Essential Factors of a Rational Policy on Intoxicant Use

Abstract

We have outlined the elements of a social policy that could deal effectively with the drug problem. These elements include (1) treating drug abusers in areas other than just their drug abuse; (2) providing more accurate information in drug education programs; (3) providing a series of symbolic but genuine gestures that indicate our society is willing to make real changes; and (4) coordinating these measures with more pragmatic and swift law enforcement. This policy would not end drug use. Nothing can do that. Neither would it be a surrender nor just a repetition of an old policy that has not worked.

Introduction

Zinberg (1974 and 1984) emphasized the importance of three variables in connection with the use of an intoxicant: the drug - the pharmacological properties of the substance itself, the set - the attitudes and personality structure of the user and the setting - the influence of the physical and social environment in which use takes place. Without knowledge of all three of these variables, we cannot identify the factors that affect the decision to use drugs, or predict either the immediate or long-term consequences of drug use on an individual.

Social setting is the least understood of the three variables. Although we have urged its inclusion in future considerations of social policy, clinical interventions and scientific research (Shaffer and Jones 1989; Zinberg 1984; Zinberg and Shaffer 1985), this plea has not been heard. The alarmed public is still thinking of drug use (as it did in the mid-sixties) as its most serious domestic problem and is not paying any attention to the social setting within which intoxicant use occurs. In this paper, we will employ the concept of social setting to develop some alternative strategies to the War on Drugs.

To begin, we briefly review the national trend of the past decade for the relatively well-off segments of society to use less drugs and alcohol. This social trend reveals the futility of the current call for a new drug war. Subsequently, we will suggest that the most important alternatives to the drug war are a greatly expanded treatment effort, more of a different kind of drug education, and more coordination in the elements of contemporary social policy.

The Drug War Paradox: Contemporary Trends

An interesting and complex paradox has developed. The use of drugs, both licit and illicit, is down overall. Cigarette consumption continues to drop Slowly. For the fourth consecutive year, more light wines and beer have been consumed than hard liquor (which had never happened before in the history of the United States and hard liquor remains at 80 proof in contrast to the 86 proof to 100 proof of just a few years ago). The age of first use of all intoxicants has been rising for ten years.(2) Marijuana use is down and for each year of the past decade the average age of heroin addicts has risen by almost a year, indicating that there are few new addicts. Cocaine and crack use also are slightly down (Johnston et al. 1988; Shaffer 1989; Shaffer and Jones 1989; University of Michigan 1989).

Here is the irony. An increasing body of evidence indicates a growing class difference in drug use, particularly in respect to cocaine and alcohol use (3) (interested readers should see Battjes and Jones 1985; Gomez and Vega 1981; Johnson and Nishi 1976; Musto 1987; Primm et al. 1981). For example, the consumption of light wines rather than hard liquor centers in the middle class and does not extend to the low-skilled working class. Similarly, the growth of employee assistance programs impacts only those with regular jobs. To get the care provided by therapy after a driving-while-intoxicated (DWI) conviction, one has to have a car.

The middle class, actually the upper-middle class, fueled the boom in cocaine use in the late seventies and early eighties. It took several years to learn that cocaine, the champagne or caviar of drugs, was powerfully destructive. The initial mild sense of well-being and enhanced performance changed after heavy, continuous use into dissociation, paranoia, sexual perversity and isolation. By the mid-eighties the members of that initial group were fleeing the drug and filling the treatment centers newly developed for them. At the same time, the use of the drug was rapidly dropping down the social scale. The consumption of crack and other more overtly intoxicating variants of cocaine quickly became associated with the South Bronx, East Los Angeles and Roxbury. It is true that the continuing residue of heroin addicts, a sizable one-half million, also comes chiefly from those same areas. At this time the cocaine drugs are the greatest problem. The qualifying phrase "at this time" is necessary for the drug scene can change with surprising swiftness. For example, the learned and comprehensive report of the National Commission on Marijuana and Drug Abuse of 1972-1973 hardly mentioned cocaine.

Thus, at the moment, when the call for an increase in the War on Drugs is at its height, including the unprecedented use of the military and urinate it looks as if these measures are to be aimed largely against a y excluded and politically under-represented group of our population. It should be added that the political representatives of these minority groups are mostly behind the war because, while the reigning cultural majority wants these intoxicant users to stop dirtying up their streets and go away, the brunt of drug-related crime, killing, and disorder is borne by their neighborhoods. Nevertheless, if this war continues to heat up, it will be more than a war on drugs. It will be a war mobilized by the reigning cultural majority, the franchised and employed, -against a minority - an essentially disenfranchised and deeply alienated segment of our society.

Alternatives to the Current Social Policy

II. a. Treatment
II. b. Education
II. c. Urinalysis, Symbolism and Policy

A rational alternative to the current drug war policy rests on twin pillars: treatment and education. The first and most important element in this alternative approach is a greatly expanded treatment system.

II. a. Treatment

Above all, we must increase treatment capacity, improve access to treatment, and train superior personnel. This group of workers will need payment at levels commensurate with their higher skill levels. This will be expensive, but it also will be cost-effective. More difficult, perhaps, will be the policy changes necessary to make access to treatment easier. These. changes require more than just the elimination of long waiting lists: they would include a variety of efforts at outreach, unheard of in a system that wants clients to start off by playing the game according to the larger society's rules. For one thing, sterile needles should be given away with the fewest possible strings attached. Data from England and the Netherlands indicate that not only does providing needles not increase use (e.g., van den Hoek et al. 1988) or seem to condone drug use, but participating in a needle-exchange program leads those people who have made this first preliminary attempt to become engaged in the larger social system and eventually seek out treatment (e.g., Buning et al. 1988; Neel 1987; van de Wijngaart 1988). The same would be true of the practice of supplying methadone on demand. Any procedure that would engage the addicts and wean them away from their resentful isolation should be encouraged. The public also must be willing to support reasonable salaries and a high level of training for personnel serving these vital functions.

Efforts to improve access to treatment should not stop with an increased treatment capacity. Active outreach is also necessary. We should be sending workers, again properly trained, onto the drug users' own turf. These outreach workers must have more to offer than the simplistic advice to "get treatment and straighten out." If society is to make a dent in this problem, these outreach workers should be able to lend a sympathetic hand if the drug users try to reenter the society - not only a society that will offer fewer harsh words, but one that will put deeds behind words by arranging special educational opportunities and job corps, physical care and rehabilitation programs. Such ideas are not new.

In 1971, the Vera Institute of Justice developed a supported work program that included many of these notions and was very successful (Vera Institute of Justice 1972). Vera recognized that, by contrast with alcoholism, which characteristically develops later in life after its sufferers have had a chance to learn some skills to which they may return, drug addiction starts early. Its sufferers have had little opportunity to acquire skills, or for that matter, to learn how to work, to be on time, or to communicate with others. The Vera program was devised to serve the client at their low level of interpersonal and vocational functioning. With what we know now, we could succeed even better in such efforts.

II. b. Education

The second element in a coherent social policy should be education. Although this would include a form of education for the person in trouble, it would also be directed at the reigning cultural majority. The majority must know about the seriousness and the perniciousness of the problem. They must hear about the terrible difficulty of struggling against addictions and must recognize that we are all addicts. Some of us have chosen a less dangerous and licit drug, such as coffee or tea (4) while others, for all sorts of social and psychological reasons, have chosen a more deadly, illicit drug with significant potential for producing physical dependence. Above all they must learn to differentiate use from abuse and put their money and their humane values to work against the latter.

Education efforts must begin to tell the truth about drugs. When current programs classify cocaine as a narcotic instead of as a stimulant, for example, they jeopardize the credibility of education and prevention programs. The truth about drugs is enough to deter most reasonable children and adults from using them. Most young people know someone who used illicit drugs and survived. They also know someone who quit on their own. When we claim that neither is possible, they tune us out.

II. c. Urinalysis, Symbolism and Policy

The drug war, the effort at zero tolerance, goes after the wrong people. Although urine testing is potentially useful in the criminal justice system, it is useful in the work place. Urinalysis only tests for 'have used" in the past, not for impairment. Not only can mandatory random urinalysis interfere with civil liberties, but it costs a fortune to pick up a few cases which usually are not the ones the system wants. If workers, including airline pilots, are impaired, supervisors can detect it if they are properly trained for this kind of detection. We would hope supervisors would also look for the other sources of severe nervous strain and debilitation, including alcohol use, which typically is not picked up by urinalysis.

To confiscate a ship, such as the notorious Monkey Business, carrying one twenty-eighth of a gram of marijuana or the oceanographic vessel from Woods Hole, yielding three joints, is chiefly a symbolic gesture and a very costly one. In part, we think, the purpose of the symbolism is to show that the war is not all class warfare, though here again the relative bulk and easy detection of marijuana make it a ready scapegoat. It probably would be worthwhile, as the education of the majority proceeds, to make symbolic gestures in the other direction to indicate that the majority wants to make sense of the issue, be humane, and recognize human rights, without opening the flood gates by adopting legalization. For example, it has now been shown that in the states that have decriminalized (not legalized) the use of marijuana, such as Oregon and California, the patterns of use, including its current reduction, are the same as in those states that have not decriminalized use. Why not, then, enact a federal decriminalization statute that includes a provision for a careful study of the effects of this change in policy? It would not be a cheap project, but it would be cheaper than current law enforcement prosecution for simple possession and use. In a decade there might be solid information that would make it easier for Mr. and Ms. Citizen to decide what would be the best option.

What is the alternative? If Congress,, in its wisdom, approves the use of the military for operations against the crack gangs, will we have soldiers in flack jackets marching into the South Bronx? One participant in a media program has already wondered what would happen if the Air Force shot down by mistake the first dentist who commuted in his own plane between his offices in Miami and Palm Beach and had his radio off at the wrong moment. At least it is worthwhile trying to find other, less warlike ways to attack the problem.

Coordinating Law Enforcement and Treatment Efforts

The alternative approaches described above do not exclude law enforcement efforts. Both James 0. Wilson (1968) and John Kaplan (1983) have emphasized the capacity of law enforcement to re-engage people with the social system when enforcement is fair, swift and effective. The substantial percentage of arrests for other than drug-related crimes in which heroin, cocaine, and occasionally PCP (in the District of Columbia and Los Angeles) have been found in the urine indicates a high level of interaction between the use of these drugs (and alcohol) and the commission of other crimes. The interaction itself is no surprise, but the high rates - seventy-two percent District of Columbia, sixty-eight percent in New York, and sixty-seven percent in Los Angeles, for an overall average in the large cities of seventy percent are greater than imagined. The so-called J-curve, which shows that a small percentage of the users of any health care system use an enormous amount of the services, is likely to operate here too. A small percentage of people will commit a high percentage of the crimes. Assuming that regular urine testing is legal it would have a place during pre-trial periods and certainly during any probationary period. Years ago George Vaillant, in his studies of people released from U.S. Public Health Service hospitals concluded that enforced parole is the best way to keep people in treatment (Vaillant l966a 1966b and 1966c). John Kaplan (1983), noting the over-crowding and the poor record of the penal system, suggests short but sure incarcerations following a dirty urine.

In fact, an approach that emphasizes coerced abstinence is not so different from treatment as it might sound. Methadone, for example, acts as a form of coercion in methadone maintenance, and the drug-free program are well known for their heavy-handed. approach to constituents. In an odd way, coercion in the treatment of drug abusers makes theoretical sense, even though it does not in most other treatment situations. In contrast to alcohol users, who can get their drug anywhere, illicit drug abusers take a certain pride in their ability to hustle, survive and keep up their habit on the street. They cohere around what Erik Erikson (1959) calls a "negative identity," and whatever self-esteem they can muster is invested in this antisocial know-how. As mentioned earlier, this source of self-esteem often prevents them from tamely submitting to the dictates of the reigning cultural outlook. They hate to admit that they can't or don't want to "hack it on the street" any more; they view giving in and asking for "help" as weakness or degradation. They save face by entering treatment under duress. "I wouldn't be here if I didn't have to" allows the program person to respond, "Of course not, but as long as you're stuck here, let's see what we can do." Such a stance works in the criminal justice system as well, but it requires greater effort.

In sum, more humane and rational alternatives are indeed available to drug wars that have failed repeatedly. Drug war alternatives rest upon an improved understanding of the social setting factors that influence patterns of drug use and abuse. These social factors also influence the implementation and effectiveness of social policies. As a result, it is time to educate both drug users and abstainers so that they can coordinate efforts to minimize the adverse consequences that can result from drug abuse and addictive behavior.

Notes

1. This article was revised in part, from Norman E. Zinberg's 4 August 1988 testimony which can be found in the Congressional Record, 134 (115): S10825S10827.
2. It was the drop in age of first use in the early seventies that caused the greatest concern and led to the formation of the parents' movement.
3. This has always been true of heroin. 
4. Coffee, tea and many soft drinks hold the potential for producing addictive behaviors that are as difficult to stop as those stimulated by illicit drug abuse. Interested readers should see Gilliland and Bullock (1984) and Greden (1981) for more comprehensive information about caffeine addiction.

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