Drug abuse and dependence
The term drug abuse most often refers to the use of a drug with such frequency that it causes physical or mental harm to the user or impairs social functioning. Although the term seems to imply that users abuse the drugs they take, in fact, it is themselves or others they abuse by using drugs.
Traditionally, the term drug abuse referred to the use of any drug prohibited by law, regardless of whether it was actually harmful or not. This meant that any use of marijuana, for example, even if it occurred only once in a while, would constitute abuse, while the same level of alcohol consumption would not. In 1973 the National Commission on Marihuana and Drug Abuse declared that this definition was illogical. The term abuse, the commission stated, "has no functional utility and has become no more than an arbitrary code word for that drug presently considered wrong." As a result, this definition fell into disuse.
The term drug is commonly associated with substances that may be purchased legally by prescription for medical use, such as penicillin, which is almost never abused, and Valium, which is frequently abused, or illegal substances, such as angel dust, which are taken for the purpose of getting high, or intoxicated, but actually have no medical use. Other substances that may be purchased legally and are commonly abused include alcohol (see alcoholism) and nicotine, contained in tobacco cigarettes. In addition, in recent years, chemists working in illegal, clandestine laboratories have developed new chemicals that have been used for the purpose of getting high. (These are called "designer drugs".) All of these substances are psychoactive. Such substancesÑlegal and illegalÑinfluence or alter the workings of the mind; they affect moods, emotions, feelings, and thinking processes.
Drug Dependence
Drug abuse must be distinguished from drug dependence. Drug dependence, formerly called drug addiction, is defined by three basic characteristics. First, users continue to take a drug over an extended period of time. Just how long this period is depends on the drug and the user. Second, users find it difficult to stop using the drug. They seem powerless to quit. Users take extraordinary and often harmful measures to continue using the drug. How dependency-producing a drug is can be measured by how much users go through to continue taking it. Third, if users stop taking their drugÑif their supply of the drug is cut off, or if they are forced to quit for any reasonÑthey will undergo painful physical or mental distress. The experience of withdrawal symptoms distress, called the withdrawal syndrome, is a sure sign that a drug is dependency-producing and that a given user is dependent on a particular drug. Drug dependence may lead to drug abuseÑespecially of illegal drugs.
Psychoactive, or mind-altering, substances are found the world over. The coca plant grows in the Andes of South America and contains 1 to 2 percent cocaine. The marijuana plant, Cannabis sativa, contains a group of chemicals called tetrahydrocannabinol, or THC. This plant grows wild in most countries, including the United States. The opium poppy is the source for opium, morphine, heroin, and codeine. It grows in the Middle East and the Far East. Hallucinogens (such as LSD), the amphetamines (speed), and sedatives, such as methaqualone (Quaalude, or ludes) and barbiturates, are manufactured in clandestine laboratories worldwide. As a result, psychoactive drugs are used for the purpose of intoxication practically everywhere (see drug trafficking).
Classification of Psychoactive Drugs
Pharmacologists, who study the effects of drugs, classify psychoactive drugs according to what they do to those who take them. Drugs that speed up signals passing through the nervous system, which is made up of the brain and spinal cord, and produce alertness and arousal and, in higher doses, excitability, and inhibit fatigue and sleep, are called stimulants. They include the amphetamines, cocaine, caffeine, and nicotine. Drugs that retard, slow down, or depress signals passing through the central nervous system and produce relaxation, a lowering of anxiety, and, at higher doses, drowsiness and sleep, are called depressants. They include sedatives, such as barbiturates, methaqualone, and alcohol, and tranquilizers, such as Valium. Constituting one distinct kind of depressants are those which dull the mind's perception of pain and in medicine are used as painkillers, or analgesics. These drugs are called narcotics. They include heroin, morphine, opium, and codeine. In addition to their painkilling properties, these depressants also produce a strong high and are intensely dependency-producing. Some drugs cannot be placed neatly in this stimulant-depressant spectrum. Hallucinogens include LSD, mescaline, and psilocybin. Such drugs produce unusual mental states, such as psychedelic visions. Marijuana is generally regarded as not belonging to any of these categories but as a drug type unto itself.
History of Drug Abuse in the United States
During the 19th century there were virtually no controls on the importation, sale, purchase, possession, or use of psychoactive drugs at the federal level and very few at the state level. Dangerous substances such as opium, cocaine, and morphine were basic ingredients in patent medicines that could be purchased by anyone for any reason, without a prescription. These nostrums were used to cure headaches, toothaches, depression, nervousness, alcoholism, menstrual crampsÑin fact, practically every human ailment.
As a result of the ready availability of addicting drugs, and as a ...
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History of Drug Abuse in the United States
During the 19th century there were virtually no controls on the importation, sale, purchase, possession, or use of psychoactive drugs at the federal level and very few at the state level. Dangerous substances such as opium, cocaine, and morphine were basic ingredients in patent medicines that could be purchased by anyone for any reason, without a prescription. These nostrums were used to cure headaches, toothaches, depression, nervousness, alcoholism, menstrual crampsÑin fact, practically every human ailment.
As a result of the ready availability of addicting drugs, and as a result of their heavy use for medical problems, many individuals became addicted to the narcotics contained in these patent medicines. In fact, in 1900, there were more narcotics addicts, proportionate to the population, than there are today. At that time, most of the users who became addicts were medical addicts. Very few abusers took drugs for "recreational" purposes. In 1914, in an effort to curb the indiscriminate use of narcotics, the federal government passed the Harrison Act, making it illegal to obtain a narcotic drug without a prescription. During the 1920s the Supreme Court of the United States ruled that maintaining addicts on narcotic drugs, even by prescription, was in violation of the Harrison Act. Approximately 30,000 physicians were arrested during this period for dispensing narcotics, and some 3,000 actually served prison sentences. Consequently, doctors all but abandoned the treatment of addicts for nearly half a century in the United States.
The use of narcotic drugs dropped sharply in the United States between the 1920s, when there were as many as half a million addicts, and 1945, when the addict population was roughly 40,000 to 50,000. The recreational use of other drugs, such as marijuana, cocaine, stimulants, hallucinogens, and sedatives, which are used so frequently today, also remained at extremely low levels during this period. The 1960s, however, was a watershed decade. The widening use of illegal drugs accompanied increased tolerance for a wide range of unconventional behavior. The period saw the growth of movements that stood in opposition to the Vietnam War and to mainstream American culture, the coming into popularity of rock music, and enormous publicity devoted to drugs, their users and proselytizers. During this time some social groups viewed drug use in positive terms and believed it a virtue to "turn on" someone who did not use drugs. Although media attention to drugs and drug use declined between the late 1960s and late 1970s, the use of drugs did not. The late 1970s and 1980s represent another turning point in the recreational use of marijuana, hallucinogens, sedatives, and amphetamines. Studies show a large drop in the use of most drug types through the 1980s, but a significant increase since 1990.
The 1980s witnessed the development of a new form of an old drug (crack), the widespread use of a drug that was not previously taken on a recreational basis ("Ecstasy," or MDMA), and the resurgence of a drug that was widely abused in the 1960s but then fell into disuse for a time (methamphetamine, or "ice"). Crack is a smokable derivative of cocaine that began to be used on a widespread basis starting in 1985; heavily abused in the inner cities in the late 1980s, it has since fallen off in use. Chemically related to amphetamines, MDMA was developed early in the 20th century as an appetite suppressant; it is not easily classified, although most observers regard it as a hallucinogen. In the 1980s it had a brief vogue among college students, intellectuals, and psychiatric patients seeking spiritual and therapeutic insight; its use has declined into the 1990s. Methamphetamine had a brief run among "speed freaks" in the late 1960s, who took huge intravenous doses on a compulsive, addicting basis. In 1989 "ice" emerged on the West Coast as a drug of choice. Its use has been far greater in some areas than others, and no national epidemic of methamphetamine abuse has developed.
Patterns of Drug Use
The illegal use of psychoactive drugs is extensive in the United States. Some 78 million Americans age 12 and over have tried at least one or more prohibited drugs for the purpose of getting high. The illegal drug trade represents an enormous economic enterprise, with annual gross sales estimated to be $40 to $100 billionÑmore than the total net sales of the largest U.S. corporation. About 60 percent of the illegal drugs sold worldwide end up in the United States.
By far the most commonly used illegal drug is marijuana. Roughly half of the total of all illegal drug use involves marijuana alone. There was a substantial decline in all measures or levels of marijuana use throughout the 1980s. In 1979, 31% of 12-to-17-year-olds and 68% of 18-to-25-year-olds had at least tried marijuana; by 1990 the comparable figures had shrunk to 15% and 52%. Since 1990 the use of marijuana has risen significantly, especially among schoolchildren. In 1990, 27% of high school seniors had used marijuana during the past year, while in 1996 this was 36 percent; the rise among eighth- and tenth-graders was even sharper. Cocaine is the second most commonly used illegal drug in the United States. In 1995 there were roughly 1.5 million monthly or more cocaine users in the United States, a decline from 5.7 million in 1985. Heroin is less widely used, but it has been used at least once by roughly one American in 100.
Most people who have taken illegal drugs have done so on an experimental basis. They typically try the drug once to a dozen times and then cease using it. Of all illegal drugs, marijuana is the one users are most likely to continue using. Discontinuation rates are very high for drugs such as methaqualone, sedatives, barbiturates, heroin, and LSD. Even most regular users of illegal drugs are moderate in their use. The typical regular marijuana smoker is an occasional user. Still, a sizable minority does use the drug frequently, to the point of abuse. In 1996 about 5% of all high school seniors used marijuana daily or nearly daily (20 or more times in 30 days). A pattern of episodic, regular use characterizes nearly all drug use for the purpose of recreation. This does not deny the problem of the heavy, chronic abuser of these drugs.
Drug Law Enforcement
In 1970 the Congress of the United States passed the Comprehensive Drug Abuse Prevention and Control Act (Drug Control Act). Most of the states followed suit, basing their state legislation on the federal model. The Drug Control Act distinguishes among several categories of drugs based on their supposed abuse potential and medical utility. Drugs that supposedly have a high potential for abuse and no currently accepted medical use, including heroin, LSD and the other hallucinogens, and marijuana, may be used legally only in federally approved scientific research. In roughly half of the states, marijuana has been approved for medical use, but it remains illegal by federal law. In practice, the criminal justice system distinguishes between "hard" and "soft" drugs; it is unlikely that a first-time offender arrested for small-quantity marijuana possession will ever serve a prison sentence.
Drugs such as morphine, cocaine, the amphetamines, and short-acting barbiturates are also regarded as having great abuse potential, even though they have accepted uses in medicine. Rigid prescription procedures maintain extremely tight controls over use. Drugs such as long-acting barbiturates and nonnarcotic painkillers are considered to have a lesser abuse potential, although they may lead to low physical dependence or high psychological dependence. These drugs have more relaxed controls, as do tranquilizers, and are classified as having low abuse potential. There has been a notable drop in the number of prescriptions written for psychoactive drugs that were most often abused in the 1960s and early 1970s. By the mid-1990s the number of prescriptions written for barbiturates and the amphetamines was one-tenth of what it was in 1970. Many other countries have also placed severe restrictions on the prescribing of drugs by doctors and have thus greatly reduced the frequency of their abuse.
Restricting psychoactive pharmaceuticals brought about a reduction in the number of legal prescriptions written for them. A decline in the illegal street use of these same drugs lagged a few years behind the decline in legal prescriptions. In 1975, 11% of high school seniors said that they had taken barbiturates for nonmedical purposes during the previous year; in 1996, that figure was 5%. For methaqualone, completely outlawed in 1985, the comparable figures were 5% and 1%. The illegal use of amphetamine in the mid-1990s is half of what it was in the late 1970s and early 1980s. However, many forms of nonmedical drug use among the young have risen since the early 1990s.
The demand for drugs for illegal purposes remains high despite law-enforcement efforts. In 1996 there were about 1.5 million arrests on drug violations in the United States; drug arrests have nearly doubled over the past decade. Each year there are roughly 300,000 arrests on marijuana charges, and nearly 80% are for simple possession. The risk of arrest does not deter substantial numbers of Americans from selling and using illegal drugs.
Treatment
From the 1920s until the 1960s treatment for drug abuse in the United States was practically nonexistent. Following the enforcement of the Harrison Act during the 1920s, few physicians were willing to treat addicts. During the 1930s two Public Health Service prison hospitals were opened, but their patients had a relapse rate of roughly 80%; during the 1970s the federal government closed them down. Since the 1920s the primary treatment program for most addicts has been no treatment at all; until recently, arrest has simply resulted in incarceration and therefore forcible detoxification. The dramatic explosion in the use and abuse of a number of illegal drugs during the 1960s demonstrated the weakness of this approach. As a result, a range of treatment programs, developed largely in the 1960s, have been widely used.
Methadone is an addictive synthetic narcotic used to combat narcotic addiction. A hospital or a clinic administers the drug, usually dissolved in artificial orange juice drink. Taken this way, the addict does not get high. Methadone blocks the action of narcotics so that addicts cannot become high, even if they were to inject heroin. According to the program's rationale, addicts will then stop taking heroin. Although patients remain addicted to methadone, they can live a normal life, since the drug supply is steady and secure. Plus, they are no longer exposed to health risks like AIDS and hepatitis from shared needles used for injecting drugs. Because the program is inexpensive to administer, methadone has become a very popular form of treatment; roughly 100,000 narcotic addicts in the United States are treated in this program.
The drug naltrexone has been approved by the U.S. Food and Drug Administration for treating alcoholism and heroin addiction, in concert with an appropriate counseling program. Naltrexone reduces cravings for alcohol and heroin, thereby decreasing relapse rates.
Therapeutic communities (TCs), such as Daytop Village in New York and Walden House in San Francisco, advocate a completely drug- and alcohol-free existence. Addicts live in the therapeutic communities, and many of the administrators are ex-addicts, who can best understand the addict residents. The view of all TCs is that the addict uses drugs as a crutch. TCs attempt to resocialize the addict by inculcating a value system that is the opposite of what prevailed on the street. Discipline in therapeutic communities is strict, penalties for breaking rules are severe, peer pressure is unrelenting, and the program benevolently dictatorial. Because of the strictness, many residents leave against the advice, and without the permission, of the staff. TCs seem to be effective for a limited segment of the addict populationÑthose who are young, middle-class, and highly motivated to quit drugs. The programs are expensive to administer; there are far fewer patients in them than in methadone-maintenance programs.
The Legalization Debate
In the 1990s there has been a strong call among some experts, politicians, judges, and government officials for the removal of all criminal penalties for the sale, possession, and use of illegal drugs. This development has taken place at a time when public opposition to such a policy has actually grown. The legalization or decriminalization program rests on three assumptions: drug abuse will not rise significantly under legalization; these illegal drugs are less harmful than the legal drugs alcohol and tobacco and are less harmful than generally believed; and the current policy of arresting and imprisoning for drug possession and sale does more harm than good.
No one can know for sure whether drug use and abuse will rise, fall, or remain stable under legalization. In nine U.S. states and in the Netherlands, where small-quantity marijuana possession has been partially decriminalized, there has been no sharp rise in the use of this drug. Evidence suggests, however, that criminalization of some drugs has produced lower use and abuse, and that legalization, if accompanied by lower cost and ready availability, might result in a significant rise in use and abuse. For example, legal controls on certain prescription drugs has been followed by a decline in their illegal street use. In addition, the continuance rates of the legal drugs alcohol and tobacco are strikingly higher than for illegal drugs. For the most part, the use of the illegal drugs tends to be more sporadic and occasional, and more likely to be given up, than the use of legal drugs. In the United States, outlawing the sale of alcohol to persons under the age of 21 has produced a significant decline in its use, as well as in the number of alcohol-related fatalities in this age group.
Many current users, abusers, and addicts state that they would take drugs more frequently if drugs were legalized and readily available. And contrary to the stereotype, evidence suggests that, during prohibition (1920-33), alcohol consumption dropped significantly. There is much information to indicate that the abuse of drugs might very well rise under a policy of legalization or decriminalization.
The prolegalization groups are almost certainly right that crime and certain medical maladies among drug abusers would decline if drugs were legalized. Perhaps a "third path" somewhere between the current punitive policy and full legalization would be most effective. Needle exchange programs have cut down on drug-related AIDS transmission in Liverpool, England. The Dutch policy of de facto decriminalization for marijuana and hashish has not resulted in a rise in use or abuse. Perhaps the guiding policy on drug use ought to be on harm reduction rather than waging a war on drug abuse. Some aspects of this policy should include a flexible or selective enforcement, vastly expanding drug treatment programs, needle exchange programs, a distinction between "hard" (cocaine and heroin) and "soft" drugs (marijuana), expanding antidrug educational efforts, and focusing on reducing the use and abuse of tobacco and alcohol. The first priority should be to make sure that the users and abusers harm themselves and others as little as possible.
