Drug Policy and Human Nature Psychological Perspectives On The Prevention, Management, and Treatment of Illicit Drug Abuse by John L. Falk (Auth.), Warren K. Bickel, Richard J. DeGrandpre (Eds.) PDF

Drug Pol icy and
Human Nature
Psychological Perspectives
on the Prevention,
Management, and Treatment
of III icit Drug Abuse
Drug Pol icy and
Human Nature
Psychological Perspectives
on the Prevention,
Management, and Treatment
of Illicit Drug Abuse
Edited by
Warren K. Bickel
and
Richard J. DeGrandpre
University of Vermont
Burlington, Vermont
Springer Science+Business Media, LLC

Library of Congress Cataloging-in-Publication Data
On file
ISBN 978-1-4899-3593-9 ISBN 978-1-4899-3591-5 (eBook)

DOI 10.1007/978-1-4899-3591-5
© 1996 Springer Science+Business Media New York

Originally published by Plenum Press, New York in 1996
Softcover reprint of the hardcover 1st edition 1996
All rights reserved
1098765432 1
No part of this book may be reproduced, stored in a retrieval system, or transmitted in

any form or by any means, electronic, mechanical, photocopying, microfilming, recording,
or otherwise, without written permission from the Publisher
Contributors
B. K. ALEXANDER Simon Fraser University, Burnaby, British Columbia,

Canada V5A IS6
WARREN K. BICKEl Human Behavioral Pharmacology Lab, Department of
Psychiatry, University of Vermont, Burlington, Vermont 05401-1419
JOSEPH V. BRADY Behavioral Biology Research Center, Hopkins Bayview
Research Campus, Johns Hopkins University School of Medicine, Bal-
timore, Maryland 21224-6823
BREENA H. BRY Graduate School of Applied and Professional Psychology,
Rutgers University, Busch Campus, Piscataway, New Jersey 08855-0819
JONATHAN CAULKINS Drug Policy Research Center, RAND, Washington,
DC 20537 and Carnegie Mellon University, Pittsburgh, Pennsylvania 15213
H. WESTLEY CLARK University of California at San Francisco and Veterans
Administration Medical Center, San Francisco, California 94121
GARY A. DAWES Simon Fraser University, Burnaby, British Columbia, Can-
ada V5A IS6
RICHARD J. DeGRANDPRE Human Behavioral Pharmacology Lab, Depart-
ment of Psychiatry, University of Vermont, Burlington, Vermont 05401-1419
JOHN l. FALK Department of Psychology, Rutgers University, New Bruns-
wick, New Jersey 08903
SHARON M. HALL University of California at San Francisco and Veterans
DWIGHT B. HEATH Department of Anthropology, Brown University, Prov-
idence, Rhode Island 02912
ARTHUR P. LECCESE Kenyon College, Gambier, Ohio 43022
v
vi CONTRIBUTORS
ROBERT MacCOUN Graduate School of Public Policy, University of Cali-

fornia at Berkeley, Berkeley, California 94720, and Drug Policy Research
Center, RAND, Washington DC 20537
A. THOMAS MclELLAN Center for Studies of Addiction, University of
Pennsylvania, and Veterans Affairs Medical Center, Philadelphia, Pennsyl-
vania 19104
STANTON PEELE Morristown, New Jersey 07960
ANTON R. F. SCHWEIGHOFER Simon Fraser University, Burnaby, British
Columbia, Canada V5A IS6
KAREN LEA SEES University of California at San Francisco and Veterans
CONSTANCE WEISNER Alcohol Research Group, University of California
at Berkeley, Berkeley, California 94720
JOSEPH WESTERMEYER Departments of Psychiatry and Anthropology, Uni-
versity of Minnesota, Minneapolis, Minnesota 55455
Preface
The formation of drug policy is a complex phenomena influenced by a multi-

tude of sources. Among others, these influences include historical factors,
contemporary public opinion regarding the nature and magnitude of drug use
and abuse, the portrayal of illicit drugs and drug use in the media, and lobbying
efforts by special interest groups (e.g., The Drug Policy Foundation), including
government agencies (e.g., the Justice Department and law enforcement). An
additional source of influence are the activities of specialists directly engaged
in studying drug use and treating drug dependence. This includes individuals
involved in drug treatment, anthropological and cultural studies, policy analy-
ses, basic psychological and pharmacological research, research on the epide-
miology of drug use and dependence, and research on prevention. This influ-
ence by specialists might be usefully distinguished from those influences first
mentioned for two reasons: First, studies of drug use and dependence attempt to
uncover empirical generalizations about drugs, and second, because these
findings are empirical, there is a hope that they guide, at least to some extent,
the actions of other forces that more directly determine drug policy.
Psychology as an empirical discipline has long been interested in the use
of psychoactive drugs. At the level of basic science in psychopharmacology, a
most important contribution has been the demonstration that drugs of abuse
function as reinforcers and thus enter into the same psychological processes as
do other appetitive stimuli. Prior to this recognition, abused drugs were viewed
as unique entities that entered into chronic use because they alleviated a
withdrawal state created previously by the drug. Psychology's interest as a
therapeutic enterprise also has a long standing, and psychologists were among
the first to develop and test treatments for drug dependence. Given the health
costs and societal costs of various drug abuse problems, these efforts are
important for both the individual and the larger community. Meanwhile, other
psychologists have been involved in examining the role that childhood settings
and experiences can play in determining later drug use. Prevention efforts that
VII
VIII PREFACE
identify risks for drug dependence are among the most important and the most
challenging areas of research. Most recently, psychologists have begun to
address issues specific to public policy, including assessments of psychology's
role in policy development.
In this volume we have brought together a group of specialists whose
work, when taken together, addresses the primary psychological issues relevant
to the making of drug policy. The purpose of the volume, however, is not
merely to inform social scientists and policy makers about the various features
of research on illicit drugs, but also to give psychologists an opportunity to
provide policy recommendations based on their own knowledge and expertise.
In doing this, we hope to show that psychology can inform us about illicit drugs
and drug dependence and can participate in the formation of policy.
To reflect these aspects of drug policy-the psychological science of
psychoactive drugs and the psychology of policy-we have organized the
volume into five parts. In the first three parts (covering psychological science),
contemporary research is reviewed with respect to drug policy. Basic science is
discussed in Part I first in terms of the evolution of drug abuse (Chapter 1), and
then in terms of the clinical implications of basic processes involved in drug
use (Chapter 2). The chapters in Part II examine the problem of changing drug
use at the individual, cultural, and societal levels (Chapters 3-5). Part III
comprises a thorough discussion of innovations in drug treatment services
(Chapters 6 and 7).
The last two parts of the volume also examine psychological aspects of
drug policy but with a greater emphasis on policy issues (covering the psychol-
ogy of drug policy). The chapters in Part IV provide a critique of assumptions
underlying current drug policies and then propose policy alternatives (Chapters
8 and 9). This is followed by Part V, comprising four chapters that look at
different social and cultural factors involved in the psychology of drug policy
(Chapters 10-13).
Together, these five parts provide the reader with a comprehensive ac-
count of psychological aspects of drug policy and, hopefully, further the
contributions of psychology to policies regarding the nonmedical use of psy-
choactive drugs.
Warren K. Bickel
Contents
Part 1. Informing Drug Policy via Psychological

Science: Basic Research in Drug Abuse and Its
Determinants
Chapter 1. Environmental Factors in the Instigation and

Maintenance of Drug Abuse ............................... 3
John L. Falk
The Estrangement of Science and Policy ..................... 3

Science and Drug Policy .................................. 4
A Brief Critique of Pharmacological Determinism in Drug Abuse 6
Intravenous Self-Administration: Utility of a Classic
Pharmacological Approach .............................. 10
Nonpharmacological Sources for the Reinforcing Function of
Drugs and Drug Abuse ................................. 12
Concluding Remark ...................................... 23
References ............................................. 24
Chapter 2. Psychological Science Speaks to Drug Policy:

The Clinical Relevance and Policy Implications of Basic
Behavioral Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Warren K. Bickel and Richard J. DeGrandpre
Research-Derived Principles ............................... 32

Empirical Support ....................................... 40
ix
x CONTENTS
Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
References ............................................. 47
Part II. Informing Drug Policy via Psychological

Science: Changing Drug Use
Chapter 3. Psychological Approaches to Prevention . . . . . . . . . . . . . 55

Brenna H. Bry
Protective Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Risk Factors ............................................ 59
Prevention Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Summary and Recommendations ........................... 70
References ............................................. 72
Chapter 4. Drug Abuse, Drug Treatment, and Public Policy 77

Sharon M. Hall, H. Westley Clark, and Karen Lea Sees
Contingency Management ................................. 78

Skill Training ........................................... 84
Pharmacotherapy ........................................ 86
Summary............................................... 94
References ............................................. 94
Chapter 5. Cultural Factors in the Control, Prevention,

and Treatment of Illicit Drug Use: The Earthlings' Psychoactive
Trek................................................... 99
Joseph Westermeyer
Drug-Alcohol Production and Commerce in Prehistoric and

Historical Contexts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Substance Use in Cultural Context .......................... 105
Modes of Control over Drug Production, Commerce, and Use. . . . 109
CONTENTS XI
Drug Subcultures and the Drug Trade ....................... 113

Interethnic Differences within the Nation-State ................ 117
Drug Control among Cultures and Nation-States .. . . . . . . . . . . . . . 118
References ............................................. 121
Part III. Informing Drug Policy via Psychological

Science: Innovations in Treatment Services
Chapter 6. Achieving the Public Health and Safety Potential

of Substance Abuse Treatments: Implications for Patient Referral.
Treatment "Matching," and Outcome Evaluation .............. 127
A. Thomas McLellan and Constance Weisner
Introduction ............................................ 127

What Brings Substance Abusers to Treatment? ................ 129
What Outcomes Are Expected from Substance Abuse Treatment? 130
Outcome Domains Based on Public Expectations .............. 132
Methods ............................................... 132
Results ................................................ 138
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Illustrating the Relationships between Substance Use and Public
Health Problems: Case Examples ......................... 146
Strategies for Achieving the Public Health and Safety Benefits of
Substance Abuse Treatments ..................... . . . . . . .. 149
References ............................................. 152
Chapter 7. Drug Policy and the Enhancement of Access

to Treatment ............................................ 155
Joseph V. Brady
Introduction ............................................ 155

Program Implementation .................................. 158
Treatment Methods and Procedures ......................... 162
Process and Outcome Evaluation ........................... 163
Policy Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
References ............................................. 173
XII CONTENTS
Part IV. The Psychology of Drug Policy: Psychological

Assumptions behind Policy
Chapter 8. Examining the Behavioral Assumptions of the National

Drug Control Strategy .................................... 177
Robert MacCoun and Jonathan Caulkins
Effects of Drug Laws on Drug Use ......................... 178

Sociodemographic Considerations . . . . . . . . . . . . . . . . . . . . . . . . . .. 181
Other Actors, Other Roles .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Addressing the Use- Hann Link: Toward Total Hann Reduction .. 188
References ............................................. 195
Chapter 9. Assumptions about Drugs and the Marketing of Drug

Policies 199
Stanton Peele
Introduction: Say Whatever You Want about Drugs as Long as

It's Negative .......................................... 199
Drug Policy and Models of Drug Abuse and Addiction ......... 203
Harm Reduction, Drug Legalization, and Models of Addiction '" 216
Marketing Alternative Drug Policies . . . . . . . . . . . . . . . . . . . . . . . .. 217
References ............................................. 218
Chapter 10. The Pharmacological Understanding of Psychoactive

Drugs: Basic Science in the Context of Differential Prohibition. .. 221
Arthur P. Leccese
Importance of Basic Phannacology ........................ " 221

Retrospective Analysis and Prospective Experiments ........... 223
Basic Pharmacology of Cocaine and Marijuana. . . . . . . . . . . . . . .. 224
Five Questions about Cocaine and Marijuana ................. 226
Differential Prohibition and Research .. . . . . . . . . . . . . . . . . . . . . . . 238
Conclusion ............................................. 241
References ............................................. 242
CONTENTS xiii
Part V. The Psychology of Drug Policy: Social and

Cultural Factors Influencing Drug Policy
Chapter 11. American and Canadian Drug Policy: A Canadian

Perspective ............................................. 251
B. K. Alexander, Anton R. F. Schweighofer, and Gary A. Dawes
The Origin of Drug Laws in the United States and Canada ...... 252
American and Canadian Drug Policy after World War II ........ 259
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 267
References ............................................. 274
Chapter 12. The War on Drugs as a Metaphor in American

Culture ................................................ 279
Dwight B. Heath
Declaration of a War on Drugs ............................. 279

Why People Care about Drugs: An Anthropological Perspective .. 283
The Elusive Nature of Drug Problems ....................... 284
Prohibition as a Problem-Solving Strategy . . . . . . . . . . . . . . . . . . .. 290
Blurred Battle Lines in the War on Drugs .................... 292
Hope for an Armistice .................................... 295
References ............................................. 297
Chapter 13. The Impact of Socially Constructed Knowledge on

Drug Policy ............................................ 301
Introduction ........................................... . 301

An Epistemological Framework ........................... . 302
Social Knowledge and Illicit Drug Policy ................... . 310
Changing Policy Means Changing the Contingencies That
Produce It ........................................... . 317
Conclusion 320
References ........................................... .. 320
Index ................................................... . 323

PART I
Informing Drug Policy

via Psychological Science:
Basic Research in Drug
Abuse and Its Determinants
CHAPTER 1
Environmental Factors
in the Instigation and
Maintenance of Drug Abuse
JOHN L. FALK
THE ESTRANGEMENT OF SCIENCE AND POLICY
This chapter is written with the hope that some of the facts presented might
affect the way in which drug abuse is considered, and that this in tum would
influence drug abuse policy. But one cannot be sanguine in this matter. Scien-
tific explication all too often does not affect the framing of policy. Changes in
the two realms are determined by quite different reinforcing events. Re-
searchers are happy to provide solid facts to the makers of policy in the belief
that good policy must necessarily be a function of good data and that erroneous
notions can only lead to unworkable policies and grief. The production of
reliable, interesting data is an activity that is reinforced by the scientific
community in a variety of ways. In presenting even the most carefully con-
trolled studies, scientists scrupulously indicate the provisional and contingent
nature of results. After all, a larger context may reveal limitations to the
conceptions that seem to follow from the results. Policy, however, operates
JOHN L. FALK • Department of Psychology, Rutgers University, New Brunswick, New Jersey
08903.
Drug Policy and Human Nature: Psychological Perspectives on the Prevention, Management, and
Treatment of Illicit Drug Abuse, edited by Warren K. Bickel and Richard J. DeGrandpre. Plenum
Press, New York, 1996.
3
4 JOHN L. FALK
under a different set of constraints. Its concepts must be initially acceptable-

otherwise it has little chance of being implemented, regardless of the facts. The
usual function offacts is to lend support to a policy's intent, not to shape it. The
production of an interesting policy is reinforced by a political community
because it upholds a set of institutions and functionaries that are already
operative. In a sense, a policy generates the kind of data that it requires as its
raison d'etre. Policy can be a closed, self-validating system, almost impervious
to scientific facts: While science considers new facts and alternative explana-
tions and rejects them on logical or empirical grounds, policy can be dismissive
of facts and alternatives simply on the grounds that they are distasteful.
Consider the following historical example. For about three centuries,
Natural Theology operated as the intellectual link between scientific inquiry
and the religious beliefs of the scientist. In Europe, but especially in Britain,
there was neither a clear demarcation nor an appreciable conflict between
biblical fundamentalism and the results of scientific studies (Mayr, 1982).
Scientific endeavors continued to reveal designs, which were taken to be
evidence of a rational intelligence in the universe. They confirmed, in detail,
God's integrated plan and the argument by design for His existence. This was
the case for both the biological and physical sciences. It has been argued that
the main motivation of scientific inquiry was this clarification of God's design.
Newton, to take a prominent example, put his science in the service of religion,
and his theoretical conceptions were influenced by his religious convictions
(Dobbs, 1991; Westfall, 1973). He was not alone in these views. Science in the
17th century, and well into the 19th, found a great and benevolent harmony and
natural order in the created world, maintained a good deal of medieval teleol-
ogy, and remained reluctant to view the universe as an impersonal machine
(Brooke, 1991; Westfall, 1973). Religion functioned as a moral and intellectual
policy, and science served that policy. In many ways this was a fortunate union
for the development of science, but not entirely so. The limited temporal frame,
anthropocentrism, and extreme adaptationist view were impediments. Science
was used to uphold the belief in God's great design, and the data of science, in
distinction to the Baconian view, were in constant service to the exegesis of
what God had framed in creation.
SCIENCE AND DRUG POLICY
For present purposes, we may ask whether the scientific study of drug
abuse has been influenced or even suborned, by drug abuse policies and
politics. To the extent that the central policy for drug abuse containment is
conceived of as supply interdiction, internal environment manipulation, and
ENVIRONMENTAL FACTORS AND DRUG ABUSE 5
genetic counseling of the inherently vulnerable, then interference with drug

access and action-the blocking of borders, exposures, and receptors-will
continue to be the main tactics of investigation and modes of therapy and
prevention. Physical blockade of access to substances and pharmacological
blockade of their opportunities to act within organisms are credible as the
major combat mode only if pharmacological determinism of drug abuse is a
valid assumption. There are ample reasons to question the assumption. Briefly,
by this view, the social and economic conditions often associated with drug
abuse are acknowledged only as permissive or facilitating factors, rather than
as major determinants. The direct, causal factors are conceived of strictly in
terms of pharmacological determinism. Social and economic variables only
serve to determine whether, and to what extent, an individual comes into
contact with a drug. Pharmacological determinants then operate to produce any
consequent drug dependence and ensuing abuse. The behavior known as drug
abuse, then, occurs in the service of the internal state engendered by pharmaco-
logical events, a state variously referred to as physical, physiological, and/or
psychological dependence. It would follow that the key to understanding and
alleviating drug abuse is to analyze and alter the troublesome internal state.
Given such a picture, the most direct way to alter an undesirable internal state
provoked by pharmacological means would be by a medicinal therapy.
There are several ways to criticize the hegemony of pharmacological
determinism. One way is to indicate that social and economic determinants are
intimately involved not just in occasioning contact with drugs, but also with the
very phenomena of drug dependence. To that end, animal laboratory studies
demonstrating and analyzing these putative "soft" determinants as central
factors in the production and maintenance of abuse will be described. Another
mode of criticism questions the logic of whether a drug problem must neces-
sarily have a pharmacological set of efficient causes. This is the analytical
problem Fischer (1970) described as the fallacy of identity, "the assumption
that a cause must somehow resemble its effect ... that economic effects have
primarily economic causes, and that the origins of a religious phenomenon are
necessarily religious" (p. 177). A drug abuse problem is not proof that a drug
stimulus caused either the initial involvement or its continuation. Nor does it
follow that abuse must be alleviated by a corresponding drug therapy, a sort of
modem-day Doctrine of Signatures.
The assumption underlying pharmacological determinism also can be
criticized by considering examples of excessive involvement with nondrug
commodities. By this stimulus-determinism view, the stimulation resulting
from television watching would derive directly from the visual-auditory stim-
ulation of monitor activation, with its excessive repetition (abuse) described in
terms of monitor-determined central nervous excitation. An increasing in-
6 JOHN L. FALK
volvement with one's baseball card collection would be described in terms of

stack accumulation and manipUlation, which provide stimulation determining
further acquisition of this commodity. Stated this way, the mechanism of action
fails to convince, for the operative assumption is transparent: An immediate or
cumulative stimulatory effect of the commodity strengthens the behavior that
produced it, which promotes even more acquisition of it. This simply describes
the Law of Effect in situations where satiation factors somehow are weak..But
for TV viewing, we explain excessive watching in terms of the narrative con-
text of the stimulation provided by the monitor (escapist drama, parades and
pageants, exciting sports) and the lack of alternative sources of reinforcement.
For card collecting, we refer to a host of contextual reinforcers: the social net-
work and the power and cachet associated with being an important collector of
a rare item (with the latter accomplishment indicating one's perspicacity, taste,
and resourcefulness). But these factors also are present in drug abuse. There are
ritual excitations, a continuing escapist drama, social approbation by a refer-
ence subgroup, and the possession and manipulation of a rare commodity that
displays the competence and power of the possessor. The reinforcing efficacy
of such factors is not easily described in terms of phannacological determinism.
A BRIEF CRITIQUE OF PHARMACOLOGICAL

DETERMINISM IN DRUG ABUSE
A major principle of phannacology is that drugs have specific actions that

are determined jointly by how their chemical structures interact with distinct
kinds of receptors. Study of these notable specificities has clarified the mecha-
nisms involved in drug action, a developing achievement of phannacology.
Specificity analysis is a continuation of the early 19th century tissue doctrine
and the later cell theory, both of which explain physiological and pathological
processes in terms of basic, localized entities (Coleman, 1977). The notion that
the mechanism underlying both normal and abnormal action is due to localized
anatomical processes and their disturbed functioning, respectively, has been an
important guiding principle. In concert with this, drugs of abuse all have their
specific biological actions. But troubles begin when one attempts to relate
abuse liability to phannacological specificity and to assume that drug abuse is
somehow a direct consequence of altered phannacological action.
Given the diversity of abused chemicals and their sites of action, attempts
were made to unify the concept of behavioral dependence on drugs by relating
dependence to physiological processes that could encompass the effects of a
diversity of chemicals. Physical dependence and tolerance were processes that
showed promise. The attempt was heroic, and its details most informative, but
it did not deliver a metric for abuse liability that could be applied across classes
of agents. It has become increasingly clear that drug dependence is not an
affliction that has a bodily locus and quantitative dimension in the sense that
diabetes mellitus, renovascular hypertension, or a microbial infection have
bodily loci and directly quantifiable manifestations. Drug abuse is a relational
construct, rather than a set of events whose loci are only centripetal to the skin.
And if so, then its specification would require more than an anatomical-
neurochemical-pharmacological description.
At this point one must tread carefully. It is facile, and most acceptable
politically, to say that drug abuse is ultimately a function of how drugs affect
the central nervous system and that any structural and behavioral toxicities are
simply consequences of that basic interactional surface. This view, that drug
abuse is a kind of "brain disease," is conservative in that it relegates social and
economic circumstances as permissive factors rather than as the basic determi-
nants of drug abuse. In another sense, it is a socially liberal view, for if drug
abuse is a brain disease requiring medical attention, then treatment costs
legitimately require coverage by medical insurance. In this scheme, a host of
"soft" determinants can be generously admitted as "modulators" of the brain
locus where the basic mechanisms of action reside. Soft determinants include a
person's subcultural values, peer pressure, drug availability, legal and other
social constraints, family structure, educational status, social responsibilities,
and alternative opportunities. The data languages and theoretical constructs of
these putative modulator disciplines are usually quite different from those that
describe molecular and central nervous events, and they lack the scientific
prestige of biochemical and brain parlance. Little equitable communication
currently exists among these disciplines; one or two patronize the rest. And
everyone understands which one or two "hard" disciplines speak with the most
elegant and authoritative intonations.
In the midst of this hierarchical picture, an interesting development oc-
curred a few decades ago. Drug abuse, which is undeniably a behavioral
endpoint (the seeking and taking of drugs to excess with negative conse-
quences), began to be studied in the laboratory in just those terms: as the
seeking and taking of drugs. This field, as did much of behavioral pharmacol-
ogy, allied itself to neuropharmacology, with salutary effects for both disci-
plines. But the marriage has always been a morganatic affair. Behavioral
science began to be used to further the primacy and privileged position of the
brain-science account of drug abuse, with behavioral data serving as soft
indicators of more basic, underlying events assumed to have their causal and
perpetuating origins in the brain.
Recent drug abuse research, however, increasingly reveals that behavioral
and brain studies are equal partners in this scientific enterprise. Behavior is not
8 JOHN L. FALK
the pale measure or reflection of more basic, internal, causal processes. Behav-
ior analysis is not the observation of shadows in Plato's cave, with the real
entities occurring inside the bony casement of the skull. The determining
factors responsible for drug abuse behavior occur not only in the brain; they
also originate as the values of independent variables in environmental events
and in the behavioral processes themselves. The specification of a "mechanism
of action" for drug abuse, then, requires terms and relationships that include
how current environmental events and their historic tracks come to initiate and
maintain abuse behavior and how the nervous system participates in this
process. The term participates requires emphasis. The nervous system is not an
autonomous, directive agent causing drug abuse.
A dramatic example of the way in which even the simplest behavioral
involvement can affect the neurochemical outcome of exposure to a drug is
illustrated by a series of experiments on morphine and cocaine by Dworkin and
his colleagues (Dworkin, Porrino, and Smith, 1992). They found that intra-
venous (IV) self-administration of a drug, compared to the effects produced by
an identical series of doses given IV noncontingently (i.e., not self-administered),
can result in very different patterns of brain-metabolic and neurochemical
effects, as well as toxicities.
An equally impressive experimental tradition has found, with a wide
variety of drugs, that the development of drug tolerance occurs only when the
drug acts concurrently with the behavior used as an indicant of tolerance and in
the same environmental context (Kalant, 1987; Siegel, 1989; Wolgin, 1989).
Otherwise, an identical pattern of drug exposures yields little or no evidence of
tolerance when evaluated by the same behavioral procedure. Similarly, the
phenomenon of drug sensitization is dependent upon the environmental con-
text where drug exposure had occurred (Hirabayashi & A1am, 1981; Post,
Lockfield, Squillance, & Contel, 1981; Stewart & Badiani, 1993). As Post and
his coworkers indicate (Post, Weiss, & Pert, 1987):
The behavioral sensitization to a single dose of 40 mgikg, i.p. of cocaine is entirely
environmental context dependent ... animals show the increases in locomotor
hyperactivity only if they are pretreated with cocaine in the same environment in
which they are tested. If they are injected with cocaine in a different cage ... they are
no more hyperactive following the challenge dose in the test environment than
animals only pretreated with saline (pp. 425-426).
This is not just a matter of demonstrating that tolerance and sensitization

are conditionable or that they can be enhanced by a facilitating environmental
stimulus. It is a more fundamental case: The very existence of tolerance or
sensitization is to a large extent dependent upon the presence of the specific
environmental context in which it was created. Again, the environment does
not function merely as a modulator of deeper, causal processes. The environ-
mental context is intimately bound up with the generation and manifestation of

these pharmacological phenomena as they occur in the integrative biology of
the whole organism.
The same case can be made with respect to the development of drug
dependence itself: Mere chronic exposure of the CNS to a drug with a notable
dependence potential is not a sufficient condition for engendering dependence
(Henning field, Lucas, & Bigelow, 1986; Schuster, 1989). For example, Woods
(1990) estimates the actual risk of addiction for patients chronically receiving
pain-relieving medication as possibly less than 0.01 %. Nor does physiological
dependence play much of a role in explaining either the initiation or mainte-
nance of drug abuse (Cappell & LeBlanc, 1979, 1981; Falk, 1983).
Although there have been interesting attempts to unify the diversity of
abused drugs within a simple explanatory scheme framed in terms of overlap-
ping neurochemical effects, the principles that have emerged are behavioral
rather than neurochemical. These principles transcend particular drug classes
or pharmacological specificities, and they generalize widely across species,
including humans (Brady, 1981). The strong implication, then, is that a drug has
a potential for abuse owing to its pharmacological properties. But this is only a
potential. Whether it will come to function as an intrusive reinforcing agent
depends on a host of other variables, among them the contingencies under
which the drug is available, individual history, competing reinforcers, and the
current discriminative stimuli controlling behavior. The reinforcing properties
of a drug are neither synonymous with, nor inevitably determined by, either its
chemical structure or pharmacological characteristics.
If the abuse of a particular drug was determined largely by universal,
unconditioned reinforcing effects following from its action at receptor sites,
then one might expect three things to be true: (1) Relatively little experience
with the drug should be necessary for behavioral dependence to occur. But drug
abuse is not immediate upon initial contact, apocryphal stories notwithstand-
ing. As with most learned behavior, becoming drug dependent requires a
protracted process of acquisition. Furthermore, as previously described,
changes in reactivity to a drug that my accrue with chronic exposure-
tolerance and sensitization-depend almost completely upon the drug-exposure
environment remaining the same. (2) Inasmuch as the effect of a drug on the
brain is quite similar across individuals, it is puzzling why, of the many persons
who have indulged in repeated contact with a drug, only a small proportion
acquire an addiction problem (Kandel, Murphy, & Karus, 1985). The strong
relation between neighborhood and crack cocaine smoking (Lillie-Blanton,
Anthony, & Schuster, 1993) points to an environmental, rather than an individ-
ual difference or genetic source of the problem. R.T. Jones (1992) makes the
point forcefully:
10 JOHN L. FALK
As scientists, do we really think that some of our inner city Black communities
are so very vulnerable to compulsive crack use because the residents have a
different serotonergic system regulating craving and satiety? This is nonsense
(p, 230).
A further set of observations bears on this point. If the abuse of a drug is

primarily due to its pharmacological determinants, then a typical syndrome
with a predictable sequence of sequelae should be evident with continued,
heavy use. However, for all abused drugs, a variety of use patterns occur, for
example: (a) chronic, uncontrolled use; (b) sporadic bingeing; (c) steady,
controlled use; (d) weekend use; and (e) ceremonial use. An individual with a
history of abusing a substance may shift his or her intake pattern in either
direction and may remain with any pattern for variable periods of time (Hill,
1985; Polich, Armor & Braiker, 1981). The sort of pattern observed is a function
of individual history, as well as social and cultural influences (Moore &
Gerstein, 1981; Rorabaugh, 1979; Waldorf, Reinarman, & Murphy, 1991; Zin-
berg 1984). For any drug of abuse, then, there are a variety of use syndromes,
and they are malleable. They are functions of complex, situational variables,
rather than the results of an inevitable progression of pharmacologically deter-
mined states. (3) If addiction is significantly the result of brain changes due to a
history of repeated drug-receptor action, and this action is quite specific phar-
macologically, then why is polydrug abuse, which often transcends drug class,
more the rule than the exception among abusers? An account that relies on
addictive behavior following directly form the action of an agent on one or
more specific receptor sites is insupportable.
Prolonged contact with a drug of high abuse liability by self-administration,
in either recreational or therapeutic contexts, does not explain the induction of a
drug abuse problem (Henningfield et aI., 1986; Schuster, 1989). Musto (1993)
comments that American drug policies have "put more emphasis on a drug's
intrinsic dangers and its presumed inherent social effects, than on the societal
context" (p. 279). The implication is that if individuals respond differently to
drugs because they behave within different societal contexts, then effecting
changes through economic, behavior-therapeutic, and educational programs is
likely to prove more effective in alleviating and preventing drug abuse than
attempting to block the intrinsic effects of drugs.
INTRAVENOUS SELF-ADMINISTRATION:
UTILITY OF A CLASSIC PHARMACOLOGICAL APPROACH
Although a classic pharmacological approach to the problem of drug

abuse may have limitations, it has much to recommend it within both experi-
mental and policy contexts. The behavioral pharmacology of drug self-

administration, although classic in its initial conception and application, has led
subsequently to research in which considerations beyond strictly pharmaco-
logical ones illuminate the processes of drug seeking and drug taking. The
direct, pharmacological approach of the pioneering IV self-administration
research produced major advances in the delineation and prediction of abuse
potential. In this research, an animal typically is provided with a chronically
implanted IV catheter through which it can self-administer dose units of a drug
by executing a simple bit of operant behavior, such as a lever press. If the dose
is a reinforcing event, subsequent lever pressing will increase in rate compared
to some initial, baseline level. Chronic drug seeking and drug taking is studied
in lengthy, daily sessions. This experimental arrangement has produced a large
and invaluable body of work. Drugs that are known to have abuse liability are
largely self-administered, and those that are not abuse problems mainly are not
taken (Griffiths, Bigelow, & Henningfield, 1980; Yokel 1987). The concordance
is remarkable. New agents can be screened for abuse liability, and the predic-
tive accuracy has been high. We know what agents should be of restricted
availability owing to their potential for abuse. But since the method has been
criticized (e.g., Hartnoll, 1990), it is worth clarifying what is being measured
and evaluated.
The animal IV drug self-administration procedure in its simplest form has
several advantages. It studies the actual behavior of drug taking. The animals
do not lie to us about their drug taking, they do not have a political agenda, and
in their laboratory lives they have limited social and historical influences to
complicate the abuse potential questions posed. The IV procedure constitutes a
pure and innocent preparation that affords us candid answers to directly posed
questions about intrinsic abuse potential. Complicating factors are either elimi-
nated or held constant in order to get as clear an answer as possible about an
agent. The question posed is a purely pharmacological one, and the answer is a
pharmacological one: intrinsic abuse potential. However, some studies have
liberalized this preparation by including environmental, individual, and histori-
cal variables, indicating that the preparation has analytic powers beyond the
strictly pharmacological. Before considering these, some criticisms need to be
addressed.
What about false positives? The maintenance of IV self-administration of
a drug by animals cannot be used as the sole criterion for claiming that the drug
necessarily will result in a notable abuse problem. A number of drugs maintain
robust IV self-administration in nonhuman primates, yet reveal little or no
record of abuse by humans: apomorphine, bupropion, procaine, mazindol, and
some of the antihistamines (Balster, 1991; Johanson, 1990). This does not mean
that under appropriate conditions they would not be self-administered. For
12 JOHN L. FALK
example, under laboratory conditions, procaine is self-administered by humans

(Fischman, 1989) in spite of its low potency and ultrashort duration of action
(Ford & Balster, 1977).
What about false negatives? There are substances-caffeine, ethanol,
nicotine, and certain psychedelic agents-that are either not self-administered
IV by monkeys or are self-administered only if special procedures are used. It
has been pointed out as a criticism that these agents are either abused by
humans or are highly prevalent in their worldwide use, or both. If one looks for
common factors, there is one that stands out: Humans agree with the monkeys
and also do not choose to self-administer these agents intravenously. They are
taken by other routes, mainly orally, although for nicotine, inhalation is more
common than the oral route. But even for some of these agents, if the experi-
menter is careful about the dose and particularly careful about the schedule of
availability, animals also will take them IV on a chronic basis (Henningfield &
Goldberg, 1983; Falk 1993).
In sum, these putative false positive and false negative cases pose no
serious challenges to the validity of the IV self-administration procedure.
Although it is a powerful procedure that renders clear and valid answers, it is
not fair to demand that in its most-used form, it should deliver answers that
coincide with worldwide abuse or prevalence statistics. The preparation makes
behavioral pharmacology statements about an agent's potential for abuse. As
typically used, it addresses mainly that factor in isolation and refrains from
making inferences about abuse when other factors come into play. A multitude
of social, individual history, and environmental context variables interact with
the biology of abuse potential to determine whether a drug will function as such
a pervasive and overpowering reinforcer that it constitutes abusive use by a
person.
NONPHARMACOLOGICAL SOURCES FOR THE REINFORCING

FUNCTION OF DRUGS AND DRUG ABUSE
In reviewing nonpharmacological factors in drug abuse, Hartnoll (1990)

stated: "It is difficult to see how laboratory models can deal with factors such
as economics, social class, culture, and subculture" (p.380). Fortunately, labo-
ratory studies in behavioral pharmacology, including animal studies, are not
limited to behavioral manifestations of intrinsic, physiological factors. They
explore the influence of individual history (Nader & Reboussin, 1994; Piazza,
Mittlemen, Deminiere, Le Moal, & Simon, 1993; Tang & Falk, 1988) and
environmental context (Bigelow, Liebson, & Griffiths, 1974; Carroll & Lac,
1993; Goldberg, Spealman, & Kelleher, 1979; Nader & Woolverton, 1991) on
the reinforcing efficacy of drugs, the behavioral economics of introducing

alternative reinforcers to compete with drugs (Carroll, 1993; Higgins, Bickel,
& Hughes, 1994; Hursh, 1993; Nader & Woolverton, 1992a), and the behavioral
processes whereby a drug, or even a vehicle, can acquire a reputation that leads
to its self-administration (Falk, 1994; Johanson, Mattox, & Schuster, 1995).
These complex cases show the analytical power of laboratory investigations in
clarifying the effects of the diverse variables that constitute the problem of drug
abuse. There is no reason to believe that human economic, social, and sub-
cultural behaviors are not amenable to continued analysis and explication by
this general methodology and its developing techniques.
The basic notion of drug abuse is a behavioral one. Its observable data are
behaviors. And the independent variables determining abuse-whether chemi-
cal, social, economic, or historical-all converge on accounts of drug-related
behavior: drug initiating, seeking, taking, persisting, eschewing, and relapsing
behavior. These behaviors constitute a unified system, which can use a com-
mon data language. Social influences on drug taking can be described and
analyzed in terms of how discriminative and conditioned-reinforcing stimuli,
as well as alternative reinforcers, affect the acquisition, maintenance, and
prevention of, as well as relapse to, drug abuse. Steady progress in laboratory
studies is clarifying the behavioral mechanisms of action of how environmental
events and commodities come to have such power in determining the individ-
ual's response to a drug.
Drug Discriminative Stimuli Can Set the Occasion

for Drug Taking
A discriminative stimulus (SD) is an initially neutral stimulus that, be-

cause it is present in a situation associated with the occurrence of some
reinforcing event, comes to occasion the reinforced class of responses that
occurred in the presence of that stimulus. Thus, an external SD, or one that is
inside the body, can set the occasion for the occurrence of behavior that is
reinforced by drug delivery (DeGrandpre & Bickel, 1993; Fa1k, 1994). A
variety of both environmental and internal stimuli, then, can come to occasion
drug seeking and drug taking, which allows these SDs to develop considerable
power for producing drug-motivated behavior.
Environmental stimuli present during drug taking can come to facilitate
future drug taking. These SDs can evoke abstinence signs and relapse in former
abusers, even if they have been drug abstinent for a long time (Wikler, 1968,
1973); they also can occasion craving and relapse without evoking withdrawal
symptoms (Childress, McLellan, Ehrman, & O'Brien, 1988; Ehrman, Robbins,
14 JOHN L. FALK
Childress, & O'Brien, 1992; O'Brien, Childress, McLellan, Ehrman, & Ternes,
1988). Although these stimuli originally were viewed as the ones proximal to
self-administration, they now "include stimuli that would occur earlier in the
stimulus chain, supposedly proximal to the decision to use" (Childress et aI.,
1988, p. 40).
Both craving and abstinence signs are drug-opposite effects. However,
when drug environmental SDs occur in situations that hold the promise of drug
availability, or closely mimic such situations, then drug-like effects can occur.
For example, drug-dependent or post-dependent individuals can persist in
injecting themselves with almost any available drug, or even tap water, and are
referred to as "needle freaks" (Levine, 1974). Substantial numbers of appli-
cants for methadone maintenance programs are not physically dependent, or
only weakly so, but bear multiple needle tracks (O'Brien, 1975). Subjects with
cocaine abuse histories may continue to inject saline when it is substituted for
cocaine under experimental laboratory conditions using a second-order, oper-
ant, IV self-administration procedure, a schedule designed to provide strong
external SD evocation of the operant behavior (Henningfield, Nemeth-Coslett,
Katz & Goldberg, 1987). Conditioned highs can occur upon drug or placebo
self-injection despite blockade by opiate antagonists (Meyer & Mirin, 1979;
O'Brien, Chaddock, Woody, and Greenstein, 1974). Coupled with 1970s data
that the mode and median levels of street-purchased heroin were only about
0.5% (Primm & Bath, 1973), all these facts indicate that external drug SDS,
when accompanied by self-administration behavior, can sustain this behavior,
even though little or no drug may be obtained.
Internal, pharmacological stimuli can act as SDs that facilitate drug taking.
Traditionally, it had been maintained that an episodic exposure to an appropri-
ate drug could precipitate relapse in a former abuser because the drug acted as a
biochemical trigger, reactivating a dormant, motivational state. However, ex-
perimental analysis supports a less conjectural interpretation of such observa-
tions. Drug self-administration behavior that has been extinguished can be
reinstated by the IV administration of drugs that posses SDs that resemble those
of the formerly self-administered agent (de Wit & Stewart, 1981, 1983; Gerber
& Stretch, 1975; Worley, Valadez, & Schenk, 1994). As de Wit & Stewart
(1981) state:
This supports the hypothesis that priming infusions given during extinction elicit
responding to the extent that they reestablish the stimulus conditions that are present
during drug self-administration (p. 140).
Moreover, if an auditory SD had been present during drug self-administration,

then it required both the external (auditory) and internal (drug infusion) SDs to
restore self-administration behavior following extinction (Stretch, Gerber &

Wood, 1971). Such data are important, for they question the sufficiency of
internal drug SDS to trigger relapse in the absence of appropriate external SDs, a
conclusion reached some time ago by the lack of support for a "loss of control"
mechanism when alcoholic subjects were primed with alcohol (e.g., Bigelow et
aI., 1974; Cohen Liebson, Faillace, & Speers, 1971; Mello, 1975; Merry, 1966).
This sort of SD control of drug taking can transfer to additional stimuli in
different environmental contexts by the process of emergent SD control (De-
Grandpre & Bickel, 1993). If a new stimulus is paired with an SD that already
occasions drug seeking or drug taking, the new stimulus can come to occasion
drug acquisition even though it is never directly paired with the drug. Further-
more, drug-produced internal stimuli can be linked by the same process to new
contextual stimuli. The new SDs may reinstate drug abuse even though they
have never been directly associated with the drug.
Periodic stimuli that in the past have been associated with drug self-
administration can, by their presence, sustain long chains of drug-seeking
behavior. In squirrel and rhesus monkeys, second-order schedules can sustain
persistent operant behavior that periodically delivers a previously neutral, brief
stimulus (light flash) if such flashes have accompanied the ultimate delivery of
cocaine injections (Goldberg, Kelleher, & Morse, 1975; Johanson, 1982). This
behavior can be maintained when saline is substituted later in place of cocaine,
provided the intermittent, response-contingent, brief stimuli still occur (Kel-
leher & Goldberg, 1977). The resilience of behavior maintained by these brief
stimuli is often described in terms of their acquisition of conditioned reinforc-
ing properties. However, brief stimuli that were not paired with drug delivery
(flashes of another color) also sustained considerable second-order schedule
responding (Goldberg et aI., 1979). Furthermore, a continuously present light
(SD) sustained choice and responding reinforced by water delivery (vehicle)
that was substituted for oral cocaine in rats (Falk & Lau, 1993; see discussion in
last section). There may be less functional difference between SDs and condi-
tioned reinforcers than is commonly assumed (Falk, 1994).
There are numerous ways in which SDS may generalize to new drug-
taking situations. For example, Rastafarians smoke marijuana as a religious
ritual, and for them the spiritual significance of smoke itself promoted cocaine
freebasing as a route of administration preferred to the intranasal route (Hamid,
1992). A more familiar domain is the multiplicity of simple and emergent SDS
created by word and image advertisements for proprietary remedies, tobacco,
and alcohol, words and images that promote the contingency between taking
substances for self-medication, or for their superior "taste," and a consequent
increase in one's sexual or social attractiveness (Stallings, 1992; Young, 1961).
16 JOHN L. FALK
Drug Discriminative Stimuli and Drug Taking Can Set

the Occasion for the Availability of Other Reinforcers
Taking a drug can produce socially mediated reinforcers, not by its direct,
pharmacological effects, but by a side effect of the drug-taking context: It
brings a person into contact with other reinforcers, which are more available in
that context. Admission to a group and its social support may depend upon
using some agent as part of the group's activities. Such usage also may allow
the avoidance of aversive tasks that await outside the drug-taking context. The
production of one or more other reinforcers, contingent upon drug taking, can
serve as reinforcing events that strengthen future drug seeking and taking. A
drug user might say that one finds better things with drugs, or, more collo-
quially, "better living through chemistry." The next section describes situa-
tions in which drugs also are attractive because of their relation to conventional
reinforcers, and these conventional reinforcers are enhanced by their associa-
tion with pharmacological action. The user might say that "things go better
with drugs."
Task Demands, or Synergism with Conventional Reinforcers,

Can Determine Drug Taking
The behavioral-demand aspect of an environmental context can affect the

reinforcing efficacy of a drug, and perhaps its subsequent abuse. Recent studies
by Silverman and his colleagues have shown that current behavioral context
crucially determines whether a drug has reinforcing efficacy, and thus whether
it will be self-administered (Silverman, Kirby, & Griffiths, 1994). Human
subjects, depending upon whether they were required to perform a vigilance
task or required to relax, made very different drug self-administration choices.
When required to perform a vigilance task, subjects chose to self-administer
color-coded d-amphetamine capsules in preference to either coded triazolam or
placebo capsules, but chose triazolam in preference to either d-amphetamine or
placebo when the activity required was relaxation. The behavioral demand was
the major determinant of which agent was chosen for ingestion, i.e., it deter-
mined whether the agent functioned as a reinforcer.
In a further study, Silverman and colleagues showed that another psycho-
motor stimulant, caffeine, was enhanced as a reinforcer when vigilance was the
required activity following drug ingestion (Silverman, Mumford, & Griffiths,
1994). The experimenters state:
The excessive consumption of drugs, which in part defines drug abuse, is not driven
solely by the intrinsic properties of the drugs or by chatacteristics of the abusers;
human drug self-administration responds in orderly ways to changes in environ-

mental circumstances (p. 246).
In agreement with these findings, historical study of drug use in America

indicates that cocaine was acceptable in its early history, as it was viewed by
some as a restorative that helped one to work harder on worthy tasks (Morgan,
1981). In contemporary America, cocaine may be employed to facilitate work
early in its use, although this aim is associated more with intranasal application
than with IV or smoke-inhalation practices (Waldorf et al., 1991). In addition to
getting high or getting to work, cocaine has been reported by heavy users to
facilitate other activities (e.g., sex, socializing, and athletic performance), and
the enhancement of a variety of such activities may be part of its reinforcing
efficacy (Waldorf et al., 1991). In these examples pharmacological action plays
only a supporting role. The drug is taken mainly, not for its intrinsic subjective
effects, but rather because it enhances performance, and thereby the efficacy of
conventional reinforcers: work, vigilance, relaxation, sex, social relations, or
competitive skills.
Task demands can be onerous, and anything that alleviates this burden has
reinforcement potential. Drug taking can provide ready escape from a task by
strongly engaging a person in an alternative activity.
There is yet another way in which negative affect can set the occasion for
drug taking. For those engaging in a chronic, excessive pattern of abuse, being
without a drug can produce moods of depression and anxiety. Drug taking
alleviates this, and is thereby reinforced. Such moods may be due to physiolog-
ical withdrawal or may occur simply because the discontinuation of any strong,
chronic reinforcer (e.g., loss of employment or social rejection) can produce
similar mood changes, complete with severe autonomic effects. Through the
process of stimulus generalization, a negative mood occurring for any reason,
including life disappointments and stresses, may come to occasion an abuser's
drug taking (Childress, McLellan, Natale, & O'Brien, 1987; DeGrandpre &
Bickel, 1993).
Reinforcing Efficacy of Drugs and Drug Abuse Determined

by the Structure of the Environment: Behavioral Economics
Inasmuch as the efficacy of a drug to function as a reinforcer can be

situational, further analysis of how the environment may contribute to reinforc-
ing action, and thus result in drug abuse, seems warranted. An obvious example
is the ecology of the urban ghetto. Although it is not the only socio-economic
matrix that reinforces participation in obtaining, dealing, sharing, and using
illicit drugs, it is one that places its residents in particular hazard. Consider the
18 JOHN l. FALK
greatly different impact exposure to cocaine has on the life of a female ghetto
resident, possessing few personal or social resources, compared to its effect on
a middle-class female user with a depth of such supports and competing-
reinforcer possibilities (Murphy & Rosenbaum, 1992). There is almost no
comparison between cocaine's abuse potential in these two contexts. It is as if
one were dealing with two different substances.
The estimate of how powerful a reinforcer a drug is depends upon what
the drug is competing with: another drug at a specified dose, a portion of food,
an amount of money, or the reinforcers that may be associated with marriage,
child-rearing, or an engaging career. The behavioral economics of drug abuse is
an area of vigorous research in both the laboratory (Bickel, DeGrandpre,
Higgins, Hughes, & Badger, 1995; Carroll, 1993; Hursh, 1991, 1993) and the
clinic (Crowley, 1987; Higgins, Bickel et at., 1994). For example, the effect of
concurrently available alternative commodities on cocaine self-administration
has been examined in several recent studies. For rhesus monkeys trained on a
discrete-trials choice procedure, in which they chose between food delivery
and cocaine injection, increases in the unit cocaine dose per injection produced
increases in cocaine choices in preference to the food alternative (Nader &
Woolverton, 1991). Conversely, increases in the number of food pellets deliv-
ered per reinforcement produced increases in food choices in preference to the
cocaine alternative. Increasing the number of responses required for monkeys
to obtain food increased choices of the cocaine alternative (Nader & Woolver-
ton, 1992a), and eliminating daily post-session food supplements produced a
shift to the right in the dose-effect relation for cocaine choice, i.e., larger unit
doses of cocaine were required for cocaine to be preferred to food (Nader &
Woolverton, 1992b). For rats self-administering cocaine, the presence of a
glucose-saccharin drinking solution was associated with less concurrent co-
caine taking than when the drinking solution was changed to water; the
introduction of glucose-saccharin solution to a group drinking water also led
to a decrease in cocaine self-administration (Carroll, Lac, & Nygaard, 1989).
Clearly, the availability of strong, alternative, positive reinforcers can effec-
tively interfere with cocaine self-administration.
The relativity of the abuse potential of cocaine is attested to not only by
animal research, but, as indicated above, the ecological situation of humans
also strongly affects their abuse of cocaine. If the availability of only weak
positive alternatives to cocaine is part of the problem, then the contingent
delivery of positive alternatives offers therapeutic possibilities (Higgins,
Bickel et at., 1994). Indeed, clinical research has shown that if outpatient
cocaine abusers are reinforced with vouchers exchangeable for retail items
when they present with urine samples free of the cocaine metabolite benzoyl-
ecgonine, more continuous cocaine abstinence occurs than in control groups
not exposed to this contingency (Higgins et aI., 1991; Higgins, Budney, et aI.,
1994).
The description of the behavioral economics of cocaine abuse given thus
far implies a more static analytic stance than is the case in experimental
practice. In addition to comparing commodities in terms of a calculus of current
choices, commodities also are explored dynamically by considering the behav-
ioral impact of a newly available commodity in terms of what is currently
engaging behavior in that context. For example, when rats were accustomed to
obtaining a glucose-saccharin solution, rather than water, in daily experimen-
tal sessions, they were retarded or prevented from acquiring IV cocaine self-
administration when this possibility was added to the situation (Carroll & Lac,
1993). Another way of exploring behavioral economic dynamics is to deter-
mine the effect of a previous commodity, which is no longer available, on the
acquisition of, and behavioral control exerted by, a substituted commodity. For
example, it was difficult to demonstrate the reinforcing efficacy ofIV diazepam
in monkeys with the drug substitution procedure when cocaine was the base-
line reference drug. When the reference agent was pentobarbital, diazepam
substitution was quite successful (Bergman & Johanson, 1985; Johanson,
1987).
Reinforcing Efficacy of Drugs and Drug Abuse Determined

by the Structure of the Environment:
Generator Schedules and Adjunctive Behavior
Environmental economic conditions, whether static or dynamic, do more

than determine commodity-choice functions. If food pellets are delivered to a
food-deprived rat at a rate of about one per minute during daily, 3-hour
sessions, this food schedule results in concurrent overdrinking, a polydipsia of
about 100 ml (Falk, 1961). Under this condition, a rat drinks about one third, or
even one half, its body weight in 3 hours. This is in contrast to the regulatory
drinking of about 10 ml that occurs in a 3-hour period if instead the same
number of food pellets in presented all at once at the beginning of the period.
The animals are not water deprived, and further experiments confirmed that
schedule-induced polydipsia is a behavioral, not a physiologic, phenomenon
(Falk, 1969). It is not a transient effect; it can be induced in daily sessions
for months on end. It is only necessary to constrain access to food and then
deliver small food pellets at about 1- or 2-minute intervals forthe polydipsia to
be generated. Interpellet intervals that are very short (a few seconds) or long
(greater than about 5 minutes) are not effective generating conditions.
When access to a valued commodity (e.g., food for the deprived animal) is
20 JOHN L. FALK
constrained to small units dispersed in time, so that the intermittency lies

between short (a "rich" schedule of availability) and long (a "poor" availabil-
ity) time values, excessive behavior is generated. The effective range for the
commodity procurement rate to induce behavioral excesses might be described
economically as a "middle-class" schedule. Schedule-induced (or adjunctive)
behavior has been studied in a wide range of species, including humans and
other primates, and is not confined to high fluid intake-excesses generated
include hyperactivity, aggressive attack, and escape (Falk, 1971, 1981). Sched-
ules of intermittency with respect to valued commodities other than food, e.g.,
a running wheel, water, cocaine self-administration, or monetary gain, can act
as generator schedules and induce adjunctive behavior (Falk, 1981).
The behavioral mechanism of action that might account for why generator
schedules give rise to excessive adjunctive behavior is beyond the scope of this
presentation (see Falk, 1971, 1977, 1986). For present purposes, it is crucial to
describe what occurs when a subject is exposed to conditions constituting a
generator schedule in a situation that also allows the self-administration of
drugs with the potential for abuse. Briefly, when exposed to a food schedule
that induces polydipsia, various species, including primates, drink large, daily
amounts of drug solutions and can become physiologically dependent. (These
studies and additional ones referred to below are reviewed in Falk, 1993.)
Drugs that have been explored include ethanol, barbiturates, benzodiazepines,
cocaine, d-amphetamine, opioids, nicotine, and phencyclidine. Moreover, food
schedules can induce not only large, oral drug solution intakes, but also
excessive IV drug self-injection. It is of interest that under schedule-induced
self-injection conditions, some of the drugs (delta-9 THe, ethanol, nicotine,
diazepam) that functioned as effective reinforcers often have presented diffi-
culties for the demonstration of their reinforcing efficacy in standard monkey
IV experiments. The IV experiments make it difficult to criticize adjunctive
drug-taking experiments as somehow reducible to a drinking aberration
brought about by pellet intermittency. Rather, the range of exaggerated behav-
iors that can be induced by generator-schedule conditions indicates that exces-
sive drug taking (oral and IV) is only a special case of excesses that can occur
as a result of commodity availability arrangements.
Situations that constitute economically or socially restricted schedules of
reinforcement can generate a variety of excessive behaviors. Drug abuse is
only one such behavior, and, owing to the generating situation, it typically
occurs along with a host of accompanying antisocial and counterproductive
behavioral troubles. Ghetto conditions were indicated as constituting generator
situations favoring the development of drug abuse. But economically advan-
taged children who are socially neglected by their parents and shunted off to
distant private schools, at which they may have ill-established social or other
extrinsic reinforcers, also are vulnerable to drug abuse. Youths who are mem-
bers of cultures shedding traditional ways, or migrant workers, are in hazard as
well for the development of drug abuse (Westermeyer, 1987). In these situa-
tions, not only are traditional social controls weakened, but old reinforcers may
also no longer be valued, or they may simply no longer be available. Access
to new, alternative reinforcers may be limited both by a lack of money and
behavioral repertoires that have not been constructed so as to take advantage of
these opportunities. Important commodities and activities, then, may be only
marginally and intermittently available in the changed circumstances, a situa-
tion that facilitates the generation of adjunctive behavior, including drug abuse.
Although it had been shown over 20 years ago (Samson & Falk, 1974) that
under schedule-induction conditions rats drank 5% ethanol solution almost
exclusively when it was available concurrently with a choice of water or dilute
glucose solution, the current and historical situational factors producing drug
preference are only now beginning to clarify. Intrinsic abuse potential is only
one of the factors that may govern commodity choice under conditions that can
induce a range of excessive behavior possibilities.
Groups of rats were exposed to a daily situation in which a schedule of
food pellet availability (fixed-interval 1 minute) was presented along with two,
concurrent fixed-ratio 6 schedules in which 2% ethanol solution and water
were available, respectively (Falk & Lau, 1993). Fluid position alternated daily,
and the position ofthe 2% ethanol was indicated by an adjacent, small So light.
Along with pressing the lever that intermittently delivered food, the animals
almost exclusively preferred the lever delivering 2% ethanol, compared to one
delivering water, and maintained a daily ethanol polydipsia. By slowly chang-
ing the content of the drug solution, animals successively preferred the follow-
ing solutions to water: 0.16 mg/ml cocaine, 0.1 mg/ml caffeine, 0.01 mg/ml
nicotine, and 0.11 mg/ml lidocaine. Drug solution position continued to be
indicated by the So light. With the exception of lidocaine, all the drugs are
known to function as reinforcers in other situations. By subsequently manipu-
lating the presence of the So, the preferences for cocaine to water and for
lidocaine to water were shown to be attributable to the prior association of the
So with ethanol, rather than to the pharmacological effects of the currently
accessible drug. Furthermore, when subsequently no drug was available, but
the fixed-ratio 6 choice in the situation became one between SO-indicated water
and water, animals consistently chose the SO-indicated water. The experiment
demonstrated the effectiveness and the durability of an established So to
determine drug seeking and drug taking under a condition of polydipsic intake,
even when the "drug" became a substituted vehicle.
In order to clarify what appears to be the crucial role of the external So in
maintaining drug choice, a simplified situation was used (Falk & Lau, 1995).
22 JOHN L. FALK
No lever-pressing was required. Groups of naive rats received food pellets once
per minute during 3-hour, daily sessions, and a polydipsic preference for 2.5%
ethanol solution, indicated by the So, to concurrently available water choice
was established. Then, the ethanol solution was gradually transfonned into a
0.16 mg/ml cocaine solution (still SO-indicated), and the preference for drug
solution to water remained. For one group of animals, the So was gradually
eliminated by fading its intensity over a I-month period, and the preference for
cocaine solution remained unabated. For a second group, the cocaine concen-
tration was the stimulus gradually eliminated, and preference for the resulting
fluid (SO-indicated water) was stably maintained. Neither group showed ex-
tinction of its preference, nor did the polydipsic intakes of these two groups
decrease during the I-month period for which the final condition was main-
tained. For two additional groups, if either the So light or the cocaine content
was abruptly removed, rather than being gradually faded out, only a few
animals in each group retained a preference for cocaine solution or So-
indicated water, respectively.
This study revealed that establishing strong stimulus control over choice
behavior was important for initiating and maintaining the choice of cocaine. Both
the initial ethanol condition and the external SD light facilitated acquisition and
maintenance of the choice of cocaine. The maintenance of addictive behavior
may occur as much because of the SD determination of self-administration
behavior as it does because of past or present phannacological consequences.
Stated another way, stable, controlling SO power can be established through its
past association with a commodity functioning as a reinforcer. In this experi-
ment, the power of the So to produce a stable choice for cocaine solution was
built on the So's association with ethanol solution. And So functions could be
gustatory as well as visual. Whether the SO-fade group, which continued to
prefer cocaine solution, also continued this preference owing to a reinforcing
effect of cocaine, cannot be derived from this experiment, although evidence in
a previous experiment using the place preference technique is consistent with
such a phannacological-reinforcement interpretation (Seidman, Lau, Chen, &
Falk, 1992). Lights and gustatory stimuli that have functioned in the past as
discriminatory stimuli for a reinforcing drug such as ethanol can come to
maintain addictive behavior every bit as powerfully and persistently as any
phannacologic event. Discriminatory stimuli carry the reputation of the origi-
nal fluid on to the ensuing choice and stably detennine addictive preference,
even if just two kinds of vehicle are involved-lit and unlit water.
Drug reputation (i.e., the SOs that are associated with a drug and its
effects) can come to command substantial abuse behavior in the absence of
significant phannacological action. If an individual is exposed to a history
whereby a neutral stimulus is associated with the availability of a drug func-
tioning as a reinforcer, the presence of that stimulus can come to determine the
later choice and continued excessive use of another commodity that has been
substituted for the drug, a commodity that can be another drug, a diluted form
of the original drug, or even a substituted vehicle (Primm & Bath, 1973). Once
an So has been established, its association with a new, substituted commodity
can define that commodity as a reinforcer (Falk, 1994). In the experiment
described (Falk & Lau, 1995), the animals imbibed excessively under the
control of a generator schedule, and the So light defined the indicated vehicle as
the preferred substance, which they then chose and drank almost exclusively.
The associative construction of drug reputation SOs need not involve a
history wherein an So is actually associated with any pharmacological action.
In the sort of experiment described above, a glucose-saccharin solution works
just as well as ethanol for establishing cocaine preference. A recent experiment
by Johanson et al. (1995) shows how a pharmacological reputation can be
acquired and can determine subsequent capsule ("drug") preference in the
absence of pharmacological action. Individuals with little history of recre-
ational drug taking performed complex psychomotor tasks in a laboratory
setting. Points, exchangeable for money, were earned and displayed on a
visible counter, ostensibly as a function of how well they performed. Actually,
the rate at which points were earned was prearranged, so that following the
ingestion of, for example, a red capsule, feedback to the subject indicated that
good performance was occurring. Conversely, ingestion of a green capsule
would be followed by indications that performance was poor. Following this
history, the subject was informed on a following day that there would be no
psychomotor testing, but mood and physiological measures would be taken.
The subject was also given a choice as to which capsule they would like to
ingest. Most chose the capsule that had been associated with good perfor-
mance. There was, in that experiment, no effect of an administered drug that
could have determined choice. The only drug effect involved was the phar-
macological reputation devised by the experimenters for a capsule of that color,
and that reputation reinforced its selection. The experiment illustrates once
again how drug SOs can set the occasion for drug taking and that a drug's
reputation need involve little or no present or past pharmacological action.
CONCLUDING REMARK
The major reason for composing this chapter is the hope that individuals
concerned with framing and executing drug abuse policy would read it and be
influenced. One is aware, however, that emphasizing the ubiquitous control and
malleability effected by environmental variables on drug taking could be
24 JOHN L. FALK
counterproductive. The policy maker may become demoralized and impatient

with an implied relativism and may remain tempted by standard "war on
drugs" exhortations to halt supplies, mete out severe punishments, apply
pharmacological fixes, and alter the moral climate of the country. Although one
may not want to argue with the aims and at least some of the combat practices
of this war, clearly something more is needed, and that something may not be
just more of the same. Manipulating broad national and international social and
economic conditions is usually beyond even the most powerful functionaries
(czars or philosopher-kings), but altering the environment can be not too
difficult locally in family or community facilities. Doubts about the phannaco-
logical detenninism of drug abuse lead, if only by default, to serious considera-
tion of other antecedents. And indeed, programs that alter the environmental
conditions detennining drug taking and that promote behavioral alternatives
are proving their effectiveness (Azrin, 1976; Onken, Blaine, & Boren, 1993).
ACKNOWLEDGMENT. Preparation of this chapter and research originating in

the author's laboratory were supported by Grants K05 DA00l42, ROI
DA05305, and R37 DA03117 from the National Institute on Drug Abuse.
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CHAPTER 2
Psychological Science Speaks

to Drug Policy
The Clinical Relevance and Policy
Implications of Basic Behavioral
Principles
WARREN K. BICKEL and RICHARD J. DeGRANDPRE
In a time of turbulence and change, it is more true than ever that

knowledge is power.
-John Fitzgerald Kennedy
JFK's paraphrase of Sir Francis Bacon's famous assertion pragmatically de-

clares that knowledge permits influence and further suggests that such influ-
ence intensifies during periods of change. Changes in drug policy may be
immanent largely due to the growing recognition that the contemporary ap-
proach has failed (Jarvik, 1990). Of course, this failure attests to our limited
knowledge and, consequently, our own powerlessness. In tum, this raises a
WARREN K. BICKEL and RICHARD J. DeGRANDPRE • Human Behavioral Pharmacology

Lab, Department of Psychiatry, University of Vermont, Burlington, Vermont 05401-1419.
Drug Policy and Human Nature: Psychological Perspectives on the Prevention, Management. and
31
32 WARREN K. BICKEL and RICHARD J. DeGRANDPRE
serious question: How can alternative policies be framed given our limited
knowledge and our seeming absence of power?
History suggests that logical and rational arguments will not suffice.
Convincing arguments have been offered both for and against greater drug
prohibition and greater drug legalization (Kleiman, 1992; Nadelmann, 1989;
Reuter, 1992). These arguments, founded largely on theoretical conjecture and
often motivated by political considerations, cannot enhance our knowledge
(Wagstaff & Maynard, 1988). Moreover, the poor results of policies so derived
should not surprise us. Only when informed by empirical knowledge will drug
policy have the opportunity to exert influence over illicit drug use.
Fortunately, considerable basic research in psychology has illuminated
the phenomena of drug dependence. These data, although largely ignored in
discussions of policy, are consistent and compelling. Our purpose here is to
foster the interdependence of psychological research and policy in addressing
the societal problem of illicit drug use. Before doing so, let us acknowledge
certain assumptions. First, we assume that preventing or decreasing an individ-
ual's dependence on drugs is desirable and should be a goal of our society.
Second, our discussion focuses on drug-dependent individuals, not on those
using drugs "recreationally." Third, by discussing an area of psychological
research, we do not mean to suggest that other research or other perspectives
are not needed or are not useful. Nor do we claim that the principles that we
derive from this psychological research are sufficient to account for every
instance of drug use or dependence (see Chapter 3, this volume). Rather, these
are principles with strong scientific support, heuristic value, and considerable
applicability to our societal situation.
RESEARCH-DERIVED PRINCIPLES
The two research-derived principles that, in our view, have great gener-
ality and applicability to issues of drug dependence are (1) the availability of
drug reinforcers and (2) the availability of competing nondrug reinforcers
(Bickel, DeGrandpre, & Higgins, 1993; Vuchinich & Tucker, 1988). These
principles derive from substantial research from the fields of behavioral anal-
ysis and behavioral pharmacology as well as from specific research domains
within those fields. Most notable among these are the study of drug self-
administration, the application of behavioral economics, and the behavior
analysis of choice.
Availability of Drug Reinforcers
The first of these principles is the availability of drug reinforcers (Bickel

& DeGrandpre, 1995; Vuchinich & Tucker, 1988). This principle has played a
PSYCHOLOGICAL SCIENCE AND DRUG POLICY 33
central role in most proposals of drug policy: One end of the continuum of
availability is known as "legalization"; the other is as known as "supply
reduction." This principle states simply that drug use covaries with drug
availability. For the purposes of this chapter, the availability of drug reinforcers
will be defined as the extent to which drugs can be acquired or bought. Factors
influencing availability include the price or responses necessary to obtain the
drug, the potency of the drug, the ease of access to obtain the drug, and the
consequences of drug use. In the basic laboratory, availability can be decreased
in several ways, but for the sake of brevity we will focus on two of the most
widely studied methods. The first is increasing the number of responses re-
quired to obtain the drug while holding the amount of drug available per
acquisition constant, and the second is decreasing the amount of drug available
per acquisition while holding the response requirement constant.
To examine the role of increased response requirement on drug taking, we
have summarized a cross-section of relevant human and nonhuman studies (see
Table 1). In each of these 16 studies, increased response requirement decreased
drug consumption. The ubiquity of this effect led Griffiths and colleagues, in a
review of many of the same studies, to conclude: "Results have shown a
Table 1
Effects of Response Requirement on Drug Consumption
Reference Drug Consumption
Animal studies
DeNoble. Svikis, & Meisch, 1982 Pentobarbital J"
Goldberg, Hoffmeister, Schlichting, & Wuttke. Cocaine, pentobarbital J"
1971
Goldberg, 1973 Cocaine, d-amphetamine J"
Goldberg & Kelleher, 1976 Cocaine J"
Lemaire & Meisch, 1984 Pentobarbital J"
Meisch, Kliner, & Henningfield, 1981 Pentobarbital J"
Meisch & Thompson, 1973 Ethanol J"
Moreton, Meisch, Stark, & Thompson, 1977 Ketamine J"
Weeks & Collins, 1964 Morphine J"
Weeks & Collins. 1978 Morphine J"
Human studies
Bickel, DeGrandpre, Hughes, & Higgins. 1991 Nicotine J"
Bickel. Hughes, DeGrandpre, Higgins, & Nicotine J"
Rizzuto, 1992
Bigelow & Liebson, 1972 Ethanol J.
Bigelow, Griffiths, & Liebson, 1976 Pentobarbital J"
Liebson, Cohen, Faillace. & Ward, 1971 Ethanol J"
Mello, McNamee, & Mendlesoq, 1968 Ethanol J"
Table 2
Effect of Dose Decrease on Drug Consumption
Reference Drug Consumption
Animal studies
Downs & Woods, 1974 Cocaine ,J..
Hammerbeck & Mitchel, 1977 Procaine ,J..
Harringan & Downs, 1978 Morphine ,J..
Marquis, Webb, & Moreton, 1989 Phencyclidine ,J..
Meisch, Kliner, & Henningfie1d, 1981 Pentobarbital ,J..
Meisch, George, & Lemaire, 1990 Cocaine ,J..
Pickens & Thompson, 1968 Cocaine ,J..
Spear, Mutaner, Goldberg and Katz, 1991 Cocaine ,J..
Wellman, Shelton, & Schenk, 1989 d-amphetamine ,J..
Wilson, Hitomi, & Schuster, 1971 Cocrune ,J..
Human studies
Bickel, DeGrandpre, Hughes, & Higgins, 1991 Nicotine ,J..
Fishman et aI., 1976 Cocaine ,J..
Goldfarb, Gritz, Jarvik, & Stolerman, 1976 Nicotine ,J..
Hill & Marquardt, 1980 Nicotine ,J..
Pickens et aI., 1977 Pentobarbital ,J..
Sechzer, 1976 Pentobarbital, lorazepam ,J..
relationship which is remarkably generalizable across species, across drug, and

across settings; as response requirement increases the amount of drug self-
administered decreases" (Griffiths, Bigelow, & Henningfield, 1980, p. 30).
The role of decreasing drug dose was examined similarly by summarizing
a cross-section of relevant human and nonhuman studies (see Table 2). In each
of these 16 studies, decreased dose abated drug consumption. Thus, like re-
sponse requirement, manipulations of drug dose have a generalizable effect,
where decreases in dose reduce drug consumption.
To further illustrate this effect, we present data from one of our laboratory
studies (Bickel, DeGrandpre, Higgins, et aI., 1995). In this study, cigarette-
deprived smokers participated in 3-hour sessions in which they could obtain
two puffs on a cigarette by completing various response requirements (i.e., 25,
50, 100, 200, 400, 800, 1600 and 3200 responses).
Results indicate that increasing response requirement decreased con-
sumption in an accelerating fashion (Fig. 1, left); that is, the number of puffs
taken by nicotine-dependent subjects decreased more proportionally following
larger than smaller price increments. On the other hand, the behavior emitted to
obtain the drug, referred to as drug-seeking behavior, increased sharply with
increasing response requirement until it becomes asymptotic at a higher re-
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3-hour sessions are plotted as a function of response requirement. Data are plotted on logarithmic
coordinates.
quirement or price. Note that the greatest amount of drug taking and drug
seeking occurred generally at the lowest and highest price, respectively.
This study provides a means to evaluate contemporary policy suggestions.
The decrease in consumption seen with increases in price-consistent with the
law of demand-supports the assumption embedded in supply side efforts, that
increases in legal and social sanctions reduce drug use. However, the corre-
sponding increase in drug seeking illustrates the conundrum of supply side
approaches, that is, if drug seeking results in criminal activity such as theft or
robbery to pay for the drug, then decreasing drug availability produces both a
desirable (decrease in drug use) and an undesirable (increases in drug-seeking
behavior) consequence. Legalization has the reverse problem; increased avail-
ability has the positive result of decreased drug-seeking behavior, but it also
produces the outcome of increased drug intake.
Note that the magnitude of these effects varies across the curve. For
example, a fourfold increase in price from 25 to 100 responses decreased
consumption by 23% and increased drug seeking by 300% for subject BM.
However, the same magnitude increase in price (fourfold) from 800 to 3200
decreased consumption by 64%, with drug seeking increasing by only 45%.
Thus, the same magnitude price increase has differing effects depending where
on the curves the price change is examined. This suggests, in tum, that to make
a prediction more specific than the direction of the effect when changing a
drug's availability would require locating where along the curve those changes
take place. The fact that most econometric analyses of drug use in society
report inelastic demand (demand less sensitive to price) suggests that drug use
is somewhere along the leftward portion of the curve (Koch & Grupp, 1971;
Wagstaff & Maynard, 1988).
Until such time that location along the curve for naturalistic drug use can
be better discerned, and, consequently, more fine-grained predictions can be
made, then policies that either increase or decrease drug availability can be
assumed to produce both desirable and undesirable consequences of some
unknown magnitude. Thus, policy adoption at this level of analysis is depen-
dent upon which consequence is more acceptable and, importantly, whether
effects evident in the nondependent user or potential drug user would tip the
scale in favor of one approach over another. For example, increased price for
drugs such as nicotine decreased drug intake to a greater extent in new and
moderate users than in dependent users (Lewit, Coate, & Grossman, 1981).
Competing Nondrug Reinforcement
The second principle, the availability of competing nondrug reinforcers,

stems largely from research on choice where the responses or the time allocated
to obtain one reinforcer is a function of the availability of an alternative

reinforcer; that is, responses allocated to the initial reinforcer decrease as the
availability of a competing reinforcer increases (Hermstein, 1961; Vuchinich &
Tucker, 1988). Competing nondrug reinforcers are broadly conceived here as
reinforcers that compete with drug reinforcers. Examples of these reinforcers
may include such events as eating, employment. recreational activities, social
activities with a nondrug using significant other, and/or participation in spiri-
tual activities and rituals. Importantly, these events must be not only available
but also relatively easy to access. For example, if the above-listed events
required 3 hours of travel to obtain them, then their probability of successfully
competing with drug use could be low; that is, nondrug reinforcers will be more
successful if they are readily available.
We have adapted a table from Carroll (1996) to examine the role of
providing competing reinforcers on drug taking in laboratory preparations.
Table 3
The Effect of Presenting an Alternative Reinforcer
on Self-Administration of a Substance or Event
Addition of Decrease in
Reference Alternative Reinforcer Behavior Maintained by
Animal studies
Wruster et aI., 1977 Food (baboons) IV heroin
Samson et aI., 1982 Sucrose (rats) Ethanol
Kanarek & Marks-Kaufman, 1988 Sucrose (rats) Amphetamine
Carrol & Boe, 1982 Glucose-saccharin IV etonitazene
solution (rats)
Carrol & Meisch, 1984 Food (rats, monkeys) Drugs that function as
reinforcers
Carroll & Rodefer, 1993 Saccharin (monkeys) Oral phencyclidine
Carroll, 1987 Oral ethanol (monkeys) Oral phencyclidine
Carroll et aI., 1989 IV cocaine (rats) Glucose-saccharin solution
Carroll et al., 1989 Glucose-saccharin IV cocaine
solution (rats)
Carroll et aI., 1989 IV cocaine (rats) Food
Nader & Woolverton, 1991 Food (monkeys) IV cocaine
Forsander, 1988 Alcohol Carbohydrates
Human studies
Vuchinich & Tucker, 1983 Money Alcohol
Landau, 1987 Video game playing Alcohol
Hall et aI., 1986 Food Cigarettes
Yung et al., 1983 Sugar, carbohydrates Alcohol
Mitchell and Herlong, 1986 Alcohol Fat, carbohydrates
aAdapted from Carroll, 1996
Table 3 lists 15 studies that demonstrated a decrease in drug-taking behavior

when an alternative reinforcer was presented. In reviewing these and other
studies, Carroll (1996) concluded that "nondrug alternative reinforcers effec-
tively reduce drug self-administration in animals and humans" (p. 33).
This effect is concretely demonstrated in the second half of the study from
our laboratory that was presented earlier. The second phase of that study
entailed examining an experimental analog of employment on concurrently
available cigarette smoking (Bickel, DeGrandpre, Higgins, et aI., 1995). The
response requirement to obtain two cigarette puffs was varied when money
(either $.25 or $.50, available to different subjects) was or was not concur-
rently available as an alternative reinforcer (employment simulation). Com-
pleting 400 responses on a second plunger incremented the total amount of
money provided to subjects at the end of the session. Data from the no-
employment condition also presented in Figure 1 are shown here for purposes
of comparison.
Across all conditions, cigarette consumption decreased in an accelerating
fashion as response requirement increased (Fig. 2). Relative to its absence, the
presence of employment decreased consumption but had no effect on the shape
of the function; that is, the function relating the number of puffs smoked to
response requirement was displaced downward and to the left in a parallel
fashion. In some cases this decrease was rather dramatic, as with subject BM,
whose consumption of cigarettes, as a result of providing employment, de-
clined approximately 90% at the lowest price. The effects on drug seeking were
similar (Fig. 2, right).
The availability of employment shifted the demand curve downward and,
therefore, resulted in less drug consumption and drug seeking at every price
examined relative to the absence of employment. These data suggest that
competing nondrug reinforcers may decrease drug consumption in current
users. Additionally, some evidence suggests that alternative reinforcers or the
lack thereof may influence vulnerability to the initiation of drug abuse (see
Chapter 3, this volume). For example, one study provided an alternative
reinforcer (a glucose-saccharin solution) that prevented the acquisition of
cocaine self-administration in rats relative to rats who were not provided the
alternative (Carroll, Lac, & Nygaard, 1989). Such a result, along with those of
the present study, suggests that the availability of alternative nondrug rein-
forcers can have an effect not only on drug consumption once established, but
also on its initiation (e.g., Lewit, Coate, & Grossman, 1981).
The presence of an alternative competing reinforcer not only decreased
cigarette smoking but also decreased the drug-seeking behavior required to
obtain cigarettes (Fig. 2). This demonstrates the utility of such manipulations
relative to increases in price alone. Increases in price alone would increase drug
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drug seeking. Data on x-axis represent zeros. See Figure I for other details.
seeking (and presumably crime). In contrast, providing alternative nondrug

reinforcers decreased drug intake and the amount of drug-seeking behavior.
Another important finding in this study, in addition to the downward
movement of the consumption curves, is the leftward shift. This leftward shift
indicates that the effects of price become functionally greater when competing
reinforcers are present. Thus, providing alternative reinforcers may also en-
hance the effects of costs, irrespective of whether they are criminal, social, or
cultural.
EMPIRICAL SUPPORT
Basic human and nonhuman research, on a vast array of species and drugs,
has lent considerable support to these two principles. However, to assume that
such principles are relevant to the actual conditions of drug dependence would
require that they be verified by studies of epidemiology, life history, and
clinical treatment of drug abuse. Studies from each of these sources will be
reviewed in this section. The results of these studies will indicate whether these
principles are robust and have broad applicability.
Epidemiology and Life History Research
To examine the role of drug availability and the effect of alternative

sources of reinforcement on drug-taking behavior, we can examine four
sources of epidemiological data associated with drug taking.
First, consider a study by Robins, Helzer, and Davis (1975) that examined
heroin dependence in 898 U.S. servicemen stationed in Vietnam. In Vietnam,
poppy plants, the raw material necessary for the production of heroin, can grow
abundantly, and competing sources of reinforcement are certainly fewer than in
the United States. Robins and colleagues found that 85% of the total sample
was offered heroin, demonstrating its ready availability. Another 43% tried
heroin, while 19% became dependent on heroin. These results are remarkable
given that only 0.7% of the U.S. population is estimated to be opioid depen-
dent. Thus, relative to the United States, opioid dependence was 27-fold greater
in this Vietnam sample.
Of equal importance were the consequences of returning to the United
States for these opioid-dependent users. Presumably, heroin availability would
decrease and the availability of competing reinforcers would increase in the
United States. Only 7% of all the opioid-dependent individuals relapsed and
were dependent a year after their return home. This contrasts sharply with the
finding that nearly 90% of detoxified heroin addicts relapse to drug use when
they return to the environments where they engaged in drug use (Hunt &
Odoroff, 1962). Thus, relapse rates were dramatically different depending upon
the environmental context of drug instigation.
The second important source of evidence for the principles comes from
the epidemiological catchment area (ECA) study (Robbins & Regier, 1991). In
this NIMH-funded study, 18,572 adults were interviewed via probability sam-
pling of census tracts and households in five metropolitan areas (New Haven,
Connecticut; Baltimore, Maryland; St. Louis, Missouri; Durham-Piedmont,
North Carolina; and Los Angeles, California). The Diagnostic Interview
Schedule was administered initially and then repeated one year later.
This source allows the two principles to be assessed in two ways. First,
consider Table 4, which shows the prevalence of drug abuse and alcoholism in
men as a function of annual income (Anthony & Helzer, 1991; Helzer, Burman,
& McEvoy, 1991). Annual income could be considered a surrogate variable
reflecting the availability of competing reinforcers; that is, the greater the
income, the more competing reinforcers that may be available. Clearly the
prevalence of drug abuse is greater among those with lower incomes than those
with higher incomes. With respect to alcoholism, prevalence is more equally
associated across income groups, although the greatest prevalence again tends
to be associated with lower incomes. This flatter distribution may reflect the
ubiquitous availability of alcohol in our society (i.e., both in price and in
absence of legal sanctions). Moreover, this alcoholism data may anticipate the
consequences of legalizing drugs; that is, legalization presumably would de-
crease both the price to obtain drugs and the legal and social sanctions resulting
from their use. This, in tum, may increase the prevalence of drug dependence
Table 4
Annual Income and Prevalence of Drug
Abuse and Alcoholism in Men (All Ages)
Current Annual Income Drug Abuse Alcoholism
Less than $5000 16.48 23.41

$5000-$9999 16.32 31.86
$10,000-$14.999 9.34 23.89
$15.000-$19,999 7.23 23.38
$20,000-$24,999 5.83 19.49
$25,000-$34.999 6.89 18.74
$35.000-$49.999 3.12 12.77
$50,000 and over 4.05 14.34
even in the presence of competing nondrug reinforcers (although consumption

would still be not as great as it would be in the absence of competing reinforcers).
The second way this ECA data permits an assessment of the two princi-
ples is by considering the prevalence of drug abuse as a function of marital
history (Anthony & Helzer, 1991). Presumably, marriage provides a competing
source of reinforcement; the more stable and long-lasting the marriage, the
more effective the reinforcement (Higgins, Budney, Bickel, and Badger, 1994).
The ECA data suggest that the less stable the marriage history, the greater the
prevalence of drug abuse (see Table 5).
A third source of epidemiological data is the relationship between unem-
ployment and drug use (Bickel, 1993). Employment can serve as a competing
reinforcement in at least three ways. First, time spent on a job prevents that time
from being spent pursuing or using drugs. Second, it provides an income that
may allow access to other sources of competing reinforcement. Third, employ-
ment may permit the development of relationships with individuals, which may
also provide a competing source of nondrug reinforcement. The analysis would
suggest that the loss or absence of employment would be a significant risk
factor for drug abuse.
Studies we are aware of that examined the relationship between drug use
and unemployment are displayed in Table 6. A total of five retrospective or
cross-sectional studies and one prospective study were identified (Anthony &
Helzer, 1991; Clayton & Voss, 1981; Newmeyer & Johnson, 1976; Pearson,
Gilman, & Mciver, 1986; Peck & Plant, 1986). In four of the five retrospective
studies, unemployment was significantly related to drug use. These and all the
other correlational studies described above suggest a relationship but do not
indicate causality. An alternative explanation, for example, could be that drug
use causes unemployment. This potential criticism underscores the importance
of prospective studies that can directly address the issue of causality. Signifi-
cantly, in this regard, the singular prospective study found that unemployment
resulted in increased drug use.
Table 5
Prevalence of Drug Abuse/
Dependence in Men
by Marital History
Married never separated or divorced 3.59
Separated/divorced only once 6.31
Separated/divorced more than once 12.04
Never married. but lived as married 30.24
Table 6
Unemployment and Drug Use
Unemployment
Location and Drug Use
Retrospective/Cross-Sectional Studies
Anthonly & Helzer, 1989 USA Not significant'
Clayton & Voss, 1981 Manhattan Significant
Newmeyer & Johnson, 1976 San Francisco Significant
Peerson et al., 1986 Glasgow Significant
Peck & Plant, 1986 United Kingdom Significant
Prospective Study
Peck & Plat, 1986 Lothian Region Significant
aBut found in men ages 30-44 that 10.49% of unemployed men but only 4.6% of employed
men had active drug abuse and dependence.
The fourth and final source of support for the two principles comes from
the life history studies of alcoholics and heroin addicts conducted by G. E.
Valliant (1966, 1973, 1988). In these studies, Valliant identified cohorts of
patients whom he followed for one to two decades. These important studies
identified admission characteristics and post-treatment factors that were asso-
ciated with abstinence. Employment was an admission variable that signifi-
cantly predicted stable abstinence among the alcoholics. Variables predicting
continued alcoholic drinking were a "skid row" social adjustment and prior
incarceration. Admission variables that predicted stable abstinence in heroin
addicts were employment for 4 or more years prior to admission and whether
the patient was employed for more than half of his adult life. Thus, in both of
these populations, employment predicted successful abstinence.
In terms of relapse, Valliant identified four factors associated for absence
of relapse for a year or more among treated and untreated alcoholics and heroin
addicts: compulsory supervision, a substitute dependence, new relationships,
and inspirational group membership. Note, however, that inspirational group
membership was not a factor for abstinent heroin addicts.
Commenting on his research, Valliant rendered two conclusions 22 years
apart, and they both serve as a fitting conclusion for this section. On initiating
drug use, Valliant noted, "In short, the addict begins drug-seeking behavior ...
because he has little opportunity to engage in other competing forms of
independent activity" (Valliant, 1988, p. 30). On remaining abstinent, he noted,
"the findings suggest that abstinence depends upon the addict's discovering
gratifying alternatives" (Valliant, 1966, p. 573).
Clinical Research
The treatment of drug dependence provides another source of data for

examining support of our two principles. The behavioral treatment used by
Higgins and colleagues are most directly related. The first main component of
this treatment is "contingency contracting," in which consequences are di-
rectly placed on drug use. For example, presentation of each drug-free urine
sample is reinforced with voucher points that are redeemable for prosocial
nondrug activities or retail items (e.g., fishing rod and license, ski lift tickets).
Reinforcing abstinence increases the cost of drug use; that is, the price of drug
use includes the forfeiture of a reinforcer derived from drug abstinence as well
as the usual cost of consuming a drug (see Bickel & DeGrandpre, 1995). We
can speculate that by doing so, the cost of the drug increases in a way that does
not actually increase the monetary cost of the drug and therefore would not
increase drug seeking. Of course, empirical studies will need to be conducted to
assess this point.
The second main component of this treatment is focused on establishing
patients' participation in nondrug activities that will be maintained and will
compete with the endemic pattern of drug taking found in heavy drug users
(e.g., Higgins et at., 1993; Higgins, Budney, Bickel, Foerg, et at., 1994; Hunt &
Azrin, 1973; Stitzer, Bigelow, & Liebson, 1979). Establishing these alternative
activities is directly analogous to manipulating the presence or absence of the
alternative activities described above (Higgins et at., 1993; Hunt & Azrin,
1973). Results from therapeutic trials using a combined treatment approach
produce replicable levels of abstinence in cocaine-dependent individuals that
far exceed most treatments of cocaine dependence presented in the literature.
This type of behavioral treatment approach has been applied to opioid-
dependent patients being detoxified with buprenorphine (Bickel, Amass, Hig-
gins, & Esch, under review; see also Bickel & Amass, 1995, for a review of
buprenorphine's treatment potential). This application also utilized one mod-
ification of the behavioral treatment outlined above; patients were explicitly
reinforced for activities that may compete with drug reinforcers instead of just
encouraging them to engage in such activities. For example, patients received,
each week, voucher points for engaging in three previously specified activities.
These voucher points were earned in addition to those earned for opioid-free
urine samples. These activities were selected with approval of the counselor,
and they were verified to insure compliance.
The results of this study with opioid-dependent patients systematically
replicated the work of Higgins and colleagues (1994) and demonstrated im-
proved efficacy relative to the control treatment. Additionally, we noted an
interesting statistically significant correlation of 0.78; patients that completed a
greater percentage of prosocial activities throughout treatment had a greater

percentage of drug-free urine samples. Of course, this correlation will require
additional study to determine if activities and opioid-free urine samples are
casually related, but these results are certainly consistent with the effects of
competing nondrug reinforcement developed above.
POLICY IMPLICATIONS
Thus far we have discerned from the basic laboratory two principles
relevant to drug intake: availability of the drug and availability of competing
non drug reinforcers. Moreover, we have illustrated the relevance of these
principles to the real-world phenomena of drug dependence as indicated by
clinical and epidemiological studies and data. In this section, we will use these
principles to examine the effectiveness of contemporary drug policies and to
provide our recommendations for potential drug policy.
Supply Reduction and Legalization
Supply reduction and legalization represent two opposing points along

the continuum of drug availability. Contemporary policy in the United States
has largely focused on supply reduction, which, when successful, increases the
price of drugs. Increases in price, in tum, result in decreased drug consump-
tion and increased drug seeking. Central to considering this policy are the
tradeoffs between the magnitude of decreases in drug consumption and the
increases in drug seeking. Moreover, the extent to which price poses a barrier to
the induction of new drug users must be weighed. Supporting this possibility is
the greater reduction of drug use in recreational users than in heavy users as a
result of the increased resources applied to addressing the drug problem
(NIDA, 1990). Clearly, a better understanding of these issues would help in
evaluating such policies.
Another policy option is legalization. The discourse concerning legaliza-
tion has accelerated greatly since the previous Surgeon General raised it as a
policy option to consider. According to our understanding of the principles
outlined here, legalization, by decreasing price, would increase drug use. If
drug use increased to an extent equivalent to alcohol, then the prevalence of
drug dependence might more than double. Similarly, one impetus for the
growth in the cocaine problem was the arrival of crack cocaine that cost only
$5-$10. This low price greatly increased the number of individuals who could
buy it and, in tum, who became dependent.
Also, as indicated by the principles we have outlined and by definition,

legalization would eliminate a considerable amount of crime. Again the bal-
ance of use versus crime becomes important in evaluating this option. If,
however, legalization is considered seriously, we recommend efforts that de-
crease consumption by increasing the nonmonetary cost of use without neces-
sarily affecting price of purchase. The consequences for cigarette smoking are
a prime example. There are many nonmonetary costs associated with cigarette
smoking, for example, having to go outside in the winter to smoke as well as
social sanctions from nonsmokers. This underscores the importance of making
access to certain social activities or benefits contingent upon verified drug
abstinence.
Our Policy Recommendations
We recommend that drug policy employ both of the principles outlined

here. We recommend restricting availability to the extent that it can serve as a
barrier to initiating drug use and to using drugs indiscriminately. However, we
do not recommend that efforts be focused on trying to "seal our borders" or to
"win the war on drugs." The focus of these methods to control or restrict
availability is to manage the initiation of drug use and to prevent the integration
of drug use into the varied environments through which individuals pass. In
many ways this might be done more effectively by increasing the nonmonetary
costs required to obtain drugs or that are associated with their use.
We also strongly recommend the development of competing nondrug
reinforcers, especially for individuals in high-risk situations. This second
principle holds both the greatest promise for outcome and perhaps the greatest
practical difficulty for political adoption and application. The promise of
providing meaningful nondrug alternatives to drugs is the likely reduction in
drug consumption, and concurrent reduction of drug -seeking behavior in heavy
users. Thus, programs designed to socially enrich the life of drug-dependent
individuals may produce positive societal results (decreased drug use) without
the negative consequences observed with supply reduction approaches (in-
creased drug seeking).
While such a program may have appeal, adoption and application of this
principle may prove difficult for three reasons. First, providing alternative
reinforcers as an intervention to decrease drug abuse is not intuitively obvious
to politicians or constituents because it does not directly focus on drugs or their
use. Second, politicians may view efforts to improve the availability of compet-
ing nondrug reinforcers as "coddling the drug addict" or as pork. Third, any
effort to provide meaningful alternatives to drug use would require the addi-
tional expenditures at a time when resources are scarce. Perhaps these diffi-
culties could be avoided by tying these efforts to more general efforts to
improve our society as opposed to labeling these efforts solely as antidrug
measures.
This is a tall order. But if the solutions to drug dependence were easy, they
would have been found by now. At a minimum, however, we know that drug
use results from drug availability and the absence of meaningful alternatives.
To manage the problem of drug dependence will require not only that drugs are
not readily available and that meaningful alternatives are accessible. The
synergistic application of these two principles would also link, perhaps for the
first time, our empirical knowledge of what controls drug taking with our
policy for managing the problem of drug dependence. Equally important is that
the application of these two principles would link the sum and focus of
demonstratively effective drug treatment with policy efforts to curb use. Of
course, the difficulties of getting the government to adopt such a policy are
many, but to do otherwise is to curse the darkness. As JFK noted, "All this will
not be finished in the first one hundred days. Nor will it be finished in the first
one thousand days, nor in the life of the administration, nor even perhaps in our
lifetime on this planet. But let us begin."
ACKNOWLEDGMENTS The writing of this chapter was supported by National

Institute on Drug Abuse Research Grants DA 06526 and DA 06969. Opinions
expressed are solely those of the authors. We thank Nancy Petry and Brandi
Smith for their helpful comments on earlier versions of this manuscript.
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PART II
Informing Drug Policy via

Psychological Science:
Changing Drug Use
CHAPTER 3
Psychological Approaches
to Prevention
BRENNA H. BRY
To be effective, drug abuse prevention policy must emerge from a scientific

understanding of why some people abuse drugs while most people do not,
despite drugs' abuse potential. Apparently, other factors compete with or
potentiate drug effects to determine actual use patterns. Indeed, research shows
that there are life circumstances, known as protective factors, that reliably
reduce the chances that an individual will abuse drugs. Likewise, there are life
circumstances, known as risk factors, that increase those chances. It follows,
then, that prevention policy should aim to ensure protective factors and elimi-
nate risk factors from everyone's life.
Our research shows that no single factor accounts for an individual's drug
abuse (8ry, McKeon, & Pandina, 1982). Instead, the cumulative number of risk
factors present in one's life plus the cumulative number of protective factors
that are absent relate to the likelihood of abuse. To test our multiple risk factors
hypothesis prospectively, we assessed how many risk factors 400 representa-
tive New Jersey adolescents had in their lives when they were 12, 15, or 18 years
old (time 1). Then we waited three years and assessed their drug use. We found
that the probability that each adolescent had used drugs heavily within those
three years (by time 2) was a very significant linear function of the number of
BRENNA H. BRY • Graduate School of Applied and Professional Psychology. Rutgers Univer-
sity. Busch Campus, Piscataway, New Jersey 08855-0819.
55
56 BRENNA H. BRY
risk factors he or she reported at time 1 (Bry, Pedraza, & Pandina, 1988) (see
Fig. 1.) A practical application of this research is that young people at risk for
future substance abuse can be identified for preventive intervention by assess-
ing their risk factors.
No particular combination of risk factors, however, predicted heavy use.
To the contrary, the 6 heaviest users by time 2 each showed a different
combination of risk factors (Bry, Pedraza, & Pandina, 1988) (see Fig. 2.) That
these multiple pathways to drug abuse are not just a New Jersey phenomena is
shown by similar longitudinal findings in California (Newcomb, Maddahian, &
Bentler, 1986), in Virginia (Farrell, Danish, & Howard, 1992), and in Pakistan
(Gillis, Tareen, Chaudhry, & Haider, 1994). Thus, susceptibility to drugs'
attractive effects is heightened or dampened by multiple, different combina-
tions of precursive life protective factors and risk factors, and this relationship
holds across races, ethnicities, socioeconomic class, geography, and in urban,
suburban, and rural locations.
So that drug abuse prevention policy can be based upon empirical find-
ings, this chapter will review scientific knowledge about etiology of drug
abuse. Results of preventive interventions that have targeted the causes will
also be reported. Then policy implications will be highlighted. Throughout, the
term drugs will refer to marijuana, cocaine, opiates, and nonalcoholic,
consciousness-altering substances. Alcohol may be included as a drug, but
studies that focus on alcohol exclusively will not be called drug studies. Drug
use is considered drug abuse to the extent that everyday functioning is some-
how impaired.
PROTECTIVE FACTORS
Reasons Not to Use Drugs
Close, enduring, non-conftict-ridden relationships with family members

and companions who disapprove of drug abuse may be the most universal
antidote for drug abuse. We found in high-risk adolescents that the most
common circumstances where they refused available drugs was when their
parents would find out (Beier, 1990). Having a valued, trusting, and accepting
relationship to lose is a powerful deterrent.
For such a close relationship to affect drug abuse, however, drug use must
be monitored and the consequent disapproval must be unambiguously clear.
Thus families who know what their members are doing and who have definite
expectations and effective, age-appropriate discipline methods produce fewer
drug abusers than do families with ineffective management practices (Dishion,
PSYCHOLOGICAL APPROACHES 57
100
bAM Reported heavy uae by Time 2
o Old not report heavy uae by Time 2
80 ... -·+---1- ---- -- - -- -- - - --------
100L----~------~---~2-------L3-------4~---~5~--~6---
Risk Factor Categories: Number of Risk Ractors

Exhibited at Time 1
Figure 1. Predictive relationship between the number of risk factors an adolescent reported at time
I and the probability that he or she would (shaded bars) or would not (open bars) use drugs heavily
within the next 3 years (by time 2),
58 BRENNA H. BRY
Risk Factors
..
A 8 C 0 E F G H J
Failing No High CigareHe High Other Stressful Low High High
Subjects Grades Religion Experience Use Psycho- Problem Problem Parent Friends' Parents'
Seeking Before lagicai Behaviors Behaviors Nurturance Use Use
..
12yrs. Distress or Control
01_.
B _B .. D
-• 01 10 m
2
-- _... .... ..
3 .. D
4 0 III
5
Figure 2. The variety of combinations of risk factors reported at time I by the six adolescents who
used drugs most heavily within the next 3 years.
Reid, & Patterson, 1988). Overly harsh or inconsistent consequences for early
drug sampling are not particularly effective for discouraging later abuse. A less
direct link between coercive parental discipline and drug abuse occurs when
children mimic their parents' coercive methods of social influence and find
themselves ostracized by all peers except those who eventually will abuse
drugs (Dishion, Patterson, Stoolmiller, & Skinner, 1991).
Parents are more likely to be warm and supportive when their children
were wanted and when they have the emotional and financial resources to care
for them well (Hendin, Pollinger, Ulman, & Carr, 1981). Social support from
other adults with whom parents can discuss good child rearing practices also
increases parental effectiveness (Wahler & Dumas, 1987). Warm relationships
with consistent surrogate parents or with neighbors who know how a person
spends time can also be protective (Werner, 1989).
Attractive Alternatives to Drug Abuse
Having other attractive ways to spend time is also an extremely effective

deterrent. Although it is not clear exactly why, religiosity is protective. Urban
African-American young adult men living in a housing project were signifi-
cantly less likely to be drug abusers if they had attended church in their
adolescence or if they were attending as an adult (Brunswick, Messeri, & Titus,

1992). Perhaps church attendance places one in a relatively drug-free context
for significant periods of time. Perhaps it provides close companions who
disapprove of abuse. Perhaps religiosity offers pleasant spiritual experiences
and a significant relationship with a greater being. Whatever the mechanism,
that religiosity at some point in time protects against drug abuse later on seems
to be found by every investigator who examines it.
People who value, participate in, and expect to succeed at other conven-
tional and challenging activities are also less likely to abuse drugs in the future
than those who do not (Jessor & lessor, 1977). Taking responsibilities for
managing a house or participating in hobbies, sports, or adult organizations are
all protective (Brunswick, Messeri, & Titus, 1992; Swisher & Hu, 1983).
Besides leaving one with less free time to use drugs, intense involvement in
activities may also protect by giving a person something valued to lose-
personal accomplishments and social support-if drug use impairs functioning
or leads to arrest.
RISK FACTORS
Reduced Susceptibility to Sanctions against Abuse
No matter how many protective factors fill a person's life, they may not
protect against drug abuse if the person has experienced neglect as a child
(Block, Block, & Keyes, 1988) or has habitually engaged in serious problem
behavior (Elliott, Huizinga, & Ageton, 1985). When children are neglected,
they become immune to protective social influence. Such children, apparently,
do not learn how to form close relationships and do not learn other lessons that
parents usually teach, such as that they are likable, can solve problems, and can
regulate their impulses. Without early parental support, many children cannot
effectively deal with the frustration of normal limitations and failures.
As Glantz (1992) states, "The [neglected] child is unlikely to be strongly
influenced by any protective factor. For example, he or she is unlikely to be
seriously involved in any social group that reinforces traditional values, such as
a religious organization" (pp. 409-410). Identifiable circumstances that can
lead to child neglect are adolescent parenthood, irritable children, parental
social isolation (Dumas & Wahler, 1983), and parental depression (Patterson &
Forgatch, 1990).
For other reasons, people with serious childhood problem behaviors may
not be influenced by protective factors. While the illegality of drugs prevents
many young people and adults from abusing, people who have become accus-
60 BRENNA H. BRY
tomed to following their impulses aggressively and to breaking rules with

impunity do not experience laws as barriers. Such people may lack experiences
where delaying immediate gratification paid off in long-term rewards. The
short-term positive effects of drugs combine with insufficient competing expe-
rience in inhibiting behavior, and drug taking predominates.
Heightened Susceptibility to Substances' Effects
A myriad of life circumstances, from experiencing serious psychiatric

disorders to doing poorly in school, have been associated empirically with an
increased risk of future substance abuse. These risk factors seem to operate by
heightening the reinforcing effects of drugs for some people. That is, the
natural effects of drugs are more valuable or attractive to some people than to
others because of past life experiences.
Recent evidence highlights traumatic experiences such as physical or
sexual abuse, violence, or becoming homeless as risk factors for substance
abuse (Clayton, 1992). These events all threaten victims' safety, survival, or
security and leave excruciating memories. Drug use may temporarily decrease
disturbing thoughts and flashbacks and aid the abused in "forgetting" for a
brief period. One victim of frequent, uncontrollable physical abuse reported
that she smoked marijuana "on the way to school, during lunch hours, after
school, and until she went to bed ... because marijuana made her feel less
depressed about her life" (Hendin, Pollinger, Ulman, & Carr, 1981, p. 26).
Growing up or living in a family with substance abusers has long been
recognized as a risk factor, although consensus has not always existed regard-
ing the mechanism of influence (Merikangas, Rounsaville, & Prusoff, 1992).
The multiple pathways model of drug abuse, however, allows for many combi-
nations of factors. These can affect different individuals uniquely, even indi-
viduals within the same family.
Drug availability is certainly enhanced when a drug abuser is in the
household. Except for friends and acquaintances, relatives are adolescents' and
women's most common source of drugs. Relatives and one's own family are
very persuasive when they offer substances. In one of our studies, adolescents
refused available substances 46% of the time when friends offered them and
18% of the time when relatives offered them, but they never refused when their
parents offered them (Beier, 1990). Family members also supply drugs when
they do not intend to, in that other family members take them without permis-
sion (Chambers, Sheridan, & Willis, 1972).
Other effects of having a drug abuser in the family may be observational
learning about drug-abusing behavior and drug effects. Family members may
also inherit a susceptibility to drugs in the form of a problematic temperament
that can be improved by drug effects. Research points to an inherited tendency

toward negative mood states, heightened arousability, and decreased sooth-
ability (Tartar, Alterman, & Edwards, 1985). Finally, substance abuse in the
family can increase other risk factors because family members become isolated
and neglected, suffer violence, and/or experience inconsistent behavior man-
agement due to the substance abuser (Chassin, Pillow, Curran, Molina, &
Barrera, 1993).
Failure in school (Kandel & Davies, 1992), school dropout (Glantz, 1992),
and unemployment (Brunswick, Messeri, & Titus, 1992) all increase the risk of
substance abuse. The role of student for a youth can be seen as analogous to the
role of employee for an adult. When a person is not experiencing the positive
relationship between striving for achievement and the pleasures of success, for
whatever reason (concentration problems, depression, lack of interest, few
skills, poor job market, or learning problems), that person has fewer positive
alternatives to positive drug effects in his or her life and has more negative
failure experiences from which to escape.
Our studies show that the more emotional problems and distress a person
experiences, whether anger, depression, low self-esteem, or serious psychiatric
symptoms, the greater is the chance of drug abuse sometime in his or her
lifetime (Witte, 1983). In a longitudinal study, Shedler and Block (1990) found
that adolescents who abused drugs already looked significantly more emo-
tionally distressed than other children at age 7. Long before anyone knew that
they would abuse drugs, they were reported "as not getting along well or
forming close relationships with other children, as having bodily symptoms of
stress, as afraid of being deprived, [and] as displaying inappropriate emotive
behavior" (p. 626).
The vulnerability of individuals with psychiatric diagnosis is staggering.
Whereas 16.7% of the whole population will abuse alcohol or other drugs at
some time, 47% of people who have had symptoms of schizophrenia will abuse
substances sometime, as will 32% of those with affective disorders, including
depression, and 23% with anxiety disorders (Mueser, Bellack, & Blanchard,
1992). Major negative life events, such as the death or divorce of a parent, a
serious hospitalization, or acquiring a visible deformity, also increase vul-
nerability to drug abuse, since the experiences increase negative affect and
decrease positive affect (Wills, Vaccaro, & McNamara, 1992). For instance,
children who lose a parent to death have 7.5 times greater risk of developing
depression than other children (Gersten, Beals, & Kallgren, 1991). The negative
events may also occasion perceptions of helplessness and decreased personal
control.
The statistical association between emotional problems and drug abuse
suggests self-medication of symptoms. Indeed, drug abusers commonly iden-
tify the time at which addiction develops, after years of casual use, as a period
62 BRENNA H. BRY
of heightened emotional distress (Woody, Urschel, & Alterman, 1992). Individ-

uals with emotional problems also progress from initial use to problem use
more rapidly than do users without emotional problems (Weiss, Mirin, Griffin,
& Michael, 1988). Drug effects may well provide immediate, if temporary,
relief from unwanted symptoms, such as anxiety, insomnia, hallucinations,
irritability, and/or rage. Also, since drugs can change negative symptoms fairly
rapidly and reliably, their use can briefly restore a sense of personal control to
someone with emotional problems. Unfortunately, however, in the long run
drug use usually worsens the original emotional problems.
Other related life experiences that are associated with increased risk for
drug abuse are involvement in a neighborhood with many drug abusers (De-
mbo, Blount, Schmeidler, & Burgos, 1986), having friends who are drug
abusers (Kandel, Treiman, Faust, & Single, 1976), and using drugs oneself
relatively early in life (earlier than age 15) (Robins & Przybeck, 1985). Under
these conditions, drug use requires less planning than does refusing drugs. Use
brings social acceptance and even high status. Fewer negative sanctions com-
pete with the positive drug effects, as neighbors are too transient or afraid to
express much disapproval.
If a person begins using drugs early in life, the statistical risk of later abuse
is greater. This relationship is probably due to the fact that the earlier that
drugs' positive pharmacological effects are experienced, the less likely it is that
a person has developed the self-discipline, maturity, and judgement that are
needed to forego those immediate good feelings for the long-term benefits of
nonusing. Furthermore, if time, effort, and money are put into drug use early
in life, then less time, effort, and money are put into developing (I) competen-
cies to cope with the various challenges that teens and adults face (Labouvie,
Pandina, & Johnson, 1991); (2) a stable, positive view of oneself (Johnson &
Pandina, 1991); (3) a record of successes at conventional activities; and (4) friends
who will not be substance abusers. In other words, early substance use prevents
a person from acquiring some of the protective factors and exposes him or her
to more risk factors.
PREVENTION TECHNOLOGY
So far, despite widespread agreement regarding factors that contribute to

future substance abuse, there exists no widespread public policy to increase
protective factors and reduce risk factors. Previously, arguments were made
that "nothing works" or "you can never know if you have prevented some-
thing." By now, however, numerous longitudinal, scientifically controlled
studies have shown that preventive interventions indeed can reduce the rate of
future problems as compared to no intervention at all or as compared to

"treatment as usual." Providing scientifically proven prevention programs will
take funding, of course, but not providing such programs will cost more-in
the form of future public assistance, rehabilitation, and/or incarceration ex-
penses. At the community level, preventing just two publicly funded substance
abuse treatments or incarcerations typically covers the cost of providing inten-
sive prevention for everyone at risk (Kinney, Haapala, & Booth, 1991). The
National Commission on Children (1991) also details the long-run cost benefits
of taking preventive action. In the next section, selected policy suggestions will
be made, accompanied by supporting evidence from controlled prevention trials.
Increasing Protective Factors
Since it is protective for children to be consistently attended to within

enduring relationships with warm, accepting parents or their designees from
birth to independence, public policy should lead to sufficient, state-of-the-
science (1) infant and preschool child care and education programs; (2) schools
that offer genuine partnership to parents; (3) after-school, evening, and summer
activities or jobs for all children and youth; and (4) apprenticeships or college
for all out-of-school youth.
Preschool child care that includes parent participation and education has
preventive effects that last into adulthood. Follow-up studies of families ran-
domly assigned to a preschool or to no program show that preschool parents
felt better about themselves as parents and were more confident that they could
handle whatever came up. Consequently, they praised their children more,
showed more affection, and used less restrictive punishment (Johnson &
Breckenridge, 1982; Rickel & Allen, 1987). High-quality preschools and parent
education also resulted in fewer school behavior problems, learning problems,
and less drop-out (Johnson & Breckenridge, 1982; Zigler & Muenchow, 1992).
Preschool and parent education can even lead to more post secondary educa-
tion, i.e., college or vocational training (Berrueta-Clement, Schweinhart, Bar-
nett, & Weikart, 1987). Additionally, young people who experienced excellent
preschools became involved in 40% fewer arrests, 42% fewer teen pregnancies
and births, less unemployment, and less reliance on welfare than randomly
assigned nonpreschoolers (Berrueta-Clement et at., 1987). All of these out-
comes in turn lower the probability of substance abuse.
Once children reach elementary school, the positive effects of good
preschool education and positive parenting unfortunately can be overridden in
some ethnic groups by the influence of peers who do not value education
(Steinberg, Dornbush, & Brown, 1992). Involving parents more in the schools
64 BRENNA H. BRY
prevents good parenting from becoming neutralized or undermined by the peer

or school environment. The School Development Program by Comer in New
Haven, Connecticut, involves parents as partners in their children's schooling.
Parents serve on the School Advisory Council, are employed or volunteer in the
classrooms, and significantly affect the way the school works. For instance, in
one school, parents recommended a program that was adopted where teachers
stay with children for two years instead of one. The results of the Comer
program are significantly increased attendance, language skills, math scores,
and social competence. In addition, the reorganized school virtually eliminated
behavior problems (Cauce, Comer, & Schwartz, 1987; Comer, 1988).
Organized after-school, evening, and summer activities for kindergartners
through seniors in high school and their parents are also protective. When
enough young people and their parents in an area are involved in constructive
activities, the amount of substance use and crime in the whole area decreases.
Schinke, Orlandi, and Cole (1992) found that the presence of comprehensive
service Boys and Girls Clubs near housing projects decreases drug activity and
vandalism to the units and increases the number of parents who attend school
parent conferences, volunteer to chaperon for children's clubs, and attend
tenant association meetings. Inner-city Families in Action has reduced nar-
cotics arrests in two housing projects by offering long-term, mUltiple, compre-
hensive, detailed, scientifically up-to-date courses for small groups of youth
and parents on the specific actions of drugs on the body. Several of the parents
who attended the course have stayed together in parent support groups to take
action to protect their children, such as riding school buses and volunteering at
school (EMSTAR Research, 1993).
Job Corps, Peace CorpsNISTA programs, American Conservation and
Youth Service Corps, National and Community Service Programs, universities,
and the military all provide young people sheltered work experiences, educa-
tional training if necessary, and opportunities to live away from home with
other young people in structured environments. Research shows that such
experiences enhance the confidence of participants in their ability to work hard.
In addition, these apprenticeships increase participants' support for conven-
tional community programs such as recycling and blood drives (Wolf, Leider-
man, & Voith, 1987, cited in Dryfoos, 1990). Both effects are protective.
It is also significant that, whereas illicit drug use among enlisted men in
the military before 1982 mirrored that of the general population, after the
military established strict rules and monitoring, the overall substance use of
young men in the military came down significantly (Bray et aI., 1986; cited in
Newcomb, 1988; Clayton & Ritter, 1985). As do university students, young
men in the military use drugs on the job (or in class) significantly less than do
young people in non sheltered civilian jobs. Newcomb (1988) reports that an
astounding 28.6% of 18- to 25-year-old men with full-time jobs have used
substances on the job in the past 6 months, while only 5 % of men in the military
have done so.
Reducing Risk Factors
In addition to experiencing the benefits of protective factors, some people

also need relief from effects of risk factors. The provision of early intervention
and effective treatment programs for risk factors when they first appear can
lower the chance of prolonged costly substance abuse later on. The following
are public policies that could reduce risk factors and research evidence that
supports them: (1) a universal, decisive, long-term, criminal justice system
response to intrafamily violence, including sexual abuse; (2) universal, state-
of-the-science, long-term, support and treatment programs for people with
emotional and lor substance abuse problems and their families; (3) long-term,
school-based outreach programs for behavior problems, school failure, and
early substance use for children and their families; and (4) long-term, state-of-
the-science family support and preservation programs for families in danger of
breaking up because of neglect or ineffectiveness.
Research has shown that mandatory arrest and brief incarceration for
physical and sexual abuse of both children and mothers deters more repeat
offenses than do warnings or counseling in lieu of arrest (Sherman & Berk,
1984). When nonoffending, previously arrested men were asked what they
thought would happen if they hit again, they responded that: (1) they could be
arrested again, (2) their partner would leave them, (3) they would lose respect
of friends and relatives, and (4) they would lose self-respect (Buzawa &
Buzawa, 1992; Williams, 1992). Apparently, the threat of guaranteed social
sanctions and life disruptions helps abusers and batterers control their battering
and abuse. Post conviction, court-mandated treatment for offenders appears to
reduce the chance of further abuse even more (Dutton, 1986). Wright (1982)
advocates that substance abuse treatment be combined with treatment for
family violence, since from 40% to 87% of adult sexual and/or physical abusers
also report alcohol or drug abuse.
Because children of people with substance abuse problems and people
with emotional problems are at higher risk for drug abuse, comprehensive drug
abuse prevention must include treatment services for emotional and substance
abuse problems. Short-term, individual, and family psychotherapies are effec-
tive in reducing the risk factors of anxiety, depression, social isolation, and low
self-esteem in children, adolescents, and adults (Bloom, 1992; Falloon, 1988a;
Feindler & Kalfus, 1990; Hersen & Van Hasselt, 1987). While more serious
66 BRENNA H. BRY
emotional problems, such as schizophrenia, are more chronic, treatment can

nevertheless reduce symptoms. Skills-training programs teach emotionally
disturbed people social skills, how to take their prescribed medication, how to
solve problems, and how to manage their leisure and recreation (Foy, Wallace,
& Liberman, 1983). Psychoeducational programs for family members not only
improve families' problem-solving and coping skills, but also significantly
decrease the number of episodes of emotional disturbance that the patients
experience (Falloon, 1988b). Thus family intervention reduces substance abuse
risk factors for both the emotionally disturbed individual and his or her family
members.
Although substance abuse is difficult to treat and most substance abusers
go through treatment programs several times before substances are no longer a
problem in their lives, there is evidence now that some treatments are more
effective than others and are more effective than no treatment (Institute of
Medicine, 1989). Treatment approaches that involve the family are particularly
effective, both in producing short-term results and maintaining them in the long
run (Bry, Conboy, & Bisgay, 1986; Monti et aI., 1990; Sisson & Azrin, 1986;
Stanton, Todd, & Associates, 1982; Szapocznik & Kurtines, 1989). Substance
abuse treatment for married parents gains effectiveness, both in the short term
and the long run, when both spouses are involved in the treatment (McCrady,
Noel, Abrams, Stout, Nelson, & Hay, 1968). Of the different ways that spouses
of parental substance abusers can be involved, the behavioral martial approach
appears to be the most effective (O'Farrell, Cutter, & Floyd, 1985). Employee
Assistance Programs, (EAPs) at work also successfully treat some parental
substance abusers (Iutcovich, 1991). All of the above treatment programs
require aftercare or booster sessions for the parents and siblings to maintain
their gains (Ahles, Schlundt, Prue, & Rychtarik, 1983; Bry & Krinsley, 1992;
Catalano & Hawkins, 1985).
When the above approaches are not effective, the Community Reinforce-
ment Approach (Higgins, Budney, Bickel, Hughes, Foerg, & Badger, 1993),
Therapeutic Communities (TCs) (DeLeon, 1989), and methadone maintenance
(for opioid dependence) (Woody, McLellan, Luborsky, & O'Brien, 1990) are
available. All of these outcomes help family members be more available to rear
children and discourage them from using substances. Children's outcomes are
better when parenting skills training is added to substance abuse treatment.
Families of substance abusers in treatment gain better communication skills,
children have fewer behavior problems, and children declare more intentions to
avoid substance use themselves (including tobacco and alcohol) (DeMarsh &
Kumpfer, 1986).
Research also clearly shows that, with help, families can reduce the risk
factors of behavior problems, school failure, and early substance use in their
children. The sooner the problems are addressed, the more completely they can
be eliminated (Dishion & Patterson, 1992). The intervention programs have
proven effective for white, African-American, and Hispanic-American fami-
lies from the full range of socioeconomic groups.
When children ages 3 to 8 do not comply with parental requests and/or
have other behavior problems, family participation in well-developed parent
training programs reduces child noncompliance behavior problems and parent
stress and depression, increases praise and positive attention from parents,
reduces spanking and critical statements and commands, improves marital
satisfaction, and improves parental perceptions of their children. The effects of
parent training can last at least 1 or 2 years after training is finished and can
improve parent interactions with other siblings. When families go for refresher
courses, improvement can be even greater and can last longer. Parent training
can be accomplished efficiently, either individually or in groups, with the aid of
program manuals and videotaped instruction, and is liked well by parents
(McMahon & Forehand, 1984; Webster-Stratton, Hollingsworth, & Kolpacoff,
1989).
Parents of children ages 6-13 who are socially aggressive (teasing, hit-
ting, noncompliant) or out of control (stealing, lying, truancy, fire-setting) can
be shown how to help their children through combined problem-solving and
parent management training or structural family therapy. Families are typically
counseled, in Spanish or English, individually in a clinic or home setting, once
a week for 4-6 months. Children improve in both external (problem behavior)
and internal (anxiety, depression) ways. Parents become less stressed and
depressed, and family functioning improves. These reductions in risk factors
and improvements in protective factors last at least 1 year (Kazdin, Siegel, &
Bass, 1992; Little & Kelley, 1989; Patterson, Reid, Jones, & Conger, 1975;
Szapocznik et al., 1989).
When adolescents display behavior problems, such as poor impulse con-
trol and the overactivity of attention-deficit hyperactivity disorder (ADHD),
early substance use or abuse, first arrests, or more serious placements in foster
homes or jail, parents can help their children reduce problems through partici-
pation in family communication and problem-solving training, Functional
Family Therapy, Multisystemic Family Therapy, or Strategic Family Therapy.
In repeated experiments with random assignment of cases, 8-15 family coun-
seling sessions, conducted according to one of the above methods, produced
less family conflict, fewer internalizing and externalizing symptoms in the
adolescent, less depression in the parents, less substance use, fewer new arrests,
fewer placements in foster homes, better marital relations, and fewer arrests
over time in younger siblings than did other methods of treatment or no
treatment (Barkley, Guevremont, Anastopoulos, & Fletcher, 1992; Barton,
68 BRENNA H. BRY
Alexander, Turner, & Warburton, 1985; Henggeler, Rodick, Borduin, Hanson,

Watson, & Urey, 1986; Klein, Alexander, & Parsons, 1977; Szapocznik, Kur-
tines, Foote, Perez-Vidal, & Hervis, 1983). Methods have been developed to
engage reluctant family members in treatment. In an experiment testing those
methods, Szapocznik, Perez-Vidal, Brickman, Foote, Santisteban, and Hervis
(1988) randomly assigned families who called to get treatment for a drug-using
adolescent to either (1) the usual methods clinics use to engage families in
treatment or (2) a more active engagement method. Whereas only 42.3% of the
families who called for help came to the intake appointment under the usual
engagement methods, 92.9% of the families came under the more active
engagement methods.
Effective methods have also been developed to help families improve
their children's school performance. Rodick and Henggeler (1980) experimen-
tally tested Rev. Jesse Jackson's "PUSH for Excellence" program. The lowest-
achieving seventh graders in a predominantly African-American inner-city
school were assigned at random to 10 weeks of PUSH or to one of three other
programs. In the PUSH program, trained graduate students oriented the parents
in their homes to spend 1 hour per weeknight working with their children on
homework and praising successes. Every parent approached participated. The
graduate student phoned each week and visited every other week to support the
parents' efforts and to answer questions. While academic performance and
enthusiasm for school waned in the seventh graders assigned to the other
programs, the students whose parents had been trained in the PUSH program
improved in both performance and motivation during the program and were
continuing to improve 6 months after the program was over.
In our research, we arranged for lower- and middle-class seventh and
eighth graders with both academic and behavior problems to have a teacher in
school show special individual interest in their overall accomplishments each
day. Then behavioral family therapists approached a randomly chosen half of
the students' parents and arranged a family meeting to discuss how the family
and the school could work together so that their children could do better in
school. Eighty-eight percent of the approached families agreed to the family
meeting. After those families saw the advantages of working with the behav-
ioral family therapists to improve their positive influence on their child's
behavior, 100% of them continued meeting with the therapist weekly, either in
their homes or at the school, for a 3-4 month period. Three booster sessions in
person or over the telephone followed over the subsequent 6 months. Com-
pared with the students who received only the special attention from a teacher,
the students whose families also received behavioral family therapy signifi-
cantly improved their grades and used drugs and alcohol significantly less over
a 2-year period (Krinsley, 1991). Thus, relatively short school-family partner-

ship programs can lead to entirely different trajectories ih people's lives.
When children's problems reappear or persist after parent education or
after family therapy, then more preventive intervention is needed. Parents
whose children do not maintain gains from family therapy are often socially
isolated and subject to many insurmountable daily hassles (Dumas & Wahler,
1983). Wahler and Dumas (1987) found experimentally that weekly follow-up
sessions with isolated parents to discuss the everyday hassles that affect their
perceptions of their child's behavior reduced (1) the number of times mothers
criticized their children, (2) the number of times children responded to their
mothers negatively, and (3) the number of child problem behaviors. Once the
weekly discussions stopped, however, the negative interactions between the
child and parent resumed.
Project 12-Ways (Lutzker, 1984) is a more comprehensive program for
low socioeconomic status parents whom Child Protective Services feels are at
high risk for child abuse or neglect. Meetings with parents are held in their
homes. Treatment goals are developed and, as needed, behavioral training is
given and learning is monitored in stress reduction, assertiveness, self-control,
leisure time planning, marital counseling, and job finding. Social support
groups, alcohol treatment referrals, homemakers, physicians, and mental health
workers are also involved. The program lasts 5-6 months, and parent compli-
ance and involvement in the program are high. Results show that over the
subsequent 20 months, lO% of a nonprogram comparison group abused or
neglected their children, while only 2% of Project 12-Ways parents did.
Crisis intervention for families on the verge of having their children
placed in foster care, a group home, or a psychiatric hospital is provided by
Homebuilders (Kinney, Haapala, & Booth, 1991). In most cases, if a home can
be made safe for a child, children develop with significantly fewer behavioral
and academic problems (and thus less substance abuse) if they are raised at
home by their own parent (Rutter, 1979). Thus, when a family in crisis is
referred to Homebuilders, a counselor with only one or two other cases be-
comes available 24 hours a day, 7 days a week, for about 6 weeks to meet with
the family whenever necessary in their home, help them out of the crisis, and
retain the child at home. Because families in crisis cannot usually articulate
well what services they need, a set of cards with questions and basic needs
listed (heat, clothing, truancy, pain management) is given to parents and
children to sort during assessment sessions (J. Kinney, personal communica-
tion, February 4,1993). Then the counselor helps parents take one problem at a
time toward resolution, teaching coping skills and connecting the parent with
ongoing community resources along the way.
70 BRENNA H. BRY
Homebuilder family preservation programs have been implemented in

many states and communities, including Washington State, Utah, and the
Bronx, New York. Whereas out-of-home placement is imminent at the begin-
ning of every case, from 73-91% of the families served are still together at the
end of 12 months (Kinney, Haapala, & Booth, 1991). Client satisfaction is very
high. Besides the human benefits, the cost savings can be notable. The cost per
child of providing families with the Homebuilders program is only $2700. That
is substantially less than the $7813 for foster care, $22,373 for group home
care, or $102,900 per year for long-term psychiatric care.
After Homebuilders, which is a 6-week crisis intervention program, many
families, particularly those with substance abuse problems, need continuing
help for a while longer. Thus, most Homebuilder families must subsequently be
linked up with longer-term community follow-up programs. With such follow-
up, Homebuilders' family preservation programs can enable many parents to
reduce substance abuse risk factors for their children.
SUMMARY AND RECOMMENDATIONS
Policy makers no longer need ask, as they did 20 years ago, if substance
abuse can be prevented. By now, repeated studies have shown not only that
individuals with substance abuse risk factors can be identified before they
abuse substances, but also that preventative interventions can reduce those risk
factors. Furthermore, recent studies indicate that reducing those risk factors
indeed lowers substance abuse.
The question for policy makers now, however, is whether or not extant
knowledge will be applied. Some communities have instituted, in uncoordi-
nated ways, several of the above methods for enhancing protective factors or
reducing risk factors. A few communities have excellent "Comer schools." A
few communities have outstanding Homebuilders family preservation. Some
communities have superior court-related family crisis intervention units or
school-based mental health services. Others have state-of-the-science parent
training and support services integrated with first-class preschool education.
Seldom, if ever, however, is there a coordinated, community-based effort, on a
family-by-family basis over an extended period of time, to help parents en-
hance protective factors and address risk factors for their children.
Our nation's social policy should make children its highest priority. Then
communities will support parents more systematically so that they, in turn, can
take better care of their children. Children are now innocent victims of a myth
that the modern family can raise them alone. In reality, contemporary families
are finding it more and more difficult to meet this expectation.
Monitoring children sufficiently enough to acknowledge good behavior

and give feedback where improvement is needed is difficult enough to do in
two-parent families with just one wage-earner and extended family at hand. It
is virtually impossible for poverty-level, single parents, or for two wage-earner
families without supportive services from extended families or surrogate parents.
If our nation really wants to prevent substance abuse before it begins,
communities must deliver extensions and supplements to families so that they
can consistently provide incentives to guide their members away from attrac-
tive risky activities, such as substance use, and toward attractive prosocial
activities, such as the arts,jobs, or sports. Healthy human development requires
that families have adequate pleasant time together to influence each other
positively. Any prevention, early intervention, or treatment programs, there-
fore, should work through, rather than bypass, an individual's family. The
conditions of people's lives, their ability to meet their potential, and their future
prospects are greatly determined by the state of their family life.
Every community should have family advocates who routinely help par-
ents of high-risk children obtain resources that enhance their children's protec-
tive factors and reduce their risk factors. Family advocates should be prevention-
oriented service providers who are experts on normal development, cultural
diversity, clinical syndromes, local prevention and treatment programs, and
interviewing techniques that help families problem solve and make decisions
among options for their children (e.g., Miller & Rollnick, 1991; Robin & Foster,
1989). The advocates could visit parents at home and begin helping parents
whenever protective factors are incomplete or risk factors are present.
A medical center-based family advocate could initially approach parents
and offer help when a baby is born or when a negative life event occurs, such as
a serious parental illness. The original advocate would then help the parents
provide protective factors and reduce risk factors for all of their children until
they reach school. If risk factors are present or protective factors are incomplete
after that, a school-based family advocate could offer parents preventive help
throughout their children's schooling and until they are settled in a career, the
service, or at college. Progress could be monitored by assessing protective and
risk factors.
Family advocate services and participation in any of the previously de-
scribed prevention programs should be paid for by universal health insurance.
Need for services can be justified in terms of protective and risk factors. Since
substance abuse rehabilitation and the treatment of related medical and mental
health problems in the whole family are very costly healthcare expenditures,
covering substance abuse prevention efforts with healthcare insurance should
eventually lower healthcare costs because less substance abuse rehabilitation
will be required.
72 BRENNA H. BRY
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CHAPTER 4
Drug Abuse, Drug Treatment,

and Public Policy
SHARON M. HALL, H. WESTLEY CLARK,

and KAREN LEA SEES
This chapter examines research and ongoing discussion in five areas of drug
abuse treatment. In keeping with the theme of this book, we focus on psycho-
logical topics and analyses of drug abuse treatment and related policy. We
discuss (1) contingency management, (2) skill training, (3) the provision of
psychological services in methadone treatment, (4) psychological issues in-
volved in different methadone treatment modalities, and (5) psychopharmacol-
ogy, specifically the psychopharmacological treatment of cocaine abuse.
The areas selected meet two criteria. First, each has a substantial body of
empirical literature available upon which to formulate policy. Second, data
from each area suggest policy directions or provides fuel for an ongoing
controversy about drug policy. These areas also allow us to address somewhat
different policy issues that are drug treatment related. In the case of contin-
gency management and skill training, the primary policy issue is the extent to
encourage adoption of these methods in the field, and how to do so. With
methadone treatment, questions of optimal service delivery and patient-
treatment matching can be discussed and the outcome of these discussions
SHARON M. HALL, H. WESTLEY CLARK, and KAREN LEA SEES· University of California at
San Francisco and Veterans Administration Medical Center. San Francisco, California 94121.
Drug Policy and Human Nature: Psychological Perspectives on the Prevention. Management, and
Treatment of Illicit Drug Abuse, edited by Warren K. Bickel and Richard 1. DeGrandpre. Plenum
77
78 SHARON M. HALL et al.
incorporated into policy formulation. Pharmacotherapy for cocaine depen-

dence raises another issue: the place of continued research in an area when the
success of the venture is unclear, but the need is great.
CONTINGENCY MANAGEMENT
Traditional Contingency Systems
Contingency management is an incentive system that relies on either

positive or negative contingencies. Positive contingencies focus on reinforcing
desirable behavior, such as drug abstinence. Negative contingencies use pun-
ishments to decrease the rate of undesirable behavior. The two systems are
often combined.
Several seminal contingency contracting studies were completed by
Stitzer's group in methadone maintenance treatment, using reinforcers intrinsic
to the program, such as dose alterations and take-home doses of methadone (for
example Stitzer, Bickel, Bigelow, & Liebson, 1986). Other studies by this
group have relied on monetary payment. Earlier studies (Stitzer & Bigelow,
1978) often used small samples, relied on payment of relatively large amounts
of money, and used relatively short test periods. These features of the experi-
ments called into question the generalizability of the technique, despite its
obvious success in controlling illicit drug use.
Recent studies, however, have emphasized more clinically useful contin-
gencies. For example, Stitzer, Iguchi, and Felch (1992) randomly assigned
subjects in methadone maintenance treatment to receive either contingent take-
home doses-contingent on urine specimen free of illicit drugs-or take-home
doses free of any behavioral contingencies. Under the contingent procedure,
four times as many subjects reduced their illicit drug use as under the noncon-
tingent procedure. The positive results were then replicated in control condi-
tion subjects who received contingent take-home doses during a second phase
of the study. Stitzer and coworkers noted that the procedure was more success-
ful with subjects with less severe drug-use problems at baseline (Stitzer et aI.,
1992). The specific drugs abused before treatment did not affect the outcome.
An important feature of Stitzer's work was the successful use of take-
home methadone as a behavioral reinforcer. The cost-benefit ratio of using
monetary reinforcement may favor contingency contracting over traditional
treatment, although this remains to be demonstrated empirically. It follows
logic all y that use of reinforcers intrinsic to the treatment program, such as take-
home methadone doses, may be even more cost-effective. Second, the 6-month
DRUG ABUSE, DRUG TREATMENT, AND PUBLIC POLICY 79
period of treatment used in this study indicated that the effects were persistent.
Stitzer et al. (1992) pinpointed light drug users as especially susceptible to
positive contingencies. This correlational finding is a first step toward the goal
of patient-treatment matching. The question needs more exploration, however,
since it is possible that subjects wiih less severe drug use problems have better
outcomes with any treatment. Given the diversity of drug treatment patients,
patient-treatment matching is an important way to advance clinical efforts
(McLellan & Alterman, 1991). Studies to delineate those patients who do well
on contingency management and, of still greater importance, to develop alter-
native treatments for those who do not are important and needed.
In contrast, the evidence for negative contingencies is not strong. Nolimal
and Crowley (1990) reviewed the outcome of 14 methadone maintenance
patients who were offered a choice of an administrative discharge or a negative
reinforcement dose decrease contract. Favorable effects occurred early in
treatment but weakened over time. The authors suggest that the lack of endur-
ing effectiveness may have reflected the counselors' failure to apply contingen-
cies. There is, then, the possibility that a major barrier to transferring this
technology from the research setting to the community clinic may be inade-
quate staff training and patient monitoring. Others, including Iguchi, Stitzer,
Bigelow, and Liebson (1988), have studied negative contingencies and found
them generally ineffective at best, or at worst, conducive to increased treatment
drop-out rates (Stitzer et aI., 1986).
In summary, recent research has advanced our understanding of how
contingencies can be more effectively used in the management of methadone
maintenance clients who continue to abuse drugs. Positive contingencies ap-
pear useful. By contrast, there is little evidence to support the effectiveness of
employing negative contingencies, for example, forced detoxification for con-
tinuing illicit drug use. Because detoxification often means a return to needle
sharing, the increased risk of HIV and hepatitis Band C transmission also
argues against detoxification. Nevertheless, negative contingencies continue to
be widely used.
Community Reinforcement Approaches (CRA) to Contingency

Management
In most treatment settings, behavioral procedures are combined in a

multicomponent treatment program. One of the most promising procedures
was developed originally to treat alcoholics (Sisson & Azrin, 1989). Called a
"community reinforcement approach" (CRA), the program is based on the
concept that reinforcement for positive behaviors begins with the treatment
clinic, but then must be transferred to the clients' more usual (community)
environment. Higgins and colleagues have studied a multi component treatment
for cocaine abuse based on this model (Higgins et ai., 1991). The program
consisted of tangible reinforcers purchased through funds earned by clients for
having had cocaine-free urine samples; behaviorally based family, employ-
ment, and recreational counseling was also included. As noted, although the
initial reinforcement comes from the clinic, the overall program goal was to
increase the subject's ability to obtain non drug-related reinforcement from the
community.
In an early study by this group (Higgins et ai., 1991),13 subjects admitted
consecutively to the clinic were treated using these procedures. Their results
were compared with those of 15 other subjects treated by a traditional l2-Step
counseling approach. All the subjects who were offered the behavioral counsel-
ing accepted, whereas only 12 of the 15 (80%) offered the 12-Step program
accepted. Also, 11 of the 13 behavioral subjects (85%) and 5 of the l2-Step
subjects (42%) in standard treatment remained in treatment for 12 weeks.
Although 23% of the subjects in the behavioral program achieved 3 months of
continuous abstinence, none of those in the l2-Step program did. These results
were then replicated (Higgins, Budney, Bickel, Hughes, Foerg, & Badger,
1993) when subjects were randomly assigned to both treatments. Recent re-
search has reaffirmed the importance of the incentive component of the treat-
ment in producing abstinence (Higgins, Budney, Bickel, Foerg, Donham, &
Badger, 1994).
Higgins, Budney, Bickel, and Ogden (1994) presented preliminary data on
outcomes at 6, 9, and 12 months in 39 cocaine treatment subjects who partici-
pated in the Vermont community reinforcement program. Scores on the Addic-
tion Severity Index (AS!) showed improvements from baseline that were
maintained during follow-up. The preliminary data presented by these investi-
gators indicated that the percent of urine specimens that were cocaine-free
increased from 46% at baseline to 77% at 12 months. These results suggest that
initial clinical improvements observed are maintained after treatment entry and
further suggest that this behavioral approach has promise as an effective
outpatient treatment for cocaine dependence.
Initial contingency contracting work was completed in a largely rural
area; subjects were mostly Caucasian males. Thus, generalizability has been an
issue. A preliminary report by Silverman, Brooner, Montoya, Schuster, and
Preston (1995), however, indicated that contingency management could be
used to increase the number of cocaine-free urines in subjects who abused
cocaine and who were recruited from inner-city methadone maintenance pro-
grams. Subjects were randomly assigned to receive either contingent rein-
forcers (up to $1155) over 12 weeks or "yoked" vouchers. In the "yoked"

voucher condition, subjects received the same reinforcers noncontingently.
Contingent subjects achieved significantly longer durations of sustained absti-
nence than the "yoked" controls.
Similar promising preliminary results from a study by Tusel et al. (1995)
support the findings of Higgins' group and those of Silverman and colleagues
(in press) and suggest that successful outcomes can be obtained with less costly
reinforcer schedules. One hundred inner-city subjects enrolled in 180-day
methadone detoxification treatment were randomly assigned to either positive
contingent reinforcement or usual care. Up to $755 in cash credits could be
earned for urines that were free of all illicit drugs and for negative breathalyzer
readings. Statistically significant differences were found in sustained absti-
nence in the contingency contracting condition for a mean cost of only $145 per
subject.
Adoption of Contingency Systems
The failure of community clinics to implement positive contingency

management procedures, in light of the years of positive findings, has long
been a disappointment to those who are convinced of their effectiveness. If
these procedures are so simple and effective, why are they not widely used?
One reason is philosophical. Two models have dominated drug treatment in
this country, and neither is philosophically congruent with positive contin-
gency reinforcement or many other innovative techniques. The first is the
medical model, which proposes that drug addiction is a disease; the second,
less clearly articulated, is the moral model, which proposes that drug addiction
is a failure of will and is morally wrong. Contingencies are superfluous to the
medical model, which suggests that adequate biological therapy and profes-
sional psychological and social supports are necessary and sufficient to pro-
duce a successful outcome. Positive contingencies are seen as morally repug-
nant to those who hold a moral model, since the choice to use or not use drugs is
based on one's free will, and "bribing" drug treatment patients to make that
choice is, at best, a temporary solution. Negative contingencies, on the other
hand, are seen as acceptable as just retribution for "bad" behavior to those who
hold a moral model and thus are more widely used; the notion of punishment as
an appropriate response to moral failure has widespread support. There is also
concern that the provision of external reinforcers will not lead to internalized
changes and that, when the reinforcers are no longer available, the new behav-
ior will no longer be performed. Ironically, this is precisely what one would
expect from a classical interpretation of the Law of Effect. On the other hand, it
can be argued, nonaddicts' behavior is controlled by a system of material

reinforcers and punishers, including salaries, fines, and taxes. These sources of
control continue effectively throughout their lives. Addicts' behavior can be
influenced by the same forces, and those influences can be gradually trans-
ferred to contingency systems that manage mainstream society. Designing
long-term contingency systems, or systems that gradually transfer control to
the natural environment, is possible.
No matter what models professionals accept, however, we must recognize
that the moral model pervades much of public thinking about drug abuse and,
lacking a major education campaign, will continue to do so. Disability pay-
ments to drug abusers are an example. At least some segment of the public
believes that the social security disability system encourages drug abuse. In
August of 1994, the U.S. Congress passed a law, Public Law 103-296 (Section
201), which imposed new requirements and restrictions on individuals whose
drug addiction or alcoholism was a material contributing factor to their disabil-
ity status. These new limitations included, among other things, (1) paying the
benefits to a representative payee of the disabled individual, (2) a preference for
organizational payees over individual payees, (3) requiring disability recipients
of either social security or Supplemental Security Income (SSI) to undergo
appropriate treatment where available, (4) a 3-year limit on the payment of
benefits beginning with the March 1995 payment month, (5) suspending bene-
fits for months in which there is a failure to comply with treatment, (6)
terminating benefits after 12 consecutive months of suspension for noncom-
pliance, (7) monitoring and testing of individuals to assure compliance, and (8)
paying past-due benefits in installments. As a result of that new law, the Social
Security Administration promulgated new regulations (currently an interim
final rule) consistent with the new federal law. The intended objective of
limiting access to disability payments is to force the drug abuser to engage in
substance treatment. The underlying, and perhaps overly optimistic, assump-
tion is that the drug abuse treatment system, as it is currently configured, can
meet the needs of every potential patient who presents, and failure to change
rests in the shortcomings of the patient, not in the inadequacies of the treatment
provided.
Reaction to the use of positive contingencies in the field of prenatal care is
illustrative for the field of drug abuse treatment. The Prudential Health Care
Plan of Baltimore offers pregnant women patients $10 for each kept appoint-
ment (Kolata, 1994). These appointments include a visit to the doctor and
sessions on nutrition, smoking, and drug abuse. This plan serves a medicaid
population of 45,000, including 1500 women a year in its prenatal program,
paying about $6000 a month. Before the implementation of the positive contin-
gency, approximately 40% of the women kept their appointments; after the
plan was instituted in 1991, the kept appointment rate increased to between 80
and 90%. Critics are reported to have objected on moral grounds. Dr. Uwe
Reinhardt, a health economist at Princeton University, was quoted as saying,
"It's a sad commentary that we have to pay people to do what they should be
doing anyway." (Kolata, 1994)
There was no external pressure imposed on the Prudential Health Care
Plan. There was the internal pressure of altering the behavior of the 1500
women in its prenatal program. As a service provider and third-party payer, the
plan made the decision that $72,000 in incentives were worth the benefit,
despite the ethical arguments. Consequently, while it is recognized that posi-
tive contingencies can be controversial, it must also be recognized that when
they work, they can be balanced against competing public policy interests.
On the other hand, encouraging use of positive contingency systems may
be sound public policy, but these systems will only be implemented if the
treatment community finds it acceptable. The drug abuse treatment commu-
nity, like other providers of physical or mental health services, is under scrutiny
for its claims. The larger society is demanding accountability and evidence of
efficacy and effectiveness-and cost-effectiveness. The rallying cry of the
substance abuse treatment community, "Treatment Works," is insufficient to
meet the demand to curtail the rising costs of healthcare treatment system.
When treatment works, the policy question is, "Can it work more cheaply?"
Contingency systems may be a cost-effective answer, and if cost effectiveness
is demonstrated, healthcare reform forces may well overcome objections based
on more abstract issues.
Systems and Innovations: Contingencies as a Model
The slowness to adopt positive contingency systems may be a metaphor

for the adoption of treatment techniques that have been found effective by
substantial research. Treatment techniques that are not congruent with the
world view of service providers will not be picked up on ethical or political
grounds. Conflicts of attitude should be taken into consideration but must not
be impassable barriers that impede the ability of the larger substance abuse
research and treatment community to establish new treatments.
Those agencies within federal, state, and local governments concerned
with the public health providers of substance abuse services may well be
advised to adopt other methods to encourage drug treatment providers to use
new methods. The philosophical and ethical barriers to accepting positive
contingency systems will have to be addressed directly. Then, the techniques
that make positive contingency systems work can be transmitted to the com-
munity of substance abuse providers. Public funding agencies should pro-

vide incentives to encourage the adoption of effective treatment strategies.
Third-party payors should also provide incentives for more effective treatment
programs.
The dissemination of information about effective therapeutic approaches
should be a priority for both governmental and nongovernmental funding
agencies. Mobilizing clinical "opinion leaders" in the drug treatment field to
use the techniques in their programs would be an important step. Assisting
these "opinion leaders" with training resources to ensure the uncomplicated
adoption of the techniques would be critical. Opinion leaders might talk about
their experiences to other clinicians, thereby assisting in the acceptance of the
new techniques. Depending on the goals and objectives of the specific treat-
ment system, new techniques and new models of treatment may be accepted by
treatment programs with minimal incentives for implementation. Funding
agencies might provide clinics with incentives that have minimal monetary
impact. These could include relaxing of requirements around record keeping,
staffing patterns, and documentation.
SKILL TRAINING
Skill Training and Illicit Drugs
Skill-training programs are based on the assumptions that drug abusers

lack the necessary social and interpersonal skills to avoid drug use and to cope
with relapse, and they lack other skills, such as social assertiveness, that
nondrug users possess. Hawkins, Catalano, Gillmore, and Wells (1989) have
consistently found that coping skills can be taught and that the newly acquired
ability generalizes from the training situation to new situations. The extent of
the impact on drug use, however, is not so clear. For example, in one study by
this group, clients in the reentry phase of a residential drug treatment program
were randomly assigned to a control group or to a lO-week behavioral skill-
training course focusing on coping with high-risk situations. A role-play test to
assess the subject's skill levels was administered before and immediately after
treatment and again 6 and 12 months after treatment. There was evidence that
the new skills were learned successfully and generalized to situations in which
subjects had not been specifically trained. Use of most illicit drugs, except for
marijuana and amphetamines, did not decrease after treatment.
A similar program has been developed for adolescents (Haggerty, Wells,
Jenson, Catalano, & Hawkins, 1989). These investigators found that drug-
specific skills (drug and alcohol avoidance, relapse coping, and consequential
thinking) were correlated with self-reported drug use 6 months later (Wells et
ai., 1989). Among those persons who relapsed, both drug-specific and general
coping skills predicted their length of abstinence.
Promising results closely linked to actual drug use were reported in an
outpatient study with cocaine abusers (Carroll, Rounsaville, & Gawin, 1991).
Forty-two outpatients were randomly assigned to a behaviorally based preven-
tion skill-training treatment described by Carroll, Rounsaville, and Keller
(1991) or to interpersonal therapy. Although differences were not statistically
significant, subjects assigned to the relapse prevention skill training were
significantly more likely to have 3 or more weeks of continuous abstinence, to
be classified as "recovered" at termination, and to complete treatment. When
the sample was partitioned by level of drug abuse, subjects with more severe
drug use who received relapse prevention skill training were more likely to
achieve abstinence and to be classified as recovered. Among subjects with less
severe problems, there were no significant differences.
In a second study (Carroll et at., 1994), subjects were assigned to one of
four conditions in a 2 (desipramine versus placebo) times 2 (relapse prevention
skill training versus clinical management) design. The treatment period was 12
weeks; baseline severity of use interacted with both psychotherapy and medi-
cation. Subjects with more severe use patterns had significantly better out-
comes when treated with relapse prevention than clinical management. It was
also noted that depressed subjects had better response to relapse prevention
than to clinical management.
Coping skills can be taught, can endure, and can be generalized. The
strength of effects on actual drug use are variable, although the reasons for this
are unknown. The populations studied have been variable, as have been the
personnel implementing the techniques, the format of the presentations, and
the treatment content. Treatment content appears to be an especially important
area on which to focus.
Skill Training in the Treatment of Nicotine Dependence:

"Natural" Dissemination of Techniques
Considerations about the use of skill training in drug treatment in the

wider community, and the extent to which its use should be encouraged and
expanded, presents a different set of problems than those encountered when
considering contingency management. First, the data are not nearly so convinc-
ing as they are with contingency management. Second, the technique is not so
easily exportable as is contingency management. Most studies have been done
using professional or intensively trained providers. Both the training and the
employment of trained staff are costly; hence, the expenses incurred in imple-
menting these techniques may be well be great, especially in programs with
few staff, or primarily paraprofessional staff. In many ways, these issues render
skill training more typical of the usual dilemma faced by the treatment re-
searcher who is attempting to help policy makers formulate recommendations
for treatment. In the case of mixed, but generally positive, results and a more or
less expensive treatment, we are faced with a conundrum: Should the treatment
research field advocate for these techniques or not? A similar situation existed
10 years ago in the field of smoking cessation. Without any encouragement,
skill-training techniques have filtered into smoking cessation programs. Their
effectiveness in this setting, however, is not known. It is unclear the extent that
the techniques used in community-based groups run by lay leaders are the same
as those employed in experimental clinics by doctoral level personnel. If the
resemblance is good, it would be serendipitous, since few materials exist to
teach smoking group leaders the techniques. Given the opportunity to be
systematic, we believe it would be best ifthe haphazard diffusion of techniques
did not once again occur. If what is useful about skill training is to survive in the
field at all, some organized effort, even if it is a low-key effort, must be made to
disseminate it properly.
With this in mind, we offer the following recommendations. First, at this
time we do not advocate that a great deal of time and effort be spent to
encourage skill training as a tool for prevention of relapse to drug abuse, nor do
we advocate encouraging drug treatment programs to budget for individuals
qualified to provide it or for extensive staff training. On the other hand, it is
sensible to develop and disseminate training programs that provide existing
staff with information about skill training and that fully discuss effective and
ineffective ways to implement skill training. Thus, we advocate that some
resources be expended to disseminate skill-training interventions, but they
need not be great. Such a low-cost, "middle-ground" approach might help
improve the quality of the gradual diffusion of these techniques that will,
inevitably, take place.
PHARMACOTHERAPY
Pharmacotherapy can play at least four roles in the treatment of drug

dependence: (1) as a maintenance or replacement strategy, as is the case with
methadone for opioid dependence; (2) as an adjunctive treatment to eliminate
withdrawal symptoms, including the more illusive symptoms such as craving;
(3) as an antagonist that reduces or eliminates the reinforcing properties of the
abused drugs; and (4) as an aversive stimulus that is automatically evoked upon
consumption of the problem drug (for example, disulfiram in alcohol treatment).
Here, we focus on the first two areas: methadone, a maintenance strategy,

and pharmacological adjuncts to treat cocaine withdrawal. Three medication-
related areas present interesting policy issues. These are: (1) the addition of
psychological interventions to methadone treatment, (2) the length and goals of
methadone treatment, and (3) the development of pharmacological treatments
for cocaine dependence.
Methadone Treatment
Opioids and nicotine are the only drugs of abuse for which a maintenance
treatment is available. For over 30 years, methadone, a synthetic and effective
opioid drug, has been widely used as a maintenance medication. Data from
Dole and Nyswander's original program (1965) were impressive. The program,
which provided an array of psychosocial services to presumably well-motivated
opioid addicts, produced important findings that led to the development of a
countrywide system of clinics. Current practices in methadone treatment differ
from those in Dole and Nyswander's original program, however. They include
less frequent urine monitoring, fewer psychosocial services, and less frequent
use of disciplinary detoxification due to fear of the spread of HIV should
patients increase injection drug use rates after leaving maintenance. Recent
studies have indicated high use rates of both cocaine and opioids in some
methadone maintenance and detoxification patients (United States General
Accounting Office, 1990).
These less than optimal treatment outcomes have raised several core
questions about the provision of methadone (Vocci & Wright, 1993) as well as
suggestions for innovation. These are (1) the contribution of psychosocial
services provided, (2) the goals of methadone treatment and the length of
treatment, and (3) matching of patients to variants of methadone treatment, a
discussion that is best typified by the selection of suitable medical maintenance
for long-term, well-functioning patients or by the decision about the appro-
priateness of detoxification versus maintenance for some subsets of patients.
These issues are couched in a context of change; many in the field expect
buprenorphine to replace methadone as the drug of choice for the treatment of
opiate addiction in the near future. Still, issues of psychosocial services and
goals of treatment are unlikely to be removed by the provision of a new
maintenance agent.
The Contribution of Psychosocial Services. Two well-controlled

studies have indicated the benefits of increasing psychosocial services to
increase efficacy in methadone maintenance treatment. McLellan, Arndt,
Metzger, Woody, and O'Brien (1993) compared three levels of psychosocial
services in methadone maintenance treatment. Subjects were randomly as-

signed to one of three treatment groups for a 6-month clinical trial. Conditions
were (1) minimum methadone services, (2) standard methadone services,
which included counseling, and (3) enhanced services. Enhanced services
included counseling and on-site medical, psychiatric, employment, and family
therapy. These investigators found that minimal services were associated with
reduction in opioid use; however, 60% of these subjects were transferred from
this study condition because of continued drug use or medical or psychiatric
emergencies. The parallel percentage in the standard condition was 41 %; in the
enhanced condition, it was 19%. The three treatment conditions showed a dose-
dependent improvement, with the standard treatment improving more than the
minimally treated subjects, and the subjects in the enhanced condition improv-
ing more than both. The investigators concluded that methadone alone, even in
substantial doses, may be effective for only a few patients. The addition of
basic counseling was associated with increases in significant efficacy; the
addition of on-site professional services was even more effective.
A recent study by Sees and colleagues (1994) extended these findings to
long-term (180-day) detoxification. Subjects were randomly assigned to either
high- or low-intensity psychosocial services. In the low-intensity condition,
treatment was the minimum required by federal regulations for 180-day meth-
adone detoxification programs and consisted of a monthly individual counsel-
ing session for treatment plan updating; in the high-intensity condition, treat-
ment was maximized with substance abuse-focused group therapy three times a
week, educational groups twice a week, and a weekly individual counselor
session. Subjects in both conditions attended four orientation classes and were
encouraged to attend 12-Step meetings in the community. During the induction
and stabilization phase, subjects in high-intensity treatment had significantly
fewer opioid-positive urine toxicology screens than subjects in the low-
intensity treatment, but there were no differences in cocaine use rates. Differ-
ences decreased markedly during the taper phase, but overall differences
between the conditions remained significant.
In summary, the evidence available is consistent in suggesting that en-
hanced psychosocial services facilitate outcome in methadone treatment. Fu-
ture work needs to identify what aspects of the psychosocial treatment actually
effect the change. For example, simple increased attention, independent of the
content of services, may enhance methadone treatment. If this is so, economics
argues for use of paraprofessional interventions, such as case management. On
the other hand, some professionally provided services may be helpful while
others may not. A dismantling strategy is needed to better address this question,
where services are sequentially subtracted across treatment conditions to deter-
mine the active components of the more complex intervention. Also, cost-
effectiveness issues will need to be addressed: Psychosocial services require

highly trained personnel and are often labor intensive. Thus, they are expensive
to implement.
The role of psychological services in methadone treatment thus appears
promising and should be encouraged. On the other hand, there are useful
modalities, for specific patients, that involve extremely limited psychosocial
interventions: (1) interim maintenance, (2) medical maintenance, and (3) harm
reduction. Interim maintenance, which is conceptualized as a time-limited
treatment that holds patients until they enter long-term maintenance, is prob-
ably better than no treatment for those patients who seek entrance into mainte-
nance programs, but who cannot get it because of limited resources (Yancovitz
et ai., 1991). On the other end of the spectrum, medical maintenance has been
provided on a limited basis for long-term, well-functioning methadone patients
who are no longer abusing drugs (Novick & Joseph, 1991). The medical
maintenance protocol focuses on dispensing in a physician's office, with mini-
mal counseling and urine testing. Harm reduction is a practical approach to
drug abuse treatment, which minimizes moralistic attitudes and recognizes that
total abstinence is not the only laudable goal. It focuses on reducing the amount
and prevalence of drug use and on changing the risk behaviors of drug users. In
other words, using less decreases risks. Psychological services provided are
minimal (Hartgers, Van den Hoek, Krijnen, & Coutinho, 1992). Thus, despite
the evidence that increased psychological services are beneficial in methadone
treatment, there are some settings, and some patients where "less is (probably)
more" with respect to services. Matching treatments to patients with respect to
psychological services is practical if the spectrum of services is available.
Future research will be needed to refine these matching strategies, but some is
possible even now, based on commonsense and straightforward clinical under-
standing of methadone patients.
Maintenance "versus" Detoxification. While not all investigators

have found benefits from methadone maintenance (for example, Dobbs, 1971),
generally, the literature reports reduced drug abuse and criminality and im-
proved social functioning (eg., Gearing & Schweitzer, 1974; Gunne, 1983;
Simpson, Joe, & Bracy, 1982). In clinical trials comparing methadone mainte-
nance to drug-free psychosocial programs, results overwhelmingly favor meth-
adone, both in treatment retention and in a decrease in illicit opioid use
(Caplehom & Bell, 1991; Caplehom, Bell, Kleinbaum, & Gabski, 1993; Gunne
& Grondbladh, 1981; Newman & Whitehall, 1979). A dose response function is
noted; higher methadone doses further improve outcomes (Johnson, Jaffe, &
Fundala, 1992). Death rates in opioid addicts have been reported to decrease
fivefold to tenfold while on methadone (Vocci & Wright, 1993).
As part of the nationwide survey, Sells (1979) reviewed 44,000 patients

admitted to methadone maintenance; he reported that employment increased
when patients were in treatment, while drug use and criminality decreased.
Similarly, Craddock, Hubbard, Bray, Cavanaugh, and Rachal (1982) found a
decrease in drug use and criminality and an improvement in depression in
12,000 maintenance patients. Recently, Condelli and Dunteman (1993) as-
sessed maintenance patients I year after leaving treatment. Although they
found no difference in heroin use for patients who had been in treatment for less
than 3 months, 3-6 months, 6-9 months, or 9-12 months, the group of patients
who had been in treatment elsewhere in the year since discharge showed a
lower rate of heroin and other drug use. This finding was interpreted as
suggesting benefits from continuity of treatment. Also, the benefits of meth-
adone maintenance may continue after the pharmacological support has ended.
Stimmel, Goldberg, Rotkopf, and Cohen (1977) reported that 35% of mainte-
nance patients were narcotic-free 6 years after voluntarily tapering off meth-
adone; however, the majority of patients (58%) had relapsed. Abstinence was
significantly associated with longer treatment on maintenance. Overall, the
evidence seems to support that, as with nonpharmacological treatments (De-
Leon, 1985; Gottheil, McLellan, & Druley, 1992), treatment outcome is pos-
itively correlated with length of stay in methadone treatment.
Although federal guidelines now allow methadone detoxification to ex-
tend up to 180 days (long-term methadone detoxification treatment; Federal
Register, March 2, 1989, p. 8954), this treatment option is not widely available
throughout the country, and most detoxification treatment episodes are 30 days
or less. The regulations were changed in part due to dissatisfaction with the
treatment outcome from the short-term methadone detoxification treatment.
While the efficacy of short-term methadone detoxification treatment may be
questionable (for example, Gossop, Griffiths, Bradley, & Strang, 1989) and is
associated with low retention and high relapse to opioids (Mann & Feit, 1983;
Resnick, 1983), few studies have been conducted to determine if the 1989
regulation revisions that allow for long-term detoxification treatment will lead
to greater success.
In 1990, our research group at the University of California and the San
Francisco Veterans Affairs Medical Center opened the first methadone detox-
ification treatment clinic to provide 180-day treatment in the country. In the past
4 years the clinic has treated approximately 400 subjects. We suggest that this
modality holds promise, especially for opioid addicts who have never received
methadone treatment, who have only had past short-term detoxification(s), or
who are not interested in long-term maintenance. Our clinical impression
indicates that many addicts entering this treatment modality view methadone
maintenance negatively; they prefer long-term detoxification because it has a

clear end date. At first, subjects view indefinite methadone maintenance as
harmful in a variety of ways. During treatment, however, patients begin to
realize that with methadone treatment, their lives become more manageable.
They begin to view maintenance as a viable alternative to their drug lifestyle.
Also, many use the long-term detoxification treatment as evidence and docu-
mentation of their addiction, as required for methadone maintenance treatment
entrance. We also suggest this treatment modality may hold promise as the
primary modality for selected opioid addicts, such as those with relatively short
histories of addictions, stable living environments, and employment.
Other data suggest some increased benefit to lengthier detoxification. In
1981, Senay, Dorus, and Showalter reported on 72 patients who were randomly
assigned to two different detoxification schedules within a 90-day, double-
blind protocol: either 84 days of methadone detoxification followed by 7 days
of placebo, or 21 days of methadone followed by 69 days of placebo. Subjects
in the 84-day methadone condition stayed in treatment longer (43 days versus
23 days), showed less drug use as measured by urinalysis, exhibited lower
levels of symptoms, and expressed fewer negative feelings about treatment.
Iguchi and Stitzer (1991) also reported decreased opioid use in an extended 90-
day detoxification protocol.
Merely extending the length of the protocol, however, may not be suffi-
cient for improved outcomes. Sorensen, Hargraves, and Weinberg (1982) com-
pared a 21-day detoxification to a 42-day detoxification. They found, at the
6-month follow-up, that an equal proportion of patients in both groups had
returned to previous patterns of drug use. Incorporating a psychological inter-
vention into methadone detoxification treatment may improve benefits achieved
by methadone alone. Rawson, Mann, Tennant, and Clabough (1983), for in-
stance, found that psychotherapeutic counseling led to improved compliance
with medication visits, fewer drop-outs, and an increased rate of transfer to
long-tern treatment, as positive findings generally supported by our recent
study (Sees et al., 1994).
What form of methadone treatment should be encouraged, and for whom,
is not a simple question. Many argue that any treatment other than maintenance
on demand is unethical due to the spread of HIY. Others suggest, as do we, that
alternative forms of treatment need to be at least considered. Certainly, to
prevent the spread of HIV, a goal should be to attract as many patients as
possible into treatment. Providing only methadone maintenance until that day
when it is demonstrated to be unequivocally superior may be counterproduc-
tive. Patient attitude must be considered. Offering a variety of modalities is one
way to engage the maximum number of patients in the treatment system.
Patients who believe that long-term methadone maintenance is harmful may

not enter the methadone treatment system if maintenance is the only available
option. The second is community attitude and resulting restriction. A few
communities will not tolerate maintenance treatment programs largely due to
views about long-term use of a narcotic. Limiting methadone treatment to
maintenance in such communities will mean that no replacement therapy is
available. Lastly, we do not have the data to make sweeping recommendations
about methadone treatment, even for a subset of patients. Neither the appropri-
ate treatment matching studies nor the relevant cost and cost-effectiveness
studies have been completed. These studies need to assess psychosocial vari-
ables such as readiness for change and vocational status as well as basic
demographic variables. As we indicated in the discussion of 180-day detoxi-
fication, patients use treatments of differing length in various ways. These
individual variations in perception are little recognized, but they must be taken
into account.
Cocaine Treatment
Data. The pharmacological treatment of cocaine dependence stands in

marked contrast to that pharmacological treatment of opioid dependence.
Despite a concerted and organized effort, there are currently no widely agreed-
upon, effective treatments for cocaine dependence. Although it seems phar-
macologically possible and would be desirable to develop a maintenance drug
for cocaine dependence, most efforts have focused on the development of
drugs designed to ameliorate craving and the cocaine withdrawal syndrome. A
number of drugs have been studied to treat cocaine withdrawal, but the results,
by and large, have not been promising. The most thoroughly studied has been
desipramine. Early studies by Gawin's group with primary cocaine abusers
were promising (Gawin & Kleber, 1984). Two well-designed studies (Arndt,
Dorozynsky, Woody, McLellan, & O'Brien, 1992) failed to find a difference,
however, between active and placebo-treated groups of methadone-maintenance
subjects who also abused cocaine. Recent controlled trials with primary co-
caine abusers also have failed to find differences between desipramine and
placebo conditions (Hall et at., 1994). Thus, there is scant evidence that
individuals who currently use cocaine are affected by desipramine treatment;
this may be due to changes in the severity of use levels or to route of
administration. Users in the study by Gawin and Kleber (1984) were more
likely to be Caucasian intranasal users as compared to current users, who are
more likely to be African American and to use smokable cocaine (crack).
Other drugs have been investigated, including amantadine (Weddington et
aI., 1991), bromocriptine (Dackis & Gold, 1985), carbidopa-L-dopa (Rosen,

Flemenbaum, & Slater, 1986), imipramine (Rosencran, 1983), lithium (Gawin
& Kleber, 1984), ritalin (Khantzian, Gawin, Kleber, & Riordan, 1984) and
carbamazepine (Halikas, Kuhn, Crea, Carlson, & Crosby, 1992) but none
seems to hold a great deal of promise. Studies by Batki's group, using quantita-
tive measures of cocaine use, found therapeutic effects for ftuoxetine in both
primary cocaine abusers (Batki, Washburn, Manfredi, et al., 1994) and in
cocaine-abusing methadone patients (Batki, Manfredi, Jacob, et aI., 1993).
While they found no difference in abstinence rates, they did find differences in
amounts of cocaine use. On the other hand, Grabowski and colleagues, using
qualitative measures of cocaine, failed to find differences in either population
(Covi et al., 1993; Grabowski, Kirby, Elk, et aI., 1992). The reasons for
differences in findings among these research groups are not clear. Batki has
argued that the use of quantitative urines is the critical factor, since these assays
are better able to detect use differences. Others suggest that decreases in
cocaine use other than total abstinence are not clinically important, since the
user remains in the cocaine-using environment and is likely to return to
pretreatment levels of use once drug administration resumes.
Data and Policy: The Search for a Pharmacological Treatment of Co-

caine. Repeated failures to find pharmacological treatments for cocaine
dependence raises questions about the wisdom of continued emphasis on the
search for pharmacological adjuncts. One wonders if such a large variety of
psychosocial treatments had failed, whether enthusiasm for pursuing them
would not have waned more rapidly than it has for pharmacological ap-
proaches. The disparity is puzzling; it reflects, no doubt, the frequently
held, but less frequently voiced, notion that behavior and environment are
not so "real" as biology, and hence are unlikely to yield truly effective
treatments.
On the other hand, pharmacological treatments offer a great deal to those
who treat drug abusers. It has been assumed (though not demonstrated) that
many cocaine treatment patients, who come from lower socioeconomic status
backgrounds and from non-caucasian ethnic groups, will not respond well to
verbal therapies. Aside from the questionable validity of this argument, given
the propensity of drug abusers for taking drugs and their general level of
pharmacological adventuresomeness, it does seem likely that pharmacological
treatment will attract some patients who would not be attracted by "talk" or
even "reinforcement" therapies. Second, drug treatment can be cost-effective.
It would be foolhardy to recommend that public policy not continue to search
for pharmacological treatments of cocaine dependence. It would seem prudent,
however, not to do so to the exclusion of more innovative approaches.
SUMMARY
In summary, the psychological perspective of this chapter highlights

several different areas of issues in policy analyses and drug treatment. The first
is the sharp contrast between the impressive data available to support the
efficacy of behavioral treatment approaches, especially contingency manage-
ment. Not only is there much data, a substantial part of that data, especially
from Stitzer's laboratory, has been available for almost a decade. Clearly, the
moral overtones that pervade drug treatment have had an effect, as has the
predominance of the medical model in drug treatment. Nevertheless, behavior-
ists must take some of the responsibility for failure of widespread adoption of
these techniques. One of these failures has been an insistence in use of termi-
nology that is foreign to the drug treatment community. A second failure lies in
the characteristics inherent to good scientists that may act against dissemina-
tion, including modesty and skepticism about findings, which may not, how-
ever, be the best characteristics of a good disseminator. Also, psychologists
often come from very different "communities" than do those who provide
most drug treatment. Thus, we may not be the most credible and persuasive
disseminators of our own material.
This chapter also addresses the role of psychological treatments and
patient-treatment matching in methadone treatment. The review of the litera-
ture suggests that psychology has a great deal to contribute to this area, but has
been rather lax in so doing. Psychological knowledge could be especially
effective in informing policy in this area. The extent and quality of psychologi-
cal treatment varies greatly in different methadone treatment programs. Treat-
ment outcome data could inform the healthcare system about what policy
decisions should be made about design of services and training of personnel.
Similarly, several different modalities of methadone treatment are now avail-
able. Patient-treatment matching studies could contribute to empirically-based
policy about use of treatment resources.
Cocaine treatment research remains puzzling. Those advocating energetic
development of psychosocial strategies need to be more energetic, perhaps, in
furthering their agenda.
Interest in healthcare reform has stimulated many discussions about for-
mulation of public policy about drug treatment. Psychological perspectives
have much to contribute on every level.
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CHAPTER 5
Cultural Factors in the

Control, Prevention, and
Treatment of Illicit Drug Use
The Earth lings' Psychoactive Trek
JOSEPH WESTERMEYER
DRUG-ALCOHOL PRODUCTION AND COMMERCE

IN PREHISTORIC AND HISTORICAL CONTEXTS
The Pre-Columbian Era
Prior to AD 1500, drug production proceeded along different lines in the so-
called Old World (Africa, Asia, and Europe) and the New World (for the most
part, North and South America). These two areas did not have regular contact
with one another prior to that time. However, the Old World did experience a
flow of ideas and technologies, albeit a slow one. Likewise. concepts and
technologies flowed consistently, if slowly, across the Americas. Oceania-
Australia, although remote from the Old World landmass, shared common
aspects of Old World substances, such as use of betel (Westermeyer, 1991).
JOSEPH WESTERMEYER· Department of Psychiatry and Anthropology, University of Minne-

sota. Minneapolis. Minnesota 55455.
Treatment ot"lllicit Drug Ahuse, edited by Warren K. Bickel and Richard 1. DeGrandpre. Plenum
99
100 JOSEPH WESTERMEYER
In the Old World prior to 1500, people consumed psychoactive com-

pounds primarily by ingestion; smoking, snuffing, and rectal clysis were un-
known as routes of administration. A few substances-especially alcohol,
opium, cannabis, and betel-were used by millions of people across thousands
of miles. Considerable ingenuity was devoted to obtaining alcohol from div-
erse sources (e.g., from fruits, grains, tubers, and milk) (Sargent 1967; Wolcott,
1974). Techniques also arose for modifying alcoholic beverages in various
ways to alter the concentration of alcohol (e.g., beers, wines, distilled bever-
ages) or the taste (e.g., the addition of herbs, the champagne method). Betel-
areca, a stimulant, was used in areas close to the equator-from the Middle
East, across Southeast Asia, and out to far Oceania (Ahluwalia & Ponnam-
palam, 1968). In more local areas, specific stimulant substances were also used,
i.e., cola nut in Africa, chat or qat leaves around the Red Sea, and kratom leaf in
Southeast Asia (Getahun & Krikorias, 1973).
While these developments were taking place in prehistoric and historic
Afro-Euro-Asia, certain similar but also quite different activities were occur-
ring in the Americas. In addition to simple ingestion of psychoactive com-
pounds, several other routes of administration were discovered (Du Toit, 1977),
including:
• chewing (e.g., coca leaf)
• smoking, via volatilization of the psychoactive compound and inhala-
tion through the lungs (e.g., tobacco, kinnikinnick)
• snuffing, including the use of assistants and blowguns to distribute the
powdered substance
• rectal clysis (Furst & Coe, 1977).
The people of southern North America were familiar with alcohol fermen-
tation. For example, the Papago peoples of the Grand Canyon areas and the
Aztecs of today's Mexico prepared wines and beers (Paredes, 1975; Waddell,
1976). However, peoples of the Americas did not widely practice fermentation;
opium, cannabis, and betel were unknown. Aboriginal Americans were largely
devoted to seeking stimulant and hallucinogenic compounds from roots, barks,
leaves, vines, flowers, mushrooms, and other plant sources. Over 200 such
substances have been identified in North and South America. (DuToit, 1977;
Furst, 1972).
Substance use during this pre-1500 era served similar ends in both the
New World and the Old World. A widespread purpose involved the enhance-
ment of spiritual or religious experiences, ranging from sacramental wine in
some Judeo-Christian sects (Smith, 1965) to use of hallucinations for the Vision
Quest so common in many New World religions (Bergman, 1971). Secular
CONTROL, PREVENTION AND TREATMENT OF DRUG USE 101
celebrations were also occasions for psychoactive substance use (e.g., alcohol,
opium, cannabis, betel, tobacco). Some of these celebrations were societal or
seasonal in nature, such as harvest time or the New Year (Bunzel, 1940). Other
celebrations were more personal, usually marking life cycle events such as
birth, naming, marriage, status change, or death. Psychoactive substance use
often accompanied work. Many of these work-related substances were stimu-
lants, such as coca leaf-chewing in the Andes or betel nut-chewing in Asia
during heavy farming or construction work (Burton-Bradley, 1977; Hanna,
1976; Negrete, 1978). Likewise, alcohol drinking sometimes accompanied
large, scheduled projects involving large groups, such as corvee labor for the
community or a barn raising. People also used psychoactive substances as a
herbal nostrum for illness; opium, alcohol, and cannabis were used for this
purpose in various times and places (Westermeyer, 1988a). Different substance
use patterns among cultural or ethnic neighbors served as a symbolic means for
maintaining cultural separatism and distance (Carstairs, 1954), as well as a
vehicle for permitting limited but necessary communication among disparate
cultures (Health, 1971, Wolcott, 1974).
During this period, individual cases of substance abuse did occur. This
was especially the case for certain highly addictive substances apt to under-
mine the psychosocial competence of the user (e.g., alcohol, opium). Although
our information from the New World is limited, the Aztecs knew about alcohol
abuse and had undertaken measures to prevent it (Paredes, 1975). Likewise,
abuse of alcohol and opiates was known at least by classical Greco-Roman
times, and probably earlier (Terry & Pellens, 1928). Certain religious strictures
began during historical times (Baasher, 1981), apparently due to episodic abuse
with horrendous consequences. For example, the Islamic proscription against
alcohol presumably began because a drunken guard did not alert a sleeping
town to the presence of an enemy-resulting in the sacking and slaughter of
that town. Buddhist monks, nuns, and devout believers should not drink
according to Buddhist precepts, although the origin of these precepts has been
lost in antiquity. Nonetheless, widespread "epidemic" abuse of substances had
not been identified.
The Post-Columbian Era
After AD 1500 the world's first "epidemics" of widespread psychoactive

substance abuse appeared. The first of these was the "Gin Epidemic" in
England, so-called because of the heavy, widespread use of gin beginning in
the 1600s and declining by the 1800s (Rodin, 1981; Thurn, 1978). In addition to
gin, rum from the East Indies, port wine from Spain, and various locally
brewed beverages were also widely consumed. Several factors appeared to
have produced, or at least predated, the Gin Epidemic, as follows:
• Ships carrying manufactured goods traveled first to Canada and then to
the more southernly colonies, selling off their cargo along the way. By
the time they reached the southern mainland and the Caribbean islands,
they required ballast. Raw foodstuffs initially provided this ballast;
later, distilled alcohol (gin, rum) served as ballast, since it brought a
good price on the docks in England.
• Few if any social constraints existed against heavy, even daily, drink-
ing. On the contrary, drinking was viewed as a sign of wealth, as a
desirable end in itself, as a source of nutrition, and as healthy practice.
On-sale taverns near the factories of the time sold beverage alcohol to
workers as their work day began and again when their work day ended.
• The Industrial Revolution was in full swing at the time. Familial,
economic, cultural, and other social changes associated with this revo-
lution may have been conducive to drinking: i.e., the conviviality of
people meeting in taverns (rather than at a church or in a village green),
the use of alcohol as a means of relaxation (rather than storytelling,
singing, hunting, fishing, gardening, or other rural village pastimes), a
new money-based economy that made ready transfer of goods possible
(rather than the old barter system still widely practiced in rural areas).
• Calories obtained through alcohol (i.e., 7 calories per gram) were
cheaper than calories obtained through carbohydrate (4 calories per
gram) or protein (5 calories per gram). This was due to the rising
standard of living in England and to the low cost of labor, including
slave labor, in the colonies and in other countries from which beverage
alcohol was imported.
• Technological advances in ship-making, sail-making, and navigation
made international ocean commerce relatively safe and economical.
Thus, large volumes of alcohol could be moved from one place to
another, even over a great distance, at relatively low cost.
• Political and economic leaders of the time perceived numerous benefits
for the populace from alcohol: i.e., a "reward" for the long hours of
boring labor required by the Industrial Revolution, a low-cost foodstuff,
and a source of "energy" for the work force.
It took several decades before English society began to perceive fully the
social consequences of widespread heavy drinking. During this time, many of
the complications and concomitants of alcoholism were first described-
including fetal alcohol syndrome, which was not "rediscovered" until the
latter half of this century (Rodin, 1981). English efforts aimed at reducing
widespread drinking are listed later in this chapter.
Another substance abuse "epidemic," the "Opium Epidemic," occurred
primarily in Asia (Merrill, 1942; Park, 1899). Some smaller "epidemics" did
occur in other times and places, such as in 19th century England and the United
States; but they were more circumscribed geographically and shorter lasting
(Berridge, 1978; Berridge & Edwards, 1981; Kramer, 1979; Musto, 1973). The
Opium Epidemic in Asia had begun by the 1600s and has persisted in some
parts of Asia up to the present time-over 300 years. It ranged from Japan and
China in the northeast, down through Southeast Asia and the Malay Archi-
pelago, across the Golden Crescent countries of South Asia, to the Middle East
and parts of Europe and Africa. Prior to 1500, opium had been known across
Asia from prehistoric times, i.e., through archeological finds of opium seeds in
prehistoric Turkey, incised opium poppy capsules in the head dresses of
prehistoric Cypriot statues, the hieroglyphics of early Egypt, and the writings
of a Chinese emperor-healer from over 1000 years ago (Terry & Pellens, 1928).
During this time, people consumed opium by eating it. Early writings suggest
that it was used primarily as a medication, rather than socially, although it has
been served socially as an intoxicant in some cultures of Asia (Westermeyer,
1982). An interesting sequence of events, leading eventually to opium smok-
ing, appears to have begun simultaneously in several countries of Asia, from
the Philippines to China. First, tobacco smoking was introduced from the
Americas during the 1500s-largely occurring in shops where smokers con-
gregated. Next, these tobacco emporiums assumed an identity as places of
political sedition, where people gathered to smoke and to discuss the political
issues of the day. Rightly or wrongly, political regimes of the time perceived
them as loci of political unrest, perhaps exaggerated by the effects of this new
and "foreign" substance, tobacco. Subsequently, tobacco shops and even
tobacco itself were outlawed in many places. The next step is not clear, and it
may not have occurred the same way in all places. In one scenario, the smoking
emporiums simply replaced the "foreign devil" of tobacco with opium, a
locally known and socially approved substance. In another scenario, the now-
skilled smokers replaced tobacco smoking with opium smoking in their own
homes. In either or both events, the outcome was increasingly widespread
opium addiction. As with the Gin Epidemic in England, the consequences of
widespread opium addiction were not apparent or widely appreciated for
decades. However, by the 17oos, the nature of the problem for individuals,
families, and societies had become apparent. The records of the English East
India Company, which exported opium from India to China, establish the
steady march of increased opium smoking in China, where it became especially

popular. The volumes of opium consumed grew to phenomenal amounts, by
geometric leaps, throughout the 1700s, 1800s, and early 1900s. Literally centu-
ries of effort to ameliorate or eliminate widespread opium dependence ensued,
including the unsuccessful Opium Wars. These efforts, and with their successes
and failures, are described below.
Despite the severity of these problems in England, much of the Orient, and
certain other places, the entire world did not focus on epidemic substance abuse
until after the mid-20th century. Cameron, a public health physician with the
World Health Organization in Geneva, first described the "pandemic" of
substance abuse (Cameron, 1968). He emphasized a new dimension to this
pandemic different from past epidemics: the involvement of adolescents in
widespread drug abuse.
From 1500 to (almost) AD 2000, several factors have accompanied wide-
spread alcohol and drug abuse in various times and places (Westermeyer,
1988b). These have included:
• Reliable, rapid, and economical means of international trade have con-

tinued to evolve over the past 500 years. These commercial vehicles,
coursing over the ground, through the water, and in the air, have per-
mitted the rapid, low-cost transfer of psychoactive substances-licit
and illicit-from one area to another. The healthful economy of entire
regions depends on this commerce: i.e., Brazil and coffee, the Carolinas
and tobacco, Kentucky and bourbon, the Golden Triangle and opium,
India and tea, France and wine, the Andes and cocaine, several Ameri-
can states and cannabis.
• Through such commerce, societies have had exposure to substances
previously unknown to them. Thus vulnerable, societies have adapted
drug usage forms that appeared initially safe and desirable but have not
always remained so.
• Not only have new drug forms spread around the world, but new
methods of administration have also spread as well. Smoking, snuffing,
and other methods of drug administration-once restricted to the
Americas-have spread widely around the globe. These new methods
of drug administration avoid the "first pass" effect of the liver, which
can metabolize significant amounts of substance before it reaches the
brain. Moreover, smoking, snuffing, chewing, and rectal clysis produce
more rapid onset of drug effect as compared to simply swallowing the
substance. Thus, these other routes of administration can be considered
more "addictogenic" than simply eating or drinking psychoactive sub-
stances.
• Technological advances in drug administration continued in the 19th

century, with development of parenteral injection. Within a decade of
its invention in the mid-1S00s, drug abusers were using parenteral
injection for self-administration of opiates. In the late 1900s, a few
opiate addicts have learned to use highly effective skin patches and
constant intravenous administration to take opioids .
• Purification and concentration of older substances permitted them to be
more easily transported or smuggled and more readily consumed by a
variety of means (including snuffing or injecting). Examples include the
synthesis of morphine and heroin from opium, cocaine from coca leaf,
and tetrahydrocannabinol from cannabis.
• Chemical synthesis has given rise to new psychoactive compounds with
addictive potential. This endeavor, beginning largely in the 1900s, has
led to new synthetic stimulants (e.g., amphetamines), sedatives (e.g.,
barbiturates, benzodiazepines), and opioids (e.g., meperidine, meth-
adone, fentanyl). Volatile inhalants, most of which were not developed
as psychoactive substances, have also become substances of abuse
(Eastwell, 1979; Kaufman, 1975).
In addition to these technological changes, sociocultural changes may
have also played a role. Economic, political, and military suppression of
weaker cultures by stronger ones may have produced vulnerability to wide-
spread substance abuse through the disintegration of the smaller or weaker
culture (Dozier, 1966).
SUBSTANCE USE IN CULTURAL CONTEXT
Culturally Prescribed Substance Use
In many, if not most, cultures, use of specific psychoactive substances at

particular times in prescribed amounts comprises a cultural imperative (West-
ermeyer, 1971). Alcohol is perhaps the most widely "prescribed" drug. How-
ever, cultures may require the use of other substances-primarily stimulants or
hallucinogens-under a variety of circumstances (LaBarre, 1969).
The number of circumstances requiring psychoactive substance use is
finite. One of these is religious celebrations, such as the consumption of wine
as representative of Christ's blood at certain Christian ceremonies (Klausner,
1964). Religious rituals may involve mandatory substance use, such as the
consumption the hallucinogenic mushroom peyote in the Native American
Church (LaBarre, 1969). Life cycle milestones (e.g., birth, naming, marriage,
death) may involve substance use at the family ceremony (Westermeyer. 1971).
Intensification of social relationships may involve mutual intoxication or toast-

ing, such as the change from formal to informal modes of address (e.g., the
"dutsen") in countries of central Europe. Economic or political agreements or
affiliations may be marked by toasting with beverage alcohol in Europe or
smoking the "peace pipe" in American Indian groups.
Culturally Permitted Substance Use (Individual Choice)
Certain substance use may be permitted at the discretion of the individual,

but without a cultural imperative requiring use. However, the society may still
set certain limits to the drug use. For example, the substance may not be
permitted for certain subgroups within the society (e.g., children, adolescents),
or outside of certain specified times (e.g., seasonal celebrations, life cycle
rituals), or in doses beyond a certain limit (Paredes, 1975). These cultural
prescriptions can, and sometimes do, change over time (Sargent, 1967).
The occasions for such use resemble those ceremonial or ritual uses
described above for prescribed or required substance use. For example, partici-
pants at some South Asian marriages may consume betel, opium, or cannabis,
but they are not required to do so. Hosts may provide opium, betel, tobacco, and
perhaps alcohol at certain social and business meetings in Asia, with use or
nonuse decided by the participants (Westermeyer, 1982). Workers may con-
sume a stimulant, such as coca leaf, coffee, tea, tobacco, or betel, in order to
persist in boring, repetitive, fatiguing, or lengthy work, such as heavy agri-
cultural or corvee labor (Negrete, 1978). Or they may consume alcohol or an
opiate before engaging in painful, dangerous, lonely, distressing, or discom-
forting work, such as prostitution or stevedoring (Westermeyer, 1974). Like-
wise, individuals may consume psychoactive substances for a variety of per-
sonal reasons. Examples include, but are not limited to, relaxation, enhancing
the taste of food, contributing to social activities, facilitating sexual expression,
inducing sleep, or relieving mental and emotional symptoms such as irrational
fears or panic attacks (Westermeyer, 1983).
The form in which a substance is consumed can affect its status as a
"required" versus a "permitted" substance. For example, a group may require
adherents to toast with and sip champagne during a ceremony, while allowing
wine or beer to be taken for individual purposes. Many American Indians
would consume tobacco with a ceremonial pipe only under special social
conditions, but they might consume tobacco in nonritual forms, such as ciga-
rettes, on their own whim. Papago people drink a beverage alcohol that they
prepared themselves in moderate doses on social occasions, but they may abuse
alcohol purchased from the majority society (Waddell, 1976).
Illegal, Illicit, or Taboo Substance Use
Subsistence-based tribal or peasant societies had access to only those

psychoactive substances produced in their own or nearby cultures. Thus, some
traditional cultures had little or no strictures against substance use. In recent
historical times, the tribal peoples of the Americas, Africa, Asia, Australia, and
Oceania are excellent examples. As new substances, or new forms of old
substances, were introduced into these societies, many of them had no social
strictures against their use. Absence of such strictures could, and sometimes
did, result in local "epidemics" of substance abuse. Some of these "epide-
mics" have continued for so long that they might be considered "endemic" at
this time (Kramer, 1979; Levy & Kunitz, 1969; Ogan, 1966).
More complex societies have had access to diverse psychoactive sub-
stances for centuries. These societies typically had various restrictions on drug
and alcohol use (Paredes, 1975; Popham, Schmidt, & DeLint, 1975; Smart,
Murray, & Arif, 1988; Terry & Pellens, 1928). One type of restriction, common
in societies with broad exposure to other cultures and societies, involves a total
prohibition against any use of particular substances. One classical example is
two adjacent groups in India, one of which approves of alcohol drinking while
the other approves of cannabis use-but both of which forbid use of the other's
substance (Carstairs, 1954). In recent times, these cultural taboos have become
institutionalized as national laws that make any use of certain drugs illegal.
Examples in the United States today are cannabis, heroin, and various hallu-
cinogens such as LSD. If instituted or enforced in an uninformed fashion, anti-
drug laws or policies can have adverse effects on patterns of drug use (Aaron
& Musto, 1981; Westermeyer, 1976).
Another variation on this theme is to permit psychoactive use under some
circumstances, but not others. For example, the Aztecs permitted alcohol
drinking at specific festivals, for specific periods of time, in specific amounts
(Paredes, 1975). Use outside of these limits was considered illicit use, i.e., use
of a legal substance, but in a fashion that is against the law. In the United States
today, our laws permit use of numerous psychoactive substances for medicinal
purposes, when taken under the direction of a physician in a prescribed fashion.
Examples of the latter include morphine, benzodiazepines, barbiturates, am-
phetamine, and various other opioid analgesics, sedatives, and stimulants.
In addition to the legal concepts of legal/illegal drugs and licit/illicit use,
the sociocultural concept of taboo has special meaning in complex, multi-
cultural societies today. In monocultural settings, it may be difficult or impos-
sible to distinguish between illegal drugs and taboo drugs or illicit use and
taboo use. In such settings, the legal system reinforces the sociocultural value
system, and vice versa. In complex, multicultural societies, substances that are
taboo to one ethnic group in a society may not be taboo to another ethnic group
in the same society. For example, Seventh Day Adventists do not approve the
use of certain caffeine-containing drinks (e.g., coffee, tea), although most
Americans have no cultural or moral strictures against these drinks. Certain
Christian groups view alcohol drinking as sinful, but other sects do not. In some
Muslim countries, the government permits alcohol use although the predomi-
nant religion forbids it. Thus, ethnic groups may have a taboo against legal
substances whose individual use is licit in the society (Chafetz, 1964).
At the other end of the spectrum, some groups may not have taboos
against illegal substances and/or illicit use. For example, many drug-using
subgroups or subcultures in the United States approve of the use of one or
another illegal substance or of its illicit use (Agar, 1973). Some ethnic groups,
especially recently arrived ones, may not have cultural taboos against sub-
stance that are illegal in the United States, or against substances whose individ-
ual use is illicit. One example is certain Southeast Asian refugee groups in the
United States who formerly raised opium and widely consumed it (Wester-
meyer, Lyfoung, & Neider, 1989). Thus, one group may foster or even approve
of the production, commerce, and/or use of a substance that the majority
society has judged to be illegal or illicit.
Changes Over Ti me
Social and cultural decisions regarding psychoactive substances can and

do change over time (Sargent, 1967). These changes can occur in the direction
of less restriction, or in the direction of greater restriction. For example, many
American townships, counties, and states that had forbidden alcohol sales for
decades have recently begun to permit on-sale, and even off-sale. Conversely,
many psychoactive substances that were previously legal have become illegal
or illicit. For example, opiate drugs, cannabis, and coca leaf derivatives were
legal in the United States until the early 1900s. Opiates and cannabis were
present in many over-the-counter nostrums. Cocaine was a component of a
popular soft drink. However, these compounds became illegal or illicit during
the early 1900s for a variety of political, international, social, and public health
reasons. Alcohol, the use of which was widely supported by most ethnic groups
in the United States, was likewise made an illicit substance during the 1920s
(Aaron & Musto, 1981). Similar changes have occurred during this century, and
even during the last decade, in countries around the world. "Model legislation"
regarding psychoactive compounds has been developed by international bodies
in response to the requests of member nations.
Sociocultural changes also can occur outside of the legal/legislative arena.
Groups that may have fostered the use of a particular substance may tum
against it (Hughes, Braker, & Crawford, 1972). For example, drug-using sub-
cultures in the United States turned against the more potent hallucinogens and
stimulants during the 1970s and 1980s. This occurred in a context of increasing
awareness of frequent psychosocial complications from chronic use and abuse
of these substances (e.g., mental illness, suicide, assault). Thus, anti-drug
taboos may develop in groups that did not have them. Conversely, groups or
societies may lose their anti-drug taboos over time if they have no common-
place experience with the consequences or complications of substance abuse.
For the latter reason, one might argue that society ought purposefully to abide
or "permit" a certain persisting, low prevalence of publicly visible, deterio-
rated alcoholics or drug abusers in order to psychologically "inoculate" subse-
quent generations against abuse of particular substances. (A countervailing
argument would state that totally eliminating abuse of a particular substance
might result in its eventual disappearance from the awareness and lexicon of
the people.) In any event, it is likely that such changes in "taboo status" toward
various psychoactive substances will continue. Hopefully, these changes will
represent increasingly enlightened state-craft and cultural awareness regarding
psychoactive substances, rather that a repetitive "yo-yo" effect as societies
forget and then, with bitter experience, re-remember the wages of substance
abuse for its people and the society at large (Hughes, Braker, & Crawford,
1972).
MODES OF CONTROL OVER DRUG PRODUCTION,

COMMERCE, AND USE
Rei igious Sanctions
In traditional monocultural societies, religious sanctions were typically

applied with considerable success (Klausner, 1964). Use of taboo substances,
or of legal substances at illicit times or in illicit amounts, was viewed as an
immoral act. Depending on the belief system within the culture, such acts could
lead to supernatural sanctions, such as bad fate in this life or punishment in the
life-after-death. Social sanctions could also apply, such as shunning by other
believers (e.g., social avoidance, noncommunication) or excommunication by
church officials, with loss of religious rights and privileges (e.g., church
attendance, religious rites of passage). In theocratic societies, church officials
might exert secular sanctions, such as fines, incarceration, or corporeal punishment.
Religious sanctions can be remarkably effective, especially ifthey involve
meaningful sanctions in the here-and-now. In monocultural societies with a
single religion, even church-based sanctions (e.g., shunning, excommunica-

tion) can be effective if church approval and participation is needed for social
integration, prestige, and other aspects of social function (see Chapter 3, this
volume). If the society has more than one religion or is a secular society in
which religion does not hold strong sway over people's lives, then these
sanctions are not so effective for those who want to ignore them or who prefer a
secular lifestyle. In strongly theocratic societies, virtually no one can ignore the
power of the state religion. Then religion acquires the power of the state, with
additional cultural influence over childhood training and public morality.
In multiethnic, multireligious societies such as the United States, religions
are limited in what they can accomplish. If one religion holds sway and is
closely allied with the economic-political fabric of the people, religious sanc-
tions can be powerful. This was fonnerly the case in the southern U.S. "Bible
Belt," in which many areas had Prohibition laws against alcohol production
and commerce. It is still the case in parts of Utah, where the Seventh Day
Adventist religion forbids use of most psychoactive substances. In general,
however, religious sanctions have had a declining power over alcohol-drug
production, commerce, and consumption in the United States over the last 50 years.
The rise of Christian, Judaic, Islamic, and other fundamentalism in the
United States and elsewhere may reverse this secular trend in some places and
times (Hippler, 1973; Kearny, 1970). For example, a fundamentalist Christian
self-help group, Alcoholics Victorious (AV), begun in 1948, targets middle-
aged, Christian, male alcoholics. AV emphasizes that substance abuse is a sin
and stresses that developing a relationship with Christ through the "Seven
Steps to Victory" is the only way to sobriety. These steps provide guidance for
spiritual growth and are based on references to the Bible. The goal is to not just
stop abusing substances, but to replace these "sinful" habits with more right-
eous behaviors through learning God's word and letting Christ "fill the void"
that has been filled with the use of chemicals.
Legal Sanctions
Legal sanctions against the production, commerce, and/or consumption of

various psychoactive substances have existed for centuries, and perhaps for
thousand of years (Paredes, 1975; Terry & Pellens, 1928). As mentioned, the
Aztecs had laws against alcohol drinking at particular times and in specific
amounts, modified by the drinker's age and social status. During the Gin
Epidemic, the United Kingdom passed an import tax law on alcohol beverages,
driving up the price until other sources of calories were more expensive and
alcoholic beverages again became a luxury. Faced with a burgeoning opiate
addiction problem, the United Kingdom likewise made opiates available only
with a physician's prescription, supplied through a registered pharmacist.
During the Opium Epidemic in Japan, Korea, China, and elsewhere, laws were
passed against raising poppy, conducting commerce in opiates, and using
opiates. Governments in various times and places have applied the full range of
legal sanctions against drug production, commerce, or use: arrest, fines, incar-
ceration, caning, stocks, loss of property, loss of citizenship and its rights, and
even loss of life (or capital punishment).
Cases exist of considerable success as a result of legal sanctions. For
example, the U.S. Narcotic Act of 1914 dramatically reduced opiate addiction
among middle-class, Caucasian women and men-the group for whom it was
targeted (Terry & Pellens, 1928). Likewise, the United Kingdom realized
considerable success with its import tax on beverage alcohol and the prescrip-
tion of opiate drug laws. Saudi Arabia has very little alcoholism in its vehe-
mently anti-alcohol theocracy. For 30 years following the establishment of
treatment for opium dependence and strict anti-opium policies by the commu-
nist Chinese government, opium abuse and addiction were virtually unknown
in China (Lowinger, 1977). Korea and Japan were able to largely eliminate
opiate abuse through a combination of strict laws and "quarantine" of addicts
in prisonlike hospitals and asylums (Kim, 1969; Merrill, 1942). In these suc-
cessful settings, the populace supported the government in its efforts-often
after a period of widespread family and community problems associated with
widespread substance abuse. Both social benefits as well as social costs have
accrued because of these drug control laws (Kramer, 1978).
Numerous examples of failures as a result of legal sanctions exist. Prohi-
bition against alcohol in the United States during the 1920s and 1930s not only
failed to eliminate alcohol abuse, but it also led to the evolution of a widespread
crime network that eventually spread into other types of illegal activities-e.g.,
gambling, prostitution, "protection" insurance, robbery, and homicide (Aaron
& Musto, 1981). The draconian anti-opium laws of many Asian countries
largely failed until humanitarian efforts accompanied strict legal sanctions in
the late 1900s (Lowinger, 1977). Even today, the governments of Vietnam,
Laos, Cambodia, Burma, Pakistan, India, Afghanistan, Iran, and several Mid-
dle Eastern countries continue to have widespread opiate addiction (Wester-
meyer, 1982). Such laws have failed for many reasons:
• the people do not support the legal sanctions

• although the majority ethnic or political group in power wants the
sanctions, disenfranchised minorities or groups out of power benefit
from ignoring or undermining the sanctions (e.g., through economic
advantages from production or sale, through anti-establishment activ-
ities that embarrass the ruling regime, through political activities that
may actually be supported by drug or alcohol profits)
• the police and/or government officials are corrupt, and producers or
traffickers can bribe them
• although the police or government officials may not have originally
been corrupt, they became corrupt because the rewards for accepting
bribes were great and punishments against accepting bribes were mini-
mal or nonexistent
Informal Social Sanctions
Families, communities, and even entire societies exert control over the
social environment through a variety of informal social controls (Czikszen-
temihalyi, 1968; Hughes, Braker, & Crawford, 1972). These include, but are not
limited to, verbal confrontation, gossip, shunning, extrusion from the group,
and withdrawal of privileges associated with group membership. Individual
citizens can also exert their informal power through official means by alerting
police and the government about illegal or illicit activities-a critical, if
informal, means of ensuring effective governance. It is probably also through
this means that religious and legal sanctions succeed or fail.
Society through its various institutions can affect these sanctions in a
variety of ways. For example, during the Gin Epidemic, writers penned short
stories regarding the evils of excessive drinking, using a popular medium sold
in cheap, widely available form. Artists of the era, working with wood blocks
that could produce thousands of copies, drew depictions of the depredations
associated with alcohol abuse. New Christian religions that espoused absti-
nence evolved. These diverse endeavors gradually changed values, attitudes,
and eventually customs, so that the people widely supported anti-alcohol laws
(e.g., taxes, licenses for manufacture and sale) (Thurn, 1978).
Similarly in China, anti-opium societies appeared in the 1800s and flour-
ished in the 19OOs. Although their members numbered in the hundreds of
thousands and they made great exertions against widespread addiction, these
societies were impotent in the face of a warlord society in which corruption
flourished. The communist regime, when it took power in the 1950s, imple-
mented many of their recommendations. Much of the experience garnered by
these groups was instrumental in developing medical treatment and social
services for addicted persons, as well as interdiction of opiate production and
commerce (Lowinger, 1977).
In sum, effective informal sanctions are necessary if religious or legal
sanctions are to succeed. In the United States 80 years ago, legal sanctions
against opiates were largely successful in Caucasian communities. However,
these sanctions were not so successful in several minority communities that
continued to be involved with opiate commerce and use, such as Sicilian and
Corsican immigrants who experienced limited success in and acceptance by the
majority Caucasian society; African-American communities in larger East
Coast cities; Mexican-American communities in the Southwest; and certain
Asian immigrant groups (Dai, 1937; Maddux & Desmond, 1981). Insofar as
individuals and families among these groups found greater affiliation with drug
traffickers, pushers, and users than with majority institutions and values, to that
extent they tolerated drug distribution and use in their streets and even within
their own families. Until individuals, families, and neighborhoods can develop
greater commitment to and allegiance with the greater society, they will
continue to accept and even support drug subcultures.
Drug production and commerce among alienated subgroups is not pecu-
liar to the United States (Howard, 1927; Westermeyer, 1982). In South Amer-
ica, Middle Eastern expatriates conduct the opiate marketplaces. In Hong
Kong, the Chieu Chow minority has traditionally run the opiate rings and the
prostitution rings. In Italy and France, the islander Sicilians and Corsicans have
a tradition for drug trading. Eliminating drug traffic under such circumstances
requires sophisticated statecraft, with enfranchisement of all ethnicities and
social classes within the mainstream society.
DRUG SUBCULTURES AND THE DRUG TRADE
Subcultures differ from cultures in that subcultures cannot exist indepen-

dently. Subcultures require a culture for members, sustenance, and support. An
ethnic group may depend upon a majority group for sustenance, but it can
supply its own members. Thus, "outlaws" are not a culture or an ethnic group
by themselves, but rather a subculture.
The Outlaw Producer
One group of "outlaw producers" are farmers who grow illegal or illicit
opium poppy, cannabis, coca leaf, and other substances (Culhane, 1989). In
some cases, local farmers have grown the crop for centuries and view contin-
ued production as their birthright. This is or has been the situation with coca
leaf farmers in the Andes and many opium poppy farmers in Asia. American
tobacco farmers would see themselves in this light. In other cases, farmers have
begun production only recently. An example of this is the cannabis farmers
from Hawaii to the Carolinas, from Arkansas to Kentucky. In several states,
cannabis has become a mainstay cash crop, with the added advantage that
profits are not taxable. Illegal poppy is also being grown in the United States,
but at a small level compared to cannabis. Many new "outlaw farmers" are
younger, approve cannabis use, and are unable to gain access to farming careers
through legal means (given the high cost of land and the highly competitive
market for farm produce). "Outlaw farmers" appear to have had greater
success in remote, sparsely populated, and/or hilly regions with poor soil and
poor economies (Geddes, 1976) and less success in flatland areas with good soil
and good economies.
A second group of "outlaw producers" are chemists (Westermeyer, 1982).
As with "outlaw farmers," they fit into both traditional and new categories.
The traditional chemists of Asia and France-while not as highly trained as
chemists-learned how to produce morphine and heroin from raw opium.
Likewise, the traditional chemists of Latin American know how to prepare
cocaine from coca leaf. Since they were usually not academically trained
chemists, they do not have ready access to other occupations. The modem
"outlaw chemist" typically has advanced education and training in chemistry,
sufficient to produce synthetic opioid, stimulant, hallucinogenic, or sedative
compounds. They may produce compounds already well known and easily
produced (e.g., amphetamines) or attempt to produce new compounds of a
certain kind (so-called "designer drugs").
"Outlaw farmers" and "outlaw chemists" have the potential to make
large sums of tax -free money. They may then act as role models to other young
farmers or chemists, who may seek to emulate them. No reliable data exist
regarding the risk of detection. Since they rely on others for their efforts to a
greater or lesser extent (e.g., purchasing chemicals, obtaining a place for
production, taking time to produce), others inevitably know about their activ-
ities. To survive in their work, others must know about them and maintain their
secrecy (i.e., "cover" for them). Thus, they require a subculture of people with
like values and attitudes (Westermeyer, 1982).
Outlaw farmers and chemists run several risks other than arrest and
prosecution. If raided or arrested, they may lose their investment-which can
be considerable. Many are at risk of developing an addiction to their own
substance-a common complication around the world. Among modem chem-
ists, a new risk is the development of temporary or permanent neurological or
metabolic damage from trying the "designer" compounds that they synthesize.
Since some of the chemicals are flammable or otherwise hazardous, chemists
may blind, disfigure, disable, or kill themselves through bums or explosions.
The Outlaw Commercial Agent
As with any agricultural or chemical product, a complex commercial

infrastructure lies behind the transport and sale of illegal and illicit drugs, as
with legal-licit substances. Capital is necessary for purchase and transporta-
tion. Bribes may be required. Drugs may have to travel a great distance from
point of production to point of consumption. Since traffickers function com-
fortably only on their home ground, several distinct agents may be needed to
move the produce through time and space. Since each agent may add 100% or
more profit to recompense their risk, this can greatly increase the cost of the
substance as it moves from source to market. Although highly sophisticated
drug distribution systems have been discovered, much commerce can and does
occur on a "cottage industry" model. That is, small entrepreneurs can enter this
market and substitute for one another. Consequently, interdiction of a large
supplier temporarily reduces supply until smaller agents can replace the large
supplier. Eventually, one of the small suppliers may co-opt other small sup-
pliers and become a large supplier (Geddes, 1976; Westermeyer, 1982).
As the illegal drug produce approaches the end user, the risks become
greater. This is true for several reasons: more strangers know about the transac-
tions; the seller must be available to meet the needs of purchasers; the concen-
trated, easily hid drug must be subdivided into numerous, bulky one-dose
packages for easy marketability, thus increasing the liability for detection,
problems with storage, and limited transportability. Although one supplier can
provide enough drugs for hundreds or thousands of people, retail merchants
can only supply to dozens or scores of people. Thus, many end-use suppliers
must exist. Due to the dangers and disadvantages of retail illegaVillicit drug
sales, most persons at this end of the distribution network are either very needy
(e.g., poor or drug users) or marginal in other psychosocial ways (e.g., alien-
ated, school drop-out, unskilled, low intelligence) (Howard, 1927; Hughes &
Jaffee, 1972).
To function effectively, a subculture network of producers, merchants,
smugglers, and traffickers must do business with one another. On the supply
side, they must also conduct business with chemists and farmers who produce
the substance. On the demand side, they must distribute the substance to street-
level pushers. And they must make deals with several other groups as the
transactions progress: i.e., police and officials who must be bribed, pilots or
boatmen or truckers who ship their produce, security people who must guard
against theft of the product and the profits. They may also have to conduct a
"front" business to hide the nature of their commercial activities and to
provide an explanation for their wealth. Such persons may belong to a "main-
stream" segment of culture, but they likewise belong to an extensive subcul-
ture that supports their efforts (Hughes, Parker, & Senay, 1974; Westermeyer,
1982).
Outlaw Support Staff
A variety of other persons filling different roles are needed to move illegalJ
illicit psychoactive substances from production to consumption (Geddes, 1976;
Westermeyer, 1987). The players in these support staff roles do not assume a
leadership role in the commercial endeavor, but they may supply skills or
resources that are essential to the eventual commercial activity. A list of such
functions and occupations is as follows:
• production supply sources: seeds, fertilizer, chemicals, assistants, la-
borers, shipment containers, retail containers
• transportation personnel: pilots, mechanics, boatmen, stevedores, truckers,
drivers, smugglers, "mules" (who carry drugs on or in their person or in
their luggage, usually at high risk), transfer agents, import/export shippers
• financial personnel: bankers, financiers, accountants, money changers,
money "launderers"
• "fronts" to appear as a legitimate business: partners, bankers, attorneys,
family, friends
The Addict: Outlaw Subculture or Mainstream?
The drug user may also belong to a drug-using subculture, especially ifhe
or she uses an illegal or illicit drug (Dumont, 1967; Hughes & Jaffee, 1972;
Westermeyer, 1974). This subculture may offer some "insulation" between the
majority society and the street-level drug trafficker-often a drug user as well
as a trafficker. This may make it more difficult for the mainstream culture to
interdict or disrupt the production-commerce-consumption network.
Addicts within some ethnic groups in our society may not be considered
"outlaws" by their families and cultural peers. One example is opium smokers
among Southeast Asian refugees in the United States today: opium addiction
would not be viewed as an acceptable reason to leave the household of the
smoker or to withdraw socioeconomic support (Culhane, 1989; Westermeyer,
Lyfoung, & Neider, 1989). Another example is cannabis use among many
Americans in several demographic categories. Likewise, cocaine abuse is not a
"shunning" behavior in many communities and families today.
INTERETHNIC DIFFERENCES WITHIN THE NATION-STATE
Minority Drug Producers, Merchants, and Support Staff
Some drug producers and merchants are members of mainstream society

who decide to become "outlaws" for reasons that would not be considered
"cultural." These reasons include group-supported antisocial or anti-authoritarian
attitudes, financial ambitions that outstrip the individual's capacity or resources
to achieve them, and difficulties obtaining legal work of the individual's
choosing (e.g., farming, chemistry, sales, aircraft flying, or maintenance). Such
individuals generally realize explicitly that they belong to a subculture that
may protect or hide their activities (Hughes, Parker, et aI., 1974; Westermeyer,
Lyfoung, & Neider, 1989).
Ethnic minority producers, merchants, and support staff may have many
of the same motivations as the "mainstream" persons described above. How-
ever, they may possess additional features that can make them more difficult to
identify, interdict, or persuade into other occupations. Their ethnic group may
have a long tradition, even within the family, of conducting such business.
They may perceive it as an honorable, if risky occupation, in which the great
rewards ensue from the risks (much as a successful athlete or stockbroker must
take risks). They may also have not only the admiration of their ethnic peers but
their support and their commitment to secrecy. That is, the loyalty of their
ethnic peers may be greater to them than it is to the majority society. In
addition, the "best and brightest" members of the group may aim at this kind of
role, if socially acceptable roles leading to high status and reward are not
available to them (Hughes & Jaffee, 1972; Westermeyer, 1974). This can make
suppression of their trade extremely difficult and costly.
Advantages of Illegal/Illicit Drug Trade for Minority Communities
Minority communities may abide illegal/illicit drug trade because of the

economic advantages it has for the family or community. In these contexts, the
minority group conducts sales to other minority groups or to the majority
group. Thus, people can see money flowing from other homes or communities
into their own, through the venue of the drug trade. This can be a powerful goad
to acceptance or even support of the trade if alternative means for adequate
income are few or next to impossible (Geddes, 1976; Westermeyer, 1982).
Symbolism may also play a role. Disadvantaged or disenfranchised
groups have long used alcohol and drugs as a means of demonstrating anti-
establishment sentiments. One example was the distillation in Ireland of a

native drink, poteen, against the laws and regulations of the English overlords
(Connell, 1961). The often-despised mountaineer minorities of Asia have long
grown poppy for illegal distribution among the lowland peoples, whose distant
and corrupt governments could not subjugate the mountaineers (Geddes, 1976).
Getting Ethnic Minorities to Join the Cultural Mainstream
Ethnic minorities can and sometimes do join the mainstream against their
own ethnic drug producers and merchants. In fact, they may become the most
avid opponents, for a few reasons. First, they may have been personally harmed
or victimized by the drug trade or its associated addiction-since the commu-
nity that contains the trade eventually suffers from it more than does the
mainstream group. Second, as the mainstream begins to accept ethnic minority
members into itself, these former "outsiders" may become the most fervent
"insiders," often outdoing the traditional majority members in their loyalty to
the majority society.
To acquire the commitment and loyalty of a minority ethnic group, the
cultural majority must enfranchise the minority. If a long history of mutual
antipathy or even overt opposition exists, this may not be easy. Therein lie the
knowledge and skills of drug-related statecraft-a critical element in imple-
menting such a strategy. Political leaders know relatively little about a1cohol-
and drug-related statecraft, thus manifesting a tendency to make the problems
worse rather than better (Westermeyer, 1989).
For its part, the ethnic minority must agree to be enfranchised. This also
may be difficult to accomplish. Once truly enfranchised, the minority group no
longer has excuses for its failures and flaws, including the drug trade. Changing
one's status as an underperson living in an underworld often sounds better than
it is in fact since the transition is long and difficult. It may also require giving up
valued aspects of one's traditions (e.g., bride price, polygamy, revenge/head
price, warrior roles, extra-legal activities) in return for adapting aspects of the
majority culture that are neither familiar nor comfortable.
DRUG CONTROL AMONG CULTURES AND NATION-STATES
Forces against Cooperation among Cultures
Numerous factors auger against cooperation among cultures and nation-

states to reduce production of and commerce in illicit drugs. Perhaps most
critical are economic factors. Countries producing and importing drugs to
countries in which these drugs are illegal or illicit obtain economic benefit from
the activity (Geddes, 1976; Westermeyer, 1982). Especially in developing
countries with large unskilled labor pools, these drug profits may be consider-
able. Any attempt to stem this economic resource may be met with consider-
able local resistance from local farmers, chemists, and merchants-and per-
haps from corrupt officials as well. In some instances, drug profits may also be
used for support of political parties, regional social institutions, or even local
security forces. This may make it very unpopular for national leaders to oppose
drug production and export in an effective fashion. A common way of handling
this double bind is for leaders to pledge opposition to the drug trade publicly
while doing nothing to threaten it. (Of course, this has a cost to local leadership
in that it promulgates duplicity, thus undermining self-esteem and integrity.)
Conflict between cultures and states may also undermine cooperation.
This may occur in obvious ways. For example, country A may not want to
reduce the drug trade to country B if country A is in conflict with country B.
But conflict among countries and cultures can operate in more complex fash-
ions. For example, consider a situation in which country A and country B-
both drug exporters-are in conflict with each other. However, country A may
be friendly with country C, which is trying to get country A to reduce its drug
exports to itself. Country A may not want to reduce its drug trade to country C
because such a reduction might then favor the drug trade of country B with
country C, leading to greater wealth for country B at a cost of less wealth for
country A. Thus, country A may act as though it is reducing its drug trade (and
may carry out a few raids) while doing nothing substantive to impede the
resilient drug trade.
Political alliances can also undermine cooperation to reduce the drug
trade. For example, country A may transport its illegal/illicit drug through
country B. Drug-importing countries may be pressuring country B to interdict
the drug trade through its territory. However, country B may not wish to do this
for fear of risking the political alliance with its drug-producing neighbor.
Drug trades may also serve as a symbol or cipher for other issues. For
example, country A may not want to see country B do well for any of a variety
of reasons-whether historical, religious, political, economic, or any combina-
tions thereof. Country A may thus be unwilling to help country B stem its drug
trade simply because it does not want country B to do well-and continued
widespread drug abuse may be an effective means for accomplishing this end.
A drug-exporting country may object to making profound changes within
its own borders simply to satisfy the demands or solve problems of another
country. And there are practical reasons for not wanting to do so. The United
States and the illegal/illicit opium trade in many countries (e.g., Laos, Thai-
land, Burma, Pakistan, Afghanistan, and other countries of Asia) provide an
example. Of all the illicit/illegal opium produced in these countries, only about
1% ever gets to the United States. The remaining 99% is consumed locally or
exported to other areas of Asia, Europe, and Africa, where opiate addiction is
as or more common than in the United States. Many countries object to
pressures from a powerful country that imports relatively little opiate drug,
when other countries are not exerting such pressures.
Perhaps most informative in this regard is the experience of China during
the 1700s to the late 1800s. Its purported European allies expressed consider-
able ethical concern about the opium trade, while continuing to accept or even
foster the trade for their own economic advantages. China tried repeatedly to
obtain the cooperation of its European trading partners to stem the opium trade
from South Asia into China. These efforts were notably unsuccessful. Even the
so-called Opium Wars (largely popular uprisings against the European lega-
tions in China) could not alter the opium trade. It was not until China took over
its own destiny in the 1950s that it was able to address its opium epidemic in an
effective fashion (Lowinger, 1977). Likewise, the United Kingdom was able to
address its Gin Epidemic (along with large imports of rum and port wine) only
by making internal changes in its own laws and public attitudes. Although the
exporting countries probably did not like the consequences of these actions by
China and the United Kingdom they had no cause for hostility against China
or the United Kingdom (Thurn, 1978).
Strategies to Elicit International Cultural Cooperation

and Drug Control
Review of the problems in international cooperation suggests historical

and "cultural" differences playa role in certain of these obstacles. However,
the case in China's long-lasting Opium Epidemic strongly implicates socio-
economic inequity as a cause of obstacles-a problem that Hawkins (1993) has
identified as a cause for lack of cooperation among ethnic groups within
nations.
Currently, many national and international strategies are designed to elicit
noncooperation and to increase drug production in drug-exporting countries.
For example, the continued production and export of opium from several
Southeast Asian countries leads to a continued influx of money to build roads,
establish crop replacement, and provide treatment-despite the absence of any
reduction in opium production and export. One could make the argument that
continued support of these programs under these conditions actually stimulates
opium production and export-since production has continued or increased
over more than two decades of such programs at the expenditure of tens,
perhaps hundreds, of millions of dollars. This is also true regarding cocaine,

cannabis, and opiate production across large areas of South America.
In order to reverse this trend, national and international donors might tie
payments or certain privileges to actual reduction in production and export.
Such privileges might include favored trading status, loans at reduced interest,
assistance with reducing air or water pollution, or other socioeconomic advan-
tages. In order to be effective, these policies would have to be continued over a
sufficient period of time (say, a few to several decades). This strategy could
occur on a bilateral basis (between two nations), a multilateral basis (among
several countries) or an international basis (through established international
organizations ).
The last suggestion is likely to be the least effective over the short run, but
potentially the most effective over the long run. This strategy consists of
promulgating a universal identity as a "human earthling" rather than a member
of a specific nation, culture, religion, political system, race, language, etc. An
"earthling" identity might prove effective in fostering empathy among people
of diverse cultures and nations. To some extent, the literate, well-informed
peoples of the industrialized world have begun to adapt this view of them-
selves, at least partially. Around the world, one sees front-page news, TV
coverage, and editorials about problems and life in other places; these have the
potential for producing values and attitudes that are international or cross-
cultural in scope. Of course, to be effective, values and attitudes must translate
into goals, plans, and actions. But the latter are not possible without common
goals, values, and attitudes. Perhaps we will see a time when we "earthlings"
can launch a trek that brings psychoactive substances back to human service
rather than disservice.
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PART III
Informing Drug Policy via

Psychological Science:
Innovations in Treatment
Services
CHAPTER 6
Achieving the Public Health

and Safety Potential of
Substance Abuse Treatments
Implications for Patient Referral,
Treatment "Matching,"
and Outcome Eval uation
A. THOMAS McLELLAN and CONSTANCE WEISNER
INTRODUCTION
Heavy use of alcohol and drugs is associated with serious public health and
public safety problems, including transmission of infectious diseases, dispro-
portionate use of medical and social services, traffic accidents, and street crime
(Gerstein & Harwood, 1990; Institute of Medicine, 1990; Merril, 1993; Rice,
Kelman, & Miller, 1991). These alcohol- and drug- "related" problems not only
reduce the safety and quality of daily life throughout this country, but they are
A. THOMAS MclELLAN· Center for Studies of Addiction, University of Pennsylvania, and

Veterans Affairs Medical Center, Philadelphia, Pennsylvania 19104. CONSTANCE
WEISNER· Alcohol Research Group, University of California at Berkeley, Berkeley, California
94720.
Treatment of Illicit Drug Abuse, edited by Warren K. Bickel and Richard 1. DeGrandpre. Plenum
127
128 A. THOMAS MclELLAN and CONSTANCE WEISNER
also a source of substantial expense. For example, Rice and colleagues have
estimated that the total cost to the country in 1990 was $99 billion for alcohol
abuse alone, and approximately $67 billion for drug abuse (Rice, Kelman, &
Miller, 1991). These economic, health, and safety issues have brought renewed
interest in the expansion of treatment programs, more public financing for
treatment, and even increased use of court-mandated treatments as a method of
dealing with the public health and safety problems related to substance abuse
(Institute for Health Policy at Brandeis University, 1993; Schmidt, 1995). At
the same time, many segments of society are skeptical about the effectiveness
of substance abuse treatments; there are those in government, healthcare fi-
nancing, and the public at large who question whether treatment is "worth it."
As recently as July oflast year, the Wall Street Journal questioned the effective-
ness and value of substance abuse treatment, saying " ... the success rate of
treatment programs is highly uncertain" (Wall Street Journal, 1994, p. A12).
In the text that follows we take the position that (1) a majority of the
substance abusers currently in treatment exhibit one or more serious public
health and public safety problems that have been attributed to their substance
use; (2) it is the severity ofthese "related" problems rather than the alcohol and
drug use itself that typically brings the abuser to the attention of family, friends,
and social agencies and ultimately leads to the treatment referral; (3) that these
"related" problems, rather than the alcohol and drug use per se, are the primary
concerns ofthe patient, the family, the employer, the insurer/payer, and society
in general; and, therefore (4) the "effectiveness" and "value" of substance
abuse treatment to society is best measured in terms of its effects upon the
public health, safety, and cost concerns associated with substance abuse-not
just its ability to reduce alcohol and drug use.
With this view in mind, we first examine some of the factors that presently
lead to substance abuse treatment referral and to the outcome expectations
among those agencies and organizations that make the referrals. Here we
consider the nature of the problems that become attributed to substance abuse
and trends in social policy toward the handling of substance abuse problems.
We argue that these initial treatment referral decisions and the expectations that
underlie them form the basis for judgments regarding the organization, struc-
ture, content, and, ultimately, effectiveness and "worth" of contemporary
substance abuse treatments. Next, we examine the potential for substance
abuse treatments, as they are presently structured, to address the alcohol- and
drug-"related" problems of AIDS and other infectious diseases, crime, unem-
ployment, and the excessive use of health and social resources. To this end, we
present data on the admission problems presented by samples of referrals to
public and private substance abuse treatment programs. Here we consider the
extent to which the treatments provided in these programs are directed toward
ACHIEVING PUBLIC HEALTH AND SAFETY POTENTIAL 129
the problems that were responsible for the referrals. Finally, we present post-
treatment outcome data across a range of substance abuse and social function-
ing indicators relevant to public health and safety concerns. The chapter thus
contrasts the problems presented by the patients both with the services offered
by the programs and with their outcomes as one approach to the policy question
of how to maximize the "effectiveness" and "worth" of substance abuse
treatments from a public health and public safety perspective.
WHAT BRINGS SUBSTANCE ABUSERS TO TREATMENT?
General models of medical service utilization have been adapted to ex-

plain who will use substance abuse treatment (Padgett, Struening, & Andrews,
1990; Schmidt, 1995; Weisner, 1993). However, the assumptions underlying
these experimental models of medical care utilization are often very different
from the special circumstances affecting entry to substance abuse treatment. To
an important extent, requests for general medical treatments come directly
from the prospective patient and are governed by personal and structural
factors such as the patient's perception of the severity of the primary medical
condition, the patient's geographic and financial access to services, and the
patient's beliefs regarding the potential help or relief that will be received for
those primary symptoms (Aday & Anderson, 1974; Greenley & Mechanic,
1976). The use of general medical services is thus typically a voluntary act and
is rarely determined by any coercive relationship from a third party.
In contrast to utilization of general medical interventions, requests for
substance abuse treatments often come from an organization, institution, or
family member who has become aware of the substance abuse indirectly
through recognition of what is attributed to be an "addiction-related" social,
family, financial, employment, or medical problem. During the last decade,
problems of crime, workplace safety and productivity, spread of various infec-
tious diseases, and even neonatal health have come to be considered
"addiction-related" problems (Weisner, 1987). Thus, organizations and agen-
cies charged with addressing these societal problems have become very impor-
tant determinants of substance abuse treatment utilization, initiating referrals
based upon the extent to which they believe that (1) an observed problem is
attributable to or associated with substance abuse, (2) amelioration of the
substance abuse problem would be instrumental in producing desirable change
in the observed problem, and (3) substance abuse treatments can produce the
desired amelioration of the substance use and thereby the desired improvement
in the "related" problem. Notice that in this formulation, the desires of the
prospective patient are not primary; many substance abuse treatment referrals
are thus characterized by some degree of external coercion, either through

criminal justice system sentences or conditions of probation/parole, employer
mandates, or social pressuring from family and community. In accordance with
these societal, institutional, and family pressures, substance abuse treatment
has changed over time to accommodate trends in substance abuse patterns,
changing levels of public concern about drug problems as well as bringing
about political commitments to provide accessible services (Schmidt &
Weisner, 1993). These pressures are very important both to the prospective
patient and to society, since they form the contract under which treatment is
provided and evaluated. Thus, we now review the role of contemporary factors
that affect patient entry into substance abuse treatments as a first step in our
examination of the appropriateness and suitability of substance abuse treat-
ments to meet the needs of both the clients that present for care and the societal
forces that have influenced their entry to treatment.
WHAT OUTCOMES ARE EXPECTED

FROM SUBSTANCE ABUSE TREATMENT?
Many public and private service institutions and organizations, such as the
welfare system, the criminal justice system, emergency medical care centers,
foster home placement centers, employee assistance programs, and family
violence centers, come into contact with alcohol and drug abuse problems in
the course of their responsibility for handling social, employment, and health-
care problems (Weisner & Schmidt, 1995). These organizations refer substance
users from their caseloads to adjunctive substance abuse treatment as a means
of dealing with these perceived "addiction-related" problems. These reasons
for referral form many of the expectations regarding the desired goals of
substance abuse treatment. For example, hospitals and other healthcare agen-
cies are major referral sources for substance abuse treatments. These primary
healthcare sources expect an "effective" treatment for substance dependence
to reduce the serious medical and public health risks associated with substance
use, such as AIDS, hepatitis, and tuberculosis, and to reduce the dispropor-
tionate utilization of primary healthcare services that is so characteristic of
alcohol- and/or drug-dependent individuals (Putnam, 1992).
Unemployment and welfare costs have been areas of tremendous public
and policy concern in recent years, given the elevated rates of alcohol and drug
abuse among public assistance caseloads (Weisner & Schmidt, 1995). Thus,
subgroups with alcohol and drug abuse problems within the welfare population
may be identified by welfare caseworkers and referred to substance abuse
treatment. These subgroups may include substance-abusing women who are
pregnant and/or caretakers of small children as well as unemployed single men.

The referring welfare or unemployment agencies are likely to expect "effec-
tive" substance abuse treatment to improve the vocational and employment
prospects of their referrals. Indeed, these kinds of addiction-related treatment
goals have been included in contracts between public service agencies and
substance abuse treatment programs that accept their referrals (Weisner &
Room, 1984).
The costs of substance abuse to the workplace have also been emphasized
during the past decade, and a growing number of employee assistance pro-
grams (EAPs) have initiated programs run by management or employee unions
designed to detect substance abusers in the work force, to screen them for
problems, and to refer these individuals to treatment programs (Kurtz, Grog-
gins, & Howard, 1984; Roman, 1988). Employers and even employee-run
unions who refer prospective patients for substance abuse treatment are typ-
ically most interested in the return of affected employees to a high level of work
performance following treatment and an assurance for coworkers that they will
not be put in danger.
Finally, Americans in general and particularly those living in urban areas
have become increasingly worried about crime (New York Times, 1994). Cur-
rent statistics indicate that as many as 60% of federal prisoners meet diagnostic
criteria for a substance dependence disorder (Gerstein & Harwood, 1990). The
statistics on street crime suggest that as much as 50% of all property crimes are
committed by those under the influence of alcohol and/or dmgs or with the
intent to obtain alcohol and/or drugs with the proceeds from the crime (Ger-
stein & Harwood, 1990). The concern for public safety and the awareness of the
relationship between crime and substance abuse have pushed the criminal
justice system to consider treatment alternatives to incarceration for drug-
related crimes (Inciardi, 1988; Rua, 1989; Wexler, Falkin, & Lipton, 1988).
Thus, police, probation/parole officers, judges, and other agents of the criminal
justice system have become major referral sources for substance abuse treat-
ments. For them, the "effectiveness" of substance dependence treatment is
measured by reductions in crime, parole/probation violations, and incarcera-
tion rates among affected individuals.
In summary, we argue that the agencies cited above that act as referral
agents to substance abuse treatment are primarily interested in the longer-term
effects of substance abuse treatment on the so-called "addiction-related"
problems (Weisner & Schmidt, 1995). Since these "related" problems are often
the factors that lead to treatment, "effectiveness" of substance abuse treatment
will be gauged in some significant part by that treatment's effects on the
"addiction-related" problems that prompted the referral. We will consider this
context in our examination of the appropriateness and suitability of current
substance abuse treatments to meet the public health and public safety needs of
the social agencies that make up the primary referral sources for treatment.
OUTCOME DOMAINS BASED ON PUBLIC EXPECTATIONS
Based on the above discussion, we suggest three outcome domains (in

addition to cost) that we feel are relevant both to the rehabilitative goals of the
patient and to the public health and safety goals of society:
1. Elimination or reduction of alcohol and drug use. This is the foremost
goal of all substance abuse treatments.
2. Improved health and social function. Improvements in the medical
health and social function of substance-abusing patients are clearly
important from a societal perspective, but improvements in these areas
are also related to prevention of relapse to substance abuse.
3. Reduction in public health and public safety threats. The threats to
public health and safety from substance-abusing individuals come
from behaviors that spread infectious diseases and from behaviors
associated with personal and property crimes. Specifically, the sharing
of needles and trading sex for drugs are significant threats to public
health. Personal and property crimes committed for the purpose of
obtaining drugs and the dangerous use of automobiles or equipment
under the influence of alcohol are examples of major threats to public
safety.
In the work reported here we have used these three outcome domains to
evaluate the effectiveness of substance abuse treatment programs for both
publicly funded and insured patients. Here we examined whether the public
health and safety goals of the agencies that referred these patients to treatment
have been met or even addressed during and following the treatment process.
METHODS
Source of Data
All data were collected as part of standard program evaluations performed

by the Treatment Research Institute at the University of Pennsylvania. This
institute follows a standard paradigm of evaluating random samples of patients
at admission to a treatment program, collecting data on the nature and amount
of treatment services provided during the course of their care, and recontacting
these samples 6 months following treatment to assess the nature and amount of
improvements shown. The effectiveness of a program is then assessed in terms
of the performance of its patient sample relative to similar samples of patients

treated in comparable programs from the institute's national database (McLellan &
Durell, 1995).
Data Collection Methods
The same core battery of evaluation instruments and research procedures

was used in each of the treatment programs and for all subjects. In each
program, samples of 75 to 100 patients were randomly or consecutively sam-
pled from those entering treatment through normal admission procedures.
Participation for all subjects was voluntary. Subjects were told that they would
be interviewed in person at the start of treatment, by telephone each week that
they were in treatment (to minutes each call), and again in person 6 months
following treatment discharge (regardless of whether they completed treat-
ment). Subjects received $25 for participation; acceptance rates ranged from
85-100%.
Subject Measures at Treatment Admission
Subjects were interviewed at treatment admission using the Addiction

Severity Index (ASI) (McLellan, Luborsky, O'Brien, & Woody, 1980; McLellan,
Luborsky, Cacciola, & Griffith, 1985; McLellan, Cacciola, Kushner, Peters,
Smith, & Pettinati, 1992). The ASI is a 45- to 60-minute structured interview
that measures the lifetime and recent (past 30 days) severity of problems in
seven areas commonly affected among alcohol- and drug-dependent individ-
uals. These include medical status, employment, alcohol use, drug use, crime,
family/social relationships, and psychiatric symptoms.
In each of these areas, items measuring the severity of the problem during
the previous 30 days are combined into a composite or factor score that gives a
general measure of problem severity (McLellan, Luborsky, Cacciola, &
Griffith, 1985; McLellan, Cacciola, Kushner, Peters, Smith & Pettinati, 1992).
Examples of the items that comprise these composites are presented in Table 1.
These composites are computer scored with values ranging from 0.0 (no sig-
nificant problem) to 1.0 (extreme problem). The ASI has been repeatedly found
to offer reliable and valid measures of patient status in each of the problem
areas in opiate-, alcohol-, and cocaine-abusing populations (McLellan, Cac-
ciola, Kushner, Peters, Smith, & Pettinati, 1992).
We have divided the entire patient sample into subgroups based on
whether the index treatment was financed primarily from private or public
sources. The overwhelming majority of patients in the public programs had
Table 1
Patient Background Characteristics at Admission to Treatment
Number of Patients
Public Programs Private Programs Total Sample

(619) (412) (1031)
Demograhic factors
Age 40 ::':: 7 37 ::'::6 39 ::':: 7
% Male 95 77 88
% White 28 78 48
% Black 70 20 50
Years of education 12 ::':: 2 13 ::'::4 12::':: 4
# Prior alcohol treatments 3 ::':: 2 I::':: I 2::':: 2
# Prior drug treatments 3 ::':: 3 I::':: I 2 ::':: 2
% Married 25 30 27
% Separateclldivorced 47 33 39
% Living with substance abuser 13 8 10
% Unstable living arrangements 14 2 5
Treatment referral source
Court mandated 31 23 27
Pressured from courts/probation/ 12 II II
police
Employee assistance program 5 27 14
Pressure from family 10 15 13
Self-referred 13 31 18
Substance abuse
Years problematic alcohol use 12 ::':: 4 4::':: 2 9::':: 2
Years problematic opiate use 5 ::':: 3 0 3 ::':: 2
Years problematic cocaine use 5 ::':: 2 3 ::':: 4::':: 2
Years problematic barbituate and 2::':: 2 + 2 ::':: 2
tranquilizer use
Years marijuana abuse 10 ::':: 2 II ::':: 2 II + 2
Longest period of abstinence 9::':: 6 15 ::':: 5 II ::':: 5
(months)
Medical problem
% with chronic medical problems 35 20 29
Medical hospitalizations 5 ::':: 2 3 ::':: 4::':: 2
Employment problem
ric with skill or trade 45 91 63
Longest period of employment 3 ::'::2 7 ::':: 5 ::':: 2
(years)
% Employed 39 89 59
Legal problem
o/e Awaiting charges II 4 8
ric Probation/parole 17 6 13
'7r Ever incarcerated 38 12 27
Table 1 (Continued)
Patient Background Characteristics at Admission to Treatment
Number of Patients
Public Programs Private Programs Total Sample

(619) (412) (1031)
Psychiatric problem
% Having previous psychiatric 30 13 23
treatment
% Attempted suicide 23 13 19
% Reporting lifetime depression 61 42 53
% Problems controlling violence 34 26 31
their care reimbursed from Medicaid, the Veterans Administration, or state or

national treatment expansion efforts (e.g., Target Cities funding from the
Center for Substance Abuse Treatment). None of the private programs received
any state or federal funding for administration or operation, while at least half
of the public programs received federal, state, or city funding to defray some of
the services provided (e.g., AIDS prevention counseling, counseling for preg-
nant women). These financing patterns are similar to those found in other
national program samples (D' Aunno & Vaughn, 1995; Schmidt & Weisner,
1993). A small proportion of the public patients (5-7%) had private insurance,
but most had exhausted their benefit in prior treatment attempts. The large
majority of patients treated in the private programs had most of their care
reimbursed through a private insurer or HMO. There were very few patients in
the public programs whose care was paid by private insurance.
Treatment Program Descriptions
Data are reported from 31 treatment programs-16 from the Northeast,

nine from the West Coast, and six from Texas. All were standard programs that
had participated in one of the alcohol and drug treatment outcome studies
conducted by the Treatment Research Institute over the past three years. We
have focused on treatment programs that were designed to provide reha-
bilitation-oriented treatment toward a goal of abstinence from both alcohol and
drugs. For these reasons we did not include methadone maintenance programs
or programs that provided only detoxification. All programs included in these
analyses treated primarily alcohol and/or cocaine dependent patients; this is
136 A. THOMAS McLELLAN and CONSTANCE WEISNER
typical of the substance abuse populations in treatment nationally (Gerstein &

Harwood, 1990; Institute of Medicine, 1990).
It is important to note at the outset that these data are not derived from a
national probability sample of treatment programs; thus it is not possible to
infer that the data would be representative of the overall treatment system. At
the same time, the programs represent the range of substance abuse treatment in
the United States and are pertinent to the issue of the nature of problems
presented by various groups of patients as they enter substance abuse treat-
ment. The 31 treatment programs included in the analyses are described briefly
by category below.
Inpatient Alcohol/Cocaine Programs: Thirteen programs, seven publicly
funded; 447 patients sampled. Planned duration of stay ranged from 10 to 40
days. Eleven programs were hospital based, while the three others were free-
standing residential programs. All were abstinence oriented, and all relied
heavily on group therapy, individual counseling, alcohoVdrug education ses-
sions, relapse prevention groups, and referral to AAJCNNA.
Outpatient Alcohol/Cocaine Programs: Eighteen programs, three pub-
licly funded; 584 patients sampled. Planned duration of stay ranged from 4 to
fifty weeks. Hours of treatment per week ranged from 8 (two 4-hour days) to 36
(six 6-hour days). Six programs (one public and five private) were hospital
affiliated; the remainder were freestanding community-based programs. Again,
all were abstinence oriented, and all relied on group therapy, individual coun-
seling, alcohoVdrug education sessions, relapse prevention groups, and referral
to AAJCNNA.
Treatment Content Measures
While the ASI measures the nature and severity of treatment problems
presented by the patient at the start of treatment and later at follow-up, the
nature and number of treatment services actually received by patients for those
problems during the course of their rehabilitation was measured by the Treat-
ment Services Review (TSR) (McLellan, Alterman, Woody, & Metzger, 1992).
The TSR is also a technician-administered interview that requires 5-10 min-
utes to complete and is administered to each patient on a weekly basis in person
or over the phone (usually each Friday) during the course of treatment. The
TSR provides a simple and reliable quantitative record of the number of
professional services (specialized therapy or treatment sessions, medications,
etc.) and discussion sessions (group or individual counseling) that each patient
received in each of the same seven problem areas covered by the ASI
(McLellan, Alterman, Woody, & Metzger, 1992). For example, in the medical
section, subjects were asked to report the number of times in the prior week
they had seen a doctor or a nurse, received a prescription for a medication,
received any type of medical testing, or had a significant discussion related to
their medical problems with a counselor or other member of the program staff.
The TSR measures the services that are provided both within the program and
through referral at other programs or agencies.
Outcome Measurement
Patients in inpatient programs were contacted 6 months from their pro-

gram discharge date. Inpatient treatments typically ranged from 14-40 days,
but outpatient programs ranged from 30-90 days. In order to make the data
from the inpatient and outpatient programs reasonably comparable, we elected
to contact the outpatient clients 7 months from admission to treatment. Follow-
up efforts were begun 2 weeks prior to the exact anniversary date and were
extended 2 weeks following that point in the event that a patient was not able to
be located. The follow-up ASI required approximately 20 minutes and was
again administered by a trained residential technician who was not part of the
treatment process. Subjects were paid $25 for the time required to complete
their follow-up interview. Ninety-two percent of patients across all programs
were successfully interviewed during the "follow-up" window using these
techniques, ranging from a high of 98% to a low of 83%.
There were several methods for ensuring information validity built into
the follow-up interview. First, subjects were repeatedly assured that their
information would not be communicated to any individual or agency. Second,
subjects were told that they did not have to answer a question with which they
were uncomfortable or provide information that they wished to keep private.
These two aspects of the interview procedure provided confidentiality reassur-
ance as well as an additional answer option for the subject in lieu of falsifica-
tion. Third, there are a number of information cross-checks in the interview,
and technicians were trained to notice and respond to inconsistencies. Sections
of the ASI that the interviewer felt were compromised by failure to understand
or by purposeful distortion were not used in the data analyses. Where three or
more sections were compromised the entire interview was eliminated. We
discarded 21 follow-up interviews due to three or more invalid sections; these
were spread approximately evenly across all the programs and populations
represented. As a final, partial check on the validity of the information col-
lected, a random sample of 15% of all subjects were asked to come in to pick up
their reimbursement following the interview; at that time they were asked to
provide urine and breath samples for testing. We had excellent compliance with
this request. Only nine subjects refused to submit samples (three from one
program, the rest randomly distributed across studies and programs), and their
data were eliminated from consideration. The accuracy of the self-report drug
and alcohol use was partially tested by comparing the patient reports of use
with the results of unannounced urine and breath tests. Overall, 76% of
urinalyses corresponded exactly with the self-reports. Seventeen percent of
self-reports were overestimates of drug use; that is, the patient reported drug
use but the urinalyses were negative. The remaining 7% of interviews were
underestimates of drug use as compared with the urinalyses and were therefore
eliminated.
RESULTS
What were the background characteristics of the patients at the time of

admission to substance abuse treatment? Subjects were 1,031 adults admitted
to treatment in the programs described above. All patients were admitted
following completion of detoxification or self-induced sobriety. They are de-
scribed in Table 1, divided into those treated in publicly funded and privately
funded treatment programs. As can be seen, the patients admitted to these
programs were approximately 39 years old and primarily male. Among the first
indications of differences between public and private patients in these samples
is the difference in ethnicity, with only 20% minority representation (African
American) in the private sample but 70% in the public sample. The total sample
of patients averaged slightly more than 12 years of education but, again, there
was a difference between the two subgroups, with the private patients averag-
ing 13 years and the public sample averaging 12 years. Further, approximately
20% ofthose patients in the public sample had completed a general high school
equivalency diploma (GED) in lieu of graduation, usually as part of an earlier
public treatment program. Fewer than I% of private program patients had a OED.
Only 10% of private program patients had been in substance abuse treat-
ment prior to the index episode. In contrast, a substantial minority of public
patients (32%) had been to substance abuse treatment prior to the index
episode. This group had averaged three prior treatments each for alcohol and
drug problems, thus indicating more chronicity than in the private program
group. Finally, the housing and day-to-day living situations were problematic
throughout the entire patient sample, but, again, were particularly more severe
among the public program patients. For example, 8% of private and 13% of
public program patients reported living with an active substance abuser. In
addition, 2% of private program patients but 14% of the public program
patients reported being homeless or living in temporary quarters.
What were the referral sources to substance abuse treatment? Patients

were asked about sources of referral and route of entry into treatment in the
baseline interview. Over one quarter, 27% (31% of public and 23% of private
patients), had been mandated to treatment by the criminal justice system
(typically for drug possession or distribution charges among public program
patients and DWI offenses for private program patients). An additional 11 %
(approximately equally divided among patients from public and private pro-
grams) reported that some member of the criminal justice system, induding
a lawyer, judge, or probation/parole officer, had "suggested" that they get into
substance abuse treatment. In addition, 14% of all patients (all from private
programs) were referred from EAP organizations or from workplace drug
detection plans. An additional 13% of patients admitted that they had come into
treatment because of significant pressure from a family member or friend. We
did not collect systematic data on the frequency of referrals or "strong sugges-
tions" from physicians, mental health workers, public assistance case workers,
or any of the many other sources of patient pressure to get treatment. Even with
the cautions necessitated by this incomplete data, it is fair to estimate that at
most only 25% of these cases could be characterized as truly "voluntary"
admissions. The nature and prevalence of these referral pressures are consistent
with what we would expect to find from the policy trends affecting both public
and private treatment described above (See Inciardi, 1988; Kurtz, Groggins, &
Howard, 1984; McLellan, Cacciola, Kushner, Peters, Smith, & Pettinati, 1992;
McLellan & Durell, 1995; McLellan, Luborsky, Cacciola, & Griffith, 1985;
McLellan, Luborsky, O'Brien, & Woody, 1980; New York Times, 1994; Roman,
1988; Rua, 1989; Weisner, Greenfield, & Room, 1994; Schmidt & Weisner,
1993; Weisner, 1994; Weisner & Room, 1984; Wexler, Falkin, & Lipton. 1988).
What were the problems presented by substance abusers at the start of
treatment? As can be seen in Table 1, these patients reported significant and
multiple substance use problems. The total sample averaged 9 years of prob-
lematic alcohol use (intoxication at least three times per week), 3 years of
regular (at least three times per week) opiate use, 4 years of regular cocaine use,
and 11 years of regular marijuana use. On average, the group had been abstinent
a total of only 11 months since beginning regular substance abuse, despite being
treated an average of three times for alcohol and three times for drug problems.
While these figures indicate serious substance use in both of the patient groups,
it is obvious again that the most severe and chronic problems were presented
by the public program patients.
As we would expect from the referral information, in addition to sub-
stance abuse problems, patients reported substantial levels of medical, employ-
ment, legal, and psychiatric problems. For example, Table 1 data indicate that
29% of patients had chronic medical problems and had been hospitalized an
average of four times previously for those medical problems. Although 63%
indicated they had some type of skill or trade, only 59% were employed at the
time of admission to treatment. Many patients also had significant legal prob-
lems, with 8% awaiting charges for a criminal act, 13% on probation or parole
at the time of admission, and 27% having been incarcerated at some point
during their lives. Finally, there was substantial indication of psychiatric prob-
lems across the total sample, with 53% reporting a significant period of serious
depression during their lives, 31% reporting trouble controlling violent behav-
ior, 19% having made a suicide attempt, and 23% having been treated for a
psychiatric problem during their lives. It is also obvious that the public patients
had significantly more, and more severe problems, in virtually all the areas than
their private program counterparts.
What services did these substance abuse treatment programs provide? As
described, weekly information was collected from all patients regarding the
nature and number of treatment services they received from their program
directly or through referral. In Table 2, we have collapsed both direct and
referred services provided into one category. While we actually recorded the
frequency of services provided each week, infact the large majority ofpatients
reported receiving no services, in most areas, each week. Thus, Table 2 reports
the percentage of patients receiving even one session or appointment, in each
of the service areas, summed over the entire course of their treatment.
In general, most patients reported receiving only a small range of service
types either in the program or through outside referral. Although data on inten-
sity of each service are not shown here, the modal pattern of services during a
week of outpatient treatment was one or two group therapy sessions (focused
on issues of relapse prevention and drug/alcohol use situations), one educa-
tional session (typically a film), and often, but not always, a single 15-20
minute individual counseling session. In addition, these patients were referred
to local AAINA groups; many programs had this as a required part of treat-
ment. Inpatient programs generally provided substantially more drug and
alcohol counseling sessions (usually group), but typically very few other
services. The modal weekly pattern of services offered in the inpatient pro-
grams included four to six group therapy sessions, three to five "community
meetings," and approximately three alcohol and drug education sessions
(again, usually film presentations). Inpatient programs usually also included
some form of organized recreation or leisure activity at least three times per
week. Again, it is important to note that in both categories of treatment
programs, most patients, even in inpatient treatment, did not receive any
professional services such as medical care, employment counseling, social
work services, or psychological therapy.
Table 2
Types of Services Received by Substance Abuse Patients
During the Course of Treatment in Public and Private Programs
Public Private
Services Received by Patients Programs Programs
Alcohol services
Received alcohol blocking meds 8a 19a
Had a breathalyzer screen 4 12
Had alcohol education session 66 58
Attended AA-out of program 26 32
Had a relapse since previous session 26 33
Had an individual discussion re: alcohol problem 26 41
Drug services
Received blocking or detox meds 3 13
Had a urine screen 24 35
Had drug education session 64 64
Attended NNCA-out of program 31 49
Had a relapse since previous session 32 45
Had an individual discussion re: drug problem 50 41
Medical services
Received physical meds prescription 4 9
Was admitted to a hospital 3 I
Saw a physician 8 25
Saw a nurselNP 3 20
Employment services
Had an individual discussion re: employment problems 6 12
Saw an employment specialist 2 11
Legal services
Had justice system contacted 0 8
Had an individual discussion re: legal problems 2 6
Family services
Had an individual discussion re: family problems 1 12
Saw a family specialist 0 8
Psychiatric services
Received psychiatric meds prescription 3 9
Had relaxation training 6
Had psychiatric testing 2 5
Saw a psychiatric specialist 12
Had an individual discussion re: psychiatric problems 3 16
aNumbers indicate percent of patients reporting even one service over four weeks of treatment.
One clear trend emerged from the available data on treatment services
provided. Virtually all services offered (both inpatient and outpatient, both
public and private) were focused exclusively on the drug and alcohol use of the
patient. These sessions, whether group or individual and whether educational
or psychotherapeutic, were all focused on the goals of motivating and teaching
patients to become and remain abstinent. There were few services directed at
the additional problems of education, employment, health, or family relations,
and this was particularly true within the public programs. There was no
category of specialized service in any program where even 50% of patients
received even one session over the entire course of treatment.
What were the outcomes from substance abuse treatment? Changes in the
ASI on the three outcome domains are presented for both the public and private
program samples in Table 3. We have purposely not compared the outcomes
between these two samples. The substantial demographic and problem severity
differences between these groups at the time of treatment admission (see Table
1) were too great to be adequately adjusted or controlled using statistical
procedures. Beyond those technical difficulties that would make interpretation
difficult, we did not think that the results from such a comparison would be
useful or clinically relevant. The intent of this chapter is not to compare public
and private treatments but rather to examine the nature and amount of treatment
received relative to the pattern and severity of the problems presented by
patients in each of the program samples. Thus, in the remainder of the chapter,
we present the results of within-group comparisons separately for each sample
as a means of characterizing the nature and amount of improvement shown.
Within the area of substance use, the Table 3 data indicate that both the
private and the public program groups showed significant reductions in the
severity of their drug problem composite scores, due primarily to reductions in
the frequency of cocaine use. In addition, both groups showed reductions in
alcohol composite scores, in the frequency of any alcohol use, and in the
frequency of alcohol to the point of intoxication (three drinks or more per
sitting).
The two groups showed different types of change in the second outcome
domain-personal health and social function. Again, the public program group
had generally more severe problems in all the areas examined, but, with the
exception of the employment composite score, there was little indication of
improvement at the 6-month follow-up in the six items that were used to
measure this domain. In contrast, the private treatment group did show some
significant reductions in the ASI medical, psychiatric, employment, and family
composite scores and in the single item examples from each of the problem
areas, possibly because these problems were so much less severe than those
Table 3
Pretreatment to Posttreatment Changes in Substance Abuse Patients
Treated in Public and Private Programs
Public Programs Private Programs
Baseline 6 Months Baseline 6 Months

Problem Measure a (n = 619) (N = 619) (N=412) (N = 412)
Outcome domain #l-Reduction in alcohol and drug use

Drug composite score .240 .115 .138 d .027
Days opiate use 2
Days stimulant use 9 5 5
Days depressant use 2
Alcohol composite score .539 .175 .451 d .124
Days alcohol use 14 8 15 d 3
Days drank to intoxication 13 5 14 d 2
Outcome domain #2-lncreased health and personal function
Medical composite score .254 .261 .131 .092
Days medical problems 6 7 3 2
Psychiatric composite score .288 .293 .139 .094
Days psychiatric problems 9 9 6 3
Employment composite score .669 .609 .344 .261
Days worked in past 30 9 10 13 17
Employment income $411 $489 $787 $1181
Family compositie score .441 .413 .187 .121
Days family conflicts 6 5 3
Days social conflicts 3 2 2
Outcome domain #3-Reduction in public health and safety problems
Shared needle/syringe 21 % 9% 3% 3%
Had unprotected sex 34% 29% 24% 11%
Legal composite score .369 .247 .046 .009
Days illegal activity 6 3 I I
Illegal income $246 $212 $57 $14
aAll measures derive from AS! interviews covering the 30 day periods prior to baseline and 6-month follow-
up. bp < .05. cp < .01. dp < .001 by paired t-test.
seen among the private program patients, and possibly because they received
slightly more services in these areas than did the public patients.
With regard to improvements in public health and public safety measures,
there was again evidence of significant improvement in both groups. The
public treatment group showed significant reductions in needle sharing, in the
ASI legal composite score, and in days of illegal activity. The private program
group showed substantially less criminal and AIDS risk behavior than the
public program group at the start of treatment. Still, these patients showed
significant reduction in unprotected sex and in the legal composite score at the
time of the follow-up.
In summary, there were pervasive improvements shown by both groups
from admission to follow-up in the target problems of alcohol and drug use and
in the addiction-related problems of crime and the spread of infectious diseases.
The private program patients also showed improvements in personal health and
social function. It should be clear that although the changes noted were statis-
tically significant, we do not suggest that treatment caused the observed
changes, as there was no untreated control group available for comparison.
DISCUSSION
We have argued that serious public health and safety problems coexist
with, and have been attributed to, alcohol and drug use problems and that these
"related" problems have been a major impetus for substance abuse treatment
referral. Consistent with this argument, we found that at least 75% of the
substance-abusing patients admitted to treatment in our sample of 1,031 pa-
tients from 31 programs had been referred by the criminal justice system, an
employer, a social service agency, or a concerned family member because of
problems in the areas of crime, employment, or family relations. Further, and
also consistent with this argument, we found that a majority of these patients
reported serious problems in the areas of health, employment, family relations,
crime, and/or family relations as well as alcohol and drug use at the admission
interview.
We argued further that among the more important expectations of "effec-
tive" substance abuse treatment is that it will produce reductions in these
serious public health and safety problems. From our examination of the nature
and focus of treatment in these programs, there was substantial and appropriate
attention paid to the alcohol and drug use of these patients. In fact, the drug-
and alcohol-focused services that are the hallmark of most contemporary
treatment programs (group therapy, individual counseling for drug and alcohol
use, AAlNA, relapse prevention, etc.) were provided in very similar amount in
both the public and private programs and in both inpatient and outpatient
settings. However, there were very few services provided for the employment,
crime, health, psychological, or family problems that were so apparent in these
patients and that were so often the impetus for treatment referral. This "mis-
match" of problems and services was particularly striking among the generally
more severe public program patients, but it was also quite evident among
private program patients.
Apparently the target problems of alcohol and drug use were effectively
addressed across all the programs sampled, since comparisons of the months
prior to admission and 6-month follow-up in these patients revealed a 60%
reduction in days of alcohol use, over 70% reduction in days of alcohol
intoxication, and over 60% reduction in days of cocaine use. These improve-
ments were seen in both the public and private treatment samples. The outcome
results also indicated smaller but important improvements in some of the
public health behaviors that were directly linked to substance use, such as
needle sharing and drug-related crime. These findings are not new or unusual
and are similar to findings from a range of national treatment evaluations
conducted over the past decade (Ball & Ross, 1991; Gerstein & Harwood, 1990;
Hubbard, Marsden, Rachal, Harwood, Cavanaugh, & Ginzburg, 1989; Institute
of Medicine, 1990).
Unfortunately, the public program patients did not show evidence of
improvement in medical status, psychiatric function, family relations, or em-
ployment, although the private program patients did show some significant
gains in these areas. It seems likely, since even the private patients did not
receive many services in these areas, that personal health and social function
problems of the private program patients were more directly linked to the use of
alcohol and street drugs, and/or that since their "related" problems were so
much less severe than those of the public patients, even the relatively meager
number of services offered was adequate to produce some benefit in those areas
for those patients.
We consider improvements in these areas of personal health and social
function to be very important for several reasons. First, as has been argued at
the outset, these "addiction-related" problems are typically the major reason
for referral to treatment. We feel that the public has come to expect improve-
ment not only in substance use but also in the range of important alcohol- and
drug-related problems that are major concerns to society and significant cost.
Perhaps more importantly from the perspective of the patient, improvement in
the personal health and social function domain is often critical to the mainte-
nance of gains in the substance abuse problem area following treatment
(McLellan, Alterman, Metzger, et al., 1994). Put simply, even those patients
who show abstinence from substance use following treatment-but continue to
have unresolved employment, medical, family, and/or psychiatric problems-
are at significant risk for early relapse (Gerstein & Harwood, 1990; Hubbard,
et ai., 1989; Institute of Medicine, 1990; McLellan, Alterman, Metzger, et ai.,
1994). Thus for both the long-range goals of society and the individual goals of
the patients, it will be important to develop treatment strategies that can be
effective in addressing the personal health and social function of treated
substance abuse patients.
ILLUSTRATING THE RELATIONSHIPS BETWEEN SUBSTANCE

USE AND PUBLIC HEALTH PROBLEMS: CASE EXAMPLES
To illustrate these conceptual issues graphically, we present the histories

and admission problems of two patients treated at the Penn-VA Center for
Studies of Addiction.
Case #1-The Addicted Physician
This individual was a physician who had a very serious opioid addiction
problem-pharmaceutical quality opiates injected three to five times daily
over the past 5 years. He was self-referred into treatment following a prolonged
period of shame about his condition and an abiding fear of being caught. While
the opioid use was a very serious problem, he had many assets in other areas of
his life, including a successful career in which he had managed to hide his
addiction quite well and had avoided having the addiction compromise his care
of patients. He also had a caring and supportive family, no significant medical
problems, and no history of criminal behavior. At the time of admission, he had
some symptoms of depression and anxiety associated with his secretive and
embarrassing lifestyle and had been drinking more heavily during the past year.
At the same time, it was clear that the problems of heavy alcohol use and
depression would likely show significant improvement or outright elimination
if the opiate addiction were treated successfully.
This patient was treated using a combination of pharmacological and
psychosocial interventions. He was detoxified over a 2-week period and in-
ducted onto the opiate antagonist naltrexone (Trexan), which blocked his
ability to feel the euphoric effects of opiates. Following this stabilization phase
(approximately 45 days), he was offered and accepted family therapy to resolve
some additional, contributing problems in his relationships. He was also re-
ferred to a physician's support group that met weekly to discuss problems in
recovery and in confronting relapse-provoking situations. Though he did not
attend more than four of these sessions, he remained on naltrexone for the
recommended duration of I year and continued active participation in family
therapy. At I-year follow-up he had had no "slips," and, though he was
somewhat anxious about discontinuing the naltrexone, he was also confident
that he had developed appropriate relapse prevention skills, especially since he
had taken a more administrative position at the hospital where he practiced,
which had reduced his exposure to some of the relapse-provoking situations.
Prognosis here was good from the start. At the same time, the treatment plan
addressed the significant "associated" problems presented, and there was good
compliance with that plan. With the combined efforts of the patient in follow-
ing the treatment plan as well as the supportive efforts of his wife and family,
his continued adjustment is likely to remain good-even if there are some
relapses along the way.
Case #2-The Pregnant, Addicted Teen
A dramatically different example of drug addiction was presented by a 17-

year-old woman whose addiction to crack cocaine became obvious during her
prenatal care at a general medical clinic. The young woman was referred to
substance abuse treatment by the medical clinic but had also been facing
pressure to "clean up" from her family and her probation officer. She had been
using crack cocaine approximately twice per month for the past 2 years. During
the 3 months prior to her treatment, these use periods had become 2-day binges
that involved multiple administrations. In addition, she had begun to drink
heavily during and particularly following the cocaine binges.
At the time of referral to treatment it was clear that beyond the medical
complications associated with her pregnancy, she had a sexually transmitted
disease (syphilis) and had begun to show signs of malnutrition, partly due to
neglected diet and partly due to the effects of the cocaine. She had not
completed high school and had almost no work experience or employable
skills. There were also looming financial problems occasioned by the preg-
nancy, and she was under state probation for two arrests for drug possession
and distribution. Following the criminal conviction, her aunt had asked her to
leave, and, at the time of the evaluation, she had been living with friends and
various relatives, though none could offer her stable residence. Not sur-
prisingly, this young woman had been experiencing severe symptoms of de-
pression, shame, anxiety, and confusion associated with her living situation.
This young woman was referred to inpatient care because of the inade-
quacy of her living situation, the medical complications of the pregnancy and
malnutrition, and the associated symptoms of depression. Following stabiliza-
tion of the primary physiological and psychological symptoms of cocaine
cessation in an inpatient setting (5 days), she was transferred to outpatient care
at a site near her home. Because of a very supportive relationship with the
medical and nursing staff at the prenatal clinic, she continued prenatal care and
delivered a healthy baby girl, whom she placed into adoption. Concurrent with
this and for 3 months following the delivery, she engaged in the group-oriented
treatment, eliminating all cocaine use and reducing alcohol use substantially.
While she received abstinence-oriented substance abuse treatment and some
continuing medical care, she did not receive vocational, legal, family, or psy-
chiatric services for her problems in these areas. She did not have sufficient
funds from the Medicaid and public assistance grants to support herself and
continued drug sales as a means of supplementing her income. She was arrested
a third time and lost the support of her aunt and grandmother. This produced a
profound depression and a suicide attempt through alcohol and cocaine over-
dose. The long-term outcome is unknown, as she dropped out of the treatment
program, has not been in contact with any of her family, and is presumed to
have returned to crime and drug use.
Two points are important in considering these cases. First, it is possible to
get very different impressions of the severity of the addiction problems of these
two cases depending on one's definition of the addiction syndrome. If the
addiction is considered solely in terms of the nature, intensity, and severity of
the substance use pattern, it is clear that the addicted physician had the most
severe substance abuse problem due to the IV pattern of drug use and the
greater frequency, intensity, and duration of use. However, if addiction is
considered in terms of the full range of conditions that may have led to, resulted
from, or co-occurred with the drug use, then it is clear that the young pregnant
woman had a much more severe syndrome, because of the extreme severity of
the social, legal, and medical problems "associated" with the addiction.
Though both treatments had an equal and successful acute effect on the
primary substance use patterns of the two patients, there were very different
effects on the "addiction-related" problems of the two cases. In both of the
cases presented the use of the problem drug was stopped at admission and full
"detoxification/stabilization" was accomplished. The addicted physician had a
relatively late onset of his addiction and had developed and maintained a
number of significant supports, including a career and a supportive family.
Further, several of the "associated" problems seen in the addicted physician
truly were directly associated with the substance use and may have shown
improvement with abstinence alone. However, he complied with a treatment
plan that provided targeted additional services for his complicating problems of
depression and family problems. The good prognosis for this patient was thus
due to a combination of factors, including the successful response to the drug-
focused treatment, the availability of services for the associated problems, and
the presence of significant personal and social supports.
The situation presented by the cocaine-abusing woman was very different.
In her case the substance use had begun at an early age, prior to the develop-
ment of significant personal skills or social supports. Many of the "associated
problems," though exacerbated by the substance use, were not causally related
to the cocaine and thus could not be expected to show maintained improvement
from abstinence alone. Nonetheless, it seems clear that even though the cocaine
use was not responsible for the origination of the psychiatric and employment
problems of this patient, these serious and unresolved problems were signifi-
cant contributors to the reoccurrence of the cocaine problems following treat-
ment. In this regard, it was unfortunate that the combination of social skills
training and supported sober living that may have directly addressed the
important complicating social problems of this young woman and thus main-
tained the good initial response to the addiction problem were not available or
accessible.
In summary, we suggest that the group data and the individual case
examples combine to argue that the maintained reduction in primary symptoms
of substance use will almost always be necessary but rarely sufficient to reduce
many of the public health and public safety concerns that often lead to relapse
and retreatment and that the "value" of substance abuse treatment will only be
achieved if the public health and public safety problems of these patients are
addressed directly and potently over an extended period of time, concurrent
with the "drug-focused" care that is typically provided.
STRATEGIES FOR ACHIEVING THE PUBLIC HEALTH AND

SAFETY BENEFITS OF SUBSTANCE ABUSE TREATMENTS
Many treatment providers have come to believe that substance abuse

treatment should be charged only with the reduction of the primary symptoms
of alcohol and drug use. As seen from the data presented, the services provided
appear to be directed primarily and sometimes exclusively at this goal. Further,
as pressures to contain costs of healthcare increase and as managed care
organizations respond to these pressures by reducing the intensity and duration
of treatment episodes and the availability of supportive services, it is likely that
this model of care will be even more prevalent. Ultimately we believe that this
narrow, symptom-specific focus is not, by itself, consistent with the expecta-
tions of the public, the payer, or even the patient and that there is a need for the
addition of professional health and social services concurrent with alcohol- and
drug-focused counseling to achieve lasting reductions in substance use and
broader public health and safety gains. Thus, we offer below three organization
and financing suggestions for consolidating and managing these services to-
ward the goal of expanded public health and safety benefits. While we admit at
the outset that none of these suggestions is particularly novel or imaginative,
each is reasonable and feasible with measurable outcomes.
One strategy for providing more adjunctive services for these patients
would be to retain the exclusively drug-focused strategy currently found
among so many substance abuse treatment programs but also to develop
collaborative institutional relationships between substance abuse treatment
programs and the social service agencies that now account for so many of the
referrals to substance abuse care, including the criminal justice system, hospi-
tals and psychiatric clinics, and welfare and public housing agencies. In this
"institutional network" model of care, a substance-abusing patient would have
a primary caseworker at the treatment program who would have the ability and
authority to access supportive services from the appropriate social agencies to
provide a coordinated network of services. There have, of course, been efforts
to formally coordinate the care and delivery of services among agencies, the
Target Cities Programs being perhaps the best examples of a national effort
(Center for Substance Abuse Treatment Annual Report to Congress, 1994). At
the same time, it is well known that increases in the complexity of a treatment
plan and/or distance between services lead to significant reductions in patient
compliance and early drop-out. In addition, the majority of public service
agencies are heavily weighted with administrative, financial, and political
problems that make true interinstitutional collaboration difficult to achieve.
A second model of care directed at enhancing and coordinating the
spectrum of services needed to achieve the public health expectations of
substance abuse treatment would be to provide adjunctive alcohol- and drug-
focused treatment on site within the agencies that now refer so many patients to
separate treatment programs. The availability of on-site drug and alcohol
counseling could offer the possibility of more integrated and coordinated care
for the patients and may be particularly useful for specialized agencies where
drug and alcohol use is linked directly and causally to failures in the interven-
tions of that agency. For example, prenatal clinics and probation/parole offices
are obvious agencies that could benefit from the provision of on-site care, and
there are important indications that such combined approaches can work
(lnciardi, 1988; Kilbey & Asghar, 1992; Rua, 1989; Wexler, Falkin, & Lipton,
1988). At the same time, as was seen in the group data presented and in the
individual case examples, many of these patients have multiple needs, and
simple substance abuse counseling may not be adequate to overcome the other
impediments to rehabilitation.
The converse of offering alcohol- and drug-focused care in social service
agencies is to expand and enhance the medical and social services available to
patients within substance abuse treatment programs. We believe this is the
most practical, achievable, and potentially cost-effective approach to the goal
of enhancing the public health and safety value of substance abuse treatment.
This has already been accomplished in a number of treatment programs and
treatment systems, such as the Department of Veterans Affairs, through enhan-
cement and professionalization of the services available within existing sub-
stance abuse treatment programs and through developing clinical case manage-
ment strategies to ensure that these services are accessible to the patients and
actually provided by the staff. This approach may only be appropriate for
treatment programs that have a patient census large enough to make these
additional services financially supportable as well as an administrative capa-
bility to coordinate the expanded level of service delivery. Many current
hospital-based treatment programs have the necessary range of service compo-
nents for such a system but rarely have the centralized administrative coordina-
tion required to make the system functional. While many of these larger
programs now employ several "certified addictions counselors," it would be
possible to reduce the number of those staff through attrition and to replace
them with healthcare workers with specialized experience in needed areas. For
example, it might be possible to hire line staff with experience in coordinating
employment training or referral, family or couples counseling, violence or
aggression management, physician assistant training, or psychiatric case man-
agement. Of course, as in the treatment of most other chronic medical condi-
tions, there is a need to structure conditions to maximize patient engagement
into the treatment process and continued compliance with the treatment plan
(Higgins, Budney, Bickel, Foerg, Donham, & Badger, 1995; Hunt & Azrin, 1973).
This third strategy example is not merely a hypothetical suggestion, as
there is evidence from many clinical research and program evaluation studies
that professional couples and family therapy (McCrady, Noel, Abrams, Stout,
Nelson, & Hay, 1986; Stanton & Todd, 1982), individual psychotherapy and
psychopharmacology (Carroll et aI., 1994; McLellan, Arndt, Woody, &
Metzger, 1993; Woody, Luborsky, McLellan, & O'Brien, 1983), job training
(French, Dennis, McDougal, Karountzos, & Hubbard, 1992; French, Rachal,
Harwood, & Hubbard, 1990), and medical care services (Fleming and Barry,
1992; Schonberg, 1988) can be incorporated into existing substance abuse
treatment programs; that these services are accepted and utilized by a majority
of patients; and that the addition of these services can provide substantial and
enduring benefit measured in terms of improvement in public health and safety
problems of these patients.
In conclusion, we have argued that the public, the payers, and the patients
themselves have come to expect that substance abuse treatment will be effec-
tive in reducing the public health and public safety problems that are so
common among alcohol- and drug-addicted individuals. Our examination of
samples of patients admitted to public and private treatment programs substan-
tiates that as many as 75% of these patients were referred to treatment on the
basis of an "addiction-related" health or social problem. At the same time, our
examination of the treatments provided by these public and private treatment
programs revealed a narrow range of drug- and alcohol-focused services that
were only minimally appropriate to the public health and safety concerns of
society in general, or of those agencies that had made the referrals. These
aggregate data and the individual case examples illustrated how drug- and
alcohol-focused education and counseling are necessary but are rarely suffi-
cient to achieve these broader public expectations, especially when the link-
ages between the substance use and the "associated problems" are complex
and multidetermined. Nonetheless, we believe that the society should expect
more from substance abuse treatment-and that there are several cost-effective
strategies that can be applied to broaden the patterns and deepen the quality of
services to achieve the public health and safety potential of substance abuse
treatment.
ACKNOWLEDGMENT. This work was supported by grants from NIDA, NIAAA,

and the VA.
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CHAPTER 7
Drug Policy and the

Enhancement of Access
to Treatment
JOSEPH V. BRADY
INTRODUCTION
The critical role of effective treatment in drug policy has been strongly empha-
sized in several recent studies of both national and international scope (Ed-
wards, Strang, & Jaffe, 1993; Falco, 1992; Reuter, 1993). Among the most
important factors that determine the effectiveness of treatment programs as
countermeasures to drug dependence and abuse are the accessibility of essen-
tial services and the maintenance of patient contact with those services (Ball &
Ross, 1991; Hubbard, Marsden, Rachal, Harwood, Cavanaugh, & Gainsburg,
1989; McLellan, Luborshy, Cacciola, Griffith, McGahan, & O'Brien, 1985;
Simpson & Sells, 1982). A major impediment to the establishment, mainte-
nance, and expansion of treatment services for drug abusers, however, is
identifying accessible sites where programs can be offered.
Inner-city treatment programs, especially those non-hospital-based out-
patient facilities for reducing intravenous (IV) drug abuse and the spread of
JOSEPH V. BRADY· Behavioral Biology Research Center, Hopkins Bayview Research Campus,
Johns Hopkins University School of Medicine, Baltimore, Maryland 21224-6823.
155
156 JOSEPH V. BRADY
AIDS, are saturated. More money will not necessarily permit these programs
to deliver more services. Yet it is becoming exceedingly difficult to find
locations to provide these essential services to drug users who are being
pressured to seek treatment by stepped-up law enforcement activity or newly
initiated outreach programs aimed at reducing IV drug abuse and the spread of
AIDS. Neighborhood and community organizations are increasingly less toler-
ant of indigenous "drug programs" despite the likelihood that those who
would benefit most from the programs are individuals who live in the very
communities that oppose the establishment of such clinic facilities.
One recent approach to enhancing access to drug abuse treatment is based
on the now confirmed fact that, in general, communities find it less objection-
able to have such services offered from mobile health units. Several years ago
in The Netherlands for example, a mobile methadone treatment program was
developed in response to the needs of a population of heroin users from the
former Dutch colony of Suriname. Faced with the familiar difficulty of having
a stable clinic building accepted by the Amsterdam neighborhoods, two mobile
bus-like clinics were commissioned to cruise the city, stopping at a total of six
different locations daily between the two vehicles. As described in a brief
report by Buning, VanBrussel & VanSanter (1990), the initiative was a product
of drug policy based upon "harm-reduction" principles (i.e., in the absence of
a "cure" for hard drug use, attempts should be made to at least minimize the
harm caused to the individual and the environment). Liquid methadone was
dispensed and consumed on the spot, and clean needles and condoms were
made available. A central methadone registration required of all Amsterdam
programs prevented double prescriptions, and clients could graduate to higher
threshold methadone programs as soon as they refrained from the use of illegal
drugs. In the absence of a counseling component, however, the reported
outcomes from contacts with many thousands of drug abusers suggest that
relatively few of the Amsterdam methadone bus clients "graduated" to the
more stable, "higher threshold" programs.
An additional development in the use of mobile methadone-dispensing
units by drug abuse treatment programs has been undertaken in the state of
Massachusetts. The service provider, the Habit Management Institute, is based
in the city of Boston and uses a converted Winnebago mobile home to transport
and dispense the medication to the Brocton, Lakeville, and Quincy suburbs of
the city. Although there have been no published descriptions of the program,
personal communication and on-site inspection has revealed at least some of
the procedural details. The vehicle travels between three and four locations
each day, remains for approximately 2 hours, and serves approximately 50
patients at each location. The mobile unit functions solely as a medication
dispensary and is available only to patients with a previously determined
ACCESS TO TREATMENT 157
commitment to treatment who would otherwise be required to travel some

distance to obtain their daily medication. Patients must be identified with
picture I.D. cards before admission to the mobile unit, and noncompliant or
unresponsive patients are referred back to more stable comprehensive treat-
ment programs. There are, however, no data available on the extent to which
the mobile unit has effectively enhanced recruitment and retention of the
indicated treatment populations.
In the city of Baltimore, where the most recent Mobile Health Service
approach to the treatment of drug abuse has been undertaken, it is estimated
that there are between 30,000 and 40,000 intravenous drug abuses, some
25,000 cocaine abusers, and 70,000 alcohol-dependent individuals. There is of
course substantial overlap across these populations, and the problem is further
complicated by the fact that between 30% and 40% of the AIDS victims in the
city of Baltimore report drug use as a corisk factor. Based on a pouplation of
750,000 (swelling to well over I million during the work day), it is estimated
that 1 in 10 Baltimoreans has a substance abuse problem, but less than I in 20 of
the substance abusers can be accommodated by the existing treatment system.
In recent years, for example, less than 5,000 treatment slots have been available
to service this burgeoning substance-abusing population, and almost 20 years
have passed since a new methadone clinic was established in Baltimore City.
In confronting the obvious need to expand drug abuse treatment and
respond to the concerns that drive community resistance to the opening of drug
abuse clinics, a demonstration of the feasibility of a Mobile Health Service
approach was undertaken in the city of Baltimore (Brady, 1993). This was
accomplished by parking such treatment units temporarily a few hours each
day at agreed-upon locations (e.g., church parking lots, city-owned facilities)
and limiting the time at each location by appropriate scheduling (e.g., avoiding
school passage times). In addition to methadone medication and counseling for
intravenous opiate abusers, the mobile units were designed to offer additional
health services to the community (e.g., blood pressure screening, diabetic
evaluations) to ensure that the program was legitimately viewed as a health
initiative.
Quite apart from the issue of feasibility as a means of responding to
community concerns, mobile units open the possibility of addressing certain
policy-related issues associated with length of stay and success in drug treat-
ment. It is now generally accepted that, for opioid dependence at least, time
spent in treatment is an important variable in determining outcome (Anglin,
Hser, & Booth, 1987; Ban & Antes, 1981; Deleon, 1985; Fisher & Anglin, 1982;
Hubbard et aI., 1989; Simpson & Sells, 1982). Patients who spend fewer than
90 days in treatment appear to fare considerably less well than those who stay
longer on most outcome measures. Furthermore, in some studies (e.g., McLellan
158 JOSEPH V. BRADY
et aZ., 1985) patients remaining fewer than 90 days appear to be worse off at
follow-up than they were at entry into treatment. A number of investigations
are exploring ways to increase length of time patients remain in treatment in
various modalities. In outpatient programs, key variables appear to be staff
skills, leadership, program morale, staff training, and, for those programs using
methadone, the dose of methadone (See Alleson, Hubbard, & Rachal, 1985;
Ball, Corty, Petroski, & Comasello, 1986; Ball, Lange, Myers, & Friedman,
1988).
Another policy-related issue that is probably of importance, but that has
never been systematically evaluated, is the response effort of remaining in
treatment. Response effort refers to the overall costs to the individual of
complying with the program requirements. Such costs include, in addition to
any economic out-of-pocket monetary expenses, those costs that are measured
in time required to get to and from the site of treatment, waiting time at the
program, and time spent in actual treatment. In a recent report, for example,
Condelli (1994) confirmed that clients are more likely to remain in treatment
programs that are easily accessed. Moreover, the savings in travel time may
also result in reduced opportunities for drug-related diversions on the way to
more distant treatment sites. Although the latter may well have direct benefits,
the time invested must also be seen as time taken from other perhaps even more
rewarding pursuits. Other costs include any side effects of medication involved
in the treatment and the distress that comes from examining one's own current
shortcomings and past failures and misdeeds. Taken together, the costs of treat-
ment from the patient's perspective may be quite high even when the treatment
cost measured in out-of-pocket monetary terms is negligible. Furthermore,
these costs are competing, at least in the early stages, with the memories of
drug-induced euphoria and/or anxiolytic effects.
The relevance of the Mobile Health Service initiative to drug policy can
thus be seen to reside in the harm and use reduction objectives of a close-to-
home approach that enhances accessibility to and retention in treatment by
minimizing travel time and dependence upon transportation without increasing
the risk of diversion.
PROGRAM IMPLEMENTATION
Two separate inner-city regional divisions in eastern and northwestern

Baltimore were selected as sites for implementation of this mobile drug abuse
treatment project (Besteman & Brady, 1994). The selection was based on the
ranking of these communities among the geographic localities with the highest
number of individuals admitted to treatment for substance abuse problems in
the city. Over the period of I year, an extended series of personal contacts and
organized meetings with key persons involved in community activities and
health service delivery ensured an essential degree of community knowledge
and support for the goals and objectives of the project as well as for the Mobile
Health Service procedures. Selection of the sites for temporary parking of the
vehicles was determined only after extensive consultation and agreement with
the Baltimore planning and zoning department, local legislators, healthcare
providers, community leaders, and especially local clergy and church groups,
whose assistance proved invaluable in this sensitive process. As a result,
several sites were identified in both the eastern and northwestern Baltimore
City localities, and the project vehicles were introduced to the community
during several "open house" visitations to each site.
During this extended community outreach period, the design and con-
struction of medication vans and counseling trailers were undertaken with the
assistance of a local supplier of recreational vehicles. Figure I shows one of the
two 25-foot Newport motor homes that were custom modified to serve as self-
propelled mobile medication dispensing-units. In addition to a secure nurses'
station with a medication safe and dispensing window, each vehicle was
Figure 1. Converted 25-foot self-propelled Newport motor home that served as a medication
dispensing van.
160 JOSEPH V. BRADY
equipped with a lavatory, a small patient waiting area, and an elaborate security
alarm system. Figure 2 shows one of the two 31-foot Newmar travel trailers that
were custom modified to serve as counseling and general health service units.
Each trailer contained two private individual counseling and examination areas
separated by a larger centralized group meeting/waiting area, all with appropri-
ate furnishings for seating and notetaking as required. A back-up unit was
provided by a 19-foot Coachman motor home custom modified in a manner
similar to the two Newport motor homes to serve as a self-propelled mobile
medication dispensing unit when required.
In order to obtain the necessary approvals and licensing to dispense
methadone, stringent requirements established by federal regulatory agencies
had to be satisfied. Not unexpectedly, the initial response of both the Food and
Drug Administration (FDA) and the Drug Enforcement Administration (DEA)
to the mobile methadone treatment proposal was less than enthusiastic. In
addition to the usual concerns about diversion and the patients becoming an
additional source of illicit methadone on the streets, the DEA agents expressed
particularly strong reservations about the plan to drive medication vans sup-
plied with methadone into the kind of neighborhoods we had identified. Under
Figure 2. Converted 31-foot Newmar travel trailer that served as a combination counseling and
general health service facility.
the circumstances, it took considerable negotiation to convince the agency

representatives that their job was to set the security standards and ours was to
meet them in accordance with extant regulations and safeguards deemed
essential for this admittedly unconventional approach to drug abuse treatment.
As a result, the medication vans required extensive modification to include
placement of a safe that was bolted and welded to the vehicle frame, construc-
tion of a nurses' station secured with heavy bulletproof Plexiglas to prevent
patient intrusion, and installation of a sophisticated security alarm system that
alerted both the local police and a private contact security agency in case of
emergency. In addition, provisions were made for the vehicle drivers to be
armed and licensed security officers.
A home base for the Mobile Health Service was established at the
Bayview Medical Center of the Johns Hopkins University School of Medicine
in Baltimore. All medications were stored in an approved security facility at
this site, with no drugs permitted to remain on the mobile vehicles beyond the
scheduled dispensing hours. In addition, a facility for initial screening and
medical evaluation of newly enrolled patients was provided in the building that
housed the rapid medical intake program of the Baltimore City Addict Referral
and Counseling Center.
Several weeks in advance of enrolling the first patients into treatment, the
trailer units alone were used to introduce the Mobile Health Service in accor-
dance with the site location schedules for the eastern and northwestern regional
divisions. Without the accompanying medication vans, project personnel on
the trailers responded to community inquiries about the program, explained the
nature of the services that were to be provided, and distributed printed material
on prevention measures, referral sources, and other health-related information.
In addition, the nursing staff on the trailers offered screening tests for hyperten-
sion (blood pressure measures) and diabetes (blood glucose determinations) to
interested individuals. During this period, staff training was also undertaken to
ensure proficiency in the use of intake evaluation forms and the data manage-
ment system for maintaining program records and generating necessary reports.
The implementation of effective information management procedures
required mobile treatment staff to carry laptop computers containing a database
providing access to essential patient records, including physicians' medication
orders and administrative notes as well as doses dispensed, patient absences,
and reporting forms. Daily transfer of laptop information to a workstation
computer accessed a local area network that refreshed the database and added
administrative and demographic information on new patients. A dedicated on-
screen file facilitated individual counselor record keeping (i.e., urine surveil-
lance, blood alcohol concentration, etc.), scheduling of appointments, group
attendance, and the development of customized treatment plans.
162 JOSEPH V. BRADY
TREATMENT METHODS AND PROCEDURES
The treatment program was designed to permit an evaluation of the

feasibility and effectiveness of drug abuse treatment provided within the
Mobile Health Service context. In keeping with these objectives, one treatment
unit (medication van and counseling trailers) was located at a single centralized
site in the eastern regional division of the city, where it remained stationary
throughout each day. A second treatment medication and counseling unit
circulated between three or four different locations in the northwestern regional
division of the city each day. After some 18 months of operation under these
conditions, a crossover procedure was introduced, with the eastern regional
division treatment unit circulating between three or four locations in that same
division each day, while the northwestern regional division treatment unit
remained stationary at one centralized site in that division throughout each day.
Admission for treatment required participants to have a verifiable I-year
history of intravenous opioid abuse and dependence and to have attained a
minimum age of 18. Following the initial screening interview, the Individual
Assessment Profile and a physical examination, including urinalysis and other
laboratory tests, were completed. Upon acceptance into the program and
completion of the informed consent procedure, a picture LD. was prepared for
each patient and assignment was made by zip code to a mobile health treatment
unit. A written order by the staff physician established the initial methadone
dose for each patient, and entry into the computerized data management system
provided the necessary information to the staff on the medication vans. Medi-
cation (methadone) was dispensed via solubilized diskettes by the Mobile
Health Service nursing staff upon picture LD. verification of the patient's
identity.
Urine specimens were obtained from each patient at least once per week,
and results on analyzed samples were returned to staff within 48 hours. Upon
acceptance into the treatment program and completion of two additional assess-
ment instruments (Beck Depression Inventory and the Symptom Checklist-
SCL90), a counselor assignment was made for each client. Collaboration
between the counselor and client provided the basis for establishing an individ-
ualized treatment plan including the development of both short- and long-range
goals that were behaviorally defined and specific. Each individualized treat-
ment plan was based upon the requirement that the patient ingest the estab-
lished does of methadone once each day for the duration of participation in the
treatment program. In addition, the clients participated in counseling sessions
scheduled at least once per week at the mobile trailer units. The weekly
counseling sessions served to identify specific objectives and to assign specific
tasks to enable the client to successfully attain the established treatment goals.
The counseling sessions also permitted periodic review and revision of the
individualized treatment plan as necessary and appropriate. Within the first few
weeks following admission to treatment, each patient completed a brief travel
questionnaire providing comparative data on the time and money expended to
attend the Mobile Health Service daily medication and weekly counseling
sessions versus the time and money expended to access these same services in
the client's previous fixed-site treatment program.
In keeping with a harm reduction program philosophy, the Mobile Health
Service focused on the maintenance of effective functioning rather than requir-
ing detoxification over the course of the study. Under such conditions, a
flexible approach to medication maintained methadone doses between 60 mg
and 80 mg whenever possible, since all the empirical evidence indicated that
patients are least likely to use intravenous opiates or drop out of treatment at
those doses. With regard to the management of noncompliant and misbehaving
patients, the emphasis on treatment retention as a major objective of the
program dictated a reasonable degree of tolerance to periodic, but not contin-
uous, drug and/or alcohol consumption. And while this "high-threshold"
approach did not expect to make "model patients" out of its clientele, it was
necessarily intolerant of belligerent and aggressive behaviors in the interest of
staff safety and the integrity of the Mobile Health Service. Finally, the avowed
aim of the counseling component of the Mobile Health Service treatment
program was behavior change as it related specifically to drug-seeking and
drug-taking performances. Despite the "high-tolerance" philosophy and pro-
file of the mobile treatment approach, participation in drug abuse counseling
was offered, strongly encouraged, and, with rare exceptions, required.
PROCESS AND OUTCOME EVALUATION
Both process and outcome studies were conducted to evaluate the fea-
sibility, implementation, and results of the mobile treatment intervention on
drug abuse and related measures. The process evaluation provided an account
of all the necessary steps required to initiate this complex undertaking. All
internal staff meetings and discussions as well as all meetings with external
individuals and groups were documented in a standardized written format and
communicated to the research evaluation team in an expeditious manner.
Essential baseline information against which to evaluate outcome measures
was incorporated into the individual assessment profile and on other client
information forms completed on each patient at intake and throughout the
course of treatment.
During the initial 3 years of operation, over 300 intravenous opioid
164 JOSEPH V. BRADY
abusers were admitted for treatment by the Mobile Health Service; the waiting
list for admission included well over 500. A substantial database was devel-
oped relevant to both accessibility and retention in drug abuse treatment under
such conditions. With regard to demographic characteristics, for example,
there were but few features that distinguished the Mobile Health Service
patients from those receiving outpatient treatment in more conventional inner-
city fixed site programs. These Baltimore intravenous opioid abusers were
predominantly African-American males (only 30% female), over 30 years of
age (90%), and mostly unemployed (over 80%). The Mobile Health Service
patients were self-referred for the most past (75%), and they appear to have had
somewhat fewer prior admissions to drug treatment programs (average less
than 2) than patients from the fixed-site treatment programs in Baltimore
(average 3 or more).
Figure 3 summarizes travel data from the reports of those patients who
had participated in other outpatient drug abuse treatment programs prior to
admission to the Mobile Health Service. Some 92% of these patients were
required to travel more than 10 minutes (average, 35 minutes) for each visit to
their previous program site; only 65% were required to travel that long (aver-
age, 26 minutes) to the mobile site. Figure 3 also shows a similar reduction in
travel cost, with 52% of the patients required to spend more than $1 (average,
$1.82) for previous program visits compared to some 35% required to pay that
much (average, $1.48) for travel to the mobile site. These results bear directly
on the issue of access and the overall cost of program compliance as determi-
nants of retention and treatment effectiveness.
A data set developed on patients who completed an interim assessment
after remaining in the program for 6-9 months provided a basis for evaluating
more directly the effectiveness of the Mobile Health Service approach to drug
abuse treatment. This data showed that there was a consistent decrease in illicit
drug use, particularly opiates, between intake and interim assessment, as
reflected in both self-report measures and urinalysis test results. Reported
illegal activity and the amount of money spent on drugs also decreased sharply
between intake and interim assessments, while legitimate employment in-
creased to at least some extent and general health status was reported to have
improved.
The scores of the Beck Depression Inventory (BDI) administered at the
time of admission to the program were analyzed in relation to reported drug
usage at both intake and interim assessments. The results summarized in Figure
4 show that the group with the highest BDI scores (31+) had the highest
percentage of monthly cocaine users (32% at intake, 23% at interim), while the
group with the lowest BDI scores had the lowest percentage of monthly
cocaine users at both intake and interim assessments. To the extent that these
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Figure 4. Percentage of patients reporting monthly cocaine usage in each of three Beck Depression Inventory scoring categories.
findings suggest the participant role of a comorbid condition that may influence
outcomes, there are clear implications for policy issues related to the integra-
tion of drug abuse treatment within the context of a general health service
delivery system (see Chapter 6, this volume).
In evaluating the effectiveness of any drug abuse treatment program,
retention rate is a factor of utmost importance. Figure 5 shows the percentage
of drop-outs (i.e., patients terminating treatment "against medical advice")
during the first year following admission to the mobile treatment program
(IBRlMHS) as compared to the percentage of first-year drop-outs from a model
fixed-site treatment program in the District of Columbia (TOPS-DCI) and from
several fixed-site outpatient programs combined, as reported in the NIDA-
sponsored Client Oriented Data Acquisition Process study (CODAPINIDA).
Over 50% of the patients from the CODAP programs and some 30% of the
TOPS patients had terminated treatment "against medical advice" within the
first year in comparison with a drop-out rate of only 15% for the MHS treatment
program. The enhancement of retention in drug abuse treatment by the Mobile
Health Service initiative is also reflected in comparisons of length of stay for all
discharges (including program transfers, hospitalization, incarceration, etc.)
during the first year following admission, as shown in Figure 6. Within the first
90 days following admission, for example, more than 65% of the first-year
discharges from the CODAP programs had taken place, while almost 80% of
the Mobile Health Service first-year discharges remained in treatment at that
3-monthjuncture. Clearly, the average number of days in treatment following
admission for all patients discharged from the Mobile Health Service within 1
year of admission can be seen to far exceed the average number of days in
treatment for the CODAP first-year discharges.
The comparisons shown in Figures 7 and 8 are of particular relevance,
since they bear upon the interrelated issues of retention and treatment effective-
ness. Figure 7, for example, shows that some 70-80% of the patients in the
Mobile Health Service (IBRlMHS) remained in treatment 9 months after
admission, compared to an approximate 30% retention rate for the District of
Columbia clinic (TOPS-DCI) at that 9-monthjuncture. When the two programs
were compared with respect to urinalysis results, however, Figure 8 shows that
the average percentage of "dirty" urines (i.e., positive for illicit drugs) for
those patients remaining in treatment over an I8-month period decreased to
well below 10% for the District of Columbia program (TOPSIDCI) but re-
mained at approximately 40% for the Mobile Health Service (lBRlMHS).
These findings suggest that the enhanced retention rate of the Mobile Health
Service may have been maintained in part at the expense of tolerating some
illicit drug use. The price of "clean" urines at the District of Columbia clinic,
60
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Figure 5, Percentage of patients who dropped out of treatment "against medical advice" at the indicated intervals during the first year '"»o
following admission to the Mobile Health Service (IBRlMHS), the single fixed-site model program in the District of Columbia (TOPS-DCI), -<
and the combined programs reported in the NIDA-sponsored Client Oriented Data Acquisition Process study (CODAPINIDA),
100 )-
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Post-Admission Intervals
Figure 6. Percentage of all patients discharged within 1 year who left treatment at the indicated intervals following admission to the Mobile '"<.C
Health Service (lBRlMHS) and to the combined Client Oriented Data Acquisition Process study programs (CODAPINIDA).
170 JOSEPH V. BRADY
100
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Months in Treatment
Figure 7 _ Percentage of patients remaining in treatment at each monthly interval during the first
year following admission to the Mobile Health Service (IBRlMHS) and the District of Columbia
program (TOPSIDCI)_
on the other hand, may have been an increased rate of treatment termination
"against medical advice," as the drop-out comparisons shown in Figure 6
suggest.
The programmatic comparisons detailed in this process and outcome
analysis call attention to important differences in treatment philosophy that are
of obvious relevance to the goals of drug policy_ The early abandonment of
treatment by those who fail to satisfy the abstinence demands of a program
based on a strong use-reduction philosophy is considered acceptable to the
extent that limited resources are thereby preserved for those individuals who
are able to comply_ By contrast, the less demanding goals of a program based
predominantly on a harm-reduction philosophy tolerates a degree of illicit drug
use in the interest of treatment retention, thereby attenuating the adverse
consequences of substance abuse for both the individual and the community_
Clearly, the policy choices involved must be based on an evaluation of the
short- and long-term costs and benefits of these alternative approaches to drug
abuse treatment.
100
_ IBRIMHS
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Months in Treatment
Figure 8_ Percentage of "dirty" urines (i-e., positive for illicit drugs) at each monthly interval for
patients remaining in treatment for 18 months following admission to the Mobile Health Service
(IBRlMHS) and to the District of Columbia program (TOPSIDCI).
POLICY RECOMMENDATIONS
The case for a mobile health service approach rests on the need to expand
drug abuse treatment and respond to the concerns that drive community resis-
tance to the opening of fixed-site clinics. A mobile delivery system can play an
important role in facilitating access to and retention in treatment as well as in
promoting the integration of healthcare services. The strength of the pioneer-
ing Amsterdam methadone bus model, for example, can be seen to reside in the
enhancement of access to street-level opiate abusers, facilitating entree into
treatment, and attenuating the spread of disease with clean needles and con-
doms. And the low-intensity Massachusetts model illustrates the importance of
retention in treatment in the interest of drug use reduction and improved
personal adjustment outcomes with relatively stable patients. From an even
broader perspective, an evaluation of the Baltimore mobile treatment program
(Brady, Besteman, & Greenfield, 1996) suggests that both entree and reten-
tion in treatment can be effectively enhanced within the framework of a
comprehensive program that integrates a range of community-based healthcare
services.
172 JOSEPH V. BRADY
Experience over the past several years in settings where strong, politically
charged community resistance threatened essential treatment expansion has
confinued that urban neighborhoods find it less objectionable to have drug
abuse treatment, including methadone maintenance, offered in the context of a
mobile health service. Both acceptance and support are enhanced by involving
community-based service providers in the treatment and coordinating of refer-
ral activities with existing mobile and fixed-site healthcare and social service
facilities.
In confronting the multiple needs of substance abusers, a mobile treatment
program can playa unique role because of its compatibility with both central-
ized and decentralized models of health services integration. Some mobile drug
abuse treatment approaches exemplify centralized models where clients re-
ceive medication, counseling, and healthcare at the same site, whereas others
follow decentralized models utilizing different sites for each of these services.
There are even some flexible and adaptable mobile drug abuse treatment
approaches that combine both centralized and decentralized functions. Under
any circumstances, the link between services (e.g., general health and/or men-
tal health) is strengthened as agencies gain comfort with and confidence in the
mobile modality as a stepping stone toward fully integrating drug abuse
treatment into a network of services.
A mobile program also has important advantages for administrators of
community-based health service programs. The program can be adapted in
ways that are consistent with an agency's mission, capabilities, and interests. A
health center can offer medical services and provide administrative support for
mobile units that dispense medication and conduct counseling. A substance
abuse agency with experience only in drug-free treatment can offer counseling
in conjunction with a medication-dispensing mobile unit. A rural community
where clinic attendance requires substantial response cost could facilitate
access by mobile treatment. And the mobile drug abuse treatment program has
many of the same advantages for a community-based health agency as those
perceived by the community at large (e.g., it is easier to operate on a trial basis,
the modularity of the mobile treatment facility make it easier to expand as
contract services, and it can serve as a stepping stone for achieving the
important goal of building a community-based capability for providing drug
abuse services.)
From a broader perspective, an effectively managed mobile program can
advance the cause of institutionalizing community-based drug abuse treatment.
Once the mobile program has become an accepted presence in the neighbor-
hood, it can function as an integral part of the community's infrastructure of
services. The several mobile sites in Baltimore, for example, have become the
focus of referral services by local clergy and other community leaders. Under
such circumstances, treatment is not only more accessible, but it is also

accepted as an integral part of the fabric of the community and can facilitate the
introduction of new and improved pharmacological treatment modalities as
well as expand the available facilities for treating a range of drug abuse and
dependence disorders. There is, of course, no clear and simple path to achiev-
ing these lofty goals, but the evidence emerging from existing programs
suggests that the mobile treatment approach may be an important step in the
right direction.
Beyond the issues of community acceptance and health services integra-
tion, there remain abiding concerns about the condition under which drug
abuse treatment can be most effectively provided. There is convincing evi-
dence that time spent in treatment is an important determinant of successful
outcome. And "response effort" or "response cost" (i.e., the time and money
spent to access treatment) has a demonstrably strong influence, since clients are
clearly more likely to remain in treatment programs that are easily accessed.
The low drop-out rates in mobile drug abuse treatment programs further reflect
one of the more important strengths of these innovative efforts to enhance
retention and improve effectiveness by facilitating access to treatment.
By virtue oftheir ability to overcome barriers to drug abuse treatment and
facilitate the integration of healthcare services, mobile drug abuse treatment
programs can penetrate areas of highest need and playa crucial role in respond-
ing to a public health crisis of alarming proportions.
REFERENCES
Alleson, M., Hubbard, R., & Rachal, 1. V. (1985). Treatment process in methadone, residential and
outpatient drug free programs. Rockville, MD: National Institute on Drug Abuse. Treatment
research monograph (Eds.) (DHHS Pub. No. AM-85 1388, pp. 1-89).
Anglin, M. D., Hser, J., & Booth, M. W. (1987). Sex differences in addict careers: Treatment.
American Journal on Drug and Alcohol Abuse, 13, 253-280.
Ball, J. C., Corty, E., Petroski, P., & Comasello, A. (1986). Medical services provided to 2,394
patients at methadone programs in three states. Journal of Substance Abuse Treatment, 3,
203-209.
Ball, J. c., Lange, w., R., Myers, P. & Friedman, S. (1988). Reducing the risk of AIDS through
methadone treatment. Journal of Health and Social Behavior, 29, 214-226.
Ball, J. c., & Ross, A. (1991). The effectiveness of methadone maintenance treatment. New York:
Springer-Verlag.
Ban, H., & Antes, D. (1981). Factors related to recovery and relapse infol/ow up (Final report of
project activities under NIDA Grant H81-DAO 1864 1981).
Besteman, K., & Brady, J. V. (1994). Implementing mobile drug abuse treatment: Problems,
procedures, and perspectives. In J. A. Inciardi, F. Tims, & B. W. Fletcher (Eds.), Innovative
approaches in the treatment of drug abuse, Vol. 2 (pp. 33-42). Westport, CT: Greenwood Press.
Brady, J. V. (1993). Enhancing drug abuse treatment by mobile health service. In J. A. Inciardi, F.
174 JOSEPH V. BRADY
Tims, & B. W. Fletcher (Eds.), Innovative approaches in the treatment of drug abuse, Vol. 1
(pp. 65-78). Westport, CT: Greenwood Press.
Brady, J. V., Besteman, K., & Greenfield, L. (1996). Evaluating the effectiveness of mobile drug
abuse treatment. In J. A. Inciardi, F. Tims, & B. W. Fletcher (Eds.), The effectiveness of
innovative approaches in drug abuse treatment. Westport, CT: Greenwood Press.
Buning, E. C., van Brussel, G. H. A., & van Santen, G. (1990). The "Methadone by Bus" project in
Amsterdam. British Journal of Addiction, 85, 1247-1250.
Condelli, W. S. (1994). Strategies for increasing retention in methadone programs. Journal of
Psychoactive Drugs, 25, 143-147.
Deleon, G. (1985). The therapeutic community. Status and evolution. International Journal of
Addiction, 20, 823-844.
Edwards, G., Strang, J., & Jaffe, J. H. (1993). Drugs, alcohol, and tobacco: Making the science and
policy connections. Oxford: Oxford University Press.
Falco, M. (1992). The making of a drug free America: Programs that work. New York: Times
Books.
Fisher, D. G., & Anglin, M. D. (1982). Survival analysis in drug program evaluation. Part 1. Overall
program effectiveness. The International Journal of the Addictions, 22, 115-134.
Hubbard, R.I., Marsden, M. E., Rachal, J. v., Harwood, H. 1. Cavanaugh, E. R., & Ginzburg, H. M.
(1989). Drug abuse treatment: A national study ofeffectiveness. Chapel Hill, NC: The Univer-
sity of North Carolina Press.
McLellan, A. T., Luborshy, L., Cacciola, J., Griffith, J., McGahan, P., & O'Brien, C. P. (1985).
Guide to the Addiction Severity Index: Background, administration, and field testing results.
Treatment research repon. Rockville, MD: National Institute on Drug Abuse.
Reuter, P. (1993). Drug policy: Recent lessons. Santa Monica, CA: RAND.
Simpson, D. D., & Sells, S. B. (1982). Effectiveness of treatment of drug abuse: An overview of the
DARP Research Program. Advances in Alcohol and Substance Abuse Treatment, 2, 729-742.
PART IV
The Psychology of Drug

Pol icy: Psychological
Assumptions behind Policy
CHAPTER 8
Examining the Behavioral

Assumptions of the National
Drug Control Strategy
ROBERT MacCOUN and JONATHAN CAULKINS
Understanding psychoactive drugs and their social impact is, and should be, an
interdisciplinary undertaking. But in recent years, psychologists have had
relatively little voice in the formation of our nation's drug policy. In saying this,
we do not mean to dismiss the important contributions that psychologists have
made to our understanding of the social and cognitive aspects of intoxication,
the etiology of addiction, and, most notably, the theoretical underpinnings and
empirical evaluation of methods of drug treatment and prevention, as docu-
mented in other chapters in this volume. But psychologists are conspicuous by
their absence from what a decade's worth of federal and state drug budgets
reveal to be the main arena of contemporary drug policy: drug law enforcement.
This is particularly unfortunate because contemporary American drug
enforcement policy is largely premised on a rational choice view of human
nature that is analytically attractive but psychologically implausible (Mac-
Coun, 1993). In this chapter, we sketch a framework for drug policy analysis
ROBERT MacCOUN • Graduate School of Public Policy, University of California at Berkeley,

Berkeley, California 94720, and Drug Policy Research Center, RAND, Washington, DC 20537,
JONATHAN CAULKINS· Drug Policy Research Center, RAND, Washington, DC 20537, and
Carnegie Mellon University, Pittsburgh, Pennsylvania 15213.
Drug Policy and HU/'lUln Nature: Psychological Perspectives on the Prevention, Management, and
177
178 ROBERT MacCOUN and JONATHAN CAULKINS
that better reflects existing psychological theory and research. We then use this
framework to predict consequences of policy changes for particular subpopula-
tions, to highlight areas of ignorance where new lines of psychological research
might make valuable contributions, and to argue for a new direction in U.S.
drug policy.
EFFECTS OF DRUG LAWS ON DRUG USE
In a 1993 Psychological Bulletin article, R. J. MacCoun reviewed and

analyzed the existing state of knowledge of the effects of drug laws on drug
use. He acknowledged the rational choice paradigm as the basic foundation of
contemporary drug policy, but attempted to expand and modify that paradigm
to make it more consistent with empirical research and psychological theory.
MacCoun (1993) identified seven mechanisms by which drug laws might affect
drug use and reviewed the available empirical evidence for each (see Figure
1).1 He then used this framework to examine the likely effects of two major
alternatives to contemporary drug prohibition: decriminalization (in which a
drug remains illegal but penalties for personal possession are reduced or
eliminated) and legalization (in which the possession and sale of a drug
become legal but are subjected to some form of regulation, such as the case of
alcohol).
Three of the mechanisms MacCoun (1993) examined are suggested by the
rational choice model. The first, fear of legal sanctions, is at the heart of
classical criminology's deterrence theory. In theory, this fear should be a
multiplicative function of the perceived certainty and severity of legal sanc-
tions, discounted by their celerity (promptness).2 A large body of literature
suggests that (1) the link between actual and perceived sanction risks is fairly
tenuous; (2) there is a modest but reliable inverse association between per-
ceived sanction certainty and drug offending, and the relationship appears to be
causal; (3) severity of sanctioning has little or no influence on offending, and
when increases in severity undermine certainty they are actually counter-
productive; and (4) individuals do not use sanctioning risk information in the
manner implied by rational choice models.
Two other rational choice mechanisms are the availability of a drug,
IMacCoun (1993) provides a much more detailed review of the relevant theory and research
supporting the conclusions summarized here.
2The function is multiplicative because it is hypothesized that severity should only matter to the
degree that sanctioning is likely to take place.
NATIONAL DRUG CONTROL STRATEGY 179
Legal System
Written laws
~
Enforcement
activities
Informal social _
control factors 1 - " - - - - - - - - - - - - - - /
Figure 1. Seven mechanisms by which drug laws influence drug use (from MacCoun, 1993).
Relationships are positive unless otherwise indicated.
which should increase the likelihood of use, and the price of a drug, which
should be inversely related to use. Direct evidence is scarce and inconsistent,
but we believe that three propositions are defensible: (1) drug use does respond
to availability and price, but probably less readily than consumption of many
other products; (2) law enforcement has at best modest success in reducing
availability or increasing prices of mass-market drugs; and (3) the threshold
levels of low availability and high price that would make drug use impossible
are essentially unattainable. However, MacCoun (1993) cautioned that research
conducted within a prohibition regime almost certainly understates the magni-
tude of changes in legal sanctioning risks, drug availability, and drug prices at
the licit-illicit threshold; e.g., the cost to the user of acquiring and consuming
drugs might drop dramatically under drug legalization.
MacCoun (1993) also noted that prohibition-based deterrence research
neglects the important role of moral judgment. For many, the mere fact that a
drug is illegal might be sufficient to discourage use, regardless of the risk of
getting caught in the act. Theory and research on moral judgment suggest that
the strength of this symbolic threshold effect is likely to vary across individuals
and within individuals over their lifespan. But several lines of psychological
theory and research suggest the possibility of a countervailing forbidden fruit
effect, whereby the mere fact that a drug is prohibited may enhance its attrac-
tiveness. This illustrates how prohibition can have unintended consequences.
Presumably, the symbolic threshold and forbidden fruit mechanisms vary
inversely within individuals, but little is known about the relative magnitude of
these effects, either within individuals or in the population at large.
A sixth mechanism is the stigmatization associated with being labeled a
drug offender. For noninitiates, stigmatization may be effective in discouraging
use. But the labeling theory tradition in psychology and sociology (reviewed in
Braithwaite, 1989) suggests that in many circumstances, by enlarging the social
and psychological boundaries between the offender and "conventional" soci-
ety, stigmatization can actually encourage further drug use and other socially
deviant activities. A seventh, related mechanism is the influence of drug laws
on informal social controls, including health-related beliefs, attitudes toward
drugs and drug users, and informal norms of situationally appropriate conduct.
There is considerable evidence (cited in MacCoun, 1993) that these informal
social controls are more important determinants of drug use than formal legal
controls. Unfortunately, we know very little about the interrelationship of
formal and informal controls. While it is often asserted that formal controls
reinforce informal controls, there is little direct evidence for this proposition,
and there are reasons to suspect that formal controls can even undermine some
informal controls (MacCoun, 1993).
MacCoun (1993) argued that decriminalization should weaken the sanc-
tion fear and stigmatization effects but leave the remaining mechanisms largely
intact. As such, while the net influence of weakening these two countervailing
mechanisms is unclear, decriminalization should have quite modest effects
either way. This is consistent with evidence for the limited effects of marijuana
decriminalization in a dozen states in the 1970s (see for example, Single, 1989).
Similarly, the decriminalization of hard drugs in Italy and Spain during the
1980s does not appear to have brought about dramatic increases in prevalence
relative to other Western European nations (Reuter & MacCoun, 1995; but also
see MacCoun, Saiger, Kahan, & Reuter, 1993, on the difficulty of drawing such
inferences).
Unlike decriminalization, legalization would likely influence the work-
ings of all seven mechanisms. Thus MacCoun (1993) argued that, given our
current state of ignorance about these mechanisms and their relative magni-
tude, it is simply not possible to predict the likely consequences of legalization
with any scientific credibility. This is not to say that legalization would neces-
sarily be disastrous, but rather that our uncertainty about its net effect on the
prevalence of drug use would make it a very risky policy option. This uncer-
tainty is compounded by the likelihood that some of legalization's conse-
quences would be irreversible. Our conclusions about the limits of drug laws
imply that restoring prohibition would not restore the status quo ante if drugs
were legalized and use increased sharply.
In the remainder of this chapter, we attempt to extend MacCoun's (1993)
framework in three ways.l First, we examine potential sociodemographic

differences in the strength of these seven mechanisms, and hence, in the likely
impact of changes in the drug control regime. Second, we extend the analysis
from users and potential users to other key actors in the system, in particular,
drug dealers and the police. Finally, whereas MacCoun limited his analysis to
drug use as a dependent variable, we examine the effects of both drug policy
and drug use on drug-related harms. We view this latter point as crucial for the
reformulation of American drug policy.
SOCIODEMOGRAPHIC CONSIDERATIONS
Policy analysis is often conducted by thinking of aggregate quantities or,

nearly equivalently, with the typical person in mind. For example, one might
ask how a new sentencing policy would affect a state's aggregate crime rate
and/or the average annual risk of victimization. Yet analyses of typical effects
can be incomplete to the point of being misleading when the population
displays significant heterogeneity along relevant dimensions. Budget analysts
would be remiss, for example, if they neglected to examine the differential
impact of a tax law revision on each income group.
The distribution and consumption of illicit drugs is characterized by
enormous heterogeneity-in substances, in individuals, and in environmental
factors. Unfortunately, drug policy writings often fail to appreciate such het-
erogeneity. We believe that in some cases, the framework above makes it
possible to anticipate the relative impact of a policy change on different
groups-even when it is difficult to predict the overall net effect in absolute
terms. In this section, we offer some tentative predictions about these relative
effects, subject to two caveats. First, these are predictions, not conclusions,
which need to be scrutinized by future empirical research. Second, these are
ceteris paribus predictions; we examine one principle (e.g., deterrence) and
one demographic dimension at a time, but in the absence of suitable data, we
cannot anticipate the net interactive effect of these factors.
Effects of Decriminalization
We argued earlier that decriminalization should have modest effects on

overall drug prevalence. Nevertheless, some predictions can be made about
lOne exlension we do not atlempt in this chapler would be to break the analysis down to take into
account the unique physiological, psychological, cultural, historical, and economic attributes of
each major psychoactive substance.
how its effects would differ across social groups. The principal effect of de-
criminalization would be to reduce the likelihood and severity of legal conse-
quences for users. There is reason to believe that the certainty of arrest is not
equal for drug users in all segments of society. Broad-based population surveys
reveal only modest ethnic differences in the prevalence of drug use (Flewell-
ing, Ennett, Rachal, & Theisen, 1993), yet minorities are greatly overrepre-
sented among those receiving prison sentences for drug possession as well as
trafficking offenses (Flanagan & Maguire, 1992, Table 6.80). This would
suggest that minorities would experience the greatest decline in sanctioning
risk, and, everything else being equal, minority communities might experience
a disproportionately larger increase in drug use.
On the other hand, the consequences of arrest may also vary demograph-
ically (Williams & Hawkins, 1989). From an economic perspective, the puni-
tiveness of arrest and incarceration is enhanced by the threat to licit income;
hence, everything else being equal, legal sanctions should be more threatening
for people with high licit incomes (current or expected) than for those confined
to the spot market for labor. From a sociological perspective, legal sanctions
may be more threatening to people for whom such an arrest would rupture close
personal relationships than for those who live alone or live in a setting where
drug arrests attract relatively less ire (e.g., Ekland-Olson, Lieb, & Zurcher,
1984). By the same reasoning, the reduction in stigmatization should be more
influential in neighborhoods where such arrests are highly unusual than in
neighborhoods where such arrests are fairly common; since stigmatization can
actually enhance postsanction offending (Braithwaite, 1989), this may be an
offsetting effect.
Effects of Legal ization
As noted earlier, legalizing a drug would have a greater impact than

decriminalization on the other mechanisms: symbolic threshold, forbidden
fruit, availability, price, and informal social control factors. It would, for
example, largely eliminate the influence of both the forbidden fruit and the
symbolic threshold mechanisms. Developmentally, it is likely that any sym-
bolic threshold effect is stronger in adults than youth; the opposite is probably
true for the forbidden fruit effect. If so, then, everything else being equal, one
would expect legalization to inorease use least among youth. That is, the
current overrepresentation of youth among users might be diluted.
Unlike decriminalization, legalization would almost certainly lead to
lower drug prices-possibly orders of a magnitude below current prices
(Moore, 1990}.1 According to economic theory, the elasticity of demand is

generally higher for goods that consume a large fraction of disposable income.
Less formally, the price effect of legalization should be greatest for those with
the least disposable income. The wealthy do not worry a great deal about the
price of drugs when deciding whether and how much to use. In contrast, for the
unemployed and working poor, the cost of a drug habit-and hence the impact
of a sudden price reduction-can be significant.
The change in price may also have regional effects. One would expect
legal prices to be relatively constant across the country, whereas currently there
is substantial variation (Caulkins, 1995). For example, cocaine at the retail level
is almost twice as expensive in Washington, D.C., and Baltimore as it is in other
major cities (Caulkins, 1994). Thus one would expect legalization to lead to
greater increases in consumption in Washington and Baltimore than elsewhere
and for the differential impact on the lower classes to be greatest in those cities
as well.
Likewise, availability would inevitably be higher, and legalization would
eliminate many of the inconveniences associated with purchasing illegal drugs,
including the risk of fraud, dangerous impurities, the lack of advertising, the
geographic concentration of open markets, and others. The people for whom
availability would change the least are precisely those for whom availability is
not currently a problem: residents in neighborhoods with open-air drug mar-
kets, college students, people who frequent bars and night clubs where drugs
are sold, and the like. In contrast, rural residents responding to the 1991
National Household Survey on Drug Abuse (NIDA, 1991) reported that it
would be substantially more difficult to get cocaine or heroin if they wanted it
than did residents of metropolitan statistical areas with populations over 1
million. The difference was particularly striking for those 16 years old and
under (and extended to marijuana), presumably because they are less able to
drive to obtain drugs. Hence, the increased availability of legalized drugs
would probably have a greater impact on consumption in rural areas than in
large cities.
Informal social controls also playa major role-perhaps the major role-
in restraining drug use. Such social controls are likely to be strongest, for
example, for people who are part of a cohesive family unit and who live in a
close-knit community. Presumably, social values concerning the acceptability
of mind-altering drug use would not change immediately after legalization.
lIt is doubtful that this could be offset by a drug tax; the recent Canadian cigarette experience
suggests that there are problems enforcing excise taxes on the order of 300%, let alone 10,000%
(Gunby, 1994).
The negative attitudes toward drugs embodied in infonnal social controls

developed over a century or more, so it might take time for them to decay. If so,
one would expect legalization's effect on consumption to take effect most
quickly with individuals who are not greatly influenced by infonnal social
controls, and to increase in a more gradual fashion for the rest of society.
Taking these observations together suggests that in the short run legaliza-
tion might increase use most among the rural working poor, particularly among
people who place a high value on obeying the law. Over time, use might spread
and ultimately be less concentrated among the young and marginalized popula-
tions than it is today.
These sociodemographic effects might be moderated by drug characteris-
tics. For example, some illicit drugs are more expensive to use than others. In
1990, roughly three times as many Americans used marijuana as used cocaine
(NIDA, 1991), yet the Office of National Drug Control Policy estimates that
Americans spent twice as much that year on cocaine as they did on marijuana
(ONDCP, 1991). Even recognizing that the household survey may miss a larger
fraction of cocaine users than marijuana users and accounting for other prob-
lems with the data, it seems clear that the average cocaine habit costs more than
the average marijuana habit. If all drugs were legalized, all prices would fall,
shrinking differences in the cost of a typical habit. Thus one would expect
legalization to have a greater impact on cocaine consumption than on mari-
juana consumption.
Gaps in Our Knowledge
Recognizing heterogeneity-between individuals and between drugs-

allows one to make statements about the likely relative impact of changes in
drug laws. This discussion further underscores, however, the real need for
quantitative estimates of the magnitude of the various effects. When dealing
with issues as complex as drug use, it is difficult to make a fortiori arguments.
There will usually be both factors that tend to increase a quantity and opposing
factors that reduce it; e.g., the symbolic threshold and forbidden fruit effects
work in opposite directions, as do deterrence and stigmatization. If quantitative
estimates of the various factors were available, it might turn out that some are
of a different magnitude than others, and the smaller ones can safely be
neglected.
Unfortunately, research on compliance with drug laws typically concen-
trates on establishing the existence of relationships, not on estimating their
magnitude. This tendency is aggravated by the impossibility of obtaining a
truly random sample of drug users. Most studies use samples of convenience
(such as arrestees) or ethnographic techniques (such as snowball sampling) and

thus fail to represent the full spectrum of users. A challenge for the future will
be to develop better synthetic estimates of the behavior of the entire population
of drug users using data that are drawn from select subpopulations.
OTHER ACTORS, OTHER ROLES
Even if we understood everything there was to know about drug users, we

would still know only a fraction of what is necessary to conduct effective drug
policy, as drug users are only one set of actors in a complex drama. There are
also drug suppliers, ranging from peasant farmers in source countries to drug
kingpins to street dealers. There are the public and private sector workers who
implement drug policies, ranging from narcotics officers to treatment providers
to teachers delivering drug prevention lessons. There are the actors who make
drug policy, including judges, legislators, mayors, governors, the President,
and ultimately, the public. And the public is also involved as the victims of the
disorder, crime, violence, and disease engendered by drug distribution and use.
Each of these groups merits research attention. Here we sketch out relevant
questions involving two groups, drug dealers and the police. Dealers have
already become the focus of a growing body of theory and research; in contrast,
drug enforcement agents have received relatively little attention.
Drug Dealers
In an era of relatively little faith in either rehabilitation or deterrence, most

criminologists believe that the principal social benefit of incarceration is inca-
pacitation: reducing the number of offenders on the street. But faith in inca-
pacitation seems questionable when it comes to the suppliers of a black market
commodity. There is little evidence that drug sellers are psychopathological
and considerable evidence that they are lured by the promise-sometimes
imaginary-of considerable economic gain (Reuter, MacCoun, & Murphy,
1990). Locking up a rapist may make the streets safer; locking up a drug dealer
creates ajob vacancy that can be filled by someone else (see Saner, MacCoun,
& Reuter, 1985).1
IDoes this mean that under legalization, existing drug sellers would simply cease criminal activity?
The economic enticement of drug seJling might attract some who would have otherwise abstained
from crime, but it does not follow that legalization would end their criminal careers; indeed, social
learning, subcultural, and labeling accounts of criminality all suggest otherwise (see Braithwaite,
1989).
The absence of an incapacitation effect would not mean that incarcerating

dealers has no impact on their markets. The greater the rate at which dealers are
incarcerated, the greater the risk to dealers. Economists would argue that this
should lead dealers to demand greater compensation. Theoretically, wages
would go up by just enough to compensate dealers for their additional risk.
Higher wages increase the cost of supplying drugs, so the retail price should
rise, leading to somewhat lower consumption. In effect, drug enforcement can
be modeled as a tax that raises the supply curve and leads to higher equilibrium
prices, lower consumption (assuming that demand is not perfectly inelastic),
and greater spending on drugs (assuming demand is not elastic).
This argument is solidly grounded in economic theory, was first clearly
articulated by Reuter and Kleiman's risks and prices model (1986), and has
been the basis of many if not most subsequent quantitative studies of drug
markets and their response to enforcement (e.g., Caulkins, 1990; Reuter, Craw-
ford, and Cave, 1988; Rydell & Everingham, 1994). Nevertheless, this ap-
proach remains (largely) untested, and it is not free from question. I Relatively
little thought has been given to ways in which drug dealers might deviate from
the model of rational utility maximizer in ways that typical licit businesspeople
do not.
For example, the risks and prices paradigm estimates the necessary com-
pensation as the product of the likelihood of a bad outcome and its conse-
quence. Yet it is ultimately the perceived risks, not the true ones, that matter,
and these are not always the same (MacCoun, 1993). If potential dealers'
probability estimates are faulty, if they are less averse to incarceration and/or
have higher discount rates than does the public at large, then an analysis of
objective enforcement rates may overstate the likely effects of enforcement.
Thus, understanding how drug suppliers acquire, update, and react to informa-
tion about the likelihood and severity of punishments associated with enforce-
ment interventions would greatly improve our ability to forecast the impact of
those interventions.
Likewise, we need to better understand the nexus of drug selling and
violence. On average, drug dealers commit more violent acts than do nondeal-
ing offenders. Is this because people who were already predisposed to be
violent are drawn to drug dealing and, hence, the apparent increase in violence
is spurious? Or is the increased violence simply an adaptive response to the
unique demands of competitive street markets? If so, does the act of becoming
a dealer fundamentally change people in ways that make them more violent
than they otherwise would have been?
IBoyum (1992), for example, questions the implicit assumption of zero long-run economic profits
in a business in which even uncompetitive enterprises generate positive accounting profits.
Determining which of these caricatures most closely approximates the

truth has important policy implications. If the correlation is spurious, then the
solution to the problem of reducing violence may not be found in drug policy. If
the violence is simply part of the job, then the problem is the black markets, and
violence can be reduced by attempting to change the nature of those markets.
And if becoming a drug dealer makes a person more violent, then aggressive
enforcement that takes established dealers off the street, creating openings for
new recruits and disrupting established territories, might well lead to greater
violence than less arrest-oriented tactics.
The Police
It is similarly important to understand the psychology of those who

implement drug policies. It may be tempting to immediately recommend that a
successful therapeutic community be replicated throughout the country. How-
ever, one's high expectations might not be fulfilled if the secret to its success
was not so much the program's regimen or physical facilities but rather the
charismatic leadership of the program's founder-something that cannot be
ordered off the shelf in large quantities.
We believe it is particularly important to understand drug enforcement
agents. The psychology of the narcotics agent is important for the understand-
ing of how policies are implemented, but also because psychological factors
may have an important influence on the likelihood of corruption and the abuse
of authority (Kelman & Hamilton, 1989). A great deal has been written about
the psychology of policing (e.g., Toch & Grant, 1991), and some has been
written about the psychology of narcotics enforcement (e.g., Manning, 1980),
but the street enforcement common today may have a substantially different
effect than the undercover, buy-bust investigations that were more common 15
years ago.
In qualitative field work, we have each heard narcotics agents compare
their situation to that of soldiers in Vietnam: driving (helicoptering) from the
suburbs (base area) into a hostile, violent environment where it is difficult to
tell the sellers (combatants) from the general public, where repugnant tactics
are employed in a struggle that cannot be won and for which there is precious
little gratitude. The actual risk of death for narcotics agents is certainly lower
than that for soldiers in Vietnam, but it is not negligible, and the average tour of
duty for a narcotics agent is longer.
Recognizing the considerable stresses under which enforcement agents
operate has myriad implications, beginning with what goals the nation should
articulate and transmit to the agents. If the goal is a "drug-free America" and
the rhetoric is one of war, the agents will inevitably conclude that they cannot
win. We hypothesize that this has adverse effects on morale and effectiveness
and enhances the likelihood of corruption. A fruitful program of research might
pursue this issue by drawing on the psychological literatures on goal-setting
(Locke & Latham, 1990), self-efficacy (Bandura, 1982), and the effects of rules,
roles, and values on compliance with official duties (Kelman & Hamilton, 1989).
In contrast, making the reduction of drug-related harm-especially to
nonusers-the primary police goal leaves open a considerable role for enforce-
ment agents and the opportunity for agents to see the benefits of their efforts.
Closing down a flagrant street market and arresting unusually violent dealers
are feasible, intrinsically rewarding, and of benefit to the community. We
examine the case for harm reduction as a policy priority in the next section.
ADDRESSING THE USE-HARM LINK:

TOWARD TOTAL HARM REDUCTION
The Supply Reduction/Demand Reduction Debate
Thus far, our analysis-like American drug policy itself-has focused

primarily on the effects of policy on drug use. Throughout the 1980s, the major
drug policy debate centered on the annual federal drug policy budget and its
emphasis on supply reduction (interdiction, source country control, domestic
drug law enforcement) relative to demand reduction (prevention, treatment).l
Critics of this one-sided focus argue that a substantial shift toward demand
reduction would yield greater dividends. But results to date aren't dramatic.
Positive effects of prevention, when found, are modest in size and sometimes
dissipate over time (Ellickson, Bell, & McGuigan, 1993), though larger invest-
ments might yield better results. A recent analysis by Rydell and Everingham
(1994) concluded that expanding drug treatment for cocaine is considerably
more cost-effective than increasing supply side measures, but it is unlikely to
offer a "silver bullet" solution to our current drug problems. They estimate that
even if drug treatment were offered to every heavy user in every year, high
relapse rates would limit any reduction in consumption to an average of one
third over a IS-year time horizon.
For some who see our current drug policies as ineffective, harmful, or
even immoral, drug legalization poses an alternative (e.g., Nadelmann, 1989).
But despite endorsements over the past 6 years by Ann Landers, former Secre-
lAs Kleiman (1992) points out, this distinction is somewhat simplistic, since user-targeted law
enforcement activities are aimed at reducing demand, not supply.
NATIONAL DRUG CONTROl STRATEGY 189
tary of State George Shultz, Baltimore Mayor Kurt Schmoke, and various
federal judges, public opinion remains hostile to the idea. Perhaps legalization
would be more palatable if there were conclusive evidence of its benefits.
Legalization would almost certainly bring about a reduction in the crime and
violence associated with drug trafficking and the demands that drug cases place
on the police, the courts, and the penal system. But as we have already argued,
we simply cannot predict whether these gains would be offset by substantial
increases in drug use.
Many cite Western Europe as a source of models of successfullegaliza-
tion, but this is largely based on misconceptions. With the possible exception of
The Netherlands' tolerance of some retail sale of formally illicit cannabis, no
European nation has formally legalized any of the United States' major illicit
drugs. However, we believe that Europeans do offer the United States a
valuable insight about drug policy, one that involves not legalization, but the
concept of harm. reduction. Harm reduction, a grass roots movement that
originated in cities like Amsterdam, Rotterdam, and Liverpool, has rapidly
been gaining influence at the national level in some European nations and in
various cities throughout the United States (see O'Hare, Newcombe, Mat-
thews, Buning, & Drucker, 1992).
The Use Reduction/Harm Reduction Debate
The alternative perspective offered by harm reduction can best be under-

stood by recognizing that demand side and supply side advocates share a
common allegiance to what might be called the use reduction paradigm (Mac-
Coun et al., 1993), a commitment-sometimes tacit-to the view that the
highest if not exclusive goal of drug policy should be to reduce (and if possible,
eliminate) psychoactive drug use. Use reduction comes in two types (see
Figure 2). Moralistic use reduction is the view that psychoactive drug use is
intrinsically undesirable or even immoral; one either shares or rejects this view
as a matter of principle, but it is relatively impervious to deductive or inductive
challenge. Pragmatic use reduction is the (perhaps unreflective) view that
reducing drug use is the most effective way to reduce the harms associated with
drugs. As such, it is amenable to both deductive and inductive scrutiny, and a
truly pragmatic use reduction advocate should willingly embrace any demon-
strably superior method of eliminating drug harms.
One might ask: Who could possibly be against something called harm
reduction? And who would endorse harm promotion? The harm reduction
critique is twofold (O'Hare et aI., 1992). First, use reduction policies fail to
achieve their intended objective, thus leaving the harms of drug use largely
Moralistic version:
1Policy 1----·1 Drug Use 1
Pragmatic version:
1Policy 1-.:...1 Drug Use I~I Harms 1
Figure 2. The use reduction paradigm.
intact. Second, in the process, use reduction policies are themselves a source of
harm, either directly or indirectly by exacerbating those harms caused by drug
use. A full taxonomy of these harms is beyond the scope of this paper, l but
examples include the stigmatization of users, the lack of drug quality control,
the artificial scarcity of clean needles, and the enormous illicit drug profits that
lure young people into crime and public officials into corruption.
The central insight of the harm reduction movement is that drug policies
can directly target harms for reduction rather than be limited to an indirect
strategy of reducing harm by reducing use. Examples include needle and
syringe exchange, low-threshold methadone maintenance, "safe-use" educa-
tional campaigns for users, reducing the priority placed on arrests and incarcer-
ation, and selectively directing arrest and incarceration toward the most violent
dealers. Evidence for the effectiveness of these programs will not be reviewed
here (see Des Jarlais, Friedman, & Ward, 1993; Heather, Wodak, Nadelmann,
& O'Hare, 1993; O'Hare et al., 1992), but these programs do appear to reduce
many of the harms associated with drug use.
Why would anyone oppose harm reduction? One concern voiced by many
use reduction advocates is that harm reduction "sends the wrong message,"
potentially (if unintentionally) signalling a social and governmental view that
drug use is acceptable. 2 This line of objection is familiar in other areas of social
IMacCoun, Reuter, and Schelling (in press) provide a taxonomy of almost 50 distinct harms that
attempts to classify each harm according to its primary source (prohibition vs. use per se) and its
primary bearer (the user, the user's family, the neighborhood, the taxpayer).
2Political opposition to harm reduction is aggravated by the fact that the principal direct benefici-
aries of many of its programs are drug users, a group that is neither politically organized nor
viewed positively by the majority of Americans. In this respect, it is worth noting that drug
addicts in several European nations have formed political lobbying groups, for example, the
Federation of Dutch Junkie Leagues or "junkiebond" in The Netherlands.
policy, for example, in disputes about the distribution of safe sex information
and/or condoms in schools. We believe this objection is considerably over-
stated, but not completely groundless. In our view, the more serious concern is
not whether harm reduction would imply government endorsement, but
whether the attractiveness of drug use might be enhanced by sufficient reduc-
tions in its riskiness. Notwithstanding our skepticism of a pure rational choice
framework, the latter notion is by no means implausible and would be consis-
tent with a growing body of evidence of compensatory behavioral responses to
safety interventions. For example, the enforcement of mandatory safety fea-
tures in American automobiles appears to have led to significant increases in
risky driving behavior (e.g., Chirinko & Harper, 1993), although the features
nevertheless have had a favorable net effect. Similarly, recent analyses (e.g.,
Blower & McLean, 1994) suggest that an HIV vaccine, if unaccompanied by
programs that reduce risky behavior, could actually exacerbate the AIDS
epidemic in San Francisco by making individuals less cautious.
Reconciling Use Reduction and Harm Reduction
Acknowledging the logical possibility that some harm reduction measures

might subtly encourage drug use need not, and should not, discourage serious
consideration of the harm reduction paradigm. MacCoun and Reuter (1994)
have proposed a simple framework for integrating use reduction and harm
reduction, which they call total harm reduction (see Figure 3). To do so, they
partition total harm as follows:
Harm per Use

- to users
Micro harm - to others
reduction
(Europe)
Macro harm
Total Harm
reduction
Use reduction
(USA) Total Use
Figure 3. Integrating use reduction and micro harm reduction (from MacCoun & Reuter, 1994).
Total Harm = Total Use x Average Harm per Use

where total use is a function of the number of users and the quantity each user
consumes, and average harm per use is a function of two vectors of specific
drug-related harms, one involving harms to users (e.g., overdoses, addiction)
and the other involving harms to nonusers (eg., HIV transmission, criminal
victimization).
If aspects of the United States' use reduction strategy do increase harm per
use, it can only reduce total drug-related harm if it generates sufficiently large
offsetting reductions in total use. As we have already argued, there is little clear
evidence that recent U.S. drug policies are responsible for significant reduc-
tions in use, and thus it is not obvious that they minimize total harm.
The central focus of European harm reduction is on reducing harm per
use, primarily health-related harms to users and their intimate associates (such
as HIV). This might be called micro harm reduction. If this reduction in harm
made use somewhat more attractive, a program might still achieve net harm
reduction, but if the increase in use was sufficiently large, it could actually
result in an increase in total harm. We think this is highly unlikely, but it is a
logical possibility.
In our view, the ultimate goal of drug policy should be total harm reduc-
tion, the largest feasible reduction in the harms to both users and nonusers.
Total harm reduction can and should involve both use reduction and micro
harm reduction. It is possible that neither libertarian harm reductionists nor
moralistic use reductionists will find the total harm reduction perspective
palatable; the former may feel that the government has no business reducing
drug use, the latter may feel that no steps should be taken to reduce the riskiness
of use. But we believe that total harm reduction offers the possibility of
bridging the gap that separates pragmatic advocates of current use reduction
approaches and pragmatic drug policy reformers, because it explicitly ad-
dresses both sets of concerns.
A greater emphasis on harm reduction seems particularly well-suited to
the current drug situation. During the past decade, the United States has
experienced substantial reductions in the number of users but increases in
average harm per use, partly reflecting an increasing concentration of use
among the most heavy users (Everingham & Rydell, 1994). These hardcore
users are presumably the most difficult users to dissuade, whether by preven-
tion efforts, treatment, or the threat of legal sanctions. A harm reduction
approach may or may not succeed in reducing use, but it does offer the
possibility of at least mitigating the amount of harm these users to do them-
selves and others.
Implications for Evaluation Research
Whether any given program achieves total harm reduction should be

viewed as a pragmatic, empirical question, not an ideological one. Current drug
program evaluation practices often preclude such an assessment. For example,
evaluations of demand and supply reduction programs generally assess effects
on use but frequently fail to measure effects on harms, or indeed whether the
program itself contributes to drug-related harm, for example, by encouraging
less safe using practices. On the other hand, evaluations of harm reduction
programs generally measure health consequences for the user but frequently
fail to assess the broader impact of the program on the frequency of use by the
client, or the prevalence and incidence of use in the local region.
A total harm reduction strategy would encourage program evaluations
that assessed effects on both use and harms. Several recent U.S. studies of
needle exchange are notable examples, finding significant reductions in health-
related harms without any increase-and even some reduction-in amount
and incidence of use (e.g., Walters, Estilo, Clark, & Lorvick, 1994). Thus,
needle exchange appears to successfully achieve total harm reduction. The
evidence suggests a similarly favorable conclusion for methadone maintenance
(Des larlais et at., 1993), assuming that methadone itself is excluded from the
definition of use. Research on Zurich's Platzspitz, or "Needle Park," suggests
that "zones of tolerance" -where users can publicly congregate without
interference-may fail to achieve total harm reduction, reducing some harms
(through public health promotion) while exacerbating others (local property
crime) (Grob, 1992).
Although we recognize that this is an area of continuing controversy, the
perspective outlined here underscores arguments against relying exclusively on
abstinence as an evaluation criterion (Peele, 1989). It implies that prevention
and treatment programs can be considered beneficial even if they fail to reduce
the number of users, so long as they demonstrably reduce the harmfulness of
patterns of use.
Implications for the Legalization Debate
Assessing total harm appears feasible at the level of particular programs,

but the empirical uncertainties surrounding some factors, and the inherent
incommensurability of others, may make it impossible to literally estimate the
total harm associated with an entire drug control regime, such as cocaine
prohibition (MacCoun, Reuter, & Schelling, in press). Nevertheless, the total
harm reduction perspective offers a useful heuristic for evaluating the merits of
the legalization debate.
We have argued that legalizers are most persuasive when making the case
that drug prohibition, as currently implemented, is itself a major source of
drug-related harms. But we have also noted the considerable uncertainty re-
garding the potential effects of legalization on levels of drug use. Legalization
may indeed achieve micro harm reduction-a decline in harm per use-but a
sufficiency large increase in total use might actually increase total harm. Thus,
the harm reduction debate should be viewed as orthogonal to the legalization
debate (Strang, 1993). The harm reduction paradigm offers an alternative to
those who are troubled by the problems of the current drug strategy but are
agnostic about, or opposed to, legalization.
Challenges for the Harm Reduction Approach
Though we feel that harm reduction holds great promise, there is still
considerable ignorance about the kinds of programs that actually achieve it. For
example, some public health researchers have suggested that the total social
costs of alcohol might be better reduced by shifting the entire consumption
distribution to the left, rather than concentrating on the most problematic
drinkers at the right (e.g., Rose, 1992). If so-and the proposal is a matter of
considerable dispute [see the series of commentaries in Addiction, 88, pages
591-600 (1993)]-then total use reduction might indeed be the best way to
achieve total harm reduction.! But note that such a shift in the consumption
distribution might be achieved by encouraging moderation for those who reject
abstinence. If those at the right don't respond to abstinence-based interven-
tions, we need interventions that encourage them to at least use drugs more
safely and moderately.
A major challenge for U.S. harm reduction is to tackle a problem that is
much less familiar in European cities: the violence and public disorder associ-
ated with street-level drug markets (Reuter et ai., 1990). What is needed is a
coherent program of harm-minimizing police tactics and strategies (MacCoun
& Reuter, 1994). This might involve setting clear harm-based priorities, for
example, regarding the most harmful drugs, most harmful settings, and most
harmful users. It would make public safety, rather than arrest counts, the
principal criterion of police performance (Conner & Bums, 1992). It might
IWe are grateful to Robin Room for pointing out tbis ironic difference between contemporary drug
policy and alcohol policy debates.
encourage the police to prefer high-profile over covert surveillance, thereby

preventing drug deals rather than allowing them to occur in order to make a bust.
None of these principles are new, and indeed some are common practice in
certain communities, but they depart from current police priorities by making
harm reduction more important than use reduction. For example, in highly
violent neighborhoods, it may be desirable to drive drug selling indoors and off
the streets, even if that makes it more difficult for the police to seize drugs. But
again, such a strategy should be evaluated empirically. Driving markets indoors
may also achieve use reduction if buyers have difficulty finding sellers (Reuter
et aI., 1990). On the other hand, while there is reason to believe that street
selling promotes violence, it is conceivable that street markets simply attract
more violent sellers. If so, driving them indoors may not reduce their violence.
A final challenge for the total harm reduction paradigm is to find a way to
preserve the beneficial effects of social stigmatization of drug addiction, while
avoiding the harmful effects of labelling. Braithwaite (1989) suggests the key is
a shift from disintegrative shaming to reintegrative shaming. To best achieve
total harm reduction, drug policy should work like a semipermeable mem-
brane, discouraging nonusers from moving into use but allowing those who do
to reenter both the psychological and the physical community. We hope psy-
chologists will work to discover and evaluate strategies for making this image a
reality.
ACKNOWLEDGMENT. Preparation of this chapter was supported by funding

from the Alfred Sloan Foundation and RAND's Drug Policy Research Center.
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163-181.
CHAPTER 9
Assumptions about Drugs

and the Marketi ng
of Drug Policies
STANTON PEELE
INTRODUCTION: SAY WHATEVER YOU WANT ABOUT

DRUGS AS LONG AS IT'S NEGATIVE
In 1972, Edward Brecher-under the aegis of Consumer Reports-published a

remarkably forward-looking book entitled Licit & illicit drugs. Among the
many myths of addiction he punctured was that of heroin overdose. To accom-
plish this, Brecher reviewed evidence that (1) deaths labelled heroin overdose
"cannot be due to overdose; (2) there has never been any evidence that they are
due to overdose; (3) there has long been a plethora of evidence demonstrating
that they are not due to overdose" (p. 102).
In category (1) are historical and pharmacological data. In New York City
prior to 1943, very few deaths of heroin addicts had been attributed to heroin
overdose; in 1969-1970, 800 overdose deaths were recorded in New York. But
over this time span, heroin purity declined steadily. In research conducted at
Jefferson Medical Center in Philadelphia in the 1920s, addicts reported daily
doses 40 times as concentrated as the usual New York City daily dose in the
STANTON PEELE· Morristown. New Jersey 07960.

Drug Policy and Human Nature: Psychological Perspectives on the Prevention. Management. and
Treatment of Illicit Drug Abuse. edited by Warren K. Bickel and Richard J. DeGrandpre. Plenum
Press. New York. 1996.
199
200 STANTON PEELE
1970s (Light & Torrance, 1929). Addicts in this research were injected with
1800 mg in a 2Y2-hour period. Some subjects received up to 10 times their
ordinary daily dosage and showed insignificant physiological changes.
In category (2) are the standard regimens of big-city coroners of simply
recording cases in which an addict died and had no other obvious cause of
death as overdose deaths. According to Brecher (1972):
A conscientious search of the United States medical literature throughout recent
decades has failed to turn up a single scientific paper reporting that heroin overdose,
as established by ... any ... reasonable methods of determining overdose, is in fact
the cause of death among American heroin addicts (p. 105).
In category (3) are results of research conducted by two prominent New

York City medical examiners, Drs. Milton Helpem and Michael Baden, based
on the examination of New York City addict deaths, which found that (1) heroin
found near dead addicts is not unusually pure; (2) the body tissue of the addicts
shows no undue concentration of heroin; (3) although the addicts usually shoot
up in groups, only one addict at a time dies; and (4) dead addicts are
experienced-rather than novice-users who have built up tolerance to poten-
tially large doses of heroin.
Yet, when we move from the 1920s and 1970s to the 1990s, we find in the
New York Times on August 31, 1994, a front-page story about the deaths of 13
New York City heroin users, part of which read: "They call it China Cat, an
exotic name for a blend of heroin so pure it promised a perfect high, but instead
killed 13 people in five days" (Holloway, 1994, p. 1). Brecher (1972) would
seem to have laid to rest claims about epidemics of "multiple overdoses" of
heroin like this one reported in the New York Times. Not surprisingly, two days
later, the New York Times announced: "Officials Lower Number of Deaths
Related to Concentrated Heroin" (Treaster, 1994, p. B3).
By this time, published reports had attributed 14 deaths to China Cat. The
second New York Times article stated, "authorities yesterday lowered from 14
to 8 the number of deaths in the last week that the police believe are related to
highly concentrated heroin" (Treaster, 1994, p. B3). The Medical Examiner
discovered that
two of the 14 men originally suspected of having died from taking the powerful
heroin had actually died of natural causes. Four others died of overdoses of
cocaine.... Of the eight whose deaths apparently did involve heroin, seven also had
traces of cocaine in their system (Treaster, 1994, p. 83, emphasis added).
The follow-up article is notable in that (1) deaths definitely attributed to

overdose on the front page of one of America's leading newspaper were now
only "suspected" overdose deaths, (2) the New York Times, after featuring and
embellishing on overdose deaths on its front page now attributed the overesti-
mate to "authorities," (3) 6 of14 people (42%) reported to have died of heroin
DRUGS AND THE MARKETING OF DRUG POLICY 201
overdose deaths had in fact not taken any heroin (two hadn't had any drugs),
and (4) 92% of the men who died after taking drugs had taken cocaine, com-
pared with 67% who had taken heroin.
Was this in fact a cocaine rather than a heroin overdose epidemic? Or,
alternately, was it an epidemic of deaths due to combining heroin and cocaine
(and alcohol along with other drugs)? The follow-up articles raised the more
basic question of how the "authorities" decided that so many men had died of
China Cat in the first place. According to the article, "The police said they
found packets of China Cat, the street name of a powerful heroin blend, and a
syringe" beside the body of one dead man. However, "they had no similar
evidence connecting the China Cat brand to the other victims, but ... they
considered it probable that a purer blend of heroin was involved" (even with
the six men who it turned out had taken no heroin) (Treaster, 1994, p. B3).
The cavalier attitude with which a leading newspaper reported misinfor-
mation as fact is a phenomenon worth examining. To put it simply, saying bad
things about drugs is never questioned, and disconfirming information never
requires revision of original claims. The paper acts as though its drug report-
ing is part of its moral mission, one not related to facts. But this absence of a
factual basis for its earlier report did not even slow the newspaper after the
discovery of the many mistakes in the original article.
In a follow-up front-age report on September 4, the New York Times drew
further conclusions about this case of "multiple drug overdose," now involv-
ing eight people (Treaster & Holloway, 1994). Only now, more of the original
report had been found to be incorrect.
At first. the police suspected that the men ... had all died after using an extremely
potent blend of heroin called China Cat. ... Now the police and the New York City
Medical Examiner, Dr. Charles Hirsch. say the men may have been victims of that
brand or some similar, equally poweiful blends of heroin .... But as one police
officer put it: "They're all still dead." In the end, drug experts said, the brand name
probably has little significance (p. I, emphasis added).
While this may be so, the New York Times did identify China Cat as the
cause of 13 men's deaths on its front page. Moreover, by the time this third
article appeared 4 days later, it was still not clear on what basis the deaths of
these men had been attributed to heroin overdose from any source (which
Medical Examiner Hirsch says "may" have been the cause of the deaths). For
example, the men all died singly, even though addicts typically use drugs in
groups. The third article described the supposed heroin overdose death of
Gregory Ancona, the only one of the cases for which eyewitness accounts were
available:
[Ancona] and a young woman went to a club ... and went back to Mr. Ancona's
apartment. ... The woman injected her heroin .... Mr. Ancona, who ... was already
staggering from the effects of cocaine and alcohol, snorted his. Soon after, he
202 STANTON PEELE
nodded off and never work up. The woman ... suffered no more than the usual
effects of heroin (Treaster & Holloway, 1994, p. 37).
The lethal effects of a brand of heroin are not supported by a case in which
a man-who generally weighs more than a woman and shows less acute
reactions to a given drug-died after snorting the drug while a woman who
simultaneously injected the same batch of the drug showed no unusual effects.
A more likely cause of Mr. Ancona's death under these circumstances would be
the interaction of drug effects, particularly those of alcohol and narcotics. Not
only has research suggested the alcohol-narcotic link may be lethal, but
addicts themselves generally suspect it and typically avoid drinking when
taking narcotics (Brecher, 1972).
This retailing of such dubious drug information can occur in a major
newspaper with no risk of embarrassment. This is because the New York Times,
its readers, and public officials share certain unquestioned assumptions-
assumptions that underlie our past and current drug policies, to wit:
1. Drugs are so bad that any negative information about them is justified.
The New York Times will not be called to task for inaccuracy in
reporting about drugs, as it might, for example, in reporting with
similar credulity, even deception, about crime or politics.
2. Heroin is the worst drug. The New York Times could seemingly have
made a better case for the toxicity of cocaine based on the original 14
deaths reported, yet it chose to focus on heroin. This may express a
permanent bias against heroin, or a return to demonizing heroin after a
period of concern about cocaine.
3. Blaming drug deaths on overdose is highly desirable for propaganda
purposes. If drugs are becoming purer, and deaths due to overdose are
epidemic, then people should be more reluctant to take heroin.
4. Middle-class heroin users in particular should beware. A focus of this
and many other news features has been the perennial concern that
street drug use is spreading to the middle class. The middle-class status
of a number of the dead men was a special feature of the New York
Times articles.
One of the nation's most prestigious newspapers confidently misreports
this story while it probably feels it is performing a valuable public service. But
does the New York Times article actually present a safety hazard? If an addict
believed that taking a specific dose of heroin is safe, he might not recognize that
combining drugs can be dangerous. In Mr. Ancona's case, for example, he
might have felt safe from a heroin overdose by snorting the drug rather than
injecting it.
But there could be even more perverse consequences from labeling drug
deaths as overdoses. Drs. Helpern and Baden interpreted their data as making it
more likely that the impurities in the injectable mixture (particularly quinine),
rather than the narcotic itself, which had been found to be relatively safe over a
wide range of concentrations for regular users, were the source of heroin-
related deaths (Brecher, 1972). In that case, the most adulterated (impure) doses
rather than the most concentrated (pure) doses of heroin would be most
dangerous, exactly the opposite of the New York Times' warning.
DRUG POLICY AND MODELS OF DRUG ABUSE

AND ADDICTION
The assumptions relayed by the New York Times article are actually quite
common. They and similar popular assumptions about drugs underlie much of
current drug policy. Policies for dealing with drugs, while presented as rational
models built on empirical bases and offering sensible plans to improve Ameri-
can society, are actually largely determined by policy makers' wrongheaded
assumptions about drug use, abuse, and addiction. As a result, policies with
long histories of failure and no chance for improving conditions in the United
States are taken for granted because their assumptions correspond so well with
popular drug myths (Trebach, 1987).
Indeed, the programmatic failure of these policies is directly related to
their empirical failures in accounting for human drug use. This chapter outlines
the assumptions underlying both our dominant drug policies and more useful,
alternative models built on sounder assumptions about drug effects, human
motivation, and the nature of addiction (Peele, 1992). It also suggests ways of
marketing alternative drug policies based on the appeal of their assumptions.
The Disease and Law Enforcement Models of Addiction
How we think about drugs, about their effects on behavior, and about their
pathological use (as in addiction) is critical for our drug policy. Much of U.S.
drug policy has been driven by a specific image of how drugs-illicit drugs-
work. This image has been that drugs cause addictive, uncontrollable behavior
leading to social and criminal excess. Under these circumstances, drugs should
be illegal and drug users imprisoned, which is how we principally dealt with
drugs for the first half of this century. This is the punitive model, which has
evolved into the modem law enforcement model of drug policy, which also
incorporates massive efforts at interdiction to eliminate the supply of drugs to
the U.S.
But the belief that drugs lead inexorably to uncontrollable consumption
and antisocial behavior creates the potential for a wholly different model. In
204 STANTON PEELE
this model, since drug use is biologically uncontrollable, people must be

excused for their drug-taking patterns and their behavior when intoxicated.
Their urges for continued drug use must be addressed through treatment.
American society is characterized, simultaneously, by strong urges for self-
improvement, by religiomoralistically oriented social groups, and by a belief in
the efficacy of medical treatments. The disease model of addiction, which grew
in dominance throughout the second half of this century, pulled all of these
strands in American thought together successfully for marketing, institutional,
and economic purposes (Peele, 1989b).
When public figures in the United States discuss drug policy, they gener-
ally veer between these two models, as in the debate over whether we should
imprison or treat drug addicts. In fact, the contemporary U.S. system has
already taken this synthesis of the law enforcement approach to drug abuse and
the disease approach almost as far as it can go. In America today, large
components of the prison population are drugusers or dealers, and treatment for
substance abuse-including 12-Step groups like Alcoholics Anonymous
(AA)-is mandated for those in prison and many who avoid prison by entering
diversionary programs (Belenko, 1995; Schlesinger & Dorwart, 1992; Zimmer,
1995).
While legal, penal, and social service institutions are able easily to incor-
porate drug treatment in their policies since drug use is illegal, the same
synthesis of disease and law enforcement models also prevails for alcohol.
Treating alcohol and drug use in the same way, despite their different legal
statuses, is possible because the disease theory was made popular with alcohol
and was then successfully applied to drug use (Peele, 1989a, 1990a). Mean-
while, the punitive law enforcement model developed with drugs was similarly
applied to alcohol. Drunk drivers and even felons who drink excessively are
given treatment in place of prison sentences (Brodsky & Peele, 1991; Weisner,
1990), which the many alcohol abusers already in prison are channeled through
AA as the modem form of prison rehabilitation.
The differences in the origins and goals of the law enforcement and
disease models guarantee that combining them will yield contradictions. But
there are also broad similarities in their views of drugs, addictive behavior, and
drug policy. Table 1 explores these differences and similarities according to the
categories of causality, the responsibility of the individual drug user, the pri-
mary modality and policy recommended by the model, and the nature and ex-
tent of treatment inherent in the model. (Table 1 also examines two alternative
models-the libertarian and social welfare models-which are discussed below).
I. Causality. The disease model claims that people are driven to consume
drugs by uncontrollable biological urges. Since its founding in 1935,
AA has implied that the source of alcoholism lies in the individual's
o
;>;l
Table 1 C
Cl
Models of Addiction: Their Underpinnings and Policy Implications Vl
)-
Attitudes toward Z
o
Model Causality Responsibility Primary Modality Treatment New Policies -t
I
m
DiseaseILaw enforcement ~
Disease Biologic Ambiguous )-
;>;l
Individual susceptibility: genetic Internal Individual Treatment, Necessary (no self- Anti-harm A
m
12-step programs cure) reduction -t
Coercive (because of
Z
Exposure: pharmacologic External External Abstinence Cl
"denial") o-n
Law enforcement o
Punitive User Individual Legal system CoercivelPunitive (in Anti-legalization ;>;l
C
place of or along Cl
Interdiction Drug External Blockading
} with punishment)
o"
r-
Current policy: combined diseasel External, uncon- External, ambiguous Legal system Paternalistic No Change n-<
law enforcement trollable Treatment Coercive
Libertarian/Social welfare
Libertarian Internal/self Individual Laissez-faire Voluntary Pro-legalization
Market demand
Social welfare External!society Society Social services Paternalistic Pro-harm
Universal reduction
Proposed policy: combined Internal (lack of Individual (moral! Individual with Available Pro-change
libertarian/Social welfare self-control) legal) social supports Voluntary
External (lack of Society (support! Diversified
opportunity) action)
'"
o\Jl
206 STANTON PEELE
biological make-up. And with the behavioral genetic revolution of the

last quarter of the century, a largely genetic basis has been proposed for
much addictive behavior. While the extreme form of this model, as
represented by Blum and Payne (1991) in what they term the "addic-
tive brain," cannot be sustained, the spirit of their analysis is broadly
popular and, in key elements, is not that far from mainstream behav-
ioral genetic models.
The disease model has several different guises. Table 1 lists the
individual susceptibility version, which includes genetic models, as
opposed to exposure models, which emphasize the pharmacological
properties of drugs. The exposure model maintains that pharmacologi-
cal properties of drugs directly cause continuous, escalating, and de-
structive drug consumption for everyone. The law enforcement model
also assumes an exposure model of drugs and addiction.
2. Responsibility. The law enforcement model faces a contradiction. On
the one hand, the society is obligated to prevent citizens from being
tempted by drug availability. But it is also the individual's responsibility
not to take drugs, and therefore people are responsible and punishable
when they do. However, both the law enforcement model's view that all
drug use is uncontrollable and the burgeoning influence of the disease
model have seriously undercut the personal responsibility and blame
that underlie the punitive component of the law enforcement model.
The assumptions that both excessive use of drugs and behavior when
intoxicated are uncontrollable have allowed many drug users/addicts
to claim that such loss of control is responsible for their behavior.
3. Primary modalities. The disease model strongly opposes the possi-
bility of controlled use, as does the law enforcement model. Like the
exposure versions of the disease model, the law enforcement model
thus strives to prevent everyone from taking drugs and recommends
abstinence as the key-indeed the sole-preventive and treatment
measure. (Although the disease model ostensibly requires only inbred
addicts to abstain, the disease view nonetheless tends to support absti-
nence from all illicit drugs.) For the law enforcement model, drugs
must be prevented from entering the country through interdiction, and
criminal sanctions must discourage all drug use. In the disease model,
the addict must be treated-or join an AA-type group to spiritually
reform himself and socially support abstinence-in order to achieve
wholeness.
4. Treatment. The disease and the law enforcement models share a pater-
nalism that focuses on peoples' inability to control themselves. In the
disease model, the addict who rejects treatment is posited to be in
denial, and the life-threatening nature of the disease makes treatment

necessary. Adding this element to the law enforcement model, since
abstinence is legally required, the addict is forced into treatment ori-
ented toward achieving abstinence. Thus, while the disease and the law
enforcement models are often thought to be opposed in their views of
treatment and while the 12-Step movement originally emphasized
voluntarism, all three currently coalesce in supporting coercive treatment.
The Modern Drug Policy Synthesis and Its Problems
The modem synthesis of the disease and law enforcement models domi-
nates drug policy in the United States and is firmly entrenched among the
public and policy makers. However, several sociaVeconomic factors have
challenged the consensual support of drug policies this synthesis has garnered.
These factors include:
1. Cost. Interdiction, legal sanctions such as prison, and treatment (partic-
ularly of the medical kind) are all very expensive policy options. In an
era of economic decline, like the one the United States faces, expensive
policies-even when broadly consensual-have come under scrutiny.
2. Effectiveness. Ineffective drug policies have long been tolerated (Treb-
ach, 1987). However, economic pressures to reduce government
spending have caused some critical assessment of current drug poli-
cies. And the interdiction, prison, and treatment mix seems to do
nothing as well as produce greater need for the very same policies.
Despite growing prison rolls of drug offenders and the constant recruit-
ment (or return) of drug users for treatment, there is a steady call for
acceleration and intensification of current police, interdiction, and
treatment efforts. The contradiction between claims of effectiveness
and worsening drug problems has led to a questioning of current
policies.
3. Paternalism. Both the disease and law enforcement models deny the
ability of individuals to resist or control drug use. Only the state, in the
form of its policing or its treatment apparatus, is capable of making
decisions about drugs for people. But such paternalism violates funda-
mental American precepts of self-determination. Moreover, it implies
an endless battle between the state and its citizens that has become
wearying.
An Example of the Pervasiveness of the Modern Drug Policy Syn-

thesis: The ABA Report. In the United States, private and public treatment
208 STANTON PEELE
for drug, alcohol, and other compulsive behaviors (such as gambling, shop-
ping, eating, and sexual behavior) modeled on the drug addiction model, as
well as treatment for other mental health problems, is more abundant by far
than that provided in any other country in the world (Peele, 1989b). Moreover, a
growing majority of substance treatment recipients today-including those in
AA and related groups-are forced into treatment. In addition to large numbers
diverted by the court system for crimes from drunk driving up to and including
serious felonies, social welfare agencies, employee assistance programs,
schools, professional organizations, and other social institutions insist that
members seek treatment at the cost of denial of the benefits of membership or
expulsion (Belenko, 1995; Brodsky & Peele, 1991; Weisner, 1990). Healthcare
cost controls on private drug and alcohol treatment and several scandals among
psychiatric hospital chains shook the industry after the late 1980s (Peele, 1991a;
Peele & Brodsky, 1994). Nonetheless, more Americans continue to be treated
for substance abuse than have citizens in any other society in history, and this
gargantuan treatment apparatus, both public and private, is maintained by
coercing patients into the treatment system (Room & Greenfield, 1993;
Schmidt & Weisner, 1993).
Even though restricting treatment to those who want it would greatly
reduce demand for substance abuse treatment in the United States, the major
American policy thrust is to vastly expand treatment rolls. To most Americans,
the existence of a drug problem by itself so clearly implies treatment that other
options cannot even be contemplated. One striking example of this unques-
tioned viewpoint was provided by the American Bar Association (ABA)
Special Committee on the Drug Crisis, which authored a 1994 report entitled
New directions/or national substance abuse policy (ABA, 1994). The president
of the ABA, R. William Ide III, introduced the New directions report by listing
eight primary drug problems: (1) health costs, (2) drug use incidence, (3) drug-
related crime resulting in (4) homicide, (5) juvenile violence, (6) prison over-
crowding, (7) drug-related arrests, and (8) economic costs of drug-related
crime.
It seems logical that the ABA would be primarily concerned with criminal
aspects and costs of the drug problem. But what is remarkable is the extent to
which the ABA conceives these as treatment issues. Following are four of six
recommendations in section VII of the report, entitled "New Directions in the
Criminal Justice System":
(I) The criminal justice system should provide a continuum of mandatory preven-
tion and treatment services to drug-involved offenders .... (2) Alternatives to incar-
ceration that include alcohol and other drug treatment ... should be expanded ....
(5) Voluntary pretrial drug testing programs should be supported as a means of
identifying and treating offenders immediately upon arrest.. .. (6) Court officers
should be trained to identify and refer offenders with alcohol and other drug
problems at the earliest possible point (pp. 34-35).
As John Driscoll, Chair of the ABA special drug committee, noted:

"there was remarkable consensus on many of the most critical questions of
drug policy" among committee members and consultants (p. 8). The clearest
consensus is that drug use must be stamped out. Section III, "New Directions
in Reducing Demand," presented a brief "Rationale" and three recommen-
dations:
(I) The federal government should establish a 'no use' standard of illicit drugs. We
agree with the Office of National Drug Control Police that [this] is vitally impor-
tant.... (2) The federal government should continue to focus on casual users
through prevention and treatment efforts .... (3) The federal government should
increase its focus on hard core drug users through treatment and coercion efforts
(p. 24, emphasis in original).
This section of the ABA report is explicit to the point of redundancy: All
drug use should be eliminated, casual drug use should be eliminated, addicted
users should be forced to quit, all through government efforts at expanding
what is already noted to be official U.S. policy. Typically the report had no
assessment of how much these policies would cost, what their chances for
success are, and what social costs are entailed. Particularly disturbing is the
complete absence of any consideration of the civil liberties of individual
citizens: the Constitution is never raised in a report from the leading private
legal organization in the United States. Yet Constitutional safeguards include
those against invasion of privacy, like illegal searches and seizures, and safe-
guards of personal freedom of beliefs and religion. In several adjudicated cases,
the courts have upheld the right of individual Americans to refuse to be forced
into treatments-like AA-that violate their religious beliefs and even their
self-concepts (Brodsky & Peele, 1991).
The assumptions motivating the ABA report are those underlying the
diseasellaw enforcement synthesis model of addiction, to wit:
1. Illicit drug use is bad. Moreover, it is inherently bad. Nothing about
styles of use or the individual's motivation for using drugs is relevant
to this determination. In general, this view of drugs is different from
the American view of alcohol, which finds moderate, social consump-
tion acceptable. However, as in the ABA report, drinking-particularly
among the young-may be assimilated to use of all drugs in being
totally proscribed and disapproved and through policies for an overall
reduction in drinking levels. Yet, despite the fact that alcohol use has
declined steadily for more than a decade, people report having more
serious alcohol problems than ever before (Room, 1989), problems that
210 STANTON PEELE
are growing most rapidly in the youngest cohorts (Helzer, Burnham, &
McEvoy, 1991).
2. Illicit drug use is unhealthy, uncontrollable, and addictive. While the
badness of drug use can be defined socially and legally-it is wrong to
take drugs-the ABA assumes drug use is unhealthy. Moreover, it is
unhealthy in the sense that even if some drug use would not harm the
individual, no one can guarantee that drug use will be limited to this
level, because drug use holds out the inevitable or irresistible danger of
becoming all-consuming (i.e., drugs are addictive).
3. Prevention and treatment work and can reduce harmful drug use. The
fundamental precept of the ABA report is, "Unless we make a commit-
ment to treat, we will never solve the drug problem, regardless of the
number of persons we arrest, convict, or confine" (p. 24). However, the
report ignores the actual treatment landscape in the United States and
assessments of current treatment efficacy. In fact, particularly with
widespread alcohol treatment, there is almost no variety in treatment
options, and the least effective treatments, such as compulsory AA,
dominate almost entirely (Miller, Brown, Simpson, et al., 1995).
Similarly, while touting greater prevention efforts, the report
notes that "statistics indicate that junior high and high school students,
in particular, are not paying attention to messages about the conse-
quences of substance abuse" (p. 25). This is not accidental, since the
standard programs-which emphasize negative results of drug use-
have been found to be ineffective and often counterproductive (Bangert-
Drowns, 1988; Ennett, Rosenbaum, Flewelling, et aI., 1994). But even
if effective treatment/prevention programs exist and are utilized, it is
an additional questionable assumption to believe that enough people
who would otherwise abuse drugs can be processed by such programs-
and that the impact of the programs is robust enough to withstand
posttreatment factors-to affect drug problems at a national level
(Peele, 1991b).
4. Individuals are not able to choose whether or not to take drugs or to
regulate their drug use. This is the external view of drug abuse-that it
"happens" to people without their choosing it. Drug use is presented
first as being both incredibly alluring and pleasurable, so that children
and others cannot resist it without constant support and instruction (if
drugs cannot be entirely eliminated through interdiction), and second
as being maintained by the involuntary motivations of addiction. By
accepting this assumption, the ABA must devise policy after policy to
prevent people from taking the drugs they want. The alternative as-
sumption is that people will take drugs if they want to and that the best
approach is to limit the potential dangers of this use-i.e., harm

reduction.
5. Coercing people into treatment is justified and effective. The ABA
endorses combining "treatment and coercion efforts," so that "hard
core drug users who are in the criminal justice system should be
required to quit their drug use" (p. 24). This entails even greater efforts
than are already in place to force people into treatment within the legal
system and to offer treatment in place of usual criminal sanctions.
Whether or not coercive treatment administered by the legal system is
effective is a lively question (Zimmer, 1995). It also shows a funda-
mental disregard for traditional notions of voluntarism psychotherapy,
as well as the Constitution. Finally, it holds out endless possibilities for
gaming by criminals seeking to avoid jail time (Belenko, 1995).
6. There is an end to the drug war. Presumably, the ABA expects its
recommendations will eventually reduce drug abuse at its sources, and
hence the need for constantly expanding drug services and policing
efforts. In other words, the goal of the plan is to enable us to cut back on
treatment and school programs, on interdiction and the policing of
American cities, on the creation of more institutions to house the
growing proportion of the prison population convicted of drug of-
fenses, on drug and alcohol research that dominates social and biolog-
ical scientific agendas, on political negotiations for greater funds for
programs like those the ABA endorses. Is there an end in sight, or are
these programs a continuation of the never-ending escalation of the
drug war?
Because the ABA and its expert panel are engaged more in a symbolic
than a policy declaration, the panel feels no need to explore basic policy
considerations in its report. After identifying the problem in the "Rationale"
part of each section, the report provides no evidence that its recommendations
would have any impact on the problems identified. Furthermore, none of the
ABA's recommendations is costed out. Even if we had reason to expect the
recommended policies would be effective, how can anyone seriously propose
that they could be implemented with no regard for cost? The ABA simply states
the costs of current drug and alcohol abuse, and these are the rationale for
following their recommendations. Interesting figures the ABA could have
presented are the spending on remedying drug abuse over the past decades, a
projection of the costs of implementing the ABA's programs, and a projection
of how much the United States will be spending on drug abuse in the year 2000
and beyond. Any realistic projection of the ABA's proposed policies will
inevitably inflate this last figure exponentially.
212 STANTON PEELE
The ABA's remarkably shopworn bromides simply express long-standing

and hard-to-prove assumptions about drug abuse and its solutions. In what way
is it beneficial or useful to public opinion, politicians, or public health officials
to broadcast alarmist statistics and rote demands for expanded treatment, which
is already so widely accepted as a panacea? Presumably, the ABA feels it can
gain public relations points by telling people that they already believe and by
boldly labelling this "New Directions." Yet policy alternatives that might
directly impact all the problems identified by the ABA-those that normalize
users of illicit drugs so that they can work, receive nonemergency treatments,
and potentially outgrow drug abuse and addiction, along with reducing or
eradicating illicit drug trade and resulting street crime-were not even dis-
cussed in the ABA report (Nadelmann et aI., 1994). Policy options such as
decriminalization and harm reduction (including needle exchange and provi-
sion of health services for street drug users) would represent actual new
directions in U.S. drug policy.
Alternative Views: The Libertarian and Social Welfare Models
Much evidence suggests that U.S. drug policies are wrong-headed and
ineffecti ve, or at least nonoptimal, not the least of which is the constant need to
escalate these same failed policies. Clearly, some evaluation of alternative
policies to accomplish desired goals is in order. Two alternatives to the domi-
nant models of drug policy are fairly well recognized in the United States.
One-the libertarian model-is put forward by a well-heeled ideological
minority. This model, while politically extreme, can nonetheless call on strong
strands in American thought-such as self-reliance and free-market capitalism-
for support. The other-the social welfare model-has wide acceptance and
has been dominant politically in the recent past. Today, although it has lost its
cache and is often presented by political opponents as antediluvian, the social
welfare model nonetheless gathers enough support to be present in every policy
discussion of drugs and related issues.
Table 1 reviews the major dimensions of the libertarian and the social
welfare models. The models contrast not only with the disease and law enforce-
ment models, but also with each other:
1. Causality. While the disease model of addiction claims that personal
choice has little or nothing to do with continued drug use, the liber-
tarian model regards personal choice as the only explanation for drug
use. In this view-as expressed, for example, by Thomas Szasz
(l974)-addiction is an unnecessary construct that does not improve
our understanding, explanation, or prediction of drug use. The social

welfare model, on the other hand, identifies social deprivations as the
source of addiction. It counteracts a genetic model of addiction, which
must rely on inbred sources as the explanation for epidemiological
differences in susceptibility such as the greater prevalence of intensive
drug use in inner cities.
2. Responsibility. The libertarian model holds the individual strictly ac-
countable for drug use and antisocial behavior while using drugs. The
social welfare model emphasizes the social forces that foster drug
abuse and addiction.
3. Primary modalities. The libertarian model allows people to choose to
use drugs or not on an open-market basis, the logical extension of
which is the policy of legalizing all drugs (Szasz, 1992). The social
welfare model believes that the key to curing addiction is to create a
fulfilling society through social welfare policies, such as those de-
signed to enhance the addict's educational, employment, and family
resources.
4. Treatment. The libertarian model views treatment in free-market terms
as a service to be provided as required by market demand. The social
welfare model, on the other hand, views treatment as an essential
service. It is the most programmatic provider of treatment services,
maintaining that the state should provide as much treatment as addicts
want whenever they demand it. On the other hand, the social welfare
goes beyond the disease model in its view of the panoply of treatment
services-including healthcare, job opportunities, skills training, and
economic supports. This model of reducing addiction through enhanc-
ing potential addicts' environments is more of a social prevention than
a treatment model.
Issues Limiting the Potential of Alternative Models. While the liber-

tarian model may be gaining ground, it is still a distinctly minority-even
radical-point of view. And while the social welfare model is still very
apparent in American thought, it is clearly losing ground in a conservative
political environment and a declining economy. The factors that limit the
acceptance of each include:
1. Extremist social positions. Most Americans are too steeped in current

drug assumptions to even consider libertarian views of a free market
for prescription and illicit drugs. They are furthermore uncomfortable
with the libertarian Darwinian social model that would allow the
214 STANTON PEELE
addicted simply to fall by the wayside if they won't stop using drugs.
On the other hand, Americans do not seem in a mood to tolerate
expanding social welfare services at a time when economic boundaries
for Americans in general are contracting.
2. Effectiveness. In the view of a clear majority of Americans, the social
welfare model has been tried and found wanting. Even after a period
beginning in the 1960s of greatly expanded services to underprivileged
sectors of society, large segments of these sectors-perhaps expanding
in number and deepening in their despondency-remain unable to
engage in mainstream society.
An Innovative Synthesis of Drug Models

and Its Implications for Drug Policy
In place of the synthesis of the disease and law enforcement models that
dominates current American policy, let us contemplate a synthesis of the best
Table 2
Assumptions of the Proposed Libertarian/Social Welfare Model Synthesis
1. Drug abuse is primarily a function of social, environmental, and personal factors, and not of
drugs. This is in contrast to the externality of the diseaseflaw enforcement model, which holds
that the drug, and not the individual, is the source of drug abuse.
2. Personal values are critical in the continuation of drug use, and addicts-like everyone else-
are responsible for their criminal behavior. Personal responsibility and self-efficacy would thus
replace the confusion over the determinism of the disease model and the punitiveness of the law
enforcement model.
3. Drug abuse treatment falls within a panoply of health, social, and economic services that
include skills/job training, general healthcare, andfamily supports. This approach, called harm
reduction, replaces the separate, highly specialized, disease-based, primarily private substance
abuse/addiction treatment system.
4. Drug abuse treatment is voluntary, and the form of treatment should respond to the values,
needs, and preferences of the individual. This replaces the coercive, one-size-fits-all current
disease treatment system of hospitals, AA, and the 12 steps, which are increasingly adminis-
tered within the framework of the law enforcement system.
5. Addiction treatment and jail are inappropriate for drug users who are not in distress and who do
not violate laws other than those making drugs illegal. This implies reevaluation of the criminal
codes with regard to drugs, an evaluation that the disease model considers impossibly dangerous
and that would largely eliminate the activities associated with the law enforcement model.
points of the libertarian and social welfare policies (see Tables I and 2). The
libertarian and the social welfare models appear to be political opposites
(indeed, the social welfare model is similar to the disease model). But the two
models have in common more empirically sound assumptions than do the law
enforcement and disease models, as well as the fact that both rely on sound
values. The social welfare model makes clear the factors-personal history,
current environment, availability of constructive alternatives-that are the
major determinants of the individual's likelihood of abusing drugs (Peele,
1985).
The libertarian model currently identifies the critical role of personal
responsibility in drug use, even in extreme cases of addiction (Peele, 1987). In
this way, it maintains the valuable assumption of personal causality for addic-
tion (and along with it personal efficacy) by noting that continued drug use is a
personal choice and by demanding personal responsibility for misbehavior. It is
significantly different from the law enforcement model in these areas, however,
in that it does not contradict itself by simultaneously endorsing the strict
exposure model of addiction. Moreover, it is nonmoralistic in that it does not
assume that drug use per se is harmful (Peele, 1990b).
While personal responsibility and motivation are crucial in this synthe-
sized model, social forces are obviously critical to the maintenance or discon-
tinuation of addiction. Together, these characteristics determine the nature of
treatment in a combined libertarian/social welfare model. In this synthesis,
treatment is part of a panoply of supportive resources, the first goal of which is
to maintain all citizens' lives and health, the second to capitalize on addicts'
desires to reform if and when they desire and feel capable of change. This
outlook influences social, prevention, and treatment policy so that skills train-
ing, economic assistance, and healthcare for addicts are included as part of the
general social welfare and health systems.
At the same time, the social welfare-and particularly the libertarian-
models prefer voluntary choice of treatment. Few people would select the most
expensive and repetitive forms of intensive addiction treatment, which would
be downplayed as only an extreme resort that is too expensive and limited in its
benefits to be justified as the main response to substance abuse. This attacks the
mainspring ofthe disease model. Addiction treatment would also be eliminated
for those users of illicit drugs who do not display signs of distress other than
that they are engaged in an illegal activity. This is the primary impetus for the
law enforcement model. Eliminating the right of the state and other institutions
to demand that the individual undergo treatment for simply using a disapproved
substance implies some form of decriminalization of use of currently illicit
drugs.
216 STANTON PEELE
HARM REDUCTION, DRUG LEGALIZATION,

AND MODELS OF ADDICTION
To practice harm reduction relative to drugs implies (I) acceptance of

nonharmful drug use, and (2) continued use of drugs, even by the addicted,
with the goal of providing heaIthcare, clean needles, and other services to
intravenous and dependent drug users (Peele, 1995). In other words, harm
reduction suggests-and begins the path toward-legalization or at least
decriminalization of drug use. How do harm reduction and drug legalization
play within the four basic models?
1. Disease law enforcement model. The law enforcement and the expo-
sure version of the disease model are obviously opposed to legaliza-
tion, since they assume any legitimizing of drugs and potential greater
use will translate into addiction. The individual susceptibility disease
model, on the other hand, would suggest that-since only a pre-
selected minority will become addicted-no increase in addiction
would result from legalization, greater availability, and even greater
use. However, harm reduction approaches in the case of alcoholism-
which is generally assumed to be genetic in American treatment
circles-are completed verboten (Peele, 1995). In this, the U.S. is
almost alone among Western nations.
Moreover, while often claiming there is a genetic basis for alcohol
dependence, U.S. alcohol education works on a seemingly very differ-
ent model. For example, all children are warned against drinking on the
grounds that it leads to the disease of alcoholism (Peele, 1993). Typ-
ically, the only speakers on alcoholism allowed into U.S. schools are
members of AA. In fact, the disease model as popularly practiced-
while claiming a medical basis-is in fact the old moral model dressed
in sheep's clothing (or a doctor's white jacket-see Marlatt, 1983).
Likewise, the disease model that purports concern for the individual
drug user is so preoccupied with abstinence that it cannot bend to
accept harm reduction, as exemplified by needle exchange programs
(Lurie et aI., 1993; Peele, 1995).
2. Libertarian/social welfare model. The libertarian model provides a
fundamental philosophical underpinning for legalizing drugs (Szasz,
1992). Libertarians maintain that the government cannot deprive indi-
viduals of personal and private activity that does not interfere with the
lives of others. The social welfare model is less clear about legalizing
drugs. However, harm reduction as an expression of humane and
nonjudgmental concern for individual drug users is central to the social
welfare philosophy. Indeed, it is this acceptance of legalization and/or

harm reduction and the need to change drug policy that most distin-
guishes these models from the disease/law enforcement synthesis.
MARKETING ALTERNATIVE DRUG POLICIES
The message from the previous sections is that it is impossible to discredit

drug myths, since even information that refutes them is interpreted in their
support. Two of New York's most prominent medical examiners regularly
testified against the diagnosis of drug overdose (see Brecher, 1972), and yet
New York City is just as likely as ever to resort to this diagnosis-and the New
York Times to trumpet the diagnosis and its readers to accept it. Clearly heroin
overdose will not disappear from usage. There is a cultural need for the con-
cept, just as there is a need for the "man with the golden arm" stereotype of the
heroin addict.
Given the popularity of stereotypes about drugs and treatment, we need to
market alternative assumptions in order to create sounder drug policies. Many
of the assumptions that underlie the libertarian and social welfare models and
that conflict with the disease and law enforcement models are not only saner
and more accurate, but also appeal to fundamental American values. Focusing
the discussion of drug policy around these assumptions and values offers the
best possibility for reversing misguided drug policy in the United States today.
A marketing plan for better drug policies should hit the following notes:
1. Traditional civil liberties. The readiness of proponents of the disease/
law enforcement model to intervene in citizens' lives-whether claim-
ing the benign need to overcome denial or protect Americans from
their appetites or the punitive goal of punishing people-is directly
opposed to fundamental American civil liberties. Some of the images
that can be marketed to show the incompatibility of current drug policy
with traditional civil liberties include: (a) raids on purchasers of gar-
dening paraphernalia; (b) drug testing, which seemingly violates in the
most basic way the Constitutional prohibition of unreasonable searches;
(c) forfeiture of property not only by drug users but also by those who
own property on which drugs are found; (d) police raids gone wrong,
like the one in Boston during which an African-American minister
suffered a heart attack and died (Greenhouse, 1994); and (e) the 1984-
ish "Big Brother"/government image, which seemingly arouses so
much suspicion and resentment in America today.
2. Humaneness. Americans pride themselves on their humanity and their
willingness to help the needy. The inhumanity of current U.S. drug
218 STANTON PEELE
policy thus has strong marketing possibilities. These include: (a) the
denial of marijuana as a popular antinausea chemotherapy adjunct (see
Treaster, 1991), (b) the medical benefits of marijuana (or THC) in
glaucoma treatment, (c) the Willingness of antidrug advocates and
public officials to, in effect, sentence many drug users to death through
the increased likelihood of AIDS in the absence of needle exchange
programs, to which America is singularly opposed among Western
nations (Lurie et aI., 1993).
3. Effectiveness!cost. Beginning in the late 1980s, insurers largely de-
cided that substance abuse treatment was not cost-effective (Peele,
1991a; Peele & Brodsky, 1994). Although in most cases this resulted
simply in providing less intensive versions of the same therapies
previously practiced in hospitals, many people continue to doubt the
efficacy of standard disease- and hospital-based drug and alcohol
treatment. Images of this ineffectiveness include: (a) prominent fail-
ures of treatment in cases such as that of Kitty Dukakis, (b) the
revolving door for most of those in public treatment programs and
many in private treatment, (c) the costly implications of filling U.S.
jails with drug law offenders, (d) the gargantuan overall costs of the
disease/law enforcement system at a time when governmental and
health costs are overwhelming U.S. public policy.
4. Justice. Americans are offended by unfairness in our legal and social
system. Examples of these drug injustices include: (a) murderers in
some prominent cases receiving less time than have some drug users,
(b) the imprisoning of drug users who lead otherwise lawful and
unexceptional existences, (c) the violation of the right to self-deter-
mination, which has become a popular conservative theme-even
though in most cases the most virulent antidrug voices are from the
conservative right.
Useless and wildly expensive drug policies could continue unabated for
years. But the possibility for epochal change in other areas of American life
offers real opportunity for change in drug policy. Nonetheless, even as our
healthcare, political, and economic systems evolve around us, such change can
only occur if it is presented in terms of traditional American precepts.
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CHAPTER 10
The Pharmacological
Understanding
of Psychoactive Drugs
Basic Science in the Context
of Differential Prohibition
ARTHUR P. LECCESE
IMPORTANCE OF BASIC PHARMACOLOGY
A scientific understanding of the effects of psychoactive drugs begins with

recognition of the importance of physical interactions between exogenous
drugs and endogenous systems. The powerful effects of personal and social
expectancies regarding the experience of intoxication and withdrawal notwith-
standing (Benson & Epstein, 1975; Schafer & Fals-Stewart, 1993), much can be
learned about the psychoactive effects of drugs through a manipulation of basic
pharmacological variables that influence the absorption, distribution, metabo-
lism, and/or excretion of a drug. Scientists and nonscientists alike have long
been manipulating these basic pharmacological variables through alterations in
initial dose, method of administration, concurrent drug use, past drug use, and
ARTHUR P. LECCESE· Kenyon College, Gambier, Ohio 43022.

221
222 ARTHUR P. LECCESE
patterns of multiple use. Of course, scientists have also manipulated other

important variables associated with the environment in which drug use occurs
or with the expectations of the user. This reveals that the "psychological"
aspects of drug use also lend themselves to sound experimental investigation
(see Chapters 1 & 2, this volume). However, the focus at present is upon how
failures to recognize the importance of basic pharmacological facts about drugs
prevent the scientific understanding of psychoactive drugs.
Lay observers have sometimes understood that both within-individual
differences and between-group differences in a response to a psychoactive drug
may be explicable in terms of deliberate or accidental manipulation of environ-
mental or basic pharmacological variables mediated by differences in gender,
genetic traits, past drug use, concurrent use, and other factors. Similarly,
scientists have begun to determine to what degree gender (Griffin, Weiss, Mirin,
& Lange, 1989; Kosten, Gawin, Kostin, & Rounsaville, 1993; Pomerleau,
Pomerleau, & Garcia, 1991), and racial (Feigelman & Gorman, 1989) differ-
ences in responses to drugs are due to sociocultural factors, and to what degree
drug responses can be attributed to gender/racial/cultural variables that have a
substantial impact on the absorption, distribution, metabolism, and excretion of
the drug. Scientists have also conducted sophisticated empirical investigations
aimed at determining whether and/or how concurrent use of one drug can influ-
ence the reinforcing effect of another drug (Foltin, Fischman, Pippen, & Kelly,
1993; Masukawa, Suzuki, & Misawa, 1993), and the pharmacological mecha-
nisms by which past experience with a drug, in these experiments cocaine, can
induce sensitization (McCreary & Marsden, 1993) and/or tolerance (Katz, Grif-
fiths, Sharpe, & de-Souza, 1993) to a subsequent acute dose. Significantly, there
are even those who look at the impact of chronic intravenous and intranasal
methods of administration of cocaine on subsequent abuse, social adjustment,
and probability of treatment success (Budney, Higgins, Bickel, & Kent, 1993).
However, due to difficulties with subject and observer bias, lay people,
and sometimes even scientists, often fail to see the ways in which alterations in
initial dose, method of administration, and concurrent and/or past patterns of
use can oftentimes provide a scientific explanation for within-individual and
between-group differences in responsiveness to psychoactive drugs. People
may instead attribute the difference in responsiveness to psychoactive drugs to
the more salient variables of, for example, gender or ethnic group. They thus
emphasize biased comparisons of between-group means while ignoring rela-
tively more important within-group variations. As noted by others (Helmer,
1983; Satinder, 1980; Szasz, 1985; Wish, 1990), this can lead to many unfortu-
nate consequences, including conclusions that certain racial and gender groups
are differentially susceptible to drugs due to moral inferiority. It may be typical
PHARMACOLOGY OF PSYCHOACTIVE DRUGS 223
for psychologists to eschew these "moral" interpretations and to instead

emphasize that different responses to drugs by different racial and gender
groups are mediated by variations in socioeconomic status, education, and/or
other contextual/environmental variables. However, it may be equally fruitful
to investigate the possibility that these differences arise from coincidental
covariation of such variables as enzyme levels, weight, percentage of body fat,
and distribution of body fat.
As noted by Wish (1990) and Musto (1973), public policy may come to
reflect, support, and reinforce majority prejudice based on spurious results and
invalid conclusions. When the majority uses its power to enact proscriptive
drug laws, a differential prohibition is the common result. Despite scientific
evidence of potential negative consequences, the use of psychoactive sub-
stances common to the majority are "passionately promoted" as evidence of
sophistication and maturity. Hypocritically, the use of pharmacologically simi-
lar drugs, preferred by a despised minority, are instead subject to a blanket
prohibition, enforced by often draconian measures-including physical vio-
lence-against possession, use, manufacture, or sale. This policy of differen-
tial prohibition may then have a profoundly negative effect on drug research.
Scientists may operate in a biased environment in which funding and prestige
are associated with activities aimed at finding support for the status quo, rather
than with obtaining the objective truth (see Chapter 13, this volume). In an
environment in which "everyone knows that drugs are bad," even the study of
nonpsychoactive therapeutic drugs can be distracted (Kahn, 1990; Wilford,
1991; Woods, 1990). At worst, research turns into post hoc, pseudoscientific
justification for current political constructions, regardless of the initial illogic
and racism of the earlier proscriptive legislation (Jensen, Gerber, & Babcock,
1991; Wish, 1990).
RETROSPECTIVE ANALYSIS AND PROSPECTIVE EXPERIMENTS
Retrospective analysis and prospective experiments are techniques that

enable scientists to attempt to limit the influence of harmful subject and
experimenter biases (Rudorfer, 1993). Retrospective investigations involve
looking at naturally occurring variations in parameters of drug use and seeing
how they correlate with the physical, psychological, and sociological effects of
these drugs (Strom, 1987). While retrospective investigations are the most
susceptible to uncontrolled variations, ethical issues sometimes require that
these techniques be used instead of prospective experiments involving admin-
istration of acute or chronically dangerous doses of drugs to subjects in the
laboratory. Those conducting retrospective analysis are, ideally, taught to

realize that these techniques explicitly preclude any ability to make statements
about causality, regardless of how strong a correlation may be. Nonetheless,
the public policy maker who is the ultimate consumer of these studies may be
overwhelmed by the sheer number of studies that show a strong positive
correlation between two variables. Scientists who conduct retrospective an-
alyses have a special obligation to make sure that the full range of potential
causal explanations of their results is given appropriate scientific consideration
in subsequent prospective studies. Similarly, scientists who conduct these
analyses should be especially concerned that cultural biases against certain
drugs and drug users do not foster a climate where their correlational data will
be interpreted in a way that biases the direction of investigation of hypothesis
through prospective investigations.
Prospective investigations are often superior to retrospective analysis,
since the former allow the researcher to have great control over the drug using
situation, enabling the selection of subjects with specific characteristics, the
matching of subjects, the administration of specific doses of a drug (or drugs)
via specific methods of administration, the use of a triple-blind study, and the
use of sophisticated observational techniques by multiple observers. Such great
control over potentially confounding variables makes it much more likely that
the experimenter will be able to manipulate, in a quantifiable way, a single
independent variable while holding nearly all else constant. When experiments
are properly conducted and there is appropriate concern for the generalizabil-
ity of the experimental results, causal statements can be made regarding the
effect of the independent variable(s) under consideration on the dependent
variables of the experiment.
BASIC PHARMACOLOGY OF COCAINE AND MARIJUANA
The large number of psychoactive drugs, their multitude of effects, and

the demands of editors makes it necessary that any review restrict itself to
specific questions regarding specific compounds. Therefore, this chapter will
investigate the scientific understanding of a few specific questions regarding
two currently illicit drugs, cocaine (DEA Schedule II in the U.S.) and mari-
juana (DEA Schedule I) (Drug Enforcement Administration, 1985). The deci-
sion to focus on two currently illicit drugs was motivated by a desire to
investigate the impact of differential prohibition on the conduct and interpreta-
tion of research. While there are likely to be effects of cultural biases on the
conduct of interpretation of research involving even legal drugs such as alcohol
and nicotine, biases are likely to be strongest against drugs the possession and
use of which have been prohibited. While any of the currently illegal drugs
might suffice for this discussion, these two particular drugs were selected
because of their popularity among those who consume, and those who study,
psychoactive drugs. Consideration of the basic pharmacological facts about
each of these drugs can reveal that (1) the prospective laws of public policy
regarding these drugs are sometimes based on a lack of understanding of the
descriptive laws so important to pharmacology, and (2) differential prohibition
has perverted the conduct of scientific research.
Scientists have utilized experimental methodologies involving both hu-
man and infrahuman subjects to determine the basic pharmacology of cocaine
and marijuana, and summaries of the results of these experiments can be found
(Leccese, 1991). Cocaine can be prepared in a variety of forms and, since it is
relatively lipophilic, can be taken by any method of administration. Thus, the
plant erthroxylone coca can itself induce intoxication when chewed and/or
swallowed, or the active ingredient of cocaine can be extracted. It can then be
taken through insufflation or application to other highly vascularized areas,
injection, or (when in the free-base form) inhalation as smoke. The drug is
rapidly absorbed, is widely distributed throughout the body, easily crosses the
blood-brain barrier, and quickly induces drug effects. Cocaine is metabolized
mainly by enzymes in blood, and for that reason metabolites, rather than the
parent compound, are likely to be found in urine. The plasma half-life of
cocaine is about 60 minutes, and the duration of drug effects is from a few to 60
minutes, depending on the method of administration.
Marijuana, on the other hand, is obtained from the common hemp plant,
cannabis sativa, and this natural mixture of active and inactive ingredients is
usually smoked or eaten. In contrast to the practice with cocaine, it is uncom-
mon for people to isolate and ingest a single, or multiple, chemical component
of the natural plant. However, the single active ingredient of delta-9-THC is
available in sesame seed oil in capsule form, although as yet there have been no
published reports of injection of illegally diverted capsule ingredients. Like
cocaine, the active ingredients of marijuana are rapidly absorbed into the body,
easily cross the blood-brain barrier, and rapidly induce drug effects. Unlike
cocaine, the active ingredients in marijuana are extremely lipid soluble and are
extensively metabolized by liver enzymes into a variety of active and inactive
metabolites. These active and inactive metabolites, as well as the parent
compound, may be stored for relatively long periods of time in high lipid areas
of the body. Active ingredients in marijuana are highly bound to plasma
proteins, and yet the complex metabolism of marijuana results in a blood half-
life that is substantially shorter than the biological half-life. It is likely that
metabolites and even traces of the parent compound will be found in urine and
feces long after psychoactive effects have ended.
FIVE QUESTIONS ABOUT COCAINE AND MARIJUANA
While there are, of course, many questions regarding cocaine and mari-
juana that are of relevance to public policy, consideration will be restricted to
the following questions. First, is either cocaine or marijuana capable of causing
physical dependence? Second, what is the probability and the consequences of
overdose of either drug? Third, does either drug cause observable brain dam-
age? Fourth, does either drug cause violence? Fifth, and finally, does either
drug cause psychosis?
Physical Dependence?
The question of whether a drug induces physical dependence is of great

importance to policy makers. Images of innocent pleasure-seekers turned
inevitably and inexorably into amoral fiends who will do anything for their next
dose of opium, cocaine, or marijuana playa significant role in paternalistic
legislation aimed at providing "negative liberty." That is, by restricting or
banning any use of the dependence-inducing substance, governments have
indeed acted paternalistically in prohibiting citizens from indulging in some
behaviors. Still, governments excuse these paternalistic acts by claiming that
they were performed in a beneficent manner so that the citizens might enjoy the
natural freedom allowed to those who have not become enslaved to a drug
(Bakalar & Grinspoon, 1984).
When attempting to determine if cocaine can cause physical dependence,
it is important to focus on the specific question of whether or not sudden
cessation of chronic cocaine use leads to a "withdrawal syndrome" similar to
that induced by sudden cessation of alcohol or the opiates. Psychologists have
insisted for quite some time that not all of the phenomena associated with
cessation of drug use can be considered to be withdrawal symptoms (Skinner,
1974). However, some individuals have been particularly impressed with the
intensity of subjective feelings associated with sudden cocaine cessation, and
they have stated that cocaine can "produce a neurophysiological addiction
having a primarily psychological clinical expression" (Gawin, 1988, p. 11).
Others argue that such a statement merely redefines original concepts of
withdrawal and physical dependency, enhancing the negative image of an
already reviled drug (Zinberg, 1984).
There is widespread confusion among scientists regarding the ability of
cocaine, and indeed other stimulants, to induce physical dependence (Bryant,
Rounsaville, & Babor, 1991; Kleber, 1990). Despite the inconclusive science,
public policy regarding cocaine continues to be based on the single perspective
that argues that the intensity of cocaine craving provides evidence of physical
dependence (see Pickens & Johanson, 1992) and that such a physical depen-
dence renders one incapable of resisting further drug use. Psychologists can
playa significant role in this debate by insisting that learning theory (with its
emphasis on increases or decreases in the probability of certain behaviors) be
considered when looking at compulsive use of a drug, regardless of whether the
drug induces a physical dependence (Goldberg & Stolerman, 1986; Kalant,
1989; Newman, 1991). Perhaps differential prohibition will continue to create a
dismal situation where those who argue against the notion that cocaine can
produce a dependency will be criticized for promoting "the misconception that
cocaine was a 'safe' recreational drug" (pollin, 1985, p. 98).
Perhaps the discovery of a cocaine antagonist will enable determination of
whether chronic cocaine use enables antagonist-induced withdrawal, as nalox-
one induces withdrawal in those who are physically dependent upon opiates.
However, the current differential prohibition has so influenced scientific dis-
course about smokeable stimulants that the failure to observe antagonist-
induced withdrawal may no longer be sufficient to convince theorists that
cessation phenomena related to cocaine differ significantly from the with-
drawal symptoms common at the halt of chronic opiate use. The nicotine
antagonist, mecamylamine, can block the behavioral and physical effects ofthe
drug without inducing any cessation phenomena in confirmed cigarette smokers
(Stolerman, 1986). Despite this failure to induce withdrawal by an antagonist,
researchers continue to discuss "nicotine addiction" (Benowitz, 1991). This
confirms the earlier fear that "withdrawal," "dependence," and "addiction"
are not always words conducive to scientific discourse, but are sometimes
instead ideological tools used to differentially discourage the consumption of
reviled comounds (Zinberg, 1984). For example, there are, as discussed, good
scientific reasons for questioning whether cessation of chronic cocaine use
leads to true withdrawal symptoms. Nonetheless, the authors of recent investi-
gations of the neurochemical events associated with cessation of continuous or
intermittent cocaine use utilized the emotionally laden and scientifically ques-
tionable term "withdrawal from" rather than the more accurate "cessation of"
in their experiment titles (King, Ellinwood, et aI., 1994; King, Joyner, &
Ellingwood, 1994).
As with cocaine, there is considerable scientific controversy regarding the
question of whether marijuana causes physical dependence and withdrawal, or
even if the question has any relevance to the understanding and/or treatment of
marijuana abuse (Nathan, 1991). In one report, the authors are quite casual
about their use of the term "marijuana dependence," asserting that diagnosis
and the need for treatment could be conducted through anonymous telephone
interviews (Roffman & Barnhart, 1987). In another, the authors promise in their
title a report on "laboratory testing in the diagnosis of marijuana intoxication

and withdrawal" (Verebey, Gold, & Mule, 1986, p. 235). This promise is made
despite the fact that they offer nothing more than a prohibitionist-oriented
primer on "marijuana detection in human biofluid .... to establish proof of its
use" (p. 236).
There is at present no antagonist to marijuana's active ingredient(s), so
determination of whether marijuana induces physical dependence has focused
on whether chronic users display characteristic symptoms of withdrawal subse-
quent to a sudden cessation. Early animal studies can be criticized on the
grounds that the failure to consistently reverse cessation phenomena through
provision of marijuana rendered the results susceptible to alternate interpreta-
tions that exclude physical dependence (Dewey, 1986). Subsequent experi-
ments, where reversal of withdrawal has been demonstrated (see review by
Emmett-Oglesby, Mathis, Moon, & Lal, 1990), have also been criticized for
using doses and drug regimens that greatly exceed the common pattern of illicit
marijuana use among humans (Hollister, 1986).
Despite these powerful criticisms of the putative evidence that marijuana
is capable of causing a physical dependence, it is possible for an individual to
obtain a DSM-Il/-R diagnosis of marijuana dependence (Nathan, 1991). This
institutionalization of the notion of marijuana dependence encourages clini-
cians to jump to the conclusion that all phenomena occurring at the time of
cessation of chronic marijuana use are best considered to be evidence of
dependence and withdrawal. For example, Rohr, Skowlund, and Martin (1989)
found that one chronic marijuana user exhibited symptoms of "gradual disori-
entation with fragmentation of his thoughts and diminished ability to concen-
trate" (p. 629) within one week of cessation of his self-reported 5-year use of 2
oz. per week of cannabis. No attempt was made in this retrospective report to
test if these cessation effects would ameliorate upon administration of can-
nabis. There was also no serious consideration given to the alternative hypoth-
esis that the individual may have long been experiencing a spontaneous psychi-
atric difficulty. Perhaps the severity of this undiagnosed psychiatric difficulty
was simply masked by years of attempted self-medication.
Clearer evidence that researchers are willing to consider any cessation
phenomenon to automatically be "withdrawal" symptoms can be seen in the
above-mentioned review of animal models of "withdrawal" symptoms by
Emmett-Oglesby et al. (1990). Without taking into account the effects on
response rates of frustrated nonreward, the authors assert that they have found
"powerful evidence that delta-9-THC withdrawal does occur" (p. 304). In-
deed, they have found nothing more than evidence that the sudden cessation of
marijuana induces disruptions of behavior reinforced by food. It is unfortunate
that this review did not consider the possibility that the sudden cessation of
even nondrug reinforcers could disrupt subsequent operant behavior. Consid-

eration of this possibility would indicate the shortcomings of their definition of
"withdrawal symptoms" as any observable behavior occurring subsequent to
termination of chronic use.
There are a number of approaches that have been taken by those who
argue that the dependence-producing potentials of cocaine and marijuana (if
they indeed exist) do not provide justification for the current differential
prohibition. Some, while acknowledging the reality of compulsive drug use,
nonetheless directly challenge the rigidly deterministic view of physical depen-
dence as a state where one is literally incapable of resisting further drug use
(Peele, 1985). Without the assumption that dependence-producing drugs must
necessarily "enslave" the user, arguments that paternalistic legislation can be
justified by references to "negative liberty" are seriously weakened.
The final determination of whether marijuana or cocaine causes physical
dependence will require a complicated and blind experimental design in which
chronic doses of the test drug are given to humans who are then given either
placebo or active drug at the time of "cessation." Some subjects are correctly,
while others are incorrectly, informed of whether they are receiving placebo
versus active drug at "cessation." This establishes a balanced design that takes
into account subject expectations regarding physical dependence (Sutton,
1991). It is, of course, quite difficult to ethically justify subjecting humans to
patterns of psychoactive drug intake that an investigator has specifically se-
lected in order to disprove the null hypothesis that "Drug X does not cause
physical dependence." Thus, despite difficulties with self-reports, it may be
necessary to experiment on subjects whose own life choices have led them to
chronically consume either cocaine or marijuana.
The paradigm discussed above has been shown to be effective in studying
the dependence-producing potential of a currently licit drug. Fully 30-40% of
subjects who chronically consume benzodiazepines will display "withdrawal
symptoms" if they are erroneously told, in a secretive way, that they are
receiving "placebos," even when they are being given a dose that ensures that
they maintain constant blood levels of benzodiazepines (Tyrer, Owen, &
Dawling, 1983). These results support the utility of "chronic consumers" as
subjects, rather than insisting on the ethically questionable, yet experimentally
preferable, chronic administration of the test drug in the laboratory. More
importantly, these results demonstrate the powerful role of subject expectan-
cies, in that "withdrawal" occurred in those subjects who thought they were
receiving placebo, despite the physiological fact of constant blood levels of
the drug. This suggests that anecdotal self-reports or retrospective analysis of
marijuana or cocaine "withdrawal" may also be the result of subject or
experimenter expectations, especially in an environment of differential prohi-
bition where "everyone knows" that these two drugs are reviled and suspected
to have the ability to induce physical dependence.
Overdose?
There is no psychoactive substance that will not show toxic effects when
taken at a sufficiently large dose. Since even excessive water intake can be
lethal (Viewig, David, Rowe, Wampler, Bums, & Spradlin, 1985), it may
appear at first that the question of the mere possibility of overdose plays little
role in public policy issues. However, the probability and severity of overdose
with a specific drug are of exceptional relevance to policy makers.
The potency of cocaine (in conjunction with its current illicit status)
ensures a high probability that users of this illicit drug might accidentally
consume an overdose. The method of administration of cocaine influences
mainly the rapidity of onset of symptoms of overdose. However, it is important
to remember that even insufflation (Litchenfeld, Ruben, & Feldman, 1984) and
vaginal application (Etinger & Stein, 1989) have been associated with the
consumption of lethal doses. As with any stimulant, overdose with cocaine is a
life-threatening emergency arising from a combination of central nervous
system overstimulation and centrally mediated overstimulation of the sympa-
thetic branch of the autonomic nervous system. Cocaine overdose can result in
high blood pressure, paranoia, confusion, high fever, heart attacks, stroke, and
convulsions. Death usually results because of heart failure or cessation of
breathing after prolonged convulsions (Olson & Benowitz, 1987).
Laboratory experiments involving injection of active ingredients from
marijuana have revealed that death in animals occurs because of respiratory
depression, but only at intravenous doses forty-fold above that necessary to
induce intoxication (Phillips, Turk, & Forney, 1971). On the other hand, it is
generally recognized that "it is almost impossible to absorb a fatal dose of
marijuana sufficiently rapidly ... via the lungs in smoke before the onset of
coma" (Truitt, 1975, p. 308). Despite the fact that larger doses might be
consumed through oral administration of marijuana, there are no unambiguous
reports in the literature of human death occurring from the direct biological
effects of marijuana. Rather than death, it is much more likely that acute
consumers of excessive amounts of marijuana are most likely to experience a
variety of acute untoward psychological effects (Hollister, 1986). These un-
toward effects respond best to calm reassurance or to the administration of
antianxiety agents (Khantzian & McKenna, 1979).
The environment of differential prohibition has perverted even the appar-
ently straightforward discussion of the question of marijuana toxicity. For
example, in a reply to a letter to the editor insisting that there had indeed been
"zero deaths attributed to marijuana use alone in 1985" (Walsh, 1992, p. 1761),
the author first castigated Walsh for making his statement without references.
He then went on to make his own unreferenced assertion that "deaths do occur
from suicide, vehicular accident, other accidents and homicide in association
with cannabis use" (Westermeyer, 1992). Westermeyer thus confuses issues of
intoxication and behavioral toxicity with the separate issue of those who note
that the usual patterns of human marijuana consumption rarely, if ever, put
users at risk of overdose.
Brain Damage?
Psychologists are particularly interested in whether the acute and/or

chronic effects of a drug include the induction of organic brain dysfunction,
since evidence of such damage might correlate with significant behavioral
difficulties. Of course, damage to the brain can result from the negative con-
sequences of overdose. However, the question of whether chronic low doses
can induce observable brain damage even in the absence of acute toxicities is of
great public policy importance. Studies aimed at determining whether chronic
cocaine or marijuana use can cause brain damage have been inconclusive. In
addition, the studies can be criticized for a variety of methodological failures.
Most studies rely on highly questionable self-reports of use of the illegal
substances. There is rarely any concern with concurrent chronic drug use
(particularly neurotoxic ethyl alcohol), nor any attempt to rule out the effects of
current intoxication.
A magnetic resonance study was conducted by Aasly, Storsaeter, Nilsen,
and Smevik (1993), in which the technique was used to determine structural
damage to the brains of users of ethyl alcohol, cannabis, inhalants, opiates,
psychedelics, amphetamines, or cocaine. It was concluded that whatever minor
structural changes they saw in the brains of users of the illicit drugs were most
likely the result of "very high alcohol consumption in parallel with drug
abuse." They thus came to the conclusion that it is likely that "alcohol is a
more potent brain toxic agent than are the most commonly abused narcotic
drugs" (p. 210). The sensitive technique of analysis of regional cerebral blood
flow measures the activity level of discrete brain areas and plainly reveals the
brain damage induced by ethyl alcohol. Researchers using this technique have
also revealed that there are no differences between chronic marijuana users and
controls (Mathew, Tant, & Burger, 1986).
Another study involving magnetic resonance reveals the negative impact
of differential prohibition upon the analysis of experimental results. In a study
by Amass, Nardin, Mendelson, and Teoh (1992), quantitative magnetic reso-

nance imaging failed to find evidence of brain dysfunction in "cocaine-
dependent" men. This negative result is particularly interesting since it was
found despite the fact that the technique was selected by the researchers
specifically because it so effectively identifies brain damage due to ethyl
alcohol. Despite this, the authors assert that their failure to find evidence of
brain damage in the brains of "cocaine-dependent," (and, incidentally, heroin-
dependent) men most probably arose from the inability of their technique to
"identify microstructural central nervous system changes resulting from
chronic opiate and cocaine abuse" (p. 15). Indeed, the negative results of this
study were used to bias others against the use of this superb technique for
detecting drug-induced receptor-related membrane changes. Even worse, the
authors did not consider the possibility that there may have been no cocaine- or
heroin-induced brain damage to cause detectable changes. Thus, the authors
used the report of their negative results as a vehicle for wild speculations,
which were so eagerly postulated without proof, about ever-more-subtle mech-
anisms by which cocaine could induce brain damage.
Violence?
Regardless of whether or not chronic cocaine or marijuana induces detect-

able brain damage, it is possible that the effects of acute and/or chronic use may
so alter brain chemistry and behavior that an individual is likely to engage in
violence. Recent improvements in the definition and study of violence (John-
son, 1993) have made it easier to generalize results from the laboratory to the
real-world environment. A retrospective study with chronic cocaine users who
were prone to either high or low levels of violence found that the high-violence
cocaine users performed better than the lower-violence cocaine users on the
Wisconsin Card Sorting Task (Rosse, Miller, & Deutsch, 1993). This experi-
ment represents a significant advance in that it studies cocaine and violence
where a correlation between the two has already been established in a particular
individual.
Other researchers have gone beyond the simple question of "Does co-
caine cause violence?" to determine instead that, for males, different types of
violence were differentially associated with certain methods of cocaine admin-
istration. For females, though, social and environmental circumstance, rather
than method of administration, most powerfully influenced the cocaine-
violence correlation (Giannini, Miller, Loiselle, & Turner, 1993). A different
study found a similarly complex gender-cocaine-violence relationship. Males
who used large amounts or engaged in chronic low dose use of cocaine were
more likely to be perpetrators of violence, while females with similar cocaine

use patterns were more likely to be the victims of violence (Goldstein, Bellucci,
Spunt, & Miller, 1991). Finally, it should be noted that one retrospective study
calls into question the basic idea that cocaine use is necessarily correlated with
violence. In an analysis of criminal behavior in patients in a methadone
treatment program, cocaine use was found to be irrelevant in predicting
whether patients were involved in further criminal activity (Kang & deLeon,
1993).
According to laboratory studies with animals, the acute and chronic effects
of cocaine include irritability, hyperactivity, and aggressive behavior (see re-
view by Yudofsky, Silver, & Hales, 1993). This pattern has suggested to some
that it would be useful to investigate the effect of cocaine on aggression in the
laboratory. Ethical concerns prevent experiments involving chronic, potentially
violence-inducing, doses of cocaine. Additionally, it is questionable whether
laboratory measures of human aggression generalize to real-world violence
and its unpredictable consequences. However, it is interesting to note that there
was one study in which human subjects given an IV loading of either 40 or 80
mg of cocaine followed by 4 hours of continuous IV infusion of cocaine
reported feeling suspicious, guarded, and paranoid (Sherer, Kumor, Cone, &
Jaffe, 1988). While this dosing regimen is extreme, it is of importance to public
policy markers to determine if a drug that can induce such paranoia may result
in some individuals acting violent so as to "get them before they get me."
However, ethical concerns limit prospective investigations of cocaine-violence
relationships, and retrospective studies are biased by the current differential
prohibition. In the meantime, it must be conceded that prospective studies have
not so far provided conclusive evidence that stimulants, including cocaine,
"consistently facilitate or inhibit aggression" (Bushman, 1993, p. 150).
The question of whether marijuana causes violence goes back to the myth
that assassins ran amok because of marijuana intoxication. In fact, the pleasures
of hashish were used not immediately prior to battle, but rather as part of a
training program to convince men of the pleasures that awaited them in
paradise should they die in their homicidal endeavors (Peters & Nahas, 1973).
Retrospective analysis of the correlations between marijuana and violence are
subject to all of the same criticisms leveled against those aimed at determining
the relationship between cocaine and violence. More discouragingly, there
have been fewer prospective studies of violence induction with marijuana than
with cocaine. In specific laboratory circumstances, one study has determined
that the use of marijuana increases the level of aggressive responding in male
humans (Cherek, Roache, Egli, & Davis, 1993). However, the result of this
single experiment is far from conclusive, since it is possible that subjects didn't
represent the normal population, that the results will not generalize to females,
that the results will not generalize to other measures of violence, and that the
experimental findings cannot be replicated in a real-world setting, where
violent behavior sometimes has consequences for the perpetrator.
In an analysis of the politics of violence research, Johnson (1993) noted
that "an enduring constraint on U.S. public policy on violence control is the
unwritten rule that taking out the bad guy after he has done his deed is
acceptable, but seeing that there are no bad guys is not acceptable" (p. 13). That
is, a violent offender may be punished after the fact, but the U.S. government
does not ordinarily place restraints on material that some think is likely to
"cause violence." However, this important constraint has not been applied
when the policy issue relates to the possible relationship between drug use and
subsequent violence. Differential prohibition supports a public policy that
assumes first that some drugs are more capable of inducing violence than
others. Secondly, it is assumed that it is quite correct to deny these drugs to the
vast majority, even if this majority would most probably engage in non-
problematic drug use. This restraint on the behavior of the many is based on the
assumption that such a blanket prohibition removes the possibility that the
susceptible few will be induced into fits of violence (Winick, 1991).
As noted earlier, an environment of differential prohibition can arise when
hysterically exaggerated claims of drug-violence relationships are used to
justify the proscription of the drug-consuming habits of minorities (Heller,
1983; Satinder, 1980; Szasz, 1985; Wish, 1990). It is important to remember,
however, that retrospective analysis that correlates drug use with violence
allows for a variety of interpretations regarding the causal relationship, if any,
between the correlated variables. It may be that there are other intervening
variables that better explain the correlation between violence and drug use. For
example, Wish (1990) conjectured that "it may be that when society prohibits a
drug from being used, a majority of those who will persist in using it are a self-
selected group of persons already prone towards deviant behavior" (p. 394). A
slightly different approach is taken by Spunt, Goldstein, Belluci, and Miller
(1990), who have begun retrospective analysis aimed at determining the role of
race/ethnicity and gender as intervening variables best able to explain any
correlation between drugs and violence.
Despite the possibility of alternate interpretations and the potential role of
other intervening variables, the author of an introduction to a recent special
issue devoted to drugs and violence reveals in his first paragraph that he
assumes that "drug use aggravates criminality" (Dembo, 1991, p. 201). Such an
assumption ofthe nature and direction of causality reveals the cultural biases of
differential prohibition impinging upon the conduct of scientific research. In
addition, it provides further support for the notion that retrospective analysis of
the relationship of drugs and crime may reflect more of an attempt to support
the status quo rather than the search for objective scientific truth.
Psychosis?
The determination of whether a drug is capable of inducing a psychosis is

fraught with as many difficulties as the determination of violence. Ever since J.
J. Moreau (Peters & Nahas, 1973) first investigated the relationship between
hashish and mental illness, those interested in drugs and behavior have realized
that the apparently simple question, "Does this drug cause psychosis?" actu-
ally involved a number of complicated issues. First, it was recognized that all
drugs could induce toxic effects at the far right of the dose-response curve and
that as other bodily organs began to fail, brain processes would become
aberrant and a toxic psychosis might result. Since this toxicosis could occur
with large doses of any substance, Moreau felt it was up to subsequent re-
searchers to determine whether chronic low doses of the drug were capable of
inducing an insidious psychosis. Secondly, it was recognized that there were
important distinctions to be made between when a drug was acting as a stressor
that merely unmasked a psychosis in an already psychosis-prone individual and
when a drug was capable of inducing psychosis in literally any individual who
consumed the drug chronically. Third, Moreau recognized that it was important
to distinguish between true drug-induced psychosis and the occurrence of other
untoward psychological effects that were short of a true psychosis.
Although each of these important issues was recognized by Moreau, and
again rediscovered as Connel (1958) conducted his investigations of amphet-
amine-induced psychosis, the zeal of antiprohibitionists who wish to discour-
age drugs that they revile has sometimes led scientists to forget these important
questions. Therefore, anecdotal reports of drug-induced psychosis are of little
value in determining whether a particular drug induces psychosis. Subjects
may be unaware of or may misrepresent their levels and patterns of drug
consumption, concurrent drug use may confound etiology of the disorder,
criminal lifestyles associated with illicit drug use may be an intervening
variable that explains the apparent drug-psychosis link, untoward psychologi-
cal effects may be incorrectly diagnosed as psychosis due to subject or observer
expectancies, observer bias may result in culturally deviant behavior being
characterized as evidence of pathology, the subject may have been using the
illicit substance in a misguided attempt to cope with already existing symptoms
of psychiatric problems, abnormal behavior may be the result of a toxicosis or
even prolonged intoxication, and finally, the subject may have been normal
before drug use but was destined to become psychotic even without the
coincidental intervention of chronic drug use (Davison, 1976). For example,
evidence that individuals who consume opiates, amphetamines, cocaine, or
marijuana have higher than normal levels of pathology (Campbell & Stark,
1990) cannot be used as proof that anyone of these drugs causes psychosis. It is
possible that there may have been multiple drug abuse by individuals, some of
whom may have been biased by cultural expectations to expect behavioral
pathologies to arise from their drug experiences. Furthermore, pathology may
have existed, perhaps in latent form, in some of these individuals even prior to
their drug use. Similar objections can be leveled against most other retrospec-
tive studies of drug-induced psychosis. It is an interesting exercise to see how
scientists in subsequent retrospective analysis will explicitly deal with one or
two of these objections, only to render their results uninterpretable because
other confounds continue to be ignored.
As noted earlier, laboratory experiments have determined that the behav-
ioral effects of large doses of cocaine can cause suspiciousness and paranoia
(Sherer et ai., 1988). Of course, it could be argued that this merely reveals that
the drug is capable of causing a toxicosis. Nonetheless, the pharmacological
similarities between amphetamine and cocaine, and the substantial evidence
that amphetamine can induce a psychosis (Connel, 1958), have led to a host of
theoretically useful theories about the relationship of dopamine to idiopathic
schizophrenia (Davison, 1976). It has been recognized that psychosis occurred
in individuals who consumed amphetamines before they were declared illegal
(Connel, 1958) and that even legal drugs that share cocaine's ability to act as a
dopamine agonist can induce psychosis (Havey, 1984). These two facts have
helped to obviate objections that cocaine-induced psychosis is nothing more
than a self-fulfilling prophecy related to cultural biases against cocaine.
Experiments have demonstrated that the chronic low dose use of cocaine
by schizophrenics in remission can lead to a return of schizophrenic symptoms
at doses much lower than those required to induce schizophrenic symptoms in
the normal population (Lieberman, Kane, & Alvir, 1987). More recent research
has indicated that schizophrenics given neuroleptic medication are more likely
to require psychiatric hospitalization if they use cocaine, when compared to
their cocaine-abstinent cohorts (Seibyl, Satel, Anthony, & Southwick, 1993;
Stone, Greenstein, Gamble, & McLellan, 1993). These experimental results
suggest that, while it may be too early to state with certainty that cocaine can
induce psychosis in literally anyone, it is likely that at least some cases of
"cocaine-induced psychosis" are the result of an unmasking or exacerbation of
pre-existing schizophrenia. However, care should be taken in asserting that it is
indeed a psychosis that is being induced, since there is evidence that cocaine
use may be associated with, exacerbate, or even induce antisocial personality
disorder (Carroll, Ball, & Rounsaville, 1993; Crum & Anthony, 1993) or
attention-deficit hyperactivity disorder (Gittelman, Mannuzza, Shenker, & Bo-
nagura, 1985).
Two recent studies investigating the question of cocaine-induced psy-
chosis suggest directions for future studies into the relationship between psy-
chosis and cocaine use. First, Satel and Edell (1991) conducted a retrospective
study that determined that those subjects who had experienced cocaine-
induced paranoia during previous bouts of cocaine use were more likely than
those who had not experienced such paranoia to later develop symptoms of an
insidious cocaine-induced psychosis. This result suggests that it may be possi-
ble to predict the possibility of insidious psychosis from the occurrence of
specific acute drug effects. Secondly, Luthar and Rounsaville (1993) have
begun to look at the question of genetic vulnerability and the unmasking of
psychiatric difficulties by cocaine use. By investigating the siblings of "co-
caine misusers" and finding that psychopathology preceded drug use in these
siblings, the authors have begun to determine the interaction of cocaine use and
genetic susceptibility to psychosis.
Unlike the case with cocaine-induced psychosis, the idea that marijuana
use can lead to psychosis is not strongly supported in the literature, nor has the
idea been of any apparent use to those who are interested in the biological basis
of psychopathology. Retrospective studies that purport to correlate marijuana
use with the induction of an insidious psychosis can be criticized for ignoring
the objections that are generally raised against retrospective analysis of drug-
psychosis relationships (Jones, 1986). It is now generally recognized that the
highly original and important work of J. J. Moreau revolved around the issue of
marijuana toxicosis, rather than an insidious psychosis (Peters & Nahas, 1973).
There have been reports that schizophrenics on antipsychotic medication have
experienced a return of psychotic symptoms subsequent to marijuana con-
sumption. However, these reports are best explained by reference to mari-
juana's ability to enhance the metabolism of neuroleptics, rather than to any
direct effect of marijuana on the central nervous system (Negrette & Knapp,
1986).
Prohibitionist-motivated concerns about the use of an illicit drug have led
to a situation where those who revile marijuana have backed off from the
notion that the drug could induce psychosis, but instead argue that the drug is
directly responsible for a host of psychological problems that are short of
psychosis (Mathew, Wilson, Humphrey, & Lowe, 1993). The bias inherent in
this argument can be seen in a work by Esteroff and Gold (1986), where the
authors created a "list of common problems associated with marijuana abuse"
that included "marked personality changes," "strange or unusual behavior,"
and "sudden mood swings" (p. 224). Interestingly, the authors also include a
host of "problems" (lack of money, legal problems) that arise more from the
prohibition of the drug than from the inherent psychopharmacological proper-
ties of the drug itself. Finally, it has been proposed that chronic marijuana use
can induce an amotivational syndrome, although recent reviewers have con-
ceded that it might be better to use the term "aberrant motivational syndrome"
(Millman & Sbriglio, 1986). This new term reveals that the authors are less
interested in defining a specific medical condition than in insisting that the
specific values of the dominant majority necessarily represent the epitome of
mental health. It is likely, in the final analysis, that those who continue to insist
that marijuana can indeed induce a literal psychosis are engaging in a medical-
ization of deviance no more supportable than previous assertions that mastur-
bation was the primary cause of psychosis (Hare, 1962, McDonald, 1967).
DIFFERENTIAL PROHIBITION AND RESEARCH
As the above discussion reveals, differential prohibition can impede the

scientific determination of what are apparently straight-forward questions
about whether cocaine and/or marijuana can induce dependence, cause over-
dose, cause brain damage, cause violence, or induce psychosis. It was argued
that this analysis justified the assertion that (1) the proscriptive laws of public
policy regarding these drugs are sometimes based on a lack of understanding of
the descriptive laws so important to basic pharmacology and (2) differential
prohibition has perverted the conduct of scientific research.
Further evidence that drug laws often conflict with knowledge about basic
pharmacology can be seen in public attitudes and proscriptive laws directed
against two forms of cocaine. A simple understanding of the basic pharmacol-
ogy of cocaine reveals that, like many other drugs, the salt form of the drug
loses potency when burned (Leccese, 1991). The free-base of cocaine hydro-
chloride, on the other hand, pyrolyzes, and thus great quantities can be rapidly
consumed through inhalation. Sadly, even the putatively value-free scientific
literature sometimes refers to the free-base of cocaine by the pejorative term
"crack. "
When delicate issues of race and illicit sexual activity are studied within
the context of this cultural bias against "crack," the consequences can be
disastrous. For example, in a recent report on non-IV drug use, unprotected sex,
and AIDS, the authors asserted that "because of its dependence potential,
'crack' cocaine may playa major role in HIV transmission, primarily because
of its links to unprotected sex" (Pickens, Battjes, Svikis, & Gupman, 1993, p.
119). Others discussing "crack" cocaine have shown a similar bias. They have
ignored the potent role played by differential prohibition in the social construc-
tion and self-perception of the drug user (see Chapter 13, this volume), and
instead have piously asserted, without supporting references, that "it is, after
all, the state of dependency that puts drug dependent people at risk for AIDS,
whether through the use of needles (injection) or the desperation and impul-
sivity that lead to unwise sexual behavior" (Nurco & Balter, 1990, p. 193).
Regardless of one's position on the "dependence potential" of stimulants (see
above), the positing of such a mechanism of causality for a correlation between
HIV and "crack" cocaine lends questionable scientific credence to what is in
fact an extension to all humans of an old racist myth (Helmer, 1983). This myth
holds that individuals who consume cocaine are necessarily so dysfunctional
that they are unable or unwilling to control their sexual appetites and behavior,
even in the fact of morbidity and mortality from sexually transmitted disease. It
could be argued that scientists should avoid the conjuring of prurient images of
cocaine-induced unbridled sexuality. Perhaps greater insights into the compli-
cated relationships between nonintravenous drug use and sexually transmitted
diseases might be better obtained through a nonjudgmental analysis of the
"marketplace economics" of prostitutes who use "crack" cocaine and also
traffic in both cocaine and sex (Feucht, 1993).
In addition to leading to laws that conflict with basic pharmacology,
differential prohibition can pervert science into a post hoc attempt to justify the
status quo. While others in this book will deal with issues associated with
treatment of drug abuse, the abuse of science is apparent in the current situa-
tion. In the United States, where reduction oflicit nicotine use through substitu-
tion of the same drug in different form is acceptable (Benowitz, 1991), cocaine-
containing gum or transdermal patches are rejected as antithetical to the
putatively essential treatment goal of "abstinence" from cocaine (Manschreck,
1993) or even a "total abstinence from all addictive substances" (Weddington,
1993, p. 87).
Further perversion of science through differential prohibition is currently
apparent in that, in the United States, subjects coerced into investigations of the
pharmacological treatment of cocaine abuse are offered, not cocaine itself, but
at best a host of currently available prescription or over-the-counter stimulants
(Gauvin, Moore, Youngblood, & Holloway, 1993; Gawin, 1988). Scientific
credence is thus given to the myth that the historical accident of the legality of a
stimulant (rather than dose, method of administration, concurrent drug use,
etc.) determined its potential for harm. It will be interesting to see how
advocates of the differential prohibition of cocaine in the United States will
deal with data from experiments conducted in other countries where there is
controlled provision, or serious discussion of controlled provision, of even
heroin to those who become physically dependent on the drug (Bammer, 1993;
Oppenheimer, 1991).
Just as cultural biases have impeded the scientific understanding of co-

caine, they have also exerted a negative effect on scientific understanding of
marijuana. Antipathy toward those minorities thought to be most likely to use
this drug resulted in a public policy that officially denied that marijuana had
any medicinal use. Hence, marijuana is a Schedule I drug in the United States,
more tightly regulated than cocaine, amphetamines, morphine, and phencycli-
dine (PCP) (Drug Enforcement Administration, 1985). For example, re-
searchers who have license to possess for research purposes Schedule II
through V drugs must nonetheless get special approval of research protocols
from police officials associated with the Drug Enforcement Administration if
they want to conduct research, even in animal subjects, with a Schedule I drug.
Researchers with a license are presumed to be able to conduct experiments with
Schedule II drugs such as cocaine, amphetamines, morphine, and phencycli-
dine without the dubious benefit of review of their research protocol by police
officials. Proponents of differential prohibition face a difficult task in explain-
ing to advocates of free scientific enquiry just how the descriptive laws of
science could possibly justify the proscriptive requirement of the Drug Enfor-
cement Administration review of research protocols involving marijuana.
A further example of how differential prohibition can have a negative
impact on the conduct of science can be found in the case of Marinol, the
delta-9-THC containing pill. Oncologists had been discussing among them-
selves for some time the fact that some of their younger cancer patients were
dealing with the nausea of chemotherapy by smoking illicit marijuana. How-
ever, citing a fear of "sending the wrong message" regarding the abuse of
marijuana, policy makers have, with few exceptions, rejected the argument that
smokeable marijuana should be available as an antiemetic (Lemberger, 1980;
Mechoulam, 1986). However, the continuing clamor for the availability of
marijuana as an antiemetic led eventually to the production of a pill that
contains a synthetic form of the most powerful of the psychoactive ingredients
of marijuana. This was touted as a better medicine than smokeable marijuana,
since it contained only one ingredient, that one ingredient was of known quality
and purity, and the physician maintained control over intake since the item was
available only through prescription (Chait & Zacny, 1992).
This belated recognition that at least some of the ingredients of smoked
marijuana have medicinal use is of great therapeutic value, although govern-
mental insistence of the superiority of the prescribed pill over smoked mari-
juana can be questioned on pharmacological and other therapeutic grounds. For
example, as noted above, consideration of basic pharmacology reveals that
there are a wide number of psychoactive and/or potentially therapeutic com-
pounds in smoked marijuana. It is in fact known that other compounds in
smoked marijuana may have medicinal value, either alone or in combination
with delta-9-THC, and that consideration of the other components might reveal
why marijuana is effective not only as an antiemetic, but also as an anti-
glaucomic and antispastic drug (Lemberger, 1980; Mechoulam, 1986).
The issue of medicinal marijuana reveals a cultural and scientific bias
against drugs that have for historical and cultural reasons often been smoked.
This bias appears to occur regardless of the question of whether this method of
administration may be the most appropriate for certain individuals. For exam-
ple, because the hot gases and particulate matter of marijuana smoke might be
associated with cardiovascular or lung disease (Hollister, 1986; Tashkin, Wu, &
Djahed, 1988), U.S. public policy almost always insists that smokeable mari-
juana is inferior to the delta-9-THC-containing pill. However, for individuals
with acute nausea from cancer chemotherapy, the rapidity of the onset of the
effects of smoked marijuana (Chait & Zacny, 1992) might well balance the risk
of cardiovascular or lung damage.
Were it not for the cultural bias against marijuana fueled by the current
differential prohibition, pharmacological considerations would likely lead to
the availability of all of the potential medicinal components of marijuana (in
whole plant form in edible goods). In particular, patients with glaucoma or
spasticity suffer from chronic conditions, rather than acute iatrogenic nausea.
These patients need more than the rather immediate and short-lived relief of a
therapeutic compound taken through inhalation. Thus, the consumption of
baked goods containing all the ingredients of marijuana would share with the
THC-containing capsule the benefit of enabling the maintenance of more
constant blood levels of the drug than would likely be achieved through
inhalation. Consideration of the basic pharmacology of marijuana reveals the
error of a public policy that denies therapeutic benefit to those who might best
profit from inhalation or oral consumption of more than one psychoactive
component of the crude marijuana plant.
CONCLUSION
The astute use of retrospective analysis and prospective experiments has

enabled the determination of the basic pharmacology of drugs such as cocaine
and marijuana. An analysis of research results and interpretations revealed that
biases fueled by differential prohibition can impede the conduct of research
aimed at answering more psychologically oriented questions about, in particu-
lar, currently illicit drugs. The perversion of scientific research, funding, and
discourse by differential prohibition has made it particularly difficult to deter-
mine whether either cocaine or marijuana is truly capable of inducing a
physical dependence. Despite biases, researchers have been able to determine
that both drugs can induce an overdose at the far right of their dose-response
curves and that overdose with cocaine is much more likely, and more devastat-
ing, than overdose with marijuana. Unfortunately, prejudice against the cur-
rently illicit drugs has muddled the discussion of marijuana overdose by
confusing behavioral toxicity leading to death with physiological overdose.
Consideration of the question of brain damage reveals that there is little
evidence that either drug induces brain damage in the absence of past toxic
experiences with the drug. In some cases, though, researchers have been unable
to accept a negative result with the culturally reviled drug and have insisted
against evidence that brain damage had indeed occurred but was inadequately
observed. The questions of whether either drug can induce violence and/or
psychosis are difficult to answer in a climate of differential prohibition, but it
appears that cocaine is more likely than marijuana to induce violence and/or
psychosis. Finally, the negative impact of differential prohibition on research
was further examined within the context of controversial discussions regarding
"crack" and AIDS, treatment of stimulant abuse, and the medicinal use of
manJuana.
ACKNOWLEDGMENTS. This chapter was written while the author, on sabbatical

leave from Kenyon College, was a Visiting Professor at the University of Am-
sterdam. Special thanks are given to Dr. Letje Lipps, Program of European Cul-
ture and History, Faculty of Letters, University of Amsterdam, The Netherlands.
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PART V
The Psychology
of Drug Policy:
Social and Cultural Factors
Influencing Drug Policy
CHAPTER 11
American and Canadian

Drug Policy
A Canadian Perspective
B. K. ALEXANDER, ANTON R. F. SCHWEIGHOFER,

and GARY A. DAWES
The United States and Canada comprise a natural laboratory for comparative
research on social policy. Recently, for example, comparisons of the U.S. and
Canadian medical systems have served to highlight both strengths and weak-
nesses in the American medical system when major changes were being
considered in the U.S. Congress.
This chapter compares drug policies in the two countries with the aim of
informing future policy development. Recent empirical scholarship depicts
U.S. drug policy as generally harsher than Canadian policy (e.g., Single,
Erickson, & Skirrow, 1991). This generalization is likely to be accepted un-
critically on both sides of the border, as Americans are often perceived to be
more aggressive than Canadians by citizens of both countries (Lipset, 1990;
Phillips & Barrett, 1988). However, even if such a perceived difference be-
tween national psyches can be justified on the grand scale of history, it may
not be manifested uniformly in all events in the two countries. Further em-
B. K. ALEXANDER, ANTON R. F. SCHWEIGHOFER, and GARY A. DAWES • Simon Fraser

University, Burnaby, British Columbia, Canada V5A IS6.
251
252 B. K. ALEXANDER et at.
pirical study of U.S. and Canadian drug policy may provide a deeper under-
standing.
Our investigations suggest that drug policy was equally harsh in the
United States and Canada from early in the 20th century until World War II and
that substantial differences have appeared only in the post-War period-and
only in the larger context of continuing similarities. The first section of this
chapter describes the remarkably parallel history of drug policy in the United
States and Canada prior to World War II. The second section describes a
divergence in the severity of some aspects of drug policy after the War. The
final section considers four explanations of the greater severity in U.S. drug
policy after World War II. This difference could be a consequence of (1), a
greater drug problem in the United States, (2) differences in the national
character of Americans and Canadians, (3) differences in political direction and
ambition that emerged in the two countries after World War II and exerted a
secondary influence on drug policy, and (4) differences in mass media in the
two countries.
THE ORIGIN OF DRUG LAWS

IN THE UNITED STATES AND CANADA
Prior to the 19th century, drug prohibition was rare in the Western world.
Throughout the middle ages, Europeans generally maintained a positive view
toward wine and beer, which were their primary recreational drugs and, some-
times, nutritional supplement. This equanimity soured somewhat as the Re-
naissance brought industrialization, urban expansion, distilled liquors, and new
drugs (primarily tobacco and caffeine) to the old world (Austin, 1985; Kiernan,
1991). However, notwithstanding occasional unsuccessful attempts at tobacco
and caffeine prohibition, European drug use generally remained subject only to
ordinary social and religious constraints and to chastisement of offensive
overconsumption by local magistrates (Austin, 1985; Heath, 1992).
The Birth of Temperance
The 19th and 20th centuries brought a dramatic and enduring change in
attitudes toward alcohol and drugs among the transplanted Europeans who had
settled in the United States and Canada (Levine, 1978; Rorabaugh, 1979). In
both countries, numerous "temperance" organizations arose early in the 19th
century to proclaim that the worst social problems could be traced to the
consumption of "demon rum" or "ardent spirits." With this diagnosis came
AMERICAN AND CANADIAN DRUG POLICY 253
the prescription for cure: universal abstention from alcohol-voluntary if

possible, enforced if necessary. In this chapter, we will refer to this diagnosis
and prescription as the "temperance mentality."
Although the temperance mentality emerged all over the Western world
during the 19th century, the United States arguably had the world's most visible
temperance movement (Levine, 1992), although Canada's was quite similar in
intensity and ideology (Smart & Ogborne, 1986). Within a few decades,
temperance organizations in the United States and Canada became politically
irrepressible, having won the support of large numbers of voters, politicians,
and industrialists. By the end of the 19th century, temperance was a perennial
election issue, and politicians who were not temperance advocates learned to
watch their tongue (Kobler, 1973).
From its early days, the temperance mentality was expressed in violent
language. The official watchword of the Montreal Temperance Society was
"War to the Death with the Demon of Intemperance" (Chiniquy, 1847, p. 26).
Later activists embroidered this sentiment, as in the welcoming speech at the
American Anti-Saloon League 1904 national convention:
We welcome you too as warriors ... To overthrow the liquor traffic means a terrific
struggle, it means fighting, constantly. persistently and relentlessly, and you are
sacrificing your time, your means and it may be your very life blood to further this
great cause ... (cited in Blocker, 1976, pp. 208-209)
The war language was not empty rhetoric. Notwithstanding the legendary
violence of Al Capone and the mob, many more bootleggers than enforcement
agents were killed during the years following World War I when alcohol was
prohibited in the United States, and in every Canadian province except Quebec.
Police and "dry" volunteers from various temperance organizations did much
of the killing (Ajzenstadt, 1992; Kobler, 1973). Temperance leaders did not
condemn this violence, even when innocent people died in the crossfire. For
example:
In Aurora Illinois, on March 29, 1929, six state enforcement agents invaded the
home of Peter De King, a suspected bootlegger. One of them clubbed him over the
head with the butt of a shotgun. As he dropped senseless, his wife Lillian sprang to
his side. A blast from the shotgun killed her. When told of the atrocity, Ella Boole of
the WCTU remarked, "Well, she was evading the law wasn't she?" (Kobler, 1973,
p. 291)
The case of Reverend J. O. L. Spracklin, minister of an Ontario Methodist

Church from 1919 to 1921, provides a Canadian example. A florid pulpit
spokesman for strict enforcement of prohibition, Reverend Spracklin was
appointed head of a special force of liquor license inspectors by the Ontario
attorney-general. After that point, "With guns strapped to his belt, he roamed
254 B. K. ALEXANDER et al.
the streets till the early hours of the morning, busting down doors with pistols
blazing and a squad of men who were tougher than the surly rum-runners"
(Gervais, 1980, p. 119). Spracklin and his men used their guns (there was at least
one shooting death), beat people badly (at least one died), and carried blank
search warrants that could be filled out as needed. Spracklin maintained his
post in spite of being charged with killing the owner of a roadhouse. He pleaded
self-defense and was acquitted in spite of eyewitness testimony against him. He
was subsequently commended by the WCTU and various Methodist organiza-
tions and exonerated by the temperance committee of the Ontario legislature
(Gervais, 1980).
Violence was not the only war measure bred by the temperance mentality.
Temperance supporters also showed a great enthusiasm and talent for warlike
propaganda (Alexander, 1990). Temperance propaganda in both countries at-
tributed unmitigated evil and catastrophic menace to alcohol. As in the propa-
ganda of international wars, truth was the first casualty-unsupported claims,
half-truths, and boldfaced lies were represented as divine writ or unimpeach-
able scientific fact and were widely propagated in the interest of the just cause
(Kobler, 1973; Smart & Ogborne, 1986).
Extension of the Temperance Mentality

into the Antidrug Movement
The logic, goals, symbolism, and bellicosity of the temperance mentality

were extended, with little modification, to the drugs that were identified as
public enemies later in the 19th century. Opium, cocaine, and heroin were the
earliest of the new drug enemies. All three were widely consumed in both the
United States and Canada, largely in the form of universally popular "patent
medicines" and in the form of smoking opium primarily used by Chinese
immigrants. These drugs came to be seen as menaces to personal virtue, social
order, and civilization itself.
In both countries, antialcohol, antidrug, and anti-German propaganda
were mixed freely in the World War I era, serving to enhance the impact of
each. For example, the Cypress River Western Prairie warned Canadians on the
eve of a prohibition referendum in Manitoba that "anyone who will vote in
favor of liquor might as well enlist under the Kaiser as far as patriotism goes"
(Thompson, 1972, p. 233). The New York Times told Americans of a fiendish
German plan to introduce "habit-forming drugs" into German toothpaste and
patent medicines that were to be exported to the United States before World
War I so that "in a few years Germany would have fallen on a world which
cried for its German toothpaste and soothing syrup-a world of 'cokeys' and
'hop-heads' which would have been absolutely helpless when a German em-
bargo shut off the supply of its pet poison" (cited in King, 1972, p. 261).
Two stock antidrug images became North American cultural archetypes
early in the 20th century. People who used forbidden drugs were said to be
transformed into "dope fiends" -slaves to their drugs and a menace to decent
society (Lindesmith, 1940). Dope fiends were popularly thought to commit the
most unspeakable of crimes without remorse. "Drug traffickers," by carrying
out their wicked trade, converted innocent boys and girls into dope fiends. They
were, in the words of a great Canadian temperance writer, "palmerworms and
human caterpillars who should be trodden underfoot like the despicable grubs
that they are" (Murphy, 192211973, p. 7). The images ofthe dope fiend and the
drug trafficker had become stock newspaper fare by the turn of the century
(Silver & Aldrich, 1979).
Historians and sociologists speculate about why Americans and Cana-
dians reacted so violently against drug use during this period. Although cocaine
and the opiates were widely used both medicinally and recreationally, and
although severe addiction and overdose did occur, these drugs were not a
problem for the great majority of the population. There was no evidence that,
on balance, these drugs did more harm than good to society (Brecher, 1972;
Trebach, 1982). Nevertheless, there were waves of panic and public antipathy.
Drugs were seen in a great variety of repugnant ways: as the cause of wide-
spread ill health and misbehavior among men, as the cause of sexual immoral-
ity among women, as the ruination of the thousands of men who proved unfit to
serve in the armed forces, as disgusting artifacts of unwelcome and inferior
races, and so forth. Public fears were bolstered and encouraged by vested
interest groups of physicians, pharmacists, and police, who could expect im-
portant professional gains from drug prohibition (Giffen, Endicott, & Lambert,
1991; Musto, 1973). Charismatic "moral entrepreneurs," many of whom were
also active in the war against alcohol, stirred up public outrage as well,
apparently out of a mixture of public interest and private ambition.
Although sociologists and historians agree that these and other social
forces all contributed to the emergence of extreme forms of suppression, no
clear consensus has emerged on their relative importance as causes (Rorabaugh,
1979; Giffen et ai., 1991). Two general conclusions seems inescapable, how-
ever. First, antidrug policy was never a calculated policy decision imposed by a
single controlling bureaucracy. Rather, it was a result of a collision of diverse
social forces and special interests that collectively had great power. Second, the
North American reaction against drugs was among the most extreme in the
Western world. Although many nations had experimented with drug prohibi-
tion at various times, most Western nations reacted to the drug and alcohol
problems of the early 20th century with more ordinary forms of regulation,
with less violence, and without a concerted attempt to achieve universal

abstinence through prohibition (Heath, 1992; Trebach, 1982).
The role of racial antagonism in the origin of drug laws in the United
States is well documented and probably familiar to American readers (Bonnie
& Whitebread, 1974; Morgan, 1978; Trebach, 1982; Wish, 1991). Anti-Chinese
sentiment grew in the western states in the second half of the 19th century when
Chinese laborers began to compete with whites for employment. This moti-
vated anti-opium laws, first in California and Nevada, and eventually on a
national level. In addition to the anti-Chinese sentiments, fears of cocaine-
induced rebellion among black Americans were prominent in antidrug rhetoric
(Musto, 1973).
One might expect to find that the role of racial issues in the emergence of
drug policy would have been less in Canada, but, although there was no
significant black population in Canada, racial animosity was at least as promi-
nent in Canadian antidrug rhetoric. When jobs became scarce in the 1880s,
earlier sympathy for Chinese railway, mine, and industrial workers on the
Canadian West Coast vanished. Responding to public hostility, the British
Columbia provincial government denied the Chinese the right to vote, to own
crown land, or to establish a registered company (Solomon & Green, 1982). In
1907, growing resentment culminated in an "Anti-Asiatic" riot in Vancouver.
The subsequent federal investigation discovered a large Chinese opium indus-
try that had quietly existed for decades. The report to Parliament that precipi-
tated the 1908 Opium Act emphasized the need for opium prohibition on the
grounds of the perception that whites, particularly young women, were fre-
quenting the opium dens and that Canada, as a Christian nation, should be a
leader in the international campaign against opium (Solomon & Green, 1982).
Drug Laws and Enforcement before World War II
If the antidrug movement found its symbolic expression in propaganda

and terrifying imagery, it found its concrete expression in law enforcement.
Comparison of drug laws between the two countries can only be made in
general terms, however, because U.S. criminal law is enacted on a federal,
state, and local level, whereas Canadian crirninallaw is generally contained in
the federal Criminal Code, although alcohol distribution is a provincial func-
tion (Single et aI., 1991).
Shortly before the "great experiment" in alcohol prohibition took place
both in the United States and Canada, federal laws were established in both
countries that were designed to impose universal abstinence from opiates and
cocaine. Canada's Opium Act of 1908 banned importation, manufacture, or
sale of opium for nonmedical purposes. Simple possession of opium became an
offense in 1911, when cocaine and morphine were also prohibited (Giffen et al.,
1991). U.S. antinarcotic legislation followed closely behind, in the form of
an anti-opium act in 1909 and the Harrison Narcotic Act of 1914 (Trebach,
1982). These "antinarcotics" laws, as they were called, were progressively
strengthened in both countries in the ensuing decades. Legislators and the
public found an easy accord in the view that harsh treatment of dope fiends and
drug traffickers was in the public interest (Giffen et aI., 1991). Opposition to the
rapidly escalating severity of drug laws before World War II was confined to
scattered professionals. The emerging profession of psychology did not playa
major role on either side of this debate, although it was prominently involved in
other public issues, such as eugenics, intelligence, and child-rearing (Danziger,
1990; Leahey, 1994). Even more recently, despite ever-increasing psychologi-
cal research on the dynamics of drug use, psychologists have not had a major
impact on the formulation of American or Canadian drug policy, but have
instead followed trends that have emerged from public debate.
In both countries, escalation in severity of the original antidrug legislation
was instigated by enforcement agencies (the Treasury Department l in the
United States and the Royal Canadian Mounted Police in Canada) and was
justified through alarmist and racist accounts of the evils of opiates, cocaine,
and marijuana and by the exertions of a few talented "moral entrepreneurs."
Harry Anslinger's colorful role in Whipping up public outrage in the United
States is well known and extensively documented (e.g., Brecher, 1972; Treb-
ach, 1982). A Canadian counterpart was Emily Murphy, well known in Canada
as the first female judge in the British Empire. She wrote popular Canadian
magazine articles and an influential antidrug book in the early 1920s. She is
quoted here to give a flavor of the extravagance, violence, and racism of the
public rhetoric that was directed toward drugs, no less in Canada than the
United States:
It is hardly credible that the average Chinese pedlar has any definite idea in his mind
of bringing about the downfall of the white race. his swaying motive being probably
that of greed, but in the hands of his superiors, he may become a powerful
instrument to this very end ... An addict who died this year in British Columbia told
how he was frequently jeered at as a "white man accounted for." ... This man used
to relate how the Chinese pedlars taunted him with their superiority at being able to
sell the dope without using it. and by telling him how the yellow race would rule the
world .... Some of the negroes coming into Canada-and they are no fiddle-faddle
fellows either-have similar ideas, and one of their greatest writers has boasted
how ultimately they will control the white man (Murphy. 192211973. pp. 188-IR9).
lThe Treasury Department is responsible for enforcing the tax laws. Both the laws enforcing
alcohol prohibition and the Harrison Narcotic Act were legally constructed in the United States as
tax laws for constitutional reasons. The most famous American drug law enforcer, Harry An-
slinger. was head of the Bureau of Narcotics within the Treasury Department (Trebach, 1982).
258 B. K. ALEXANDER et aJ.
Canadian historians differ on the importance of racist sentiment as a

motivation for antidrug legislation. There can be no doubt, however, that the
enforcement of Canadian drug laws targeted the Chinese. Chinese-born people
accounted for only a small fraction of the total population of Canada, but
they comprised a majority of those convicted of a drug violations in every
year but one from 1922, when convictions were first classified by race, until
1935. In 1921, the probability of a person not born in China being convicted of a
drug offense was 7 per 100,000, whereas the corresponding probability for a
Chinese-born person was 3,030 per 100,000, an astronomical rate by any
standards (Giffen et aI., 1991).
Although we have found no quantitative evidence for the existence of a
similar racial bias in U.S. enforcement, it is known that many narcotics agents
did not enforce the law against elderly respectable addicts who obtained their
drugs from a physician, or against physicians who were themselves addicted.
Trebach (1992) has suggested:
It is quite possible that there was a heavy element of class bias in the exemptions for
physicians .... This type of bias extended to the very top of the narcotics enforce-
ment hierarchy, to the U.S. commissioner of narcotics, Harry Anslinger, who
admitted in writing that he had helped a U.S. senator ... obtain regular supplies of
morphine. Anslinger also wrote that he had helped a Washington society lady obtain
regular supplies of Demerol (p. 141).
Increasing severity in antinarcotics laws in both countries during the

1920s and 1930s included stiffer sentences, running up to life imprisonment in
the United States and whipping in Canada; reverse onus clauses, which put the
burden of proof on the defendant in some drug crimes; and federal prohibition
of marijuana beginning in 1923 in Canada and 1937 in the United States (Boyd,
1984; Giffen et aI., 1991; Solomon & Green, 1982, Trebach, 1982). Only
Canada introduced "writs of assistance," a more intrusive legal device than the
American "no-knock law," which was not enacted in the United States until
1968 (Bellis, 1981; Brecher, 1972; Solomon & Usprich, 1991). Canada uniquely
introduced whipping as a penalty, although it was actually rarely applied
(Giffen et aI., 1991). If there was a difference in severity of drug laws and law
enforcement before World War II, Canada's were arguably the more severe.
At all stages of the growth of the antidrug movement before World War II,
there was a strong flow of influence, primarily from south to north, across the
United States-Canada boundary. However, there are no indications before
World War II of any effort of the United States to control Canadian policy or of
lack of accord between the two countries. In fact, there seems to have been a
remarkably parallel evolution of drug law and enforcement policy (Giffen et
aI., 1991).
AMERICAN AND CANADIAN DRUG POLICY

AFTER WORLD WAR II
In both the United States and Canada, drug policy since World War II has
been a further extension of the "temperance mentality" that was born in the
19th century. Although there were fluctuations in the decades following the
war, the general trend in both countries was toward increasingly severe drug
policy. The stringency of domestic drug laws, the militancy of antidrug propa-
ganda, and the violence of military interventions in "producer countries"
eventually increased to the point that drug policy came to be called the "War on
Drugs" by both its supporters and its opponents.
However, beyond the continuing similarities between the two countries,
important divergences have appeared. Some divergences became evident
shortly after the war, more in the 1970s, and more still in the 1980s. We will first
describe the almost parallel developments in drug law and then more divergent
developments in enforcement practices and in public opinion. Other diver-
gences can be documented, notably in the harshness of treatment, the violence
of foreign interventions in producer countries, the levels of drug testing, and
the frequencies of vigilantism and informing by private citizens, and the
visions of successive national drug strategies in the two countries, but these
must be omitted here for lack of space. The final section of this chapter will
speculate about the causes of the overall difference in severity of drug policy
in the two countries.
Drug Laws after World War II
The continuing similarity between U.S. and Canadian drug law is not
altogether coincidental. It partially reflects the fact that both countries are
signatories to international conventions that are designed to shape drug law for
the entire world.
American Drug Laws. American drug law has now reached a point that
seems, to many people, incompatible with American ideals of individual
freedom. Arnold Trebach (1993) has argued that "The essential nature of the
U.S. drug enforcement has an alien tinge to it, more suited to an intrusive
totalitarian society than to the democratic ... culture that evolved ... here in the
United States" (p. 26).
The 1950s saw the United States bolster already severe federal narcotics
laws with provisions for life imprisonment and the death penalty for traffickers
under certain conditions. Congress and several states created mandatory mini-
mum sentences for drug offenses in the belief that lenient judges were to blame
for increasing drug use among the young. The trend toward increasing severity
was diverted during the 1960s, when, in the context of a more tolerant public
mood, both Republicans and Democrats conceded that mandatory minimums
did not deter narcotics use. As a result, Congress repealed almost all the
mandatory sentences for drug offenses in 1970 (Schlosser, 1994).
During the 1970s the mood changed again, however, and the Nixon
administration introduced a new "no-knock law" that, for the first time,
permitted narcotics agents to legally break into private premises without warn-
ing (Brecher, 1972). By the mid-1980s American lawmakers had reintroduced
mandatory minimum sentences.
In the 1980s, under two consecutive Republican administrations, U.S.
drug laws reached heights of severity that some observers found absurd. In
1985, the U.S. Supreme Court upheld the right of U.S. customs officials to
detain anyone who enters the United States until they defecated into a con-
tainer, allowed their feces to be examined, and thereby demonstrated their
innocence of drug trafficking. Since contraband was found in less than 20% of
these searches (Trebach, 1987), hundreds of innocent visitors must have been
amazed as well as embarrassed by this unique welcoming ceremony. New
forfeiture laws in the 1980s allowed assets of suspected traffickers to be seized
even in the absence of a criminal conviction, thus depriving them of funds to
conduct a legal defense. Other laws made it possible to compel attorneys to
testify against their own clients in drug cases and to seize fees paid to defense
attorneys if the money came from drug trafficking. Some recent American
cases show that these laws can make defense against drug charges almost
impossible (Trebach, 1993; Zeese, 1986).
Following the election of a Democratic administration in 1992 there have
been minor shifts in emphasis in federal drug policy, including some additional
expenditures for treatment of addicts. Moreover, the tone of public statements
by the second American "Drug Czar" (Brown, 1994) and other high-ranking
officials is less bellicose than that of previous administrations. However, the
trend toward increasing severity in lawmaking has not been deflected. The
recently passed Violent Crime Control and Law Enforcement Act of 1994
continues the escalation. For example, it allows the death penalty for the crime
of being a "drug kingpin" ("Crime Bill," 1994). Other legislation and judicial
decisions made during the Clinton administration have introduced or increased
mandatory minimum st!ntences for a variety of drug offenses (Drug Policy
Foundation, 1994b), eliminated the possibility of physicians prescribing mari-
juana to the medically ill (Drug Policy Foundation, 1994a), and failed to change
the existing federal embargo on funding for needle exchange programs (Drug
Policy Foundation, 1994a).
Canadian Drug Laws. As in the United States, already severe Canadian

drug laws escalated in severity after World War II. In Canada, the police have
"far broader enforcement powers in even a minor drug case than they have in a
murder, arson, rape, or other serious criminal investigation" (Solomon, 1988,
p.263).
The 1961 Narcotic Control Act' raised the maximum penalty for traffick-
ing, possession for the purpose of trafficking, importing, and exporting from 14
years to life. Under the Canadian Narcotic Control Act, importing or exporting
drugs became subject to a minimum2 sentence of7 years' imprisonment-only
murder and high treason carried as severe a minimum sentence (Solomon &
Usprich, 1991). A reverse onus clause was included in cases of possession for
the purpose of trafficking. The police were given almost unrestricted powers of
search and seizure. Writs of assistance were carried over from pre-War legisla-
tion into the Narcotic Control Act. In effect, the writs allowed certain police
officers, and other officers who were in their company, to break into any home
at any time if they suspected illicit drug use, damage it severely in the process
of search, punch and choke persons they suspected of swallowing drugs, and
detain any person they found in the process (Solomon & Usprich, 1991). On the
other hand, the Canadian Narcotic Control Act did not include a provision for
the death penalty as did the corresponding U.S. Narcotic Control Act of 1956,
and it removed the provision for whipping from the pre-War years.
Since the enactment of the Canadian Charter of Rights and Freedoms in
1982, there has been a court-ordered retreat from the more heavy-handed
practices of the Narcotic Control Act. For example, writs of assistance were
abolished (Solomon, Hammond, & Langdon, 1986), as were the reverse onus
clause and the mandatory minimum sentences in the drug laws (Erickson,
1992). Mandatory minimum sentences have not been recreated in new Cana-
dian drug laws currently under consideration by Parliament.
However, recent legislation has broadened enforcement powers by giving
the courts the power to seize the assets of drug offenders, including those who
IThe Narcotic Control Act is one of the two main Canadian drug laws. The other is the Food and
Drug Act, which regulates certain pharmaceuticals as well as LSD, psilocybin, and DMT.
Although the maximum penalties under the Food and Drug act are 10 years' imprisonment,
compared to life imprisonment under the Narcotic Control Act, the intent and logic of the two acts
are similar. Only the Narcotic Control Act will be discussed here, for the sake of simplicity.
2The wording of the Narcotic Control Act provides for "minimum" sentences, which are often
called "mandatory minimum" sentences in the United States.
have been arrested but not yet convicted (Canadian Legislative Index, 1987).
New prohibitions on drug paraphernalia and literature that appears to recom-
mend use of illegal drugs (Section 462.2, Canadian Criminal Code) have also
been enacted, but their status is not yet certain, because a recent provincial
court ruling has placed their survival in question (Nasrulla, 1994).
In spite of judicial obstacles, the trend in federal drug legislation remains
toward increasing severity, no matter whether liberals or conservatives form
the government, and despite some palliative rhetoric about "harm reduction"
(Fisher, 1994). The present liberal government, elected in 1993, has recently
proposed a new drug act, introduced ostensibly to consolidate existing legisla-
tion. In fact, however, the new act does much more; it introduces new drug
crimes, raises the penalty for some existing crimes, and gives the enforcement
bureaucracy the right to add new drugs to the schedule of prohibited substances
without consulting Parliament. Among many other specific changes, the new
act raises the penalty for cultivation of narcotics (with the exception of mari-
juana) from the present 7 years to life imprisonment and in all other regards
maintains the homogeneous classification of marijuana with the other "nar-
cotics" (House of Commons of Canada, 1994). At the time of this writing this
act has passed "second reading" in the House of Commons, and passage
through the Canadian Senate appears probable.
Enforcement of Drug Laws
In both the United States and Canada heavily armed and terrifyingly
garbed police squads routinely and legally crash through the closed doors of
homes of suspected drug criminals without prior warning. Once inside, they
can physically and emotionally intimidate whoever they find there, eventually
arresting some or all if illegal drugs are found on the premises. In neither
country is the legitimacy of these procedures ever seriously challenged. In fact,
they are not considered unusual enough to be newsworthy-unless a person of
incontestable innocence is killed or beaten during the procedure, as sometimes
happens in both countries (Drug Policy Foundation, 1994c; Hall, 1993).
In spite of fundamental similarities in enforcement practices, there are
important quantitative differences between enforcement in the United States
and Canada. U.S. drug law is enforced more often and more severely. This
important difference is difficult to document precisely, because the offense
categories are not the same in the two countries and because all Canadian drug
crime is a federal offense, whereas in the United States there is a large number
of state and local arrests and convictions for drug crimes.
American Enforcement. Three times as many people are imprisoned

per capita in the United States than in Canada (see Christie, 1993; Statistics
Canada, 1992a), and a significant portion of the difference is due to plisoners
convicted of drug crimes. At the beginning of the 1990s there were about one
third of 1 million people incarcerated in U.S. federal, state, and local prisons for
drug possession or drug trafficking (Duke & Gross, 1993), 25-30% of the
entire penal population.
U.S. courts have imposed increasingly severe sentences on convicted drug
offenders, including those guilty only of possession, in part because mandatory
minimum sentences leave judges with no other alternative (see Harrison, 1992).
It is now routine practice to give low-level drug offenders 5- or lO-year
mandatory minimum sentences (Drug Policy Foundation, 1994b). This was
highlighted in a newspaper article that noted that since 1991, approximately
2,000 Grateful Dead concertgoers have been arrested for buying and selling
illicit drugs at, or around, concert sites. Most are first-time offenders. However,
"Because of mandatory drug sentences, many of these 2,000 new prisoners are
serving longer sentences than rapists, kidnappers, armed robbers and big time
heroin dealers" ("DEA sticks on trail," 1994).
U.S. enforcement efforts have expanded greatly since 1980. For example,
the United States drug arrest rate for all law enforcement agencies almost
doubled between 1980 and 1990 from 256 to 449 per 100,000 (Bureau of Justice
Statistics, 1983, 1992). The number of people convicted by U.S. district courts
for violations of the Drug Abuse Prevention and Control Act tripled between
1980 and 1992 to 17,200 (U.S. Bureau of the Census, 1993). Among U.S.
federal prison inmates in 1991, 56% were incarcerated for drug offenses (Bu-
reau of Justice Statistics, 1992).
The severity of sentences is illustrated by the disposition of drug convic-
tions in U.S. district courts. Of 16,186 defendants convicted of drug law
violations in U.S. district courts in 1990, 83% were given a prison sentence,
13% received probation, and 1% were fined. The average sentence length was
over 6 years, and almost 90% of the sentences were for more than 1 year
(Bureau of Justice Statistics, 1992). There are no signs that any of this has
changed under the new federal administration. A 1994 American government
study indicates that the percentage of federal prisoners who are incarcerated for
drug offenses has risen from 56% in 1991 to 59% (Drug Policy Foundation,
1994b).
Canadian Enforcement. Canada's drug law enforcement appears to be

more restrained on all these dimensions. Some of the statistical comparison
must be rough and ready, because the offense categories are somewhat different.
Although there are indications of differences shortly after World War II,
the differences became dramatic after 1980. The Canadian arrest rate for drug
offenses declined appreciably between 1980 and 1992, while the U.S. rate
doubled. l In 1990, only 53% of those convicted under all Canadian drug
legislation went to prison (compared to 83% in the United States). Of these
60% were sentenced to less than 6 months, compared to the average U.S.
sentence of over 6 years. Thirty five percent of convictions resulted only in a
fine (Bureau of Dangerous Drugs, 1991). Sentences for importation, tradi-
tionally considered a particularly serious offense, have decreased dramatically
since 1987 (Statistics Canada, 1990). Only 9% of Canadian federal prisoners in
1991-1992 were incarcerated for violations ofthe Narcotic Control Act (Statis-
tics Canada, 1992c). Minimum sentences for drug offenses are not currently
being imposed in Canada since they were ruled to constitute "cruel and
inhuman punishment" by the Supreme Court of Canada in 1987. The new
federal drug legislation now before Parliament does not introduce new mini-
mum sentences, although federal guidelines for judges are currently under
consideration. Clearly, the Canadian judicial system is far less eager to incar-
cerate drug offenders, and offenders in general, than is the U.S. system.
Political and Public Opinion
Both Americans and Canadians believe that the use of illicit drugs has
reached epidemic proportions and that their countries face a serious drug
problem (Single et aI., 1991). In both countries this view must be at least
partially attributed to incessant antidrug messages presented on all public
media and through the schools.
In spite of obvious similarities, American public opinion is more militant
than Canadian public opinion on the topic of drugs, and has been so since the
1970s. In our view, this difference in public opinion provides the most revealing
comparison between the two countries. We will summarize the results of some
public opinion polls, particularly focusing on how the citizenry of the two
countries has responded to various calls to the "war on drugs" from their
national leaders.
American Political and Public Opinion. U.S. President Nixon called

heroin addiction America's "Public Enemy Number One" in a major cam-
lThis is based on the rate of "drug offense incidents," i.e., offenses that police investigations have
established did occur, whether or not an arrest took place. The number is probably greater than the
number of actual arrests. The rate in 1992 was 206 per 100,000. This represents a one-third decline
from a high of 309 in both 1980 and 1981 (Statistics Canada, 1992b).
paign speech in 1968. Following his election he launched a "war" on heroin in

1969. Public fear was increased by the fear that thousands of American soldiers
would return from Vietnam as lifelong heroin addicts. In 1971 heroin addiction
ranked third in polls behind only "Vietnam" and "the economy" among the
most serious problems facing the United States (Bellis, 1981).
In 1986, Ronald and Nancy Reagan jointly made a televised speech to the
nation. They asserted that a drug crisis was gripping America and called for a
renewed drug war. The Reagan's call to arms produced a groundswell of
political and popular support. A subsequent poll indicated that 13% of Ameri-
cans considered drugs the single most important problem facing the United
States. Indeed, two thirds said they would willingly pay more taxes to jail
traffickers (Clymer, 1986).
When President George Bush redec1ared war on drugs in a televised
speech in 1989, public support for strong measures was far greater. A poll found
that 43% of the respondents felt that drugs were the nation's most important
issue. The pollsters "found a nation willing to try even extreme measures to
combat the drug problem" (McQueen & Schribman, 1989, p. AI). For exam-
ple, 58% of Americans favored sending troops to South America to eradicate
illegal drug growing, 62% were willing to give up "a few of the freedoms we
have in this country" to support a war on drugs, and 52% said they would be
willing to have homes searched (see Wicker, 1989). Another 1989 poll found
79% willing to pay higher taxes to fund the war on drugs (Barrett, 1989).
Another way of assessing public opinion is looking at the fate of public
figures who become associated with drugs in the public mind. Indeed, accusa-
tions of past drug use seem to be considered standard and acceptable means for
discrediting political opponents in the United States (Duke & Gross, 1993; The
Senate race, 1994) and have even undermined Supreme Court nominations
(Press, McDaniel, Defrank, Clift, McKillop, & Hutchison, 1987). President
Clinton's famous admission of personal marijuana experimentation-lack of
inhalation notwithstanding-carried much greater public and political reper-
cussions than have followed similar admissions in Canada.
Canadian Political and Public Opinion. Just a few years after Presi-
dent Nixon had called for an all-out war on drugs, his Canadian counterpart,
Prime Minister Trudeau, told a group of Canadian youth that "Certainly the
spirit of government policy-and it hasn't been passed yet-is that if you have
a joint and you're smoking it to your private pleasure-you shouldn't be
hassled" (Bryan, 1979, p. 181). Whereas such an attitude might have been
political suicide in the United States, Trudeau served a long term as prime
minister and remains a respected political figure.
Canadian public response to the call to arms of the 1980s was different too.
A few days after the Reagan's 1986 declaration of war, which many Canadians
would have seen on television, Prime Minister Mulroney made his own dra-
matic declaration that "Drug abuse has become an epidemic that undermines
our economic as well as our social fabric" and called for urgent measures
(Cruickshank, 1986, p. AI). However, public support did not materialize in
Canada. The day after Mulroney's speech, the headline of Canada's conserva-
tive national newspaper read "PM's war on drug epidemic baffles experts"
(Poirier, 1986). The article described the reaction to Mulroney's speech:
Law enforcement officials and experts on addiction are puzzled by Prime Minister
Mulroney's use of the word "epidemic" in announcing a government initiative to
fight drug abuse ... Police sources and drug researchers refused to use the word to
describe the drug abuse problem in Canada ... Liberal leader John Turner suggested
Mr. Mulroney is merely following u.s. President Ronald Reagan's lead in announc-
ing a campaign against drug abuse ... "1 can't help wondering if there isn't any
bandwagon that goes by that Mr. Mulroney doesn't jump on," Mr. Turner said (p. AI).
Other dissenting voices were reported from the labor movement, other
liberals, and even from a conservative party cabinet minister (Alexander,
1992), although a poll showed that 75% of the Canadian public agreed that
there was an epidemic of illegal drug use (Gallup Report, 1986).
Although 75% of Canadians still believe that there is an epidemic of drug
abuse in Canada (Bozinoff & Turcotte, 1992), most polls investigating what
Canadians consider the country's most important problems do not even show
drugs among the list of concerns (Macleans, 1986-1989, 1992-1994). A 1990
poll that directly compared public opinion in the two countries found that 21 %
of Americans but only 1% of Canadians considered drugs and/or alcohol
problems their country's most important national issue (Macleans, 1990). A
1991 poll found that 4% of Canadians thought that drugs, but only in conjunc-
tion with social and moral issues and crime, constituted the nation's most
important issue (Macleans, 1991).
There is an obvious difference in reactions to admissions of drug use by
public officials on different sides of the border. During Canada's 1993 national
election, then Prime Minister Kim Campbell acknowledged that she had previ-
ously smoked marijuana-and that she had even inhaled. This admission
provoked only bemused comment from the public and her political opponents.
Canada's present Prime Minister, Jean Chretien, was recently asked at a
meeting with high school students if he had smoked marijuana. Much in the
spirit of Trudeau (if lacking some of Trudeau's linguistic elegance), Chretien
replied, "1 never smoked that [marijuana] but for me, 1 don't pass judgment on
that" (Ward, 1994, p. A4). Again, there was no public or political outcry
following this statement. It is difficult to imagine an American president saying
such things to young Americans.
DISCUSSION
Differences in drug policy between the United States and Canada are of a
different sort than the differences in medical services. Whereas the political
ideologies underlying the medical services in the two countries are different,
the two drug policies have grown from the same assumptions-the temperance
mentality-and are carried out within a similar structure of legislative and
administrative decisions.
Nonetheless, in the years since World War II, there has been a clear
divergence in the vigor with which drug laws are enforced, in the mood of
political and public concern about drugs, and in other aspects of drug policy
that have not been reviewed here. In general, it can be said that the United
States has attacked the drug issue more vigorously and punitively than has
Canada. In this section of the chapter we will address some possible causes of
these differences and then venture some conclusions.
Possible Causes of American-Canadian Differences
There are, to us, four plausible reasons for the difference in severity
between the two countries following World War II. We will discuss them in no
particular order, since we cannot as yet decide which is the most important. Our
current perspective is that each of the four contributes to the difference and that
their relative weight is an important matter for future scholarship to resolve.
Differences in Rates of Drug Consumption. Americans probably con-

sume more illicit drugs than do Canadians (Single et at., 1991; Erickson, Adlaf,
Smart, & Murray, 1994). This possibly contributes to the difference in vigor
and punitiveness of drug policy between the two countries following World
War II. However, we do not believe this is the sole, or even the major, cause of
the differences that have been described.
There are several reasons to suspect that differences in drug consumption
between the two countries are not the most important determinant of differ-
ences in policy. First, social science research has shown repeatedly that the
relationship between the magnitude of a country's drug consumption and the
severity of its drug policy is not straightforward. For example, it has been
shown that Ronald Reagan's successful attempt to galvanize the American
public into a "war" against a growing drug menace in 1986 came at a time of
decreasing or stable drug consumption (Jensen, Gerber, & Babcock, 1991).
Likewise, Canadian drug consumption was decreasing or stable at the time of
Brian Mulroney's unsuccessful attempt to rouse the Canadian public to war on
drugs. Jensen and Gerber (1993) explain the different outcome of the call to
arms in the United States and Canada, not as a consequence of differing levels
of drug consumption but as a result of different credibilities of the two govern-
ments at that time.
History records more dramatic discrepancies between the magnitude of a
country's drug problem and severity of its response. For example, authorities
agree that use of cannabis was well established in the United States by the
1930s, but was negligible in Canada until the 1960s (Abel, 1980; Green &
Miller, 1975). Nonetheless, in the severe climate of pre-World War II Canada,
cannabis was banned in 1923, 8 years before the first case of marijuana
smoking came to public attention and 14 years before cannabis was banned
federally in the United States in 1937. In 1961, cannabis was included in the
Canadian Narcotic Control Act, making cannabis offenders subject to life
imprisonment for trafficking, importing, or exporting-still before any signifi-
cant amount of cannabis use had occurred. A Royal Canadian Mounted Police
report stated that "prior to 1962, isolated cases of cannabis use were encoun-
tered, but generally in connection with entertainers and visitors from the United
States ... its use on a more frequent basis appeared in Montreal only in 1962, in
Toronto in 1963, and in Vancouver in 1965" (Green & Miller, 1975, pp. 498-
499). Therefore, the policy response was clearly not a function of widespread
consumption or associated problems.
A second reason to question the importance of differences in drug con-
sumption as a cause of differences in drug policy is that levels of drug
consumption cannot explain the similarity in policy before World War II. It is
possible that relative drug consumption in the two countries was equal before
World War II and became different subsequently. Whereas this is not impos-
sible, the existing information, such as the police records of marijuana con-
sumption cited above, do not point in this direction.
A third reason to not place too much emphasis on differences in drug
consumption as the cause of the difference in drug policy is that Canadians,
possibly influenced by American media, think there is a drug epidemic, regard-
less of whether there is or is not. Some of the public opinion data are recounted
above and have been summarized in other sources (Single et aI., 1991). Never-
theless, when Prime Minister Mulroney launched his antidrug campaign in
1986, he had small success in arousing the Canadian pUblic.
A final reason to question the importance of differences in drug consump-
tion as a cause of differences in drug policy is that existing data on differences
in drug consumption between the two countries are inadequate. Use of illicit
drugs is covert, and attempts to measure it are always questionable. The best
attempt at a comprehensive U.S.-Canadian comparison is probably Erickson
and colleagues' (1994) recent study of cocaine use. Although these authors
concluded that more cocaine is used in the United States, they judiciously
pointed out that they were forced to rely heavily on survey data. American
"household surveys" are based on carefully stratified samples, but they neces-
sarily miss prisoners, the homeless, and people who refuse to be interviewed,
and they are vulnerable to underreporting from those who do participate.
Canadian data are more problematic still. The only two existing Canadian
national surveys were conducted by telephone, which introduces an additional
set of sampling limitations because the demographic characteristics of people
without telephones are similar to those of people who use cocaine heavily
(Nadeau, Alexander, Wong, Matthews, Dawes, & Toneatto, 1994) and because
there are few incentives for a person to be candid with an anonymous telephone
interviewer. Provincial household surveys provide strong indications of under-
reporting in the national telephone survey. For example, the 1985 Canadian
national telephone poll reported a lifetime prevalence of cocaine use of 2% for
residents of British Columbia (Health and Welfare Canada, 1988). By compari-
son, a 1986 household survey independently conducted in British Columbia
(Ministry of the Attorney General, Province of British Columbia, 1987) pro-
duced a lifetime prevalence estimate of 11.2% for the same population, more
than a fivefold difference. Therefore, it is difficult to know the magnitude of
differences in consumption between the two countries or to state with complete
assurance that it exists at all.
Alcohol is the one intoxicating substance for which use can be monitored
with reasonable accuracy. Since World War II, alcohol consumption in the two
countries has been approximately equal or slightly greater in Canada (Smart &
Ogborne, 1986).
Differences in National Character. Could there be a difference in

national character or temperament, with Americans being generally more
moralistic, perhaps more "puritan"? This speCUlation can find support in the
work of a number of scholars (e.g., Adams, 1995; Rorabaugh, 1979). Dwight
Heath (1992) has stated the idea as follows:
Within a month of President Bush's [1989) speech on drugs, public opinion polls
reported that nearly 65% of the people identified drugs as "the major issue facing
this country," and there appeared to be a consensus supporting a militant agenda
against drugs. The imagery of war not only caught people's attention and won
strong support from the media; it also spoke to attitudes and values that have deep
roots in the US national character (p. 270).
Such an explanation of U.S. policy can easily slip from the empirical
realm to the realm of tautology or of facile anti-Americanism. However, our
research group at Simon Fraser University and at Utrecht University in the
Netherlands has undertaken international comparisons that provide some em-
pirical grounding for what may comprise an American-Canadian difference in

temperamental inclination toward moralistic and punitive solutions to drug
problems.
In part, this research was based on a Temperance Mentality Questionnaire
(TMQ) that was designed to measure adherence to the beliefs expressed by the
North American temperance movement in the 19th and early 20th century (Burt
et al., 1994). The TMQ was developed systematically to ensure that it included
only mainstream claims from the historical temperance literature, rather than
marginal ideas or claims from contemporary antidrug rhetoric that could be
retrospectively attributed to temperance doctrine. About half of the items on
the resulting questionnaire, which we called "alcohol-only" items, were state-
ments of moralistic and punitive claims about the intrinsic evil of alcohol,
putatively factual claims about the dire health and social hazards inherent in
drinking alcohol, claims about the necessity of total abstinence as opposed to
moderate use of alcohol, and claims about the desirability of temperance
education and legislated prohibition.
The responses to alcohol-only items of the sort described above are less
important in the context of this article than responses to a variant of them,
which we called "drugs-and-alcohol" items. Drugs-and-alcohol items were
constructed to investigate the degree of support for moralistic and punitive
temperance claims that have been retargeted to the disreputable drugs of the
20th century. In the drugs-and-alcohol items, references to alcohol were re-
placed with a reference to one of the targets of contemporary antidrug cam-
paigns, such as "marijuana," "crack cocaine," "drugs," "alcohol and other
drugs," "illegal substances," and so on. Such items, in effect, restate the
moralistic and punitive mentality of the 19th century temperance movement
and apply it to drugs that are held in low repute today. Sample items of this sort
would be: "Selling marijuana would be immoral even if it were legal,"
"Citizens should take action if the government fails to enforce (maintain) drug
laws," and "Alcohol and drug use lead to family breakdown and domestic
violence" (Burt et al., 1994).
A comparison of responses to drugs and alcohol items by almost 2,000
university students in seven countries appears in Table 1. It will be seen that
support for the temperance mentality as applied to drugs and alcohol ranged
from about Y5 of the university students in the Dutch and French Canadian
Sample I to more than 415 of the students in the Bulgarian and Iranian sample
(Alexander, Dawes, van de Wijngaart, Ossebaard, & Maraun, in preparation).
The position of two United States samples is clearly toward the temperance end
IOttawa is a bilingual city. but the data reported here all come from francophone students at the
Universite d'Ottawa.
Table 1
Percentage of Students Expressing Support, Neutrality,
or Opposition to Twenty-Two Drug and Alcohol Items a
City, Country Overall Neutral Overall
Opposition or Mixed Support
Utrecht, Netherlands 13.2 67.3 19.5

Ottawa, Canada (francophone) lOA 68.1 21.5
Vancouver, Canada (anglophone) 11.0 57.7 31.8
Dublin, Ireland 3.0 61.6 35.4
Bologna, Italy 5.1 58.6 36.3
Seattle (Washinhton), USA 304 50.0 46.6
Lawton (Oklahoma), USA 204 2804 69.2
Paisii, Bulgaria 0.0 17.8 82.2
Teheran, Iran 0.7 11.9 8704
aX' = 347.2; df = 24; P < .001
of the distribution, and the difference between the Canadian and American
mean scores is statistically significant. The relative position of the United States
and Canada is similar when scores on the alcohol-only items are compared.
We believe it is significant that the wording of these items is directly taken
from a historical literature that is easily recognized as rigid, moralistic, and
punitive. These data are compatible with the possibility that the American
proclivity toward severity in drug policy has, in Heath's (1992) words, "deep
roots in the U.S. national character" (p. 270). These data also suggest that the
temperance mentality is not an exclusive temperamental quality of Americans,
since higher scores came from the university students in Bulgaria and Iran.
Obviously, further research will be necessary to explore the roots of this
possible national difference in the temperaments of Americans, Canadians, and
others.
Post-War Differences in Political Direction and Ambition. The pre-

vious section could be taken to support a widely held stereotype about Ameri-
can "puritanism." On the other hand, a pair of Canadian historians (Hillmer &
Granatstein, 1994) have suggested that the Canadian capacity for moralism is
also prodigious, but that events after World War II conspired to tum it in a
different direction from American moralism (Hilmer & Granatstein, 1994).
From this point of view, the divergence in national drug policy in the
United States and Canada might also be understood as a consequence of
differences in political direction and ambition in the two countries after World
War II that secondarily engendered differences in drug policy. Whereas most of
the social forces that supported severe antidrug policy in both countries before
World War II remained in place after the war, at least two differences emerged
between the United States and Canada that might have influenced drug policy.
Before World War II, antidrug policy had proved itself effective as a
means of controlling racial minorities that were perceived as menacing. How-
ever, in both the United States and Canada, the Asian racial problem had
largely dissolved by the end of the war. Racial assimilation was well underway,
in spite of substantial new Asian immigration and the unfortunate wartime
internment of Japanese-Americans and Japanese-Canadians. But, uniquely in
the United States, a large racial problem remained-the stubborn lack of
assimilation between black and white Americans. A number of authors have
suggested that drug enforcement policy is fulfilling its historic function in the
United States of serving to repress a racial minority that is perceived as
menacing. Heath (1992) has pointed out that "In 1989, with Blacks comprising
12 percent of the population, and a similar percentage of drug users, 42 percent
of drug arrests involved Blacks" (p. 284). Burgess (1994), writing in the French
press, has pointed out that 9 out of 10 of those receiving the death penalty in
American drug cases are black or Hispanic, whereas three quarters of those
who are indicted are white (Burgess, 1994). Whereas these observations sug-
gest a disproportionate application of drug law to black and other members of
the American underclass, the disproportion is not nearly as great as that directed
against the Chinese in Canada in the 1920s and 1930s, described above.
A second difference between the two countries after World War II that
could have an impact on drug policy is that Canada, having lost its position as a
powerful member of a worldwide British empire and having been denied the
membership that it sought on the UN Security Council, was in a position to
focus on domestic welfare and international peacemaking as a "middle
power." The United States, as the new head of an emerging Pax Americana,
had maintained and perhaps expanded its "great power" ambitions (Hillmer &
Granatstein, 1994). Such a difference in national ambition might affect the
inclination toward "wars" of all sorts, including drug wars. Said (1993) has
documented how the imperialistic ambitions of Britain, France, and the United
States in the 19th and 20th centuries had major impacts on their domestic
literature and social institutions.
It has been argued that successive American governments relied on strong
antidrug fervor at home and an expensive worldwide market for drugs as tools
in achieving great power ambitions, e.g., for covertly raising money for allied
guerilla forces (Cockburn, 1987; McCoy, Reach, & Adams, 1972; Chomsky,
1992). Chomsky (1994) has provided a detailed analysis of the use of drug
charges as a way of condemning political factions in Guatemala, Columbia,
Panama, and other countries that were perceived as opposing American inter-
ests during the Reagan and Bush administrations. He has argued that the
political need to associate Third World enemies with drug trafficking has
grown greater with the disappearance of a credible threat from the U.S.S.R.,
which permitted enemies to be labelled as communists.
Differences in Media. Sensational and provocative media stories have

been featured in United States and Canadian media throughout the 20th century
(see Silver & Aldrich, 1979; Murphy, 1920a-d; Schweighofer, 1988). Most
Americans and Canadians do not have direct experience with illicit drugs-
with the possible exception of marijuana. Therefore, the only basis for their
perceptions and beliefs is often the media. Although the media commonly
promulgates myth and misinformation concerning drugs (Bomboy, 1974;
Erickson et ai., 1994; Reeves & Campbell, 1994), those who lack complete
information "seem unable to challenge the pictures and narrations" that appear
in the media (Iyengar, Peters, & Kinder, 1982, p. 855).
Although media depictions of illicit drugs in the two countries are similar,
there may be enough of a difference to account for differences in public opinion
and, ultimately, public policy. We have been unable to obtain quantitative data
on this topic, but we have noted that Canadians visiting the United States con-
sistently report surprise at the prominence and ubiquity of antidrug messages,
which seem greater than in Canada. The kind of displays that returning Cana-
dians mention include full-page ads in major American newspapers, large
roadside billboards warning of the danger of illicit drugs, and T-shirts bearing
antidrug warnings. One returning Canadian reported with amazement a city
bus that was painted completely black with the exception ofthe words "DARE
to Keep Kids Off Drugs" in red and white lettering across the side of the bus.
Conclusions. Although many sources of data reviewed here provide an

imperfect basis for comparison, a consistent picture has emerged from the
totality. The picture is one of a very large country that is preoccupied by illicit
drugs and a second smaller country that is comparably concerned, but that has,
since World War II, been less moralistic and punitive about drug use and more
focused on other priorities.
Perhaps naively, our initial plan was to end this analysis with a set of
recommendations concerning the aspects of Canadian drug policy that could be
profitably imported by the United States and vice versa. This design lost its
credibility in the face of the historical and social science literature showing that
drug policy has never been rationally formulated. Rather, it has always been an
outcome of diverse pressures exerted by incompatible ideologies and interests.
There seems little possibility that rational analysis of pros and cons of various
features could be adopted by any disinterested agency of policy control in the
future. Conclusions about the possibility of policy change obviously must

address the dominant motives that maintain current policy. Yet, on the basis of
the evidence we have been able to review, no clear conclusion about which
motives are dominant is yet possible.
We have come to believe that drug policy issues have been too much
studied in isolation from larger matters of cultural and national concern. The
development of attitudes toward drugs in the United States and Canada cannot
be adequately understood outside of the cultural history of the temperance
movement and the larger social forces that environed it. Likewise, current
policies toward drugs cannot be fully explained as a response to current drug
problems. Other political problems create political needs that can be furthered
through certain forms of drug policy.
Finally, because they dramatically alter the contents of our mind, psycho-
active drugs are an issue of great symbolic, religious, and political significance
to many people in the world. Analysis of drug problems and drug policy cannot
be adequate if it is limited to rational concerns. People are passionately protec-
tive of their access to drugs that have acquired symbolic value for them and are
passionately concerned to suppress drugs that they fear for rational or irrational
reasons (Szasz, 1985). In the end, society may be as welJ served by study of the
dynamics of the drug war as by study of the dynamics of drug use.
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CHAPTER 12
The War on Drugs

as a Metaphor
In American Culture
DWIGHT B. HEATH
DECLARATION OF A WAR ON DRUGS
George Bush had been President of the United States for half a year, elected by
a landslide victory and inaugurated in a time of welling chauvinism and
superficial prosperity. The American people seemed eager to hear his plans
when he gave his first televised address in August of 1989. Whatever disap-
pointment there may have been over pressing needs that were not mentioned,
his call to arms in the war on drugs struck a responsive chord. During the next
several months, the media was full of feature stories, editorials, news reports,
and background accounts about "the drug menace," the "war on drugs," and a
host of other approaches to drug use and its deadly impact. At one level the
imagery of war could be viewed as just a metaphor, a rhetorical device virtually
guaranteed to galvanize public opinion, demonstrate the speaker's decisive-
ness, rally support, and draw a sharp line between "us" and "them." No longer
a wimp, as he had earlier been characterized, Pres. Bush had identified a
DWIGHT B. HEATH • Department of Anthropology, Brown University, Providence, Rhode

Island 02912.
Treatmenl of Illicit Drug Abuse. edited by Warren K. Bickel and Richard 1. DeGrandpre. Plenum
279
280 DWIGHT B. HEATH
common enemy, announced a firm stand, and promised to take action to

"defeat" the other side. Such rhetoric on the part of other presidents had been
applauded in connection with the "war on poverty" and the "war on illit-
eracy," as it had been earlier with the "war against drink" and, probably, in a
series of other pseudoevents in American history.
It is an unfortunate characteristic that the United States literally seems to
"need" an enemy, as is evidenced in the widespread and vehement spate of
Japan-bashing that sprang up as the Cold War with the former Soviet Union
wound down. Subsequent interventions in Iraq, Rwanda, Somalia, and Haiti,
whatever the details given as immediate justification, also fit the long-term
pattern. The pervasive imagery of warfare has even permeated our view of
health and human biology-the body is characterized as being "attacked" by
various kinds of intruding germs or toxins, which are "fought off" by compo-
nents of the immune system; if the "invading forces" should "overwhelm"
them at one point, they are likely to encounter a "second line of defense" in
another biochemical process, and eventually be "mopped up." There can be no
doubt that war is a powerful metaphor, however reluctant Americans may be to
admit to favoring it.
Within a month of Pres. Bush's call to arms, public opinion polls reported
that nearly 65% of the American people were identifying drugs as "the major
issue facing this country," and there appeared to be remarkable consensus in
support of a militant agenda against them. A year later, the same pollsters found
only 10% responding that way, and the number has been diminishing ever
since. Pres. Clinton, and, subsequently, even the "new Republicans" have
made little mention of any such concern. What was happening on the home
front in the war on drugs? This striking change of outlook reflects the complex-
ity and ambivalence of what is often too glibly characterized as a homogenous
American culture.
The imagery of war not only caught people's attention and won strong
support from the action-oriented media; it also fit with attitudes and values that
have deep roots in the U.S. national character. It was perhaps scary, but in a
way reassuring, that "the bad guys" who were making huge profits outside of
the law, victimizing children and other vulnerable individuals, were mostly
foreigners-generally shorter, darker-skinned people with alien names and
accents, often operating with apparent impunity in corrupt nations of the Third
World. Reports of "drug-related deaths" and other violence mushroomed in
number, with the implication being that the few demonstrably innocent victims
were more representative than the vast majority who were themselves crimi-
nals vying over turf or money.
Even within the United States, those who were "on the other side" in the
war on drugs were generally portrayed and perceived as being black or His-
WAR ON DRUGS AS A METAPHOR 281
panic, poor (or unjustly rich), unwilling to work, too quick to resort to violence,
and in other respects deserving of collective condemnation. Such a stereotype
of addicts is regularly contradicted by national surveys of drug use and by
enrollment in treatment programs, both of which reveal that regularly em-
ployed middle-class whites predominate in number in both categories.
Some social scientists who bring a psychoanalytic perspective to this issue
emphasize the tendency of populations to project their fears and vices onto a
safely remote and outcast group, unconsciously but effectively pointing to a
scapegoat. The suggestion is that we "need" addicts and "drug lords" as
vessels for all the negative qualities that we decline to admit within ourselves,
seeing them in ways that justify our "waging war" upon them (Stein, 1985).
All of those themes were played out as hostile gangs, no longer content to fight
among themselves in Los Angeles, were said to be infiltrating smaller cities,
and even the previously uncorrupted Midwest. Fidel Castro, who rid Cuba of
its traditional drug problem, was accused of trafficking, and General Manuel
Noriega-previously an esteemed ally but, in the wake of the Iran-gate trials,
branded a "drug lord" -was brought to trial even though the United States had
to invade Panama to get him. Evidently the war on drugs, even if it had started
as a metaphor, quickly became much more than that.
As if to facilitate the coordination of strategy and to minimize accoun-
tability, a new Office of National Drug Control Policy was established. Within
the White House, it was effectively insulated from influence by the Department
of Health and Human Services, the Justice Department, and other agencies in
which some administrators already had experience relevant to drug use and its
outcomes. First directed by "Drug Czar" William Bennett, whose thinking
about drugs was not prejudiced by any previous knowledge on the subject, it
rapidly promulgated a policy directed almost exclusively at the supply side.
With 70% of its generous budget devoted to keeping drugs from entering the
United States or from being sold to users, the agency employed a panoply of
military hardware and tactics. Large grants were made to the armies and to
paramilitary police forces in producing countries, ostensibly to support the
Office's efforts to eradicate the noxious crops of coca, poppy, and cannabis.
Those who had long been committed to lessening the physical, psychic,
and social harm that stems from excessive use of some psychoactive drugs
expressed concern that the 30% left over for the demand side was grossly
inadequate. They deplored the loss of funds for programs of education, preven-
tion, and treatment that they knew relieved much human suffering and that they
hoped could immunize the populace against the spread of such problems.
When Director Bennett was asked about the insignificant number of deaths that
are attributed to "hard drugs" each year and the much larger numbers that are
attributed to tobacco and alcohol, he held fast to the idea that legality was the
282 DWIGHT B. HEATH
significant boundary, once even recommending the death penalty for drug
dealers but exempting legal substances from his policy. As long as the Cold
War remained an international preoccupation, the Pentagon served as a quiet
broker for providing training, supplies, and equipment to other countries, but
steadfastly declined to become more actively engaged in the war on drugs.
However, as soon as people started talking about how to spend "the peace
dividend" that some assumed would flow from progressive disarmament fol-
lowing the collapse of the Soviet Union, the Department of Defense changed its
mind and eagerly joined the war on drugs, committing large numbers of planes
and ships to constant monitoring of the vast air and sea traffic by which drugs
are brought into the United States. Uniformed soldiers were sent to comple-
ment Drug Enforcement Agency operatives as "trainers" and "advisors," and
some have already been killed in action in Peru (Morales, 1986; Walker, 1985).
Helicopters, jeeps, guns, ammunition, uniforms, radios, and other kinds of
military supplies and equipment have been provided so lavishly that, at the
second interAmerican drug summit, held in early 1992, the presidents of both
Bolivia and Colombia declined further assistance. Although they did not say so
in public at San Antonio, they made it clear at home that they had become
fearful for the security of their own governments in the face of increasingly
powerful and corrupt military officers, who appear more often to profit from
drug dealers than bring them to justice (Mac Donald, 1989).
Farmers in the Andes, who are being paid not to plant coca on old terraces
near towns in which it has been the staple crop for centuries, are moving to
cultivate it in new areas at a rapid rate (Morales, 1990; Sanabria, 1993). Efforts
at interdiction cost far more than the insignificant amounts that are captured,
and few traffickers have been caught. The profit margin is so great that
smugglers readily abandon planes or boats that are likely to be intercepted, and
there is no shortage of personnel at any level in the various stages of production
and distribution. The drugs that are banned have probably never been more
abundant, less expensive, and of better quality than is the case now, some years
after Pres. Bush's dramatic declaration of war on drugs.
Bennett's successor, Lee Brown, was given some symbolic support by
having his position added to the President's Cabinet, while simultaneously
seeing his budget and staff both sharply curtailed. He added alcohol to the list
of drugs to be dealt with under the national policy but has done nothing to
change laws or regulations about alcohol. Meanwhile, the Director of the Food
and Drug Administration undertook to regulate tobacco products (which had
been exempted from its jurisdiction as "agricultural"), on the basis of calling
nicotine an addictive drug. During the first half of Clinton's presidency, little
else had changed except that the attention devoted by the media and the public
to the subject of drugs sharply diminished as concerns about health, the

economy, and foreign relations became more dominant.
If it seems paradoxical that, after years of a so-called war on drugs, they
are so cheap and readily available, a brief view of the ambivalent love-hate
relationship that humankind has had with drugs over time may help us to
appreciate some of the factors that are involved.
WHY PEOPLE CARE ABOUT DRUGS:

AN ANTHROPOLOGICAL PERSPECTIVE
Throughout all of recorded history, and probably much earlier according

to archaeological evidence, psychoactive drugs have been used by humankind.
The tendency for people to alter their perceptions deliberately is so old and
widespread that Weil (1986) postulated a universal human need for occasional
changes in mood and perception, and Siegel (1989) extended that to "the fourth
need" for all animals, on the basis ofthe frequency with which many species of
insects, birds, and mammals appear to seek out substances that are psycho-
active. What such substances do is alter consciousness, perceptions, moods,
and sensations in ways that are closely linked with changes in logical thinking,
often resulting in drastic changes in overt behavior. Many of us have noticed
that bees or yellow jackets often cannot fly well after having drunk the juice of
overripe fruits or berries; bears have been seen to stagger and fall down after
eating fermented honey; and birds often crash or fly haphazardly while intoxi-
cated on ethanol that occurs naturally as free-floating microorganisms convert
vegetable carbohydrates to sugar. In tropical areas, watching monkeys may
have led humans to discover some of the hallucinogenic mushrooms and
naturally occurring snuffs that flourish in the jungle. Although some of the
psychoactive drugs that are now commercially popular are products of fairly
sophisticated chemical technology, others occur naturally, with no human
intervention. The glib ideal some people voice of achieving a "drug-free
environment" is therefore elusive, if not impossible to achieve.
Although there is still confusion about what constitutes a drug, what drugs
may be more harmful or less harmful, and what the costs and benefits of a drug-
free workplace are, nevertheless it is altogether feasible for people to exert
varying degrees of control over access to and use of such drugs. In most human
societies, there are different kinds of social control exercised over those psy-
choactive substances that are locally recognized, so that not everyone may use
them all of the time. Regulation may mean that one drug should be used by
males and another by females, that children under a certain age may be
284 DWIGHT B. HEATH
discouraged from taking any, and that members of different castes, classes,
occupational groups, or other relevant categories may be expected-or for-
bidden-to indulge. At the same time, there may be social rules defining what
is appropriate and what is not in terms of time and place, who else is present, or
what one is doing at the same time.
One of the principal reasons why people tend to feel so strongly about
psychoactive drugs-whether for or against-is the customary tradition of
such social controls, which presumably grew out of ancient observations about
the nature of alterations in behavior that accompanied mind alteration. In much
of the Western world these days, there are many and severe regulatory and legal
restrictions on drugs, including outright prohibition of some, and there appear
to be increasing calls for progressively more restrictions, with extremes such as
"zero tolerance," a "drug-free workplace," and "Just Say No." At the same
time, there has been another strong current of opinion favoring a more liber-
tarian approach to drug use, variously referred to as "legalization," "relegal-
ization" (to emphasize what was legal earlier), or "decriminalization."
These strong countercurrents have resulted in a large and rapidly growing
literature, often cast in terms of juxtaposed "pro" and "con" arguments,
whether as op-ed essays in newspapers, magazine articles, or paired chapters in
books and professional journals. Much of what has been written about drugs
lately has been cast in terms of a simplistic "either/or" dialectic: for or against
"the war on drugs" or related liberal legal reforms. However accurate, well
written, and thoughtful some such efforts have been, most do not address the
telling fact that substantive data on the subject are all too scarce. For that
matter, it is difficult to imagine what kind of methodologically and ethically
sound experiments would really help us weigh these alternatives in a rigorously
scientific manner. What we can and should do is go beyond the almost formu-
laic exchanges that too often present premises as if they were conclusions and
represent affect as if it were data.
THE ELUSIVE NATURE OF DRUG PROBLEMS
If we hold to a cultural perspective, we may be able to address the real

harm that is done to society as well as individuals and to understand better the
probable consequences of various courses of action. By looking at the socio-
cultural system of the United States in relation to a number of other cultures
around the world and in relation to its own historical antecedents, we can
muster relevant evidence from a number of "natural experiments." That is,
since we cannot easily conduct experiments on large human populations using
the classic scientific method of manipulating variables, what we do is refocus
our lens and pay attention to those variables as they occur in different combina-
tions around the world. In anthropological terms, such controlled comparison
can be said in some measure to do violence to the functional integration and
contextual meanings that are sometimes of great significance for certain cul-
tural traits, but more often such strictures are of only minor importance.
Cross-cultural and historical evidence can help us understand the range of
psychoactive drug use, its meanings, and its outcomes. As we see that people's
views of both drugs and associated problems differ markedly from one popula-
tion to another, and that such views can change significantly in short periods of
time within a given popUlation, it becomes evident that "drug-related prob-
lems" are social constructs more than they are objective facts and associations
(see Chapter 13, this volume). The natural experiments provided by a cross-
cultural perspective also demonstrate the greater value of informal (social and
normative) controls over formal (legal and regulatory) controls in shaping
individual and collective behavior.
When we take a cross-cultural perspective, some striking facts quickly
emerge. One is the great variety of psychoactive drugs that humankind has
discovered and invented, some occurring ready-made in nature and others
requiring elaborate preparation. Another is the great variety of uses to which
they are put, rarely just for relaxation and recreation but more often in close and
important association with religious, medical, or other practices. Similarly,
there are often fads and fashions, with drugs that have been popular at one time
being neglected or even scorned at another time. There are always closely
related rules and social norms about who may use a drug, when and where, in
the company of whom, in what way, with what utensils or paraphernalia, and
even with what result. Such rules and norms are not only clear in prescriptive
terms, but they are also usually mirrored by equally strong proscriptions, a list
of "Thou shalt not's."
To illustrate, first consider the industrialized nations of North America,
which are not generally thought of as being culturally alien. Even in this
familiar setting, we find that there is a marked ambivalence toward alcohol and
drugs, from strongly favorable to distinctly negative over time, with popular
beliefs and attitudes as well as laws and regulations changing to reflect those
shifts. Although the view of drugs as "the enemy" has been remarkably
persistent, it has been applied to different drugs at different times (Musto,
1989). Similarly, associated restrictions and warnings have been remarkably
similar, although the substances targeted have changed. Increase Mather, the
quintessentially ascetic Puritan minister of 17th century New England, con-
demned drunkenness but at the same time celebrated "drink" (a category
including distilled spirits as well as beer) as "a good Creature of God" (Mather,
1674). A century later, Declaration of Independence-signer and physician
286 DWIGHT B. HEATH
Benjamin Rush wrote a book that became a best-seller condemning liquor as a

major cause of physical and mental illness (Rush, 1784). By 1840, nearly half of
the states had voted their own prohibition laws, but most were repealed in the
1860s (Rorabaugh, 1979). Per capita consumption rose dramatically and
saloons-formerly cherished as "the working men's social club" -were tar-
geted as dens of iniquity, sedition, and family break-up. The temperance
movement was not a reactionary fringe phenomenon at the time; on the con-
trary, it tended to be linked closely with such progressive causes as equality of
the sexes, child labor laws, and increasing welfare programs. Other ideas that
tended to recur regularly with the temperance sentiment have been concerns
with fresh air and exercise as wholesome necessities and a preference for loose
clothing and "natural" (substantial and unadulterated) foods.
National prohibition (1919-1933) is often derided as a failure because
moonshining, speakeasies, and the unprecedented fashionable public drinking
by women made a mockery of the law, while criminal gangs gained wealth and
power in the illicit trade. After repeal, there was a steady rise in drinking until
the 1980s, when a downward trend began and continues. Not only are individ-
uals drinking less-and the beverages themselves are often offered with low-
ered alcohol content-but the whole meaning of drinking is again being
refocused. A highly vocal and effective New Temperance Movement (Heath,
1989), pointing to traffic fatalities, learning disabilities, accelerating health
costs, and falling productivity and working through a number of so-called
"consumer-interest groups" is attempting increasingly to restrict the availabil-
ity of alcoholic beverages, by increasing taxes, limiting hours and outlets of
sale, and a variety of other restrictive measures. Although they reject the label
of "Neo-Prohibitionists," they were effective in imposing prohibition on any-
one under 21 years of age, even though the vote, right to marry without parental
permission, and other legal perquisites of majority are afforded to 18-year-olds.
Although it has not yet been enacted into law, we have already seen waiters in
restaurants try to enforce prohibition on pregnant women, and U.S. govern-
ment publications often recommend abstention for women "who might be-
come pregnant" -a sizeable portion of the population-as well as for those
"planning to drive or to operate heavy equipment."
If we expand our vision and look beyond North America, we find that all
of the psychoactives that are now legal and widely enjoyed were at one time
illegal and feared (Brecher, 1972). Coffee and chocolate, which most North
Americans now consider innocuous, were viewed with suspicion when they
first became available in Europe and the Near East. In terms very similar to
those used with reference to "hippy drugs" in the 1960s, they were associated
with laziness, sexual license, and political intrigue. In the 17th century, just
visiting a coffeehouse was a capital offense in what are now Egypt, Saudi
Arabia, and Turkey-all places where coffeehouses are now important centers
of sociability and business (Hattox, 1985). King James I of England wrote a
diatribe against tobacco and would probably have banned it if his advisors had
not made so much of its tax value; at various times it was illegal in China,
Germany, Persia, Russia, and Turkey, and its use is rapidly being restricted in
the United States, after 80 years of unprecedented popularity. Kava was tradi-
tionally drunk in ceremonial contexts in much of Melanesia, but it has recently
come to be viewed as dangerous when taken with alcohol (Lebot, Merlin, &
Lindstrom, 1992). Peyote is a sacrament among various Mexican Indian tribes
and in the Native American Church, although its secular use is illegal.
Beer is more important than bread as a staple food in many parts of the
world, and may well predate it historically. It was an important offering to the
gods in pharonic Egypt, and still is in many African and South American tribes.
Hogarth vividly depicted it in his etchings as bringing health, happiness, and
prosperity to 17th century London. It was associated with lazy but conniving
German socialists in the United States at the beginning of this century, as it is
now linked to drunken college students in a noisy "animal house" fraternity or
with the brawling "lager louts" who riot after English soccer games.
Marijuana has long been used as an energizer by sugarcane harvesters in
Jamaica and by stevedores in Costa Rica. In the United States of the 1920s, it
was known but use was virtually limited to poor blacks and jazz musicians.
With the repeal of Prohibition, government agents shifted their attention from
moonshine to cannabis (Grinspoon, 1977), which they portrayed as leading to
the uncontrolled lust of "reefer madness," and, just a few decades later, the
diametrically contrasting but equally deplorable "amotivational syndrome."
Widely adopted as a relaxant and euphoriant, marijuana was briefly habilitated
by many in the medical community. Within less than a decade, the pendulum of
opinion swung back, and both physical and mental damage are again often
attributed to its use. Many jurisdictions that had decriminalized its sale and use,
and more its possession, have rescinded those laws, and the federal government
in 1992 banned its use for medical purposes, even under prescription.
The Opium War resulted from British violation of a long-standing ban on
opium in China in much the same way that 50 years later, the Chinese were
blamed for having forced opium on unsuspecting North Americans (Blum &
Associates, 1974). The image of opium, which has been esteemed in the
Western world as a stimulant to artistic creativity, became tarnished late in the
19th century, as the association shifted from vague exoticism to utter depravity,
part of the Oriental "yellow peril" that was threatening to lure American
women into "white slavery" and to erode American will and industriousness.
Coca has been used for nutritive, social, and religious purposes by Andean
Indians for millennia, with no evidence of deleterious consequences. In the late
288 DWIGHT B. HEATH
1800s, it and its derivative cocaine were widely regarded as virtual panaceas,
supposedly endorsed by famous and successful people including the Pope.
During World War I, cocaine was rumored to have been a tool of German spies,
and in the 1930s the image of the "dope fiend" illustrated how its use sup-
posedly resulted in a kind of amoral and antisocial madness. By the 1970s it had
come to be viewed by many, including physicians, as an innocuous "recre-
ational drug," but in the 1990s, it was again deplored as being addictive, a
major cause of crime, and a significant threat to the next generation. The
smokable derivative "crack" took on an even more sinister image, popularly
(but inaccurately) believed to cause "instant addiction." Heroin was initially
hailed as a safe alternative to morphine in much the same way that methadone
is now used as an addictive but legal substitute for heroin. Tranquilizers that
were hailed as a boon in relieving the stresses of the 1960s have evolved, in our
thinking, to play an important role in the "multiple dependency" of not only
those who use them but also in the "codependency" that supposedly debilitates
people who care about such users.
The recent invention and rapid diffusion of glue- and solvent-sniffing as a
means of altering consciousness is a fascinating instance of popular inventive-
ness, adapting familiar industrial products to wholly unforeseen purposes. In
that instance, it is apparent that the U.S. mass media played a significant role in
rapidly converting what had been harmless tools into dangerous drugs (Brecher,
1972); the same appears to have happened later in Canada (Alexander, 1990).
Much earlier in history and halfway across the world, the Arab culture in
which Mohammed was reared valued not only drink but drunkenness; Persian
poets waxed eloquent about both in a land that is now officially dry. Similarly,
poets and philosophers of ancient China sang the praises of wine and its
disinhibiting effects, but prohibition was enacted throughout the empire at
various times. Ambivalence is not a new or a Western invention.
For that matter, a visitor from another planet might well be suspicious of
Homo sapiens' vaunted preoccupation with positivism and pragmatism, and
suggest that it is highly unlikely that the pharmacological action of any given
substance, interacting with the physiology of a single species, could result in
such diverse effects, whether among different populations at the same time or
on the same population at different times. And such a visitor would be justified,
inasmuch as many of us earthlings have wondered about the same apparent
anomalies.
To a social scientist accustomed to interpreting evidence that is gleaned
from natural experiments, the fact that official and popular attitudes toward the
use of alcohol and drugs differ not only among various cultures, but that they
also shift-often diametrically within a single culture over only a few
decades-strongly suggests a few points that appear simple but that may be
crucial. First, we must recognize that problems are in no way inherent in an

inert substance, but they can emerge in an interaction between it, the user, and
the context. As an important corollary of this, we must also recognize that the
user is not just a biological organism affected by a chemical, but is also a
complex biopsychosocial system. What this means, in specific terms, is that the
user also comprises a personality (influenced by expectations, values, and
attitudes), a unique life history (influenced by all sorts of teachings and experi-
ences), and a distinctive combination of statuses, many of which imply very
different roles (eg., female, adult, mother, sister, aunt, godmother, professional,
etc.) Most of these and other relevant variables have little relationship (of a
kind that might be discernible by strict scientific methods) to any psychoactive
substance. Nevertheless, they interact in ways that are salient in determining
use, quantity and frequency, and even outcomes of use.
The significance of such realizations is that we must also recognize that
many of the problems that are said to be caused by or associated with alcohol
and drugs can best be viewed as social constructs. Because they have virtually
no direct link to the nature of the substance and little linkage to the way those
substances interact with the human body, such problems are based instead on
clusters of attitudes and associations in the minds of people. In this way, social
problems can be seen to reflect opinions and prejudices of the moment, being
highly selective among the facts that are available, rather than objectively
reflecting actual events or empirical trends.
A striking example is the shift from virtual tolerance of "tipsy" drivers,
whose escapades a decade ago were often reported in the press as humorous
when no one was hurt, to a rising vengeful clamor to "get the killer-drunks off
the road." A sociologist (Gusfield, 1984) effectively documented the process
by which drinking and driving so rapidly came to be perceived as a major
problem in the United States. A high percentage of traffic crashes are regularly
reported as being "alcohol-related," although there is no mention that many
are "darkness-related," or "poor road condition-related," because no one has
chosen to shape a public definition of such problems. Even some physicians
have complained that, "When an adult beats a child, we do not talk about a
'physical abuse problem,' and we do not refer to the danger of drowning as the
'deep water problem.' The idea of a drug problem is not necessarily much more
coherent. "
One of those who early on proclaimed himself a member of the New
Temperance Movement in the United States asserted that the major obstacle to
broad public support for education, prevention, and treatment of alcoholism
was the invisibility of the problem (Beauchamp, 1980). The growth of private
and public agencies, the emergence of Mothers Against Drunk Driving and
related organizations, and voluminous media coverage are a few illustrations of
290 DWIGHT B. HEATH
how quickly that has changed. The sociologist Wiener (1981) has traced not
only the emergence of "the alcohol problem," but also the rapidly changing
"ownership of it." It is especially ironic that pressures against advertising and
in support of higher taxes, shorter hours and fewer licenses for sale, and a host
of other restrictions on the availability of alcohol continue to mount even as
consumption has rapidly diminished since 1980, there are fewer cirrhosis
deaths, and an increasing number of teetotalers appear in national surveys.
Even the National Institute on Alcohol Abuse and Alcoholism, the federal
agency that has most to gain from inflated figures on the subject, recently
revised its estimates of the economic costs of alcohol abuse. For methodologi-
cal reasons, the specific numbers are still suspect, but the overall figures are less
than half of what they were just a few years earlier. In light of the social con-
struction of alcohol and drug problems, it is little wonder that people often seek
a quick and easy solution through prohibition-and that they almost always
fail (see Chapter 13, this volume).
PROHIBITION AS A PROBLEM-SOLVING STRATEGY
There is a simple and direct logic that, if something is troublesome, you're

better off without it. Presumably this has been at the root of the various bans on
different drugs that we have noted around the world. A striking regularity,
however, is that all such prohibitions have been circumvented at the time, and
almost all were rescinded by administrators who eventually judged the costs to
outweigh the benefits.
This often occurs when violations of a prohibition become so common-
place that people recognize the discrepancy between law and practice, and
challenge the law. If the gap yawns too large, what is challenged may be not
only the specific restrictive law of prohibition, but also the rule of law in
general. The United States appears to have come close to this kind of anarchy in
the waning days of its federal prohibition on alcohol (Levine, 1985). Canada,
Finland, Iceland, India, and Tsarist Russia all tried to prohibit drinking during
this century, but each found that the combined ills of moonshining, bootleg-
ging, poisoning from non beverage alcohol, and bribery of police and officials
made for a general sense of corruption and lawlessness that outweighed what-
ever gains there may have been in other respects. Saudi Arabia and Iran are
nation-states where prohibition appears to be relatively effective, presumably
because it is so firmly imbedded in religious ideology and context.
If we shift our focus from the nation-state to other entities, it is noteworthy
that, even after the repeal of federal prohibition, several states in the United
States remained officially dry, with Mississippi the last to repeal prohibition
laws in 1984. There are many scattered counties and communities that still
forbid sale under "local option" laws, and certain places are kept alcohol-free
even in otherwise wet jurisdictions (e.g., in cities, state parks, theaters, sports
arenas, etc.).
Prohibition applies differently not only to places but also to populations.
There are some religious groups, in whatever country, who abstain as an article
of faith. The wording of the Koranic injunction about drinking and gambling is
equivocal, but most Muslims interpret it as a prohibition (Badri, 1976); sim-
ilarly, members of the Church of Jesus Christ of Latter Day Saints (Mormons),
the Native American Church, and several Protestant churches cite religious
justification for avoiding alcohol; some also forbid caffeine.
For that matter, prohibition is usually in effect for at least part of many
societies at any given time, although we tend not to phrase it as such. One such
selective prohibition is by age; a minimum age for purchase (and sometimes for
use) of alcohol was effectively set at 21 throughout the United States in re-
sponse to economic pressures, with the federal government withholding high-
way fund allocations until states complied. Other jurisdictions have set a
minimum age for purchase of tobacco and even glue. In Spain, some bars are
closed to those under 18-not because of the access to alcohol, but because
they contain video games, which are thought to be addictive.
For many years it was illegal to give, sell, or trade alcoholic beverages to
Australian Aborigines, Swedish Saami (Lapps), Native Americans, and Alaska
Natives. Such bans were "justified" on the basis of a supposed "constitutional
weakness" that made drinking more dangerous for those subordinated popu-
lations than for members of the politically and economically hegemonic popu-
lation. It is interesting that, when offered the choice in the 1960s or later, a
number of Native American reservations and Alaska Native communities in
the United States remained dry. In Canada in recent years, many Native
American and Inuit bands and reserves have also opted for prohibition; some
Australian communities are experimenting with self-imposed bans on alcohol.
The outcome of such local prohibitions has been uneven, with some evidence
that they exacerbate rather than relieve problems (American Indian and Alaska
Native Mental Health Research, 1992; Contemporary Drug Problems, 1990).
In other instances, selective prohibition is socially enforced with a variety
of attitudes, norms, values, and sanctions, even when it does not carry the
weight of law. At the height of the Inca Empire, coca chewing appears to have
been the prerogative of the nobility. In Aztec society, only priests and old men
were allowed to drink, except on rare religious occasions. Opium smoking was
traditionally limited to the aged in many parts of southeastern Asia, as khat-
chewing is generally monopolized by men in the Near East (Kennedy, 1987).
Within a single village in Indian, one caste drinks cannabis tea and another
292 DWIGHT B. HEATH
drinks liquor, each scorning such barbarous behavior in the other (Carstairs,
1954).
Not only are whole polities, religious groups, and social categories char-
acterized by differential rules about availability, but there is also selective
prohibition with respect to place. Within the United States, there are increasing
calls for "drug-free workplaces," "drug-free schools," and other zones of
prohibition. Even within the workplace, all are not treated equally. Frequent
drug testing, supposedly with "zero tolerance," is being promoted for em-
ployees in the fields of atomic energy, public transportation, and public admin-
istration. The fact that such proposals are phrased in terms of protecting the
public interest has not diminished the resentment of discrimination on the part
of individuals who hold such jobs.
Context need not be restrictive, however; it can also be permissive. Even
Orthodox Jews, world-renowned for their usual sobriety, are exhorted as part of
the Purim festival to drink until they can't distinguish the hero from the villain
in a Biblical story (Snyder, 1958). Drinking is similarly an integral part of
saints' days and other fiestas among Roman Catholics throughout Latin Amer-
ica, where drunkenness is eagerly sought as a religious act (Heath, 1982).
Similar illustrations of intrasocietal as well as cross-cultural variability
could be cited for most psychoactive drugs and for many of the world's nations
and their component societies. The major point is that prohibition, far from
being a distinctively North American anomaly, has been an intermittent ancient
and widespread phenomenon, usually applied inconsistently on various seg-
ments of the population. This very inconsistency strongly suggests that the
basis for such controls is not grounded in biochemical, neurophysiological, or
even psychosocial effects of use.
BLURRED BATTLE LINES IN THE WAR ON DRUGS
Despite the flurry of concern that followed Pres. Bush's call to arms,
media and popular concern flagged early as economic recession worsened, and
there was recognition that the highly touted policies were winning few battles
and held no promise of winning the war; similar lack of media coverage
continues under Pres. Clinton. The General Accounting Office (GAO) and
various Congressional committees issued authoritative reports that contra-
dicted assertions of the National Office of Drug Control Policy and revealed
major methodological and arithmetic flaws in the Office's calculations (e.g.,
U.S. Senate, 1991). People became aware that interdiction could not be effec-
tive and that there was not even support for treatment of those addicts who
requested it. Ever larger quantities of drugs, at even lower prices, told the lie to
a supply side approach. Although few U.S. citizens were aware of it, growing
resentment of U.S. drug-related intervention abroad was eroding the patience
of some of our allies (Trebach and Zeese, 1990 a,b).
Another aspect of the war on drugs that some prefer to ignore, and others
would eagerly change, is the mushrooming rate of prison construction and
incarceration. With 455 per 100,000 of the population in jails or prisons, the
United States now has the dubious distinction of leading the world-far ahead
of South Africa, second with 311. By way of contrast, Japan's rate is only 34.
While Pres. Bush's Attorney General rated this a sign of success and called for
more prison space as the only alternative to more crime, a growing number of
critics now view with dismay the expansion that has already occurred and
consider it a monument to society's failure in terms of economic opportunities,
racial discrimination, education, and other respects.
Although the rhetoric of the "war on drugs" has cooled somewhat and
domestic economic and political issues have come to the fore in terms of
journalistic attention during Clinton's presidency, there has been little change
in governmental policy or police and military actions. More than half of the
prison population are still there on drug charges, with blacks and Hispanics
disproportionately represented. According to government statistics reported in
the 1980s and 1990s issues of National Crime Survey and Jail Inmates (U.S.
Department of Justice, 1973-, 1983-), federal and state prison popUlations
have increased by 90% during the past decade, while the crime rate (adjusted
for population) remains virtually unchanged. It is evident that massive incar-
ceration has had little effect in reducing crime. Increased reliance on manda-
tory sentencing, eliminating parole, and building more jail cells has nothing to
do with rehabilitation and apparently accomplishes little in the way of deter-
rence. Poverty, broken families, and unacculturated immigrants are often cited
as important causal factors, but the experience of other countries and the
historical precedent in the United States both suggest that other, more funda-
mental, factors must be involved.
Every major city has had too many incidents in which an innocent by-
stander was shot, but the majority of drug-related violence is directed against
competing drug dealers. In similar fashion, although many addicts resort to
theft and a variety of petty deceptive schemes to support their habit, those most
frequently victimized by such "hustles" are their friends, family, and acquain-
tances rather than wealthier strangers (Preble & Casey, 1969; Lex, 1990).
Selective detention may be part ofthe problem, with a persistent pattern of
racial and ethnic prejudice acted out daily, as police harass innocent members
of one group and are overly tolerant of another. This is not a universal pattern,
but it occurs far too often. Similarly, repeated studies have shown that, al-
though justice can't be bought in a simple straightforward transaction, minority
294 DWIGHT B. HEATH
suspects with lower income and education are disproportionately booked by

police. In 1989, with blacks comprising 12% of the popUlation, 42% of drug
arrests were of blacks. In the same way, among defendants who are tried, those
of minority status with lower income and education are disproportionately
sentenced, and their sentences are consistently, and significantly, more severe,
even for similar offenses (U.S. Department of Justice, 1930-). To call such
discrimination genocidal is polemical overstatement, but to call it normal
would be a terrible indictment of our legal system.
In a sense, even those who are not members of the discriminated minor-
ities are being hurt by the heavy involvement that the criminal justice system
has in prosecuting the war on drugs. In many jurisdictions the police are so
burdened with drug issues that other aspects of their work are often neglected.
Courts are incredibly overcrowded, as are jails and prisons. Associated costs
add a significant burden to already strained budgets, resulting in escalating
taxes that weigh heavily on already overtaxed constituents.
An inner-city individual's occasional "success" (in wealth, prestige, and
so forth) associated with drugs is taken by many as evidence that "the system"
is failing and that amoral behavior is rewarded. However rare they may be,
instances of corruption among police, judges, and other government agents
carry the same message. Rightly or wrongly, drugs are associated with the high
drop-out rate in schools, slow learning, teenage pregnancy, accelerating unem-
ployment, falling productivity, the cost of social welfare, and a host of other
aspects of contemporary life that people find annoying and discouraging.
Ironically, some of the problems that can be directly and unequivocally
linked with excessive use of drugs-such as the costs of rehabilitation and
treatment, and the maintenance of impaired infants-are even more significant
than seems to be recognized by many who complain most loudly about drugs
and their negative impact on society. This can be taken as another very different
kind of evidence in support of the view that public problems are socially
constructed. In a social construction, what is left out may be no less important
than what is included.
What is being ignored in the dominant image of "the drug problem" in the
United States today is the fact that so many of the ills that are cited derive more
from the prohibition policies that are in effect than from the use of drugs as
such. Nadelmann (1989) succinctly phrased it: "The greatest beneficiaries of
the drug laws are organized and unorganized drug traffickers. The criminaliza-
tion of the drug market effectively imposes a de facto value-added tax that is
enforced and occasionally augmented by the law enforcement establishment
and collected by the drug traffickers" (p. 941). The same occurred earlier with
the prohibition of alcohol in the United States and more recently with strict
controls on the availability of alcohol in the former Soviet Union (Heath, 1991).
HOPE FOR AN ARMISTICE
The presumed connections among drugs, crime, violence, and disturbed

youth are complex, but the experience that other countries have had with public
maintenance of drug-dependent persons, together with the artificially inflated
prices that illegality imposes and the politically corrupting influence of the
huge sums of money that are involved, all suggest that it is counterproductive
to leave monopolistic control of production and distribution of now-illicit
drugs in the hands of criminal entrepreneurs.
The fallacy of such action, or inaction, has driven many to contemplate
appropriate terms for an armistice in the war on drugs. Specific details can be
worked out later, but if we again turn our attention to natural experiments as
they occur in cross-cultural experience, the broad outlines of crucial first steps
appear clear.
One of the leading nations in the liberalization of drug laws is The
Netherlands, in keeping with a governing principle of their public health
system: Minimize harm. They still distinguish between "hard" and "soft"
drugs and actively restrict traffic in "hard" drugs, but they recognize that those
who need hard drugs should not be driven into the underworld in order to
survive. Heroin and cocaine are available, at reasonable prices and with hy-
gienic apparatuses, in government clinics. Although the sale of marijuana by
unlicensed individuals is still illegal-to curb "pushers" who profit from
engaging new users-anyone may buy it in the many coffeeshops that are
designated outlets, which are marked by a discreet silhouette of a leaf displayed
in a window. The Dutch system is not libertarian, as it is often mislabeled; half
of those in prison are there on drug charges. Neither is the country encouraging
a generation of drop-outs. The Netherlands has become a favorite hangout for
expatriates from around the world, but, contrary to dire predictions, its drug
policy, in combination with easy availability of treatment, has resulted in a
reduction rather than an increase in the number of addicts. The Dutch also have
much lower rates of incidence of overdose and of HIV seropositivity in
comparison with the United States (Buisman, 1988; Leuw, 1994).
An early experiment with governmental monopoly of "hard drugs" took
place in England but was cut short by the Conservative government. On a
smaller scale, a program in Liverpool continues to do much to normalize the
lives of addicts by making drugs available at a clinic under safe conditions and
with the encouragement of self-help group therapy and other treatments, which
appear to be enjoying at least as much success as freestanding programs. In
such a situation, addicts can hold regular jobs and take part in a wide range of
community activities that would be closed to them in a context of prohibition.
In a way, the Liverpool alternative is not markedly different from methadone
296 DWIGHT B. HEATH
maintenance that is offered at many places in the United States. (The progress
of various such programs is chronicled in the International Journal on Drug
Policy.) No one doubts that methadone is addictive in the sense of creating a
regular craving and psychological dependence; users suffer classic withdrawal
syndrome if they are deprived of it too long. But it is a legally controlled drug,
doled out regularly at clinics around the country and widely accepted as
preferable to heroin, which remains prohibited. The dubious logic of this licit-
illicit (or "soft" - "hard") drug distinction has been challenged by spokes-
persons for many minority groups who resent state-supported alternative ad-
diction at a time when they are told that funds for treatment are not available
even while facilities have long waiting lists of those who want to rehabilitate
themselves.
Legalization of drugs need not be viewed as a single giant step in which all
restrictions are abruptly removed, resulting in a chaotic free market. Again, the
parallel with the repeal of national prohibition on alcohol is relevant. The
federal government retained some oversight over production, quality control,
and so forth, and levied a tax on both fermented beverages (wines, beers, ales,
and related drinks) and distilled spirits (or "hard liquor"). A remarkable degree
of discretion was given to the individual states, some of which further allowed
for "local option" at a lower level. Even so, alcohol remains one of the most
regulated products available, in terms of licensing, location, time, pricing,
advertising, and other respects. Similar liberalization-with taxation and other
regulation-could be tried for other drugs by various states.
In any such program, realistic education about alcohol and drugs and the
outcomes of their use should be a cornerstone. The salutary experience of the
Framingham, Massachusetts, heart-health study (reported in great detail in a
series of books, The Framingham Study) and of a related study in Pawtucket,
Rhode Island, demonstrates that public education can be immensely effective
in promoting salubrious changes in behavior, despite the skepticism voiced by
many in the drug field. The discrepancy probably results from a narrow
interpretation of education, as if it were restricted to material taught in the
classroom, often by individuals who are neither knowledgeable nor particularly
interested in the subject. When serious efforts are made to educate an entire
community, however, engaging grocery stores, scout groups, civil action orga-
nizations, churches, and other institutions as well as schools and the media,
abundant knowledge can be effectively communicated in ways that affect
attitudes and behavior, which in tum result in significant changes in the
incidence and prevalence of various illnesses and other health problems (An-
derson, 1988; Downie, Fife, & Tannahil, 1990).
The futility of the drug war in its present mode-both abroad and on the
home front-suggests that it is time to call an armistice. Continuing legal
prohibition as the major strategy for combating drugs is to attempt the impos-
sible, by means that have already been discredited. Historical and cross-
cultural evidence suggests that a wiser course would be to aim for a realistic
accommodation, to permit but discourage risky misadventures by means that
have already proven their effectiveness. This would not mean "surrender" to
"the drug lords," nor would it usher in a period of reckless anarchy. Perhaps it
would be less threatening to the narcomilitary complex if we were to speak in
terms of "liberalization," rather than legalization, relegalization, or decrimi-
nalization. To allow people legal access to a substance does not mean that they
need have unrestricted access to unlimited quantities. It might even be feasible
for different jurisdictions to set up some natural experiments by adopting
different specific regulations within a broad pattern of liberalization. In that
way, we could soon expect at least quasiscientific evaluations of the outcomes,
valuable information that could eventually serve as substantive data for making
more confident choices among alternatives, in terms of public health and social
welfare, as well as efficiency and efficacy. Instead of suffering a defeat, it could
well be that such actions would, in the long run, signal a major victory for the
people who are always the ones to suffer most in any kind of war.
ACKNOWLEDGMENTS. This paper was prepared specifically for this book.

Although some of the ideas herein were used in the author's "U.S. drug control
policy: A cultural perspective" in Daedalus: Journal of the American Academy
of Arts and Sciences, and Proceedings of the American Academy of Arts and
Sciences, 121, pp. 269-291, 1992, much has been expanded and updated from
the earlier version.
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ed.). Boston: Houghton Mifflin.
Wiener, C. L. (1981). The politics of alcoholism: Building an arena around a social problem. New
Brunswick, NJ: Transaction.
CHAPTER 13
The Impact of Socially

Constructed Knowledge
on Drug Policy
RICHARD J. DeGRANDPRE
INTRODUCTION
Examining illicit drug policy is a twofold task. One aspect involves under-
standing illicit drug use, and the other addresses changing behavior through
public policy. These two aspects of drug policy must be distinguished, as
success in one does not necessarily imply success in the other-and because
success in both is necessary for any overall success in achieving effective
policies regarding the management of illicit drug use.
As the chapters in this volume show, psychology has much to offer both of
these aspects of drug policy. For several decades, psychopharmacologists have
been investigating the behavioral, cultural, environmental, pharmacological,
and social factors involved in the use of psychoactive drugs and drug depen-
dence; moreover, psychologists have begun contributing to the literature on
public health and public policy in general, and drug policy in particular (e.g.,
Kendler, 1981, 1993; MacCoun, 1993). Because many of the chapters in this
RICHARD J. DeGRANDPRE • Human Behavioral Pharmacology Lab, Department ofPsychia-

try, University of Vermont, Burlington, Vermont 05401-1419.
301
302 RICHARD J. DeGRANDPRE
volume are concerned with only one or the other of these two aspects, this
chapter explores the relationship between them. In doing so, there is a hope that
a general context can be defined within which the development and implemen-
tation of drug policy can be better understood.
The chapter begins by introducing a basic epistemological framework for
evaluating the relationship between policy and empirical research. This frame-
work is then applied specifically to issues concerning illegal drugs; an exam-
ination of the framework's implications for drug policy follows. The chapter
concludes with a discussion of how a pragmatic approach to drug policy might
be used to temper the influence of socially constructed beliefs, making policy
more open to empirical knowledge.
AN EPISTEMOLOGICAL FRAMEWORK
Certain problems concerning the limitations of human knowledge might be closer

to solution if the behavior of knowing were further analyzed (Skinner, 1974, p. 243).
Humans have always sought to reduce uncertainty and improve upon

circumstance by understanding and manipulating aspects of their world. There
is today a popular consensus that in these enlightened times we have now
moved from an era ofjiction to a time of/act. But if this is true, if knowledge of
the world has improved both qualitatively and quantitatively, why do social
problems abound? A partial answer to this question lies in the fact that, because
knowledge comes from multiple sources, knowledge claims vary and, at times,
come into conflict with one another. That is, culturally accepted knowledge and
practices may compete against the development and dissemination of new
forms of knowledge, some of which might lead to more effective solutions to
recognized social problems. In terms of drug policy, this competition provides
the foundation for the thesis of this chapter: The public health has been lost to a
struggle between two sources of human knowledge-socially and scien-
tifically constructed knowledge.
Social Constructionism
Social constructionism refers to knowledge that evolves out of ongoing

social processes (e.g., social interactions) rather than, say, out of firsthand
experience in the nonsocial world (Moscovici, 1987). For example, many
Americans believe that going out in cold weather can put one at risk for
catching a cold. People believe this, not because they read it in a medical
journal or because they experimented with their health, but rather because they
SOCIALLY CONSTRUCTED KNOWLEDGE AND DRUG POLICY 303
learned it from someone as a bit of cultural folklore. Socially constructed

knowledge is not reducible to personal opinion or attitudes, however, in that
it evolves, and is suspended, within a sociocultural-not individual-realm.
Nor is it fixed within that realm, ready to be assimilated in identical form in
different individuals. Rather, as a social product, it changes as it is learned,
used, and passed on by individuals through human practices. Thus, although
individuals learn by directly experiencing or observing events in the world,
much of what they come to know, and how they come to interpret their
experience, is influenced by verbal and nonverbal social practices.
That understanding and knowledge claims are socially constructed has
deep roots in academic domains of anthropology, sociology, and the human-
ities, roots that have only recently spread to psychology (see Cushman, 1990;
Gergen, 1985; Guerin, 1992; Kvale, 1992). Marx, for example, was crucial in
bringing to light how meaning in people's lives is both collective and historical.
Because individual actions have led to larger, self-determining social systems,
individual actions must be interpreted as resulting, at least partly, from those
systems. More recently, critics of classical metaphysics like Foucault (1970),
Heidegger (1962), and Wittgenstein (1957) have challenged notions of encyclo-
pedic knowledge and objectivity, replacing them with more self-reflexive
concepts like discourse, language games, and epistemes.
Social constructionism represents a formalizing of these earlier ideas with
respect to the role of the social sphere in the evolution of human knowledge. By
defining humans as interpretive beings, social constructionism contextualizes
human action within social practices. Such practices are seen as responsible for
much of the meaning that puts people into action and that allows them to make
sense of, or interpret, their experience. By emphasizing the role these social
practices play in constructing human knowledge, we are able then to character-
ize human knowledge as having deep social and historical roots. As noted by
Lana (1994):
The myths of a society are verbal prescriptions for behavior that have taken a
narrative or fictional form and that have developed over long historical periods ....
myths are historical accounts of both the previous behavior of a community and of
desirable and undesirable behavior that provide a prescription for the present
generation (pp. 318-319).
Thus, social constructionism helps us see that, although individuals acquire

knowledge of themselves and their surroundings by interpreting their experi-
ence, this interpretive process develops throughout one's lifetime within a set
of highly evolved and complex cultural practices; although each individual has
his or her own unique understanding of the world, these different understand-
ings overlap with others' because of a shared cultural existence.
Guerin (1992) cited four tenets of social constructionism used in social
psychology taken from Geigen (1985) that will be useful in discussing the
relationship between psychological science and the psychology of policy. First
is the argument that our understanding of the world may be a social product
rather than a direct result of interacting with the natural world. "Objects and
relationships appear to be invented or constructed, yet still influence our
behavior and thought," wrote Guerin (1992, pp. 1423-1424). Second is the idea
that the popularity or prevalence of social understandings have no necessary
relationship to their empirical validity, but rather stem from the role they have
acquired in the stream of social processes (e.g., a rhetorical device used in
competitive social exchanges). Third is the notion that the concepts and terms
we use to describe and understand the world-those that give meaning-are
also socially and historically derived. Last is the notion that socially con-
structed understandings are built into the social fabric of human existence and
are therefore inseparable from other aspects of people's lives and culture.
Guerin (1992) adds to social constructionism by showing how, from a
behavior-analytic standpoint, such knowledge develops out of and is main-
tained by socially mediated contingencies of reinforcement. For example,
children often receive positive feedback from parents when verbalizing or
acting in ways consistent with what their parents have told them previously.
Generalized social consequences are viewed here as crucial to the social
development of knowledge and refer to social consequences that have a history
of being associated with primary reinforcers (e.g., positive behavioral, emo-
tional, or material consequences).
Empirically Based Knowledge
The motivation to understand, describe, and manipulate the world was

formalized during the Enlightenment in two epistemological assumptions-
assumptions that are now commonly held throughout the Western world: first,
that there is an objective world and, second, that we are able to gain truths about
this world through special cognitive powers, empirical methods (e.g., science),
and language. From these powers comes empirically based knowledge, which
in behavior-analytic terms, is a function of contingencies associated with
prediction and control-the law and order expounded by the scientific commu-
nity. In the model case, scientists are free from personal biases and social
values, allowing them to pursue questions through the application of inductive
and deductive logic. Researchers are thus considered scientific when their
behavior is guided more by empirically derived observations and less by social
custom, armchair rationalism, or idle reasoning. The dominance of the scien-
tific paradigm has often led to the positivist claim that more traditional forms of
knowledge-nonscientific knowledge-are irrational and inferior, a claim that
has come under increasing scrutiny (Foucault, 1970; Harding, 1991; Marglin &
Marglin, 1990).
Just as socially constructed knowledge is influenced by empirical obser-
vations, scientific knowledge evolves out of a larger context that includes
cultural, economic, and social factors; the scientist is a cultural member first
and a scientist second (Skinner, 1969, 1974). That the scientist is highly
susceptible to social and normative pressures, including those within science
itself, was documented in Kuhn's The Structure of Scientific Revolutions, first
published in 1962. Kuhn offers a compelling account of how scientists cooper-
ate in allocating their resources to the conduct of "normal" science. As a
conservative mode of scientific activity, normal science is guided by a system
of rules-accepted and enforced by key members of the research community-
which constrain the development of new ideas and methods. Consistent with
Kuhn's account is the individual scientist who, knowingly or unknowingly,
overlooks or shies away from certain questions or interpretations of data that
are inconsistent with his or her own values. At a personal level, a scientist may
view this behavior as an individual right, but when hundreds of scientists act in
a like manner for years or decades, whole societal issues can go unexplored (for
example, women's health; see Harding, 1986, 1991).
Thus, although scientists often hide behind a romanticized image of
rational objectivity, historians and social critics have shown a powerful role for
socialization and cultural events in scientific research and interpretation (see
Feyerabend, 1975; Harding, 1986, 1991; Hubbard & Wald, 1993; Lifton, 1986;
for an explicit discussion of "the social construction of science," see Van den
Daele, 1977). Even the National Academy of Sciences (1989) has explicitly
acknowledged that science is an enterprise greatly shaped by social values.
This is not to say, however, that such factors altogether diminish the role for
empirical methods in informing social knowledge, opinion, and policy. As a
feminist critic of science noted:
The criticisms of science-as-usual are made in the context of a call for better
science: important tendencies within feminism propose to provide empirically more
adequate and theoretically less partial and distorted descriptions and explanations
of women, men, gender relations, and the rest of the social and natural worlds,
including how the sciences did, do, and could function (Harding, 1991, p. 1).
Although empirical evidence from psychology may not be well suited for
deriving ethical mandates, as was argued in Kendler (1993), it can nevertheless
aid us in "choosing among competing social policies by revealing their empiri-
cal consequences" (p. 1046).
A Continuum
These two types of knowledge-social and scientific-actually represent

extremes on a continuum. At one end, truth is largely a social matter; at the
other, it is largely a matter of prediction and control. As we move toward either
extreme (e.g., religion and science), there are within them ongoing struggles
over what will and will not wield the power of truth. Competition also exists as
we move toward the center of this continuum, where we find that social and em-
pirical knowledge interact to the greatest degree. Indeed, this is where the
development of public policy takes place. Whether it is illicit drug use, crime,
AIDS, global warming, or the economy, makers of policy operate in a political and
personal realm, replete with social contingencies; but because of an increasing
reliance on science and technology, policy makers also are expected to inform
and/or substantiate their decisions with available empirical evidence. Thus, as
our society increasingly looks to science for its solutions to social and health
problems, the likelihood of conflict between social and empirical knowledge
increases, as has been the case in recent decades (see Latour, 1993).
There are many recognized examples of these two types of knowledge
competing for popular acceptance. Cosmological science and evolutionary
biology both have, for example, challenged Christian science beliefs on the
nature of the earth and mankind. Science has not always been victorious in this
competition, however, as in cases in which individuals or groups have tried to
make "improvements" in less technological societies but failed because they
ignored the role being played by socially constructed knowledge.
In an essay entitled "Smallpox in Two Systems of Knowledge," Marglin
(1990) challenged "the claim of Western science to be a superior form of
knowledge which renders obsolete more traditional systems of knowledge" (p.
102). This study concerned Britain and India's attempt to bring Western vac-
cination methods to India in place of an older inoculation method called
variolation. Because the traditional method was contextualized in a highly
ceremonial ritual and because the vaccination approach was introduced as a
state-controlled authoritarian substitute, the vaccine was interpreted as a threat
to cultural values and therefore was largely resisted. The language of "eradica-
tion" and "disease" used by those enforcing vaccination, for example, was
interpreted as an attack on Indian religion and as an insult to the worship of the
smallpox goddess. The Indian government only began to succeed in improving
public health with the smallpox vaccine after recognizing and intervening
within the existing social realm of understanding. Marglin (1990) concluded:
If development means fewer deaths from diseases and starvation, superior tech-
nologies such as vaccination must be used to alleviate the suffering of the masses.
However, to be successfully diffused and transplanted they must be decoupled from
their negative political and cultural entailments. This is seldom if ever done,
probably because of the widespread perception that more efficacious techniques

reflect superior forms of knowledge (p. 140).
Cases such as this help identify a crucial difficulty that arises during
attempts to use scientific knowledge to modify human affairs. Because the
natural and social sciences address matters of social import, they often find
themselves at odds with already existing, socially constructed knowledge-
knowledge that may have been functioning for hundreds of years. In other
cases, new scientific evidence comes into conflict with popular conceptions
that are already partly informed by scientific views, albeit views of an earlier
and incommensurable sort. In either scenario, existing social contingencies
often remain intact because, as in the case of the smallpox vaccine, the new
scientific knowledge represents more of an apparent threat than a salvation.
Such traditional beliefs and values may be, and often are, powerful enough to
constrain the influence of new scientific viewpoints, even in a society such as
the United States, where science is widely embraced.
This conclusion highlights a second set of difficulties. If empirically based
knowledge often conflicts with preexisting social knowledge (the first set of
difficulties), how can we know whether scientific viewpoints (and technolo-
gies) will make matters better or worse-and how do we evaluate what is better
and worse? The answer to these questions offered below is that science and
public policy must be grounded in an explicit ethical framework (Prilleltensky,
1994). For a framework to be explicit and ethical, it must be established in the
public sphere through a democratic process. A problem arises, however, when
this process is hindered because the public lacks a sufficient understanding of
the economic and moral influences steering the development of policy. Thus,
ensuring that the public health is in fact the top priority of public policies
requires the identification of the forces influencing policy development and an
assessment of whether the effects of those forces is serving the agreed-upon
purposes of the policies.
The need for scrutinizing what and who is served by public policies is
especially great today because of the growing influence and pervasiveness of
socially constructed knowledge. As recognized by Moscovici (1988, 1990),
social communities have become less cohesive, relationships more impersonal,
and, as a consequence, knowledge increasingly removed from direct experience
of the world. This has allowed mass media (and its sponsors) to acquire a power-
ful role in constructing people's understanding of the world, an understanding
that, again, may have no positive relationship with the public's welfare. Guerin
(1992) has advanced this formulation by describing the effects of the break-
down of the social sphere in terms of social contingencies. He notes that:
In behavior-analytic terms, the sources of control have changed from smaller

cohesive communities to a more general and widespread control. A problem with
modern infonnation media such as television is that they can support the creation of
counterfactual social representations even in the absence of a social group, because
the consequences for repeating something heard or read in this way are extremely
diffuse and intennittent. This means that there is great potential for counterfactual
knowledge being maintained in modern society because behavior is becoming more
frequently verbal, because the controls on verbal behavior are becoming more
easily detached from nonsocial environmental controls, and because mass media
can maintain counterfactual verbal behaviors that previously could only be con-
trolled by communities (p. 1428).
Given popular faith in scientific objectivity and truth, and given that people are
less aware of the sources of their knowledge, there is an even greater tendency
for people to assume today that their knowledge is in fact empirically derived
and tested.
The continuum just described provides a basic framework for interpreting
the relationship between empirical knowledge and social policy by suggesting
that (1) scientific viewpoints almost always evolve in an environment in which
socially constructed knowledge already exists, (2) given the different contin-
gencies operating in these two realms, the various existing knowledge types are
likely to be incompatible, and hence (3) they will often compete against
another. In short: When scientific knowledge is congruent with the dominant
belief systems, it is readily assimilated; when it is incongruent, a competitive
struggle ensues. This thesis helps explain why policymakers often fail to
incorporate representative empirical data into their policies.
Having introduced this basic framework, let us explore it with some
contemporary nondrug-related examples, followed by a more detailed discus-
sion of the framework in terms of illicit drugs and drug policy.
Examples
Cases in which either ideological or popular views are at odds with

scientific evidence are inherently controversial. For example, consider the
relationship between consumer culture and human contentment. Many Ameri-
cans believe-at least as is evidenced by their actions-that financial and
material gain correlate positively with life satisfaction. Empirical evidence
does not support this assumption, however, and may even suggest a negative
relationship between these two variables under some conditions (see Belk,
1985, 1988). So why do people continue to work more to buy more, even if this
does not translate into an improved quality of life? The social construction of
meaning offers a partial explanation. The "average" American experiences
several thousand television commodity advertisements prior to adulthood
(Comstock, 1991), creating a fetishization of goods; then, as adults, this "mod-
em infonnation media," as found in advertisements promoting cars, clothing,

cosmetics, cigarettes, and lotteries, constructs and reinforces a highly roman-
ticized image of how one's life experience should feel. Together these forces
create social beliefs that overshadow the empirical observations suggesting
that less materialistic, prosocial practices might promote a more fulfilling life
experience.
Equally controversial are cases concerning public health, as in the case of
the 50-year war against bacterial infection in the United States. In the last
several decades, an ongoing development of new antibiotics has been needed to
keep up a fight against the evolution of bacterial disease. As greater selection
pressures have been placed on existing bacteria, however, this "contingency"
has led to an evolution-selection-of increasingly virulent strains (Ewald,
1994). Consequently, there are now cases where individuals are treated for
complex medical conditions only to die from infections that were once suc-
cessfully treated (e.g., tuberculosis).
Might socially constructed knowledge-and social contingencies gener-
ally-be influencing physicians who continue prescribing and individuals who
continue self-administering antibiotics despite empirical evidence document-
ing both short-tenn (personal) and long-tenn (societal) harms for this ap-
proach? Suggesting that this may indeed be the case is the prevailing social
belief that antibiotics are a fail-safe technological solution to infection-and to
the risk of infection. Exemplifying this understanding is the use of antibiotics
as a preventive measure for reducing infection by men who engage in anal
intercourse. This application of the socially constructed understanding of infec-
tion has an especially tragic consequence here, given the apparent correlation
between antibiotic use and impaired immunity in gay men who later come to
develop AIDS (Root-Bernstein, 1993).
A second public health example also concerns AIDS. The AIDS pan-
demic has many facets, some of which are widely accepted (e.g., some groups
are at higher risk), others of which are coming under increased scrutiny. A
growing number of researchers, practitioners, and activists now question, for
example, whether the original consensus that HIV = AIDS may have been
premature (Duesberg, 1989; Fumento, 1990; Root-Bernstein, 1993). Such data
as those showing that heterosexuals who belong to no risk groups have a 1 in
about 5 million probability of acquiring AIDS (Root-Bernstein, 1993) has
skeptics asking whether cofactors may be necessary (and even sufficient) for
the development of AIDS (Fumento, 1990).
Cofactors like disease, nutrition, and drug use have been implicated in
cases where individuals died from AIDS but failed to test positive for HIY.
(About 5,000 such cases have been reported in the literature; see Duesberg,
1995.) In studies being conducted in Africa, moreover, vitamin A deficiency
has been linked as a cofactor in the transmission of HIV from mother to infant,
suggesting that in "the high-tech rush to develop vaccines and other therapies,
we have been ignoring some of the basics" (R. D. Semba, quoted in Altman,
L. K., February 3, 1995). Illicit drugs also have been implicated as a cofactor in
AIDS, not only in terms of transmission through needle sharing (HIV infec-
tion), but also in terms of their effects on the immune system and on sexual
behavior (see Duesberg, 1995). Data from the Centers for Disease Control
show, for example, that although the rate of HIV infection has been constant
since the late 1980s, the proportion of AIDS sufferers who use drugs has
steadily increased (reported in the New York Times, February 28, 1995). All
these data on cofactors have led critics to charge that early consensus has
created an unnecessary public hysteria about the spread of AIDS, has led
research in some wrong directions, and has hampered public health efforts to
lower the overall prevalence of AIDS.
The public (and much of the scientific) understanding of AIDS represents
a case in which early scientific explanations confirmed preexisting social
beliefs-perhaps in part because of those beliefs-making them resistant to
empirically based viewpoints that came later and that contradicted the earlier
understandings. The early hypothesis that AIDS = HIV conformed to people's
notions of infection and sexually transmitted diseases, making it difficult to
introduce, even within the scientific community, the possibility that AIDS is a
medical complex that emerges only when a number of individual conditions are
fulfilled (Root-Bernstein, 1993). As with the overprescription of antibiotics, the
cofactor hypothesis of AIDS has little public support, not only because it is
inconsistent with beliefs about simple cause and effect relationships, but also
because it implicates larger social and behavioral causes (and solutions) in the
disease complex. This brings us to two general conclusions: First, speculation
by scientists concerning a social problem can become entrenched as truth in the
social realm if that speculation is compatible with the prevailing common
sense; second, such social truths are likely to be highly resistant to change even
if further evidence shows them to be wanting.
SOCIAL KNOWLEDGE AND ILLICIT DRUG POLICY
The concept of socially constructed knowledge suggests both barriers and

limits to informing public policy through empirical research. Although this
may appear self evident, many researchers, policy analysts, policy makers, and
much of the lay public maintain, perhaps to a greater extent than ever, that
policy follows from empirical research (see Formaini, 1990). To examine the
implications of the social-constructionist framework for drug policy, let us

examine research on drug use and dependence with regard to the four tenets of
social constructionism outlined in Gergen (1985).
Knowledge May Be Invented and Still Influence

Thought and Behavior
The concept of socially constructed knowledge can explain why a great

chasm exists between what the public (and some scientists) believes about
illicit drugs and what empirical evidence actually suggests. Like other myths of
popular culture, the public understanding of illicit drug use, drug effects, and
drug dependence is comprised of a nexus of socially constructed beliefs, many
of which are powerful enough to exert influence over the funding, conduct, and
interpretation of research (see Chapters 1 and 12, this volume).
One of these beliefs is analogous to the belief that HIV = AIDS: Illicit
drug use = drug dependence, either immediately or after continued used (see
Chapter 9, this volume; Zinberg, 1984). For example, consider how this belief
has led us to treat "drugs" and "alcohol" abuse as separate phenomena. The
most commonly used psychoactive drug has been alcohol. Its prevalence of use
has made it clear, however, that because most users remain casual users,
alcohol does not appear to have inherently addictive properties. Hence, the
common sense about drugs being inherently addictive had to be revised,
creating two types of addiction. First, for those drugs that appear to induce
addiction in most of their users-illicit drugs, nicotine, and caffeine-the
classical model of addiction and dependence remained; second, an alcoholism
"disease" was socially constructed to reconcile the fact that only a few
individuals were prone to heavy drinking ("alcoholics"), putatively because of
some genetic predisposition (see Chapter 9, this volume).
But does illicit drug use necessarily lead to addiction? Epidemiological
research suggests the answer is no. For example, Zinberg (1984) and others
documented numerous cases of long-term controlled heroin and cocaine use
where an escalation of use is absent over a period of drug taking that spans
years or decades (see also, Biernacki, 1986). Similarly, research shows that
very few who use an illegal drug continue use or become drug dependent. Data
from the National Comorbidity Survey and the National Household Survey of
Drug Abuse, for example, show that although about 50% of respondents report
lifetime use of one or more of these drugs, few show dependence at any time
during their life (about 5% for ages 18-44; Warner, Kessler, Hughes, Anthony,
& Nelson, 1995). One report specifically on cocaine-the drug often consid-
ered today as the most addictive-concluded that:
Cocaine use appears to be experimental in nature and to involve few experiences

for a substantial portion of those who report any lifetime experience with the drug.
One-half (53%) of the male users and two-thirds (67%) of the female users have
used cocaine less than 10 times in their lives; 34% and 28%, respectively, have used
10 to 99 times, 9% and 3% have used 100 to 999 times, 3% and 2% have used 1,000
or more times. (Kandel, Murphy, & Karns, 1985).
Underlying the public's beliefthat "illicit drug use = drug dependence" is

the assumption that drug use will escalate into abuse because of the "addic-
tive" properties of illicit drugs. This assumption also has little empirical
support. Basic research on animal and human drug self-administration suggests
instead that drug effects are derived from an interaction of social, environmen-
tal, pharmacological, and behavioral factors (see Chapters 1 & 2, this volume).
For example, animals under highly impoverished conditions self-administer
opiates and psychostimulants in harmful amounts (Bozarth & Wise, 1985).
However, when nondrug alternative reinforcers (e.g., a sweet solution) are
made available in the drug-taking environment, this greatly reduces the fre-
quency of drug self-administration in animals already self-administering the
drug (e.g., cocaine; see Carroll, Lac, & Nygaard, 1989; Nader & Woolverton,
1992); similarly, when made available prior to having access to the drug, nondrug
alternatives have been shown to significantly decrease the number of animals
acquiring a pattern of drug use (Carroll & Lac, 1993). Results similar to these
have been reported in laboratory studies on human drug self-administration
(Bickel, DeGrandpre, Higgins, Hughes, & Badger, 1995) and in the treatment
of cocaine dependence (see Higgins, Budney, Bickel, Hughes, Foerg, & Badger,
1993). Such data led one behavioral pharmacologist to note that "[a]lthough
current rhetoric would often have one believe otherwise, the self-administration
of cocaine is governed by the same laws that govern behaviour maintained by
other positive reinforcers," or, in other words, "the reinforcing effect of co-
caine is the result of an interaction between a drug, an organism and an environ-
ment" (Woolverton, 1992, pp. 157-158).
As with the public misunderstanding of AIDS, empirical research from
basic laboratory, epidemiological, anthropological, and clinical practice sug-
gests that drug dependence emerges from a confluence of forces upon the
individual over extended periods of time rather than from a simple cause-and-
effect relationship between A (illicit drugs) and B (drug dependence) (see
Chapter 3, this volume). When a drug shifts from something used casually to
something used compulsively, this is because the meaning of drug use (i.e., its
effects) has changed for the individual. This is no different from the individual
who, after experimenting with use, quits using. What is different in these two
scenarios will not be found in the pharmacological properties of the drug
(which remain constant) but rather in the individual's unique personal histories
and the overall context of their drug use (DeGrandpre & White, in press).
As with the equation "HIV = AIDS," the mainstream understanding of

illicit drugs likely evolved as part of a cultural system of beliefs and practices
that was maintained by social contingencies. At the individual level, these
contingencies would ensure that people acquire a particular commonsense
view of illicit drugs during child and adult development. This common view of
illegal drugs would then guide the interpretation of drug-related events and
stories that subsequently occurred, ensuring their consistency with the prevail-
ing common sense.
In explaining an evolution of socially constructed beliefs that conflict with
empirical evidence, this framework does not predict that these beliefs about
illegal drugs will serve as a prophylac~ic and eliminate drug demand altogether-a
prediction that obviously would be in error. Rather, the framework suggests
that drug use and dependence may still occur in some individuals as long as
contingencies promoting use are more powerful than those promoting behav-
iors consistent with social beliefs about the risks of illicit drug use. Such
contingencies to use drugs may be social (e.g., social contingencies existing
within a peer subculture), or they may have more to do with the absence of
alternative activities that would otherwise compete with drug taking. Indeed,
the existence of illicit drug use in the realm of social contingencies supporting
such public fears and such punitive consequences for drug use suggests just
how impoverished the lives of drug users have become.
Socioeconomic and Cultural Functions

of Socially Constructed Knowledge
Like the feathers of a bird or the shell of a tortoise, any bit of knowledge
likely exists because it serves (or once served) some function for the individual
or group. Although many Americans may view scientifically established
"truths" as the ultimate knowledge in a society, it has been argued here that the
lives of most individuals are saturated with socially constructed knowledge,
knowledge that functions as a guide to social interaction and other daily
activities. According to social constructionism, then, popular conceptions
about illegal drugs and drug dependence need not be empirically valid as long
as they serve social and/or individual functions (see Chapter to, this volume).
What possible functions might the public understandings of drugs serve in
contemporary society, either for the public itself, or for larger groups or
institutions that rely on certain public opinions for their livelihood (e.g.,
corporations, political parties)? With regard to the function of public beliefs for
individuals, knowledge and opinion can serve as a source of individual mean-
ing that helps one create a personal identity. Here, people's views of illicit drug
use allow them to support and be involved in a social movement directed
toward solving a widely recognized social problem (i.e., the "war on drugs").
This would explain, among other phenomena, the public consensus on "zero
tolerance" for illegal drugs.
It is not at all clear, however, that each person's views about illicit drugs
derive from personal experience. Rather, as suggested in Fromm's classic
work, Escape From Freedom (1969), knowledge may reflect a kind of mass
public opinion:
We forget that, although freedom of speech constitutes an important victory in the
battle against old restraints, modem man is in a position where much of what "he"
thinks and says are the things that everybody else thinks and says ... We neglect the
role of the anonymous authorities like public opinion and "common sense," which
are so powerful because of our profound readiness to conform to the expectations
everybody has about ourselves and our equally profound fear of being different (p. 125).
Fromm warns us that knowledge and opinion may be more in the service of the
priorities of institutions than the priorities of the public that actually holds those
opinions. In the case of drugs, this possibility can be seen by examining
whether there are any qualitative differences between legal drugs, like alcohol
and nicotine (from tobacco), and illegal ones, like opiates, marijuana, and
cocaIne.
Suggesting that there may in fact be no consistent differences in the
psychological effects of legal and illegal drugs are empirical data showing that
alcohol and tobacco products are as correlated with abuse and dependence as
any illegal drugs are, and that alcohol has a much greater correlation with
violence than does any illegal drug. If there are qualitative differences, evi-
dence suggests that they are more apt to be found in their histories of use,
production, and sale (as cash crops) in Europe and America (see Chapters 5 &
12, this volume). Unlike drugs that are now illegal, alcohol and nicotine have
the longest histories of use and production in Europe and by European immi-
grants in North America. This suggests that perhaps contingent historical
circumstances may be more helpful in explaining our different conceptions of
legal and illegal drugs. In other words, might these conceptions serve economic
and moral concerns that have evolved over hundreds of years rather than
represent essential characteristics of the drugs themselves?
Language Is Not a Direct Representation of the World
If language gives meaning to the world and is partly socially constructed,

it is worth examining the evolution of concepts and metaphors animating
popular thinking about illicit drugs today, including an assessment of their
relationship to empirical findings. Language, often viewed instrumentally as a
tool for describing the world, can also be viewed as a tool that shapes and
constrains the way we interpret phenomena in the world. In this sense, lan-
guage is as much constitutive as it is descriptive of our experience.
Two concepts that are relevant here are "addiction" and "drug abuse." In
their mainstream forms, both are used as rhetorical catch-phrases to promote
and sustain a hysteria around illegal drugs. l The concept of addiction-
although sometimes applied metaphorically to behavior not associated with
drug use-helps to distance heavy drug use from other excessive repertoires
that are more often viewed innocuously as habits (e.g., excessive working or
exercising). As suggested by Peele (1985), the consideration of heavy drug
use in the same terms as other forms of compulsive behavior would allow for
a more far-reaching theory of compulsive behavior; such a theory could focus
on the functions these behaviors have for the individual, rather than attempt-
ing theoretical explanations that focus only on the structure of behavior
(McKearney, 1977).
The concept of "abuse" also serves to block finer distinctions between
different styles of drug use. Individuals who self-administer drugs like cocaine
and heroin on a regular basis, for example, are often viewed as drug abusers
("addicts") even though drugs are not disrupting other aspects of their life.
This is exemplified by the household survey of drug use conducted by the
National Institute on Drug Abuse. Although the survey, conducted every few
years, primarily assesses use, its title is "National Household Survey on Drug
Abuse." Equating use with abuse has the effect of reinforcing socially con-
structed views about illegal drugs by hiding the fact that continued use is not
isomorphic with abuse.
Another aspect of the relationship between language and the social under-
standing of drugs concerns the "connotations" that illicit drugs acquire. Unlike
alcohol, which is portrayed both positively and negatively in the media (e.g.,
positively in social gatherings, negatively in stories of alcoholism), illicit drugs
are often viewed primarily in negative imagery. Crack is viewed as hyperaddic-
tive, phencyclidine (PCP) as a drug that induces violence, and marijuana as a
drug that drains one of his or her motivation. In fact, this imagery is so negative
that most of the public is horrified at the thought of a legalized use of sub-
1As an example of such hysteria. consider this advertisement from the "Partnership for a Drug-
Free America," from the New York Times (June 20. 1995): "Now he's at your door. If your
company doesn't have a drug policy, you're just what he's looking for. Because he has a drug
problem-a problem you can't afford. It's a problem that can mean low productivity, more health
claims, on-the-job accidents, even costly lawsuits. That's why many small businesses are imple-
menting a drug-free workplace policy. Protecting your business from drugs is easier than you
think .... If drug users know your business doesn't have an effective drug policy, you might as
well be inviting them in."
stances like "heroin" or "crack." This is true despite the fact that most of the
public will hear, read, and develop strong beliefs about these drugs without
ever having any direct experience using them.
Changes in the public's view of marijuana illustrates how social beliefs
about a drug, disconnected from direct experience, can be radically revised
even within a period of a few decades. During much of the 20th century,
smoking marijuana was thought to stimulate a kind of "reefer madness."
Today, however, the imagery provoked by the drug in popular culture has been
inverted such that marijuana is now portrayed as a drug of slovenliness and
indolence. As documented by Heath (Chapter 12, this volume), the understand-
ing of illicit drugs varies considerably from country to country and over time.
Heath notes similar changes for caffeinated substances like coffee and choco-
late, which are now considered innocuous in places where they were once
viewed as dangerous and corruptive of human behavior. Such shifts in the
meaning of drugs in those who do not use them illustrates the powerful
influence of socially constructed knowledge.
In fact, direct experience with drugs may have less to do with creating the
way in which drugs are socially understood than their social understanding has
to do with how drugs are experienced by those who do use them. In most cases,
individuals who use illicit drugs participate in popular beliefs about them prior
to actually using them. Given evidence that drug dependence emerges out of a
confluence of forces, this raises the possibility that reductionistic beliefs about
drugs may be one of these forces, creating a self-fulfilling prophecy. That is,
members of a culture where drugs are perceived as "naturally" causing addi-
tion may in fact be more prone to a pattern of dependence, especially since it
leads one to overlook the influence of other factors (and thus solutions) in the
dependence process. This possibility suggests an even greater role for the
social construction of knowledge in illicit drug use and policy.
Socially Constructed Knowledge Is Woven

into the Fabric of Culture
The belief that illicit drugs have inherently addictive properties that
inevitably lead to dependence is a popular myth, sustained and promoted
because of the various societal and personal functions it serves in mainstream
society. Before examining how this myth affects drug policy for illegal drugs,
let us conclude our discussion here by briefly examining the larger cultural
context in which it has evolved.
The belief that drugs have universal behavioral properties-and the lan-
guage of addiction and abuse that serves this myth-have become social
instruments in a public realm that has always been uneasy about the effects of
(illicit) drugs imported into the United States. The tendency to see these
psychoactive substances as alien and threatening to American culture has led to
a selective portrayal of their use as amoral and harmful, a pattern that culmi-
nated in their criminalization. Their illicit status then created a self-fulfilling
prophecy by placing the use of these drugs in a black-market, turning users into
criminals of the state. In addition to having the effect of making drug use a
crime, prohibition also increases drug costs, ensuring "real" criminal activity,
and creates a "pusher's" market in which great sums of money can be gained
by expanding existing markets and creating new ones (e.g., selling to children
and adolescents).
Although this account ignores some of the complexities of the evolution
of drug use and prohibition, it can nevertheless account for much of the
ideological and moralistic rhetoric that has long inhabited public discussions of
illegal drugs (and the growing debate over drug policy). In fact, the emo-
tionality of this issue shows the extent to which socially constructed beliefs
about illicit drugs are woven into mainstream culture. To the extent that this
model can be substantiated, it suggests that serving the public health must be
envisaged as a struggle against forces designed to serve other goals. Although
these forces may not intend to hinder public health and safety (they may even
be in the name of public health), they nonetheless may have this effect. Thus,
fighting for the public health means recognizing that ideological and moralistic
positions on drugs block access to more humane approaches to drug policy-
approaches that would give greater import to epidemiological research and
research in psychopharmacology. Such an approach would seek, to use Hard-
ing's words (1991), "less partial and distorted descriptions and explanations"
(p. 1) of how drugs currently function in American society.
CHANGING POLICY MEANS CHANGING

THE CONTINGENCIES THAT PRODUCE IT
The application of social constructionism to the topic of illicit drugs is not

meant to be exhaustive, but rather to illustrate how social knowledge and
values may serve other purposes than promoting the public health. Social
constructionism does not imply, moreover, that knowledge that is empirically
informed will necessarily be "better" or more "valid" than social knowledge,
just as it does not imply that scientific knowledge will necessarily be in conflict
with knowledge comprised primarily in the social realm (see Marglin, 1990).
However, by providing a continuum for distinguishing between different types
of knowledge, it does have implications for the construction of public policy:
1. The epistemological framework anticipates the possibility for conflict,

thus providing a broad framework for evaluating the development and
implementation of public policy, especially in areas where knowledge
is heavily socially constructed.
2. By recognizing the influence of social contingencies in producing and
reinforcing social beliefs and perceptions, this framework helps to
undermine the pervasive but flawed public assumption that scientific
contingencies alone-associated with prediction, control, and truth-
determine the viewpoints of scientists and the outcomes of science. In
doing this, it also exposes the false assumption that scientific activities
will inevitably lead to knowledge that enhances the public sphere, and
that, if research succeeds in producing data that may be useful in
constructing public policy, those data will inevitably find their way
into its development.
3. Although it does not provide the values that guide the construction of
policy from knowledge, it highlights the need to monitor and evaluate
what and whose values are in fact influencing the making of policy.
4. Finally, it implies that changing policy to improve public health will
require changing the contingencies that determine policies. (This final
point is the focus of the concluding remarks on the development and
implementation of drug policy.)
If we start with the assumption that the highest priority of drug policy
should be improving public health and safety of Americans-in both the short
and long term-it is clear that the data on the effectiveness of federal and state
drug policies show them to be a failure. These policies are based on a model of
deterrence via criminal fines and imprisonment, and it is hard to imagine that
the overall situation could have turned out worse without them. Rather than
having the desired effect of actually deterring drug-related behavior, these
solutions have been iatrogenic: They have almost doubled the prison popula-
tion in the past 15 years without decreasing violent crime or decreasing drug
use by the population most likely to be incarcerated (see Chapter 12, this
volume). In fact, the United States now imprisons more individuals per capita
than any other country in the world, many of whom are held for nonviolent,
drug-related crimes (Currie, 1993).
Such data not only highlight a need to revise our drug policies but also
suggest a pressing need for determining how to ensure that such revisions will
indeed safeguard public health and safety (see Chapter 9, this volume, for a
more detailed discussion of marketing alternative drug policies). An immediate
task, then, is to explain why these policies still remain in place today, despite
their failure. Perhaps the most significant reason has to do with the confounding
of illicit drug use with the by-products of a black market.
Sustained drug use (and drug pushing), combined with increasingly se-
vere penalties, has led to an explosion of the so-called drug problem. This has
been especially true in the past two decades, partly because of the continuing
decay of America's urban environments. As a consequence, the harms associ-
ated with drug use have become intertwined with the harms produced by a
black market for drugs. Thus, given the prevailing social belief that drug effects
are a direct consequence of the drugs themselves, there has been a tendency to
link these harms directly to illegal drugs and drug use, overlooking their
relationship to the context of drug use created by militant drug policies. Among
other effects, this has provided abundant opportunities for antidrug zealots to
publicly demonize drugs and drug users, legitimizing the denial of social,
cultural, and economic factors that have been implicated in the societal mainte-
nance of drug demand for illegal drugs. Note, for example, that when critics of
current policies promote a decriminalization or medicalization of drug use,
they are often attacked for promoting greater drug use, as if use itself was
causal to all the problems resulting from a black market for drugs.
The public misunderstanding of the "drug problem" suggests that the first
step in challenging current drug policies should be to ensure that policy
analysts and the public begin to identify and differentiate the harms associated
with use from the harms associated with the context of use (see Chapters 8 & 9,
this volume). This focus on "harm" may be an effective way to deal with the
issue of revising American drug policies for several reasons. First, it is a rather
straightforward tactic that has some historical precedent. Public support for
medicalized treatment of opiate dependence with methadone shows that the pub-
lic has been willing and able to recognize that the context of drug use can
change its consequences and thus its meaning (see Chapters 4 & 7, this volume).
Second, the focus on harm is consistent with an understanding of the
influence of socially constructed knowledge. If changing public beliefs about
illegal drugs is a prerequisite for obtaining support for alternative drug policies,
and if these beliefs are maintained by social contingencies, social construction-
ism suggests that there is a need to change the consequences for maintaining
these beliefs. Linking current drug policies with "harm" does just that. That is,
this tactic has the useful consequence of reversing the contingencies surround-
ing the debate of drug policy so that advocates of current policies can be
charged with harm promotion. If the war on drugs and the moralist stance
against drugs are empirically demonstrated as harmful, perhaps policy makers
will be more sensitive to empirical research and the health and safety conse-
quences of their policies.
CONCLUSION
The public health has been lost in a competitive struggle between scien-
tific and socially constructed knowledge. Despite increased knowledge in the
social, behavioral, and medical sciences, there remains a considerable dissocia-
tion between socially constructed knowledge and the knowledge derived from
basic, applied, and epidemiological research. If the war on drugs has only been
a war against the use of illicit drugs ("zero tolerance"), rather than a war
against the root determinants of illicit drug use (and drug pushing), this is
because the priorities of these policies have not been to minimize personal
harms and maximize public health. Rather, the goals of current drug policies
have been to serve specific interest groups (whether moral, political, or eco-
nomic), groups that have been influential in promoting a social understanding
of illicit drugs consistent with these policies. Hence, changing drug policy
requires analyses and tactics that are sensitive to the relationship between em-
pirical research and policy development. However, such tactics as "harm
reduction" are only a minimum of what needs to be done if more pragmatic
policies are to be seriously considered. We cannot realistically hope to radically
change the public's understanding of drugs until we begin eliminating the
conditions that make drugs so attractive and destructive in contemporary
society. Herein lies the paradox of drug policy.
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Index
Abuse liability, 6, 7, 10, 11 Behavioral genetics, 5, 9, 206, 212, 216,

Access to drug treatment, 129, 155-173 237,311
Addiction Severity Index (ASI), 80, 134 Behavioral pharmacology, II, 12, 32
Adjunctive behavior, 19-20 Bennett, William, 281, 282
Adjunctive services, 149 Benzodiazepines, 20, 105, 107,229; see
Adolescent drug use, 55-70, 84--85,317 also Triazolam, Diazepam
Africa, 99, 103, 107, 120,309 Black market, 185, 187, 319
AIDS, 128, 130, 135, 143, 309-310, 311 Blood--brain barrier, 225
Alcohol use Brain damage, 231-232
calories from, 102, 110 Bromocriptine, 92
prevalence, 41,157,209,290 Bupropion, II
Prohibition (1919-1933), 108, 286, 296 Bush, George, 265, 269, 273, 279, 280,
relationship to income, 41, 13G-131 282, 292, 293; see also Public
toxicity, 231 opinion-"War on Drugs"
Alcoholics Anonymous (AA), 144,204,
206-207,210 Caffeine, 12, 16,21, 108,252,291,311
Alcoholics Victorious (AV), 110 Canadian drug policy
Amantadine, 92 comparison to US policy, 251-274
American Bar Association (ABA), 208--212 Narcotic Control Act (1961),261
Antihistamines, II Cannabis, 100, 101, 104, 106, 107, 108, 113,
Antiprohibitionists, 235 114,116,121,189,225,228,231,
Anxiety and drug use, 17,61,62,65,67, 268, 291; see also Marijuana
146 Carbidopa-L-dopa,92
Apomorphine, II Castro, Fidel, 281
Arrest rates, 263, 264 China, 103, 104, III, 112, 120,258, 287
Attention-deficit hyperactivity disorder Cirrhosis, 290
(ADHD),67 Civil liberties, 209,217
Aztecs, 100. 101, 107, 110,291 Cocaine
basic pharmacology of, 224--238
Bacon. Sir Francis, 4, 31 crack,9. 10,45,92, 147,238,239,250,
Beck Depression Inventory, 162, 164, 166 270,288.315,316
Behavioral dependence, 6,9 overdose,20l,230, 242
Behavioral economics, 12, 17-19,32-40,186 prevalence of use, 45,157,269.312
consumption, 33, 34, 38,45,46, 183, 186 treatment of abuse, 18,44. 77-S2. 85, 87,
drug price, 179, 182, 186 92-93,135-138,147-148,188,
elasticity of demand, 183 239; see also Pharmacotherapy
323
324 INDEX
Cold War, The, 280 Drug treatment (cont.)

Community Reinforcement Approach (CRA), strategies for, 44,66, 77-94, 158-173
66,80 utilization of, 128-129
Contingency management in drug treatment, Drug withdrawal, 13, 17,86,87,92,221,
18, 44, 77, 78-84 226,227,228,229,296
Craving, 10, 13. 14, 18,92,227 DSM-JJl-R.228
Crime, 40. 46, 64, 111, 127, 128, 129, 131,
144,147,181,185.190,208,235, East Indies, 102
26~263,288,293,295,306,318 Employee Assistance Programs (EAPs), 66,
Crisis intervention, 69-70 131, 139
Cross-cultural comparisons (of use and policy Employment status (and drug use), 38,
development). 251-274, 284-297 42-43,61,63,90,131,133,148.
Cultural factors (in use and policy develop- 164
ment), 10,71,99-121. 217. 222, 224, English East India Company, 103
24~241.301-303.305, 313-315 Environmental factors (and drug use), 19,
Cultural taboos, 107, 108, 109 23,30,41,181,214,223,232
Epidemiological Catchment Area Study,
d-amphetamine, 16,20,33 41. 42
Decriminalization, 178, 180, 181-182,215, Epidemiology, 41,42,45, 213, 31 I, 320
284,297,319
Demand reduction, 188-189 Fallacy of identity, 5
Depression and drug use, 17, 59, 61, 66, 67, Family advocate services, 71
90, 140, 146, 147 Fluoxetine, 93
Desipramine, 85, 92 Food and Drug Administration (FDA).
Department of Veterans Affairs, 150 160
Diagnostic Interview Schedule, 41
Diazepam, 19, 20 Generator schedules, 19--23
Disability payments, 82 Genetic vulnerability, 237; see also Behav-
Discriminative stimuli and drug use, (environ- ioral genetics
mental control/stimulus control), 8, Gin Epidemic, 101, 102, 103, 1l2, 120
13-16,21,22,41,308 Greatful Dead, 263
Disulfiram treatment, 86
Doctrine of Signatures, 5 Harm reduction as drug policy, 89, 156,
Drug Abuse Prevention and Control Act, 263 158,163,170,188-195,215,
Drug availability, 7, 33, 36, 40, 45, 47, 60, 178, 295,319,320
179, 183, 206 Harrison Narcotic Act of 1914, 257
Drug Enforcement Administration (DEA), 160, Heroin
224,282 overdose of, 199-203
Drug legalization, 3 I, 32, 36, 41, 45, 11 ~ 112, prevalence of, 40-41
179--180,182-184,188,193-194, treatment of, 14,40-41,43,44,66,77,
215--216,296--297 87-92, 156, 193,233.296; see
Drug self-administration, 9--12, 14, 15,32,38, also Pharmacotherapy, for heroin
105,312 abuse (methadone)
Drug sensitization, 8,9, 222 High school equivalency diploma (GED),
Drug tolerance, 8.9, 222 138
Drug treatment Homelessness, 60, 138, 269
case studies in, 146--149 Homicides, III, 208, 231, 233,
outcome domains, 132, 143 Human immunodifficiency virus (HIV), 79,
referral to, 69, 127-152, 161, 172 87,91,191,192,238,239,295,
retention in, 89, 163, 170 309--310,313
INDEX 325
Imipramine, 92 Narcotics Anonymous (NA), 136, 140, 141,

Incarceration, 43, 63, 65, 109, 131, 167, 182, 144
185, 186, 190, 293 National Commission on Children, 63
India, 103, 104, 107, 111,290,306 National Comorbidity Survey, 311
Industrial Revolution, 102 National Household Survey on Drug
Inner-city Families in Action, 64 Abuse. 183, 311, 315
Intravenous (IV) drug use, 148, ISS, 233, 239 Natural Theology, 4
Netherlands, The, 156, 189, 269, 270, 295
Kennedy, John Francis, 31, 47 New York Times. 200--203, 254
Ketamine, 33 Newton, Sir Isaac, 4
Nicotine, 12,20,21,33,34,36, 85, 87,
Law of demand, 36 224,227,239,282,311,314
Law of effect, 6, 82 Nixon, Richard, 260, 264, 265
Law enforcement
of drug laws, 177, 262 Office of National Drug Control Policy, 184
effect on drug use, 179, 252-263 Old World, 99-100, 252
effect on minorities, 111,182,240,257,272, Ontario legislature, 254
293 Opium, 100, 101, 103, 104,111,112,113,
Learning theory, 227 116, 118, 120. 226, 254, 256,
Legal sanctions, 41. 110--112, 178, 182, 192. 207 257,287,291
Life history studies, 43 Opium Act (1908),256
Lithium, 92 Opium Epidemic, 103, III, 120
Longitudinal studies, 56, 61 Opium Wars, 104,287
Malnutrition. 147 Pentobarbital, 19, 33

Marijuana Pharmacological determinism, 5-10, 24,
basic pharmacology, 224-238 288
legal status, 180, 258, 268, 287, 314 Pharmacological specificity, 6, 9
therapeutic value. 217-218. 240--241 Pharmacotherapy
See also Cannabis for cocaine abuse, 77, 92-93
Marinol, 240; see also Marijuana for heroin abuse (methadone), 14.66,77,
Marital history and drug use, 42 87-92,156,193,233,296
Mass media Phencyclidine. 20, 34, 37, 315
effect on drug policy, 264, 269, 288, 307-308 Physical dependence, 6
effect on drug use, IS, 121,252,273,290,292 and cocame, 226-230
Mazindol, II and heroin: see Pharmacotherapy. for her-
Medicaid, 82, 135, 148, oin abuse (methadone)
Methadone, 14,66,77,87-92,156,193,233,296 and marijuana, 226-230
detoxification, 79, 81, 87-92, 135, 163 Plato, 8
maintenance, 79, 87-92, 135, 163 Polydipsia, 19, 21-22
take-home methadone, 78 Polydrug abuse, 10,
See also Pharmacotherapy Prevention of drug use,S, 13, 45, 55-59,
Mexico, 100 62-71, 185, 188,209,210,213
Models of addiction, 81-83.203 Procaine, II, 12, 34,
disease (medical), 81, 203-207, 238, 311 Prohibition (as a policy), 31, 107, 179-180,
law enforcement, 203-207 223,224-242,256,286-289,
libertarian, 204, 212-214 290--292,317
social welfare, 204, 212-214 temperance movements. 252-256,
Montreal Temperance Society, 253 270--271
Mothers Against Drunk Driving (MADD), 289 Prospective studies, 42, 224, 233
326 INDEX
Prostitution, 106, III, 113, 239 Smoking cessation, 86

Protective factors, 55, 56, 63 Social controls and drug use, 112-113,
Prevention policies, 45, 55-59, 62-71 283-286; see also Cultural factors
Psychiatric diagnosis, 61, 145; see also specific Social constructionism, 285, 289-290, 294,
disorders 301-320
Psychosocial services, 87-89, 93 Sociodemographic variables, 42, 181-185
Public assistance, 63,130,139,148 Socioeconomic status, 17,60,69,223
Public health policy, 83, 127-152, 176, 194, Stigmatization, 180, 182, 184, 190, 195
223, 302-3 \3 Subcultures and drug use, 12, 108,
and smallpox, 306-307 113-118.313
Public opinion Subjective effects of drugs, 17
and US "War on Drugs," 265-266, 279-283, Suicide, 109, 135, 140, 148,231,265
313-314 Supply reduction. 32, 36. 45-46, 18~189,
of Canadian drug policy, 265-266 193, 281, 292
in shaping drug policy, 189, 273 Supplemental Security Income (SS!), 82
PUSH for Excellence Program, 68 Surgeon General, The. 45
Syphilis, 147
Rastafarians, 15
Rational choice, 177-180 Target Cities Programs, 150
Reagan, Ronald, 265, 266, 267, 273 Taxation, 82, 110, 112, 114, 181, 186,265,
Rehabilitation, 63, 71, 136, 150, 185, 204, 293, 286-287,294,296
294 Temperance Mentality Questionnaire
Religiosity, 58, 59 (TMQ),270
Religious sanctions, 109-110 Treatment Services Review (TSR), 136, 137
Reinforcers, availability of alternative, 6, 18, Triazolam, 16
21, 31,36-39,44,5~59 Turkey, 103. 286, 287
conditioned, 23
efficacy of, 5, 13, 16, 17-23 U.N. Security Council, 272
Relapse, 13, 15,90,132,136,141,145,146, U.S. Congress, 82, 251, 260, 292
188 U.S. Narcotic Act of 1914, III
Renaissance, 252 U.S. Supreme Court, 260, 264, 265
Retrospective analysis, 42, 43, 223-224, 228, Vietnam, 40--41, III, 265
229,232,233,241,270 Violence, 60, 65,130,135,185,186,187,
Risk factors, 56, 58--62, 89, 145 226,232-235,270,280,281,
how to reduce, 65-70 293,295,314
Ritual dug use, 15,37,105-106,306 Violent Crime Control and Law, Enforce-
ment Act of 1994, 260
Satiation, 6
Schizophrenia, 61,236-237 Welfare system, 63, 130, 131, 150, 204,
School Development Program, 64 286
Self-reported drug use, 85,228,230, 231 World Health Organization (WHO), 104
and urinalysis testing, 138, 164
Skills training, 66, 84-86 "Zero tolerance," 284,292,320

Drug Policy and Human Nature Psychological Perspectives On The Prevention, Management, and Treatment of Illicit Drug Abuse by John L. Falk (Auth.), Warren K. Bickel, Richard J. DeGrandpre (Eds.) PDF

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Drug Pol icy and

Springer Science+Business Media, LLC

ISBN 978-1-4899-3593-9 ISBN 978-1-4899-3591-5 (eBook)

© 1996 Springer Science+Business Media New York

All rights reserved

No part of this book may be reproduced, stored in a retrieval system, or transmitted in

B. K. ALEXANDER Simon Fraser University, Burnaby, British Columbia,

ROBERT MacCOUN Graduate School of Public Policy, University of Cali-

The formation of drug policy is a complex phenomena influenced by a multi-

Part 1. Informing Drug Policy via Psychological

Chapter 1. Environmental Factors in the Instigation and

The Estrangement of Science and Policy ..................... 3

Chapter 2. Psychological Science Speaks to Drug Policy:

Research-Derived Principles ............................... 32

Part II. Informing Drug Policy via Psychological

Chapter 3. Psychological Approaches to Prevention . . . . . . . . . . . . . 55

Chapter 4. Drug Abuse, Drug Treatment, and Public Policy 77

Contingency Management ................................. 78

Chapter 5. Cultural Factors in the Control, Prevention,

Drug-Alcohol Production and Commerce in Prehistoric and

Drug Subcultures and the Drug Trade ....................... 113

Part III. Informing Drug Policy via Psychological

Chapter 6. Achieving the Public Health and Safety Potential

Introduction ............................................ 127

Chapter 7. Drug Policy and the Enhancement of Access

Introduction ............................................ 155

Part IV. The Psychology of Drug Policy: Psychological

Chapter 8. Examining the Behavioral Assumptions of the National

Robert MacCoun and Jonathan Caulkins

Effects of Drug Laws on Drug Use ......................... 178

Chapter 9. Assumptions about Drugs and the Marketing of Drug

Introduction: Say Whatever You Want about Drugs as Long as

Chapter 10. The Pharmacological Understanding of Psychoactive

Importance of Basic Phannacology ........................ " 221

Part V. The Psychology of Drug Policy: Social and

Chapter 11. American and Canadian Drug Policy: A Canadian

Chapter 12. The War on Drugs as a Metaphor in American

Declaration of a War on Drugs ............................. 279

Chapter 13. The Impact of Socially Constructed Knowledge on

Introduction ........................................... . 301

Index ................................................... . 323

Informing Drug Policy

THE ESTRANGEMENT OF SCIENCE AND POLICY

under a different set of constraints. Its concepts must be initially acceptable-

SCIENCE AND DRUG POLICY

genetic counseling of the inherently vulnerable, then interference with drug

volvement with one's baseball card collection would be described in terms of

A BRIEF CRITIQUE OF PHARMACOLOGICAL

A major principle of phannacology is that drugs have specific actions that

This is not just a matter of demonstrating that tolerance and sensitization

mental context is intimately bound up with the generation and manifestation of

A further set of observations bears on this point. If the abuse of a drug is

Although a classic pharmacological approach to the problem of drug

mental and policy contexts. The behavioral pharmacology of drug self-

example, under laboratory conditions, procaine is self-administered by humans

NONPHARMACOLOGICAL SOURCES FOR THE REINFORCING

In reviewing nonpharmacological factors in drug abuse, Hartnoll (1990)

the reinforcing efficacy of drugs, the behavioral economics of introducing

Drug Discriminative Stimuli Can Set the Occasion

A discriminative stimulus (SD) is an initially neutral stimulus that, be-

Moreover, if an auditory SD had been present during drug self-administration,

restore self-administration behavior following extinction (Stretch, Gerber &

Drug Discriminative Stimuli and Drug Taking Can Set