affective-education approach emerged in the 1970s, along with psychological inoculation. Addressing the social structure and family in which young people live, and targeted community action, attracted substantial support in the 1980s and 1990s.
National policy toward drug use is systematically promulgated by the Office of National Drug Control Policy (1999). The office has established the goal of reducing drug use and availability by 50 percent and reducing the rate of related crime and violence by 30 percent by 2007. It is proposed that these goals will be achieved by expanding current approaches.
Although drug abuse has been called ‘‘the American disease,’’ physicians have had little impact on policy. Between 1912 and 1925, clinics in various states dispensed opiates to users. More recently, however, the federal government has opposed making marijuana available for medicinal purposes, even to treat persons with terminal or debilitating illnesses. Nevertheless, eleven states decriminalized marijuana possession in the 1970s and others, by referendum vote in the 1990s, have permitted physicians to recommend and patients to use marijuana medically.
In the United States, programs to control the supply of mood-modifying substances are intended to interdict the importation of illicit materials, enforce the laws, and cooperate with other countries that are interested in minimizing the availability of controlled substances. In addition to illicit substances (such as heroin, that has no established medical use), prescription products can be abused. These include substances such as barbiturates, that are used without medical supervision in an inappropriate manner. The problem also includes over-the-counter drug products that are not used for the purpose for which they were manufactured. Some nondrug substances like airplane model glue and other inhalants that can provide a ‘‘high’’ and are difficult to regulate, are also considered part of the country’s substance abuse burden.
Preventing illicit drugs from entering the United States is difficult because of heavily trafficked, long, porous borders. Large tax-free profits provide incentives for drug entrepreneurs to develop new ways to evade customs barriers, process the drug for the market, and sell it (Johnson, Goldstein, Preble et al. 1985). For example, approximately seven-eighths of the retail price represents profit after all costs of growing, smuggling, and processing cocaine for illegal sale in the United States. The increasing globalization of the world economy further facilitates the international trade in illicit substances.
A key component in efforts to reduce the supply of stimulants, depressants, and hallucinogens is the Comprehensive Drug Abuse and Control Act of 1970, which established a national system of schedules that differentiated the public health threat of various drugs of abuse. This law, which has been modified over the years, classifies controlled substances into five categories, based on their potential for abuse and dependency and their accepted medical use. Schedule I products, such as peyote, have no acceptable safe level of medical use. Schedule II products, such as morphine, have both medicinal value and high abuse potential. Schedule III substances, such as amphetamines, have medical uses but less abuse potential than categories I or II. Also acceptable medicinally, Schedule IV substances, such as Phenobarbital have low abuse potential, although the potential is higher than Schedule V products, such as narcotics that are combined with non-narcotic active ingredients. Conviction for violation of federal law against possession or distribution of scheduled products can lead to imprisonment, fines, and asset forfeiture.
Ever since it assumed a major role in promoting the Hague Opium Convention of 1912, the United States has been a leader in the international regulation of drugs of abuse. The United States convened the 1961 Single Convention on Narcotic Drugs and the 1971 Convention on Psychotropic Substances. Some countries, like England and Holland, subscribe to the treaties but interpret them more liberally than does the United States. The United States has also provided technical assistance, financing, and encouragement to other countries to minimize the growth of drugs such as cocaine and marijuana. Programs have been conducted in Mexico and Turkey to eradicate these crops and related programs have been encouraged in Peru and Columbia.
Regular or frequent drug users, without outside income, are likely to engage in a range of criminal activities in order to buy controlled substances. They typically engage in six times more criminal activity when using than when they are not using drugs. Urine testing of arrestees, under the federal Arrestees Drug Abuse Monitoring program, indicates that some two-thirds of those arrested in urban communities had used an illicit substance prior to arrest. It is, thus, not surprising that the rates of street crimes tend to be positively correlated with the number of illegal drug users in a community.
During the last fifteen years, both state and federal prison populations have experienced a massive increase due to the number of people convicted and jailed for selling or using drugs. Other developments contributing to the surge in the prison population include aggressive enforcement, longer sentences, the decline of parole, and mandatory sentencing procedures that provide less latitude for judges. Thus, for example, federal penalties for possession of crack, a rock-like form of cocaine that became popular in the 1980s and sells for a low price on the street, are 100 times greater than for powdered cocaine. Sellers targeting crack to urban minorities represent one of several factors that have led to a disproportionate number of young blacks in federal and state prisons, for violation of possession laws. Ninety percent of prisoners in federal prisons for crack violations are black, although twice as many whites as blacks use it.
Survey and other data consistently report that the use of mood-modifying drugs is distributed among all the socioeconomic and ethnic groups in the United States; nevertheless, arrests, convictions, deaths, and other negative outcomes of drug use are disproportionately concentrated in specific geographic areas and population subgroups. In state prisons, blacks make up some 60 percent of the drug-law violators although they represent 12 percent of the country’s population and 15 percent of regular drug users. Selective enforcement of the laws might reasonably be considered a possible contributor to such statistics.
For members of both majority and minority groups sentenced to prison, recidivism rates are high and represent one reason that the United States has higher rates of incarceration (approaching two million) than any industrialized nation. Although treatment of former drug users in prison settings has produced some promising results, treatment opportunities in prison are scarce and have not kept pace with the growth in the population of incarcerated former users. Approximately one in eight state inmates and one in ten federal inmates have taken part in treatment since their admission to prison. On a limited basis, treatment is being offered in an effort to keep offenders from returning to prison.
The treatment of substance abuse has consistently been a lower priority than efforts to control drug abuse through interdiction and criminal sanctions, although cost-benefit studies have demonstrated that every dollar invested in treatment saves seven dollars in other costs. The federal government has usually spent more than two-thirds of its substance abuse budget (which now totals nearly $20 billion) on such supply-reduction and criminal justice system strategies. Only a small minority of drug abusers have access to treatment, since health insurers tend to discriminate against persons with substance abuse problems and there are inadequate treatment resources.
Current treatment for drug abuse, in addition to withdrawal, ranges from psychotherapeutic interventions (provided in both inpatient and outpatient settings), pharmacology agents, and various forms of milieu therapy. It frequently includes information on relapse prevention. Psychotherapy is often used in combination with other forms of treatment, and is provided both on an individual and group basis by therapists trained in medicine, psychology, social work, nursing and education. Pharmacological treatments include approaches that substitute or block the effect of an abused substance, such as methadone maintenance for heroin (Ball and Ross 1991). Milieu therapies include a variety of residential programs where drug abusers can learn or relearn how to live substance free. Although some relatively short-term hospital based programs exist (particularly for those with independent resources to pay for such services), the most common milieu consists of longer-term therapeutic communities such as Phoenix House, where drug users live in a setting in which they are closely monitored. The residents’ progress through the several levels of the program’s hierarchical social structure depends on their ability to implement the program’s rules for ‘‘right living’’ (De Leon 1997).
Although often not considered a treatment, various fellowship groups deriving from the Alcoholics Anonymous model are widely used by drug abusers. Thus, for example, groups such as Narcotics Anonymous, Cocaine Anonymous, and parallel groups for spouses and parents of drug users exist in almost every community. Such groups, which have no professional staff and rely on the reinforcement of abstinence, support drug abusers in maintaining drug-free lives and help family members aid their drug- abusing relatives. Many treatment programs encourage their patients or clients to participate in such a twelve-step fellowship simultaneously with the treatment period or after treatment are completed.
Although substantial resources have been devoted to treatment outcome research, our knowledge of who does best in what treatment is limited. Particularly for cocaine, the use of which can lead to dependence in a short period of time, effective pharmacological treatments are not available. A combination of strategies is often most effective especially if it recognizes that drug abuse is a chronic relapsing disorder that is likely to include multiple treatment failures on the way to an ultimately favorable outcome. Of the treatment approaches to drug abuse, milieu treatments have been among the most intensely studied. For those able to participate in such programs, they can have extremely high rates of relatively enduring positive outcomes. Whatever the treatment modality, it must include job readiness, habilitation and vocational rehabilitation, and other dimensions that will enable the former user to function effectively in the modern information-oriented community and economy.
In the late 1980s, the social problems associated with drug abuse, particularly in terms of the possession and sale of cocaine in urban areas, were perceived to have reached crisis dimensions and there was a marked increase in criminal justice efforts to control substance use. Another positive response was a renewed emphasis on the prevention of drug abuse and the collateral development of broad-based community strategies designed to reduce demand for illicit drugs. Currently, such demand-reduction efforts are undergoing systematic study in several long-term longitudinal public and private programs. There has been a transformation in views of substance abuse as we have moved from a focus on individual pathology to programs that engage community institutions. Such efforts aim to change norms about substance use through the involvement of community members and the integration of the substance-abuse programs pursued by public and private agencies. The 1990s saw the expansion of community-based programs to include a broad range of institutions, including the police and courts, the voluntary sector, as well as the media (Falco 1994). Fostered by the government’s Center for Substance Abuse Prevention (part of the Substance Abuse and Mental Health Administration) and efforts of the Robert Wood Johnson Foundation, the country’s largest health foundation, hundreds of communities are engaged in broad-based efforts to change the culture within which substance abuse takes place (Saxe, Reber, HalFors, et al. 1997).
The belief that substance abuse is sustained by community norms represents an ecological approach. Environmental conditions, whether they reflect physical conditions in the community, poverty, or available health care, are thus seen as risk factors for drug use and abuse. Supporters of this view believe that what is needed are coordinated, community-wide efforts to address drug abuse at multiple levels of social organization and the collaboration of many groups. The idea that multicomponent community-action efforts can prevent drug abuse derives from earlier studies of programs designed to cope with cardiovascular disease. It is consistent with efforts to promote a variety of other health issues, but substance abuse is now a primary focus of these efforts.
The largest of these comprehensive efforts is the federal government’s Community Partnership Program, which has supported over 250 partnerships. The Community Partnership Program was initiated in 1990 after the Robert Wood Johnson Foundation had begun to develop a model and sponsor broad-based community efforts. Called ‘‘Fighting Back’’ programs, they now provide long-term support to more than a dozen communities to develop comprehensive demand-reduction interventions. The foundation has also provided support and technical assistance to hundreds of additional communities through groups such as Join Together.
A significant element of many such prevention programs is the presence of a strong media component. The Partnership for a Drug-Free America, for example, develops and places hundreds of millions of dollars of advertising each year, and communities are encouraged to leverage local media to present anti-drug messages directed at youth. Although there is limited direct evidence of the effectiveness of media campaigns, it is likely that they reinforce education and prevention messages being delivered to youth through other means.
Schools play a central role in prevention programs, under the assumption that drug abuse will be more easily prevented if programs are started early. The goal of these programs is to provide youth with the skills to become successful adults and to teach them the community’s norms and values. There is substantial evidence that positive school experiences are linked to lower levels of drug use and conversely, that drug use is related to delinquency and problems in school.
The role of school environments in affecting adolescent substance use has been validated by specific school-based trials. In both the Midwestern Prevention Project and Project Northland, significant reductions in the prevalence of substance use by adolescents were reported (Pentz, Dwyer, MacKinnon, et al. 1989; Perry, William, Veblen-Martenson 1996). Designed for students in grades six through eight, the programs include academic curricula, along with parental and community involvement. Often, a significant mass media component is part of the effort, with a focus on correcting misperceptions about the consequences of drug use and providing alternative positive behavior. The D.A.R.E. program (Drug Abuse Resistance Education) also has been a widely used school-based prevention strategy.
Schools are not the only public institution that affects youths’ likelihood to abuse drugs. The police and justice agencies, as well as the network of health and social service agencies that serve a community, have a crucial influence and prevention activities typically involve such agencies. The ability of health and social service professionals to attend to drug use is clearly important, but their role is often reactive, providing treatment rather than prevention.
One of the most important programs that has contributed to attempts by law enforcement agencies to deal with drug abuse is community policing. It represents a shift from reactive policing where the goal is to arrest offenders, to an active strategy designed to identify crime problems and work with citizens—including offenders—to avoid further difficulties. The heart of the approach is that officers get to know citizens and help them deal with minor transgressions and, in so doing, avoid serious crime. A collateral approach, widely used in the 1990s (‘‘fixing broken windows’’) is designed to improve morale and confidence and stem the physical and social deterioration of communities by prompt attention to small visible manifestations of community dysfunction or decay. There is evidence that such approaches are, at least partly, responsible for declines in violent crime, which is closely related to substance-abuse problems.
A community’s resources and social institutions have a critical impact on drug use, but the attitudes and behavior of peers and family may have an even more direct influence. The affluence of a community and the quality of its schools have a substantial effect on the initiation of drug use, but their impact is mediated by adolescents’ peer relationships and their interactions with significant adults in their lives. Thus, peers and parents are perhaps the most vital elements of the community context—directing or guiding youngsters’ needs and desires through the obstacles in their environment. Some of the most important programs designed to address community substance abuse focus on changing peer culture and addressing family attitudes and behavior.
Parents (or other adult ‘‘guides’’) arguably have the greatest potential effect on how the youngster learns to negotiate the environment as it exists (good or bad), and they can also affect the influence that the youngsters’ peers exert. The use of drugs by parents significantly increases the likelihood that their youngsters will also use drugs. Although this might seem to be a clear example of youngsters modeling the behavior of their parents, the influence of parents’ own use of drugs is probably more complicated. Some research suggests that it is not merely that youngsters mimic parents’ behavior, but instead such modeling interacts with what they see in their peers. If both peers and parents engage in substance use, there is far greater likelihood that young people will become regular users.
The influences of peers and parents may interact in complex ways and each community is different— its resources and institutions function differently. Communities can be directed to the key levers, but there is no simple formula available to determine which activities will be most important for a particular community. What is clear, however, is that to understand and develop strategies that reduce adolescent substance abuse, it is necessary to consider the social context in which a child lives. Only by identifying the resources available within a community, the roles played by the social institutions within that community, and the behaviors and values of the individuals (parents and children) who live in that community, can the interactions among the multiple forms and levels of influence begin to be understood.
Social science research has played a critical role in the identification of the substance-abuse problem, it ocial consequences, and strategies to arrest the use of illicit drugs. There is now a long-standing tradition of surveys to identify drug use and attitudes toward the use of mood-modifying substances and their consequences. Surveys, such as the National Household Survey on Drug Abuse (which assesses the drug use of a random sample of U.S. residents over twelve years old) and Monitoring the Future (a school-based survey of junior and senior high school students), have each been conducted for more than two decades. Although there is considerable discussion about the validity of these surveys and how to ensure veridical data (Beveridge, Kadushin, Saxe, et al. forthcoming), there is no question that they have influenced social policy.
More recently, much of the focus of social research has shifted to assessing strategies to prevent drug use and to evaluate treatment programs. Under the auspices of the National Institute on Drug Abuse (a component of the National Institutes of Health), a variegated research program includes both biological and sociopsychological components. An emphasis of research is on assessment of programs such as D.A.R.E., the Community Partnership Program, and Fighting Back. Determining whether these programs achieve their goals of preventing substance abuse is a particularly difficult challenge. The programs are implemented differently across communities and the research design needs to separate the effects of race, socioeconomic status, and other factors from program implementation (Rindskopf and Saxe 1998).
It is also the case that antidrug programs develop loyal followings and their proponents develop a stake in showing that their efforts are successful. Thus, for example, there has been a major debate about the D.A.R.E. program and whether it is successful, with researchers claiming that the evidence suggests it is not effective. In other cases, such as the Community Partnership Program and Fighting Back, the issue has been the availability of data that can show the effects of the program over time.
One development that will likely allow much better utilization of social research is the availability of sophisticated methodologies. Thus, for example, meta-analytic techniques are now available that permit the synthesis of data across multiple studies, allowing us to amalgamate multiple small-scale tests of programs. In addition, new analytic strategies are being developed to allow construction of multilevel statistical models. Such hierarchical linear modeling permits one to take account of the fact that programs are conducted in particular settings and facilitates the segregation of community effects from overall program effects. Qualitative ethnographic techniques have been used to track the life cycle of substance abuse and the structure of the illegal markets.
The war on drugs is far from being ‘‘won,’’ but drug abuse appears to have stabilized, with use remaining nearly constant. Two trends, that could be counter reactions, have emerged and may help to shape future use of illicit drugs. The first is the call for legalization or decriminalization of the possession of drugs such as marijuana. Several national organizations have emerged to promote this goal and to urge a harm reduction approach. The second trend is the increased licit use of mood-altering prescription substances, such as Prozac and Ritalin. Such powerful psychotropic agents are being prescribed by physicians for depression, difficulties in concentration, and similar problems. As the medical options increase, misuse of prescription drugs will likely increase and it may be more difficult to control the sale of less powerful nonprescription drugs.
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