Technologies for Understanding and

Preventing Substance Abuse and Addiction

September 1994

OTA-EHR-597

NTIS order #PB95-109625

GPO stock #052-003-01388-6
Recommended Citation: U.S. Congress, Office of Technology Assessment, Technologies

for Understanding and Preventing Substance Abuse and Addiction, OTA-EHR-597

(Washington, DC: U.S. Government Printing Office, September 1994).

For sale by the (U. S. Government Printing Office

Supcrintendent of Documents, MaiI Stop: SSOP.. Washington, DC 20402- 9328

ISBN 0-16 -045198-1
Foreword

s

ubstance abuse and addiction are major problems in the United States,

resulting in lost human potential, increased health costs, violent behavior, crime, lost productivity, and premature deaths. Substance abuse and

addiction are not confined to one, or even a few, subpopulations. The

complex interactions of biochemical, physiological, psychological, and sociological factors leading to substance abuse and addiction are incompletely understood, and reports of success in reducing illegal drug abuse and addiction

are often contradicted by reports of failure.

This report has four parts. The first part, Necessary Preconditions, focuses

on several factors that are necessary for substance abuse and addiction to occur, including an examination of the biological research regarding the phenomenon of addiction to a variety of substances. The second part, Individual

Factors, describes individual risk and protective factors that contribute to the

abuse of, and addiction to, alcohol and drugs. The third part, Community Contexts, looks at how risk and protective factors play out in subcultures and in

major activity settings (home, school, workplace, and recreation), and assesses

the effectiveness of various substance abuse prevention initiatives. The fourth

section, Policy Options, addresses a range of legislative issues and options for

Congress arising from an understanding of the factors leading to substance

abuse and addiction.

The request for this report came from the House Committee on Government

Operations, the Senate Committee on Labor and Human Resources, and the

Senate Committee on Governmental Affairs. Numerous individuals, including

an advisory panel chaired by Patricia Evans, assisted the Office of Technology

Assessment (OTA) in the development of this report. OTA gratefully acknowledges the contribution of each of these individuals. OTA also acknowledges

and thanks the Strong Museum in Rochester, New York, for providing OTA

with access and reproduction rights to graphics from their exhibit entitled Altered States: Alcohol and Other Drugs in America. As with all OTA reports, the

final responsibility for the content of the report rests with OTA.

ROGER C. HERDMAN

Director
Advisory Panel

Patricia E. Evans

Chair

Bayview–Hunter’s Point

Foundation

San Francisco, CA

Marilyn Aguirre-Molina

Robert Wood Johnson Medical

School

Piscataway, NJ

Jeffrey G. Becker

The Beer Institute

Washington, DC

Lawrence S. Brown, Jr.

Harlem Hospital/College of

Physicians and Surgeons

Columbia University

New York, NY

Mary Edwards

Camden House

Detroit, MI

Bernard Ellis, Jr.

Consultant

Santa Fe, TN

Robbie M. Jackman

State of Tennessee

Department of Public Health

Nashville, TN

Sheppard Kellam

School of Hygiene and Public

Health

The Johns Hopkins University

Baltimore, MD

Herbert Kleber

College of Physicians and

Surgeons

Columbia University

New York, NY

George F. Koob

Department of

Neuropharmacology

The Scripps Research Institute

La Jolla, CA

Mary Jeanne Kreek

Department of Biology and

Addictive Diseases

The Rockefeller University

New York, NY

John Lucas

John Lucas Enterprises

Houston, TX

Spero Manson

National Center for American

Indian and Alaska Native Mental

Health Research

University Health Science Center

Roger Meyer

George Washington University

Medical School

Washington, DC

David F. Musto

Child Studies Center

Yale University

New Haven, CT

Ruben Ortega

Police Chief

Salt Lake City, UT

Sue Rusche

National Families in Action

Atlanta, GA

Lawrence Wallack

School of Public Health

University of California, Berkeley

Berkeley, CA

Kenneth E. Warner

School of Public Health

University of Michigan

Ann Arbor, MI

Roger Wilkins

George Mason University

Fairfax, VA

Denver, CO

Note: OTA appreciates and is grateful for the valuable assistance and thoughtful critiques provided by the advisory panel members.

The panel does not, however, necessarily approve, disapprove, or endorse this report. OTA assumes full responsibility for the report

and the accuracy of its contents.

iv
——

Clyde Behney

Assistant Director

OTA Health, Life Sciences, and

Environment

Denise Doughertyl

Program Director

OTA Education and Human

Resources Program

Nancy Carson*

Program Director

OTA Education and Human

Resources Program

Michael Gough3

Program Manager

OTA Biological and Behavioral

Sciences Program

PRINCIPAL STAFF

Kevin W. O’Connor

Project Director

David Liskowsky4

Senior Analyst

Ellen McDermott

Research Analyst

Jennifer Schmidt5

Analyst

Thomas Vischi6

Morris Udall Congressional

Fellow

ADMINISTRATIVE STAFF

Cecile Parker

Office Administrator

Jene Lewis

Administrative Secretary

Linda Rayford

PC Specialist

Madeleine Gross

Contractor

Project Staff

Publishing STAFF

Mary Lou Higgs

Manager, Publishing Services

Cheryl Davis

Electronic Publishing Specialist

Susan Hoffmeyer

Graphic Designer

Chip Moore

Production Editor

OTA STAFF

ACKNOWLEDGMENTS

Patricia Durana

Gerard Fergerson

Peter Johnson

Gail Kouril

Deborah McCurry

Robyn Nishimi

‘Since July 1994.

2March-July 1994.

3Until March 1994.

4Until December 1992.

5

July 1992-December 1993.

6August 1992-November 1993.

v
contractors

Sema Aydede

Istanbul, Turkey

Frank Baker

Baltimore, MD

Carter Blakey

Editor

Bethesda, MD

Brenna H. Bry

Rutgers University, NJ

Center for Youth Development

and Policy Research

Washington, D.C.

Theodore J. Cicero

Washington University School of

Medicine

Stephen H. Dinwiddie

Jewish Hospital of St. Louis

Chris Hansen

Olympia, WA

William B. Hansen

Bowman Gray School of

Medicine

Wake Forest University, NC

Stephanie Lin

Cupertino, CA

David Liskowsky

Arlington, VA

Alan Lozier

Stanford, CA

William J. McBride

Indiana University School of

Medicine

The National Center for Juvenile

Justice

Pittsburgh, PA

Mitchell S. Ratner

TIGER Research

Takoma Park, MD

Theodore Reich

Jewish Hospital of St. Louis

Janice Roehl

Institute for Social Analysis

Pacific Grove, CA

The Urban Institute

Washington, D.C.

George Woody

Philadelphia Veterans

Administration Medical Center

and University of Pennsylvania

vi
1

2

Executive Summary 1

Root Causes 1

Necessary Preconditions 2

Individual Factors 9

Community Contexts 15

policy Options 18

Introduction 23

Root Causes 25

What Are Substance Abuse and Addiction? 25

Magnitude of the Problem 34

Measuring Substance Use and Abuse 35

Organization and Scope of the Report 38

Part 1: Necessary Preconditions 41

3 Biology and Pharmacology 43

Drug Action 44

Genetic Factors 50

Role of Learning 55

Summary 55

4 Availability 57

Availability 57

Are Drugs Readily Available? 62

Marketing 63

Summary 69

5 Substance Use and Transitions to Abuse

and Addiction 71

Substance Use 72

Stages in the Initiation of Use 74

Stages in the Cycle of Use, Abuse, and Addiction 76

Stages in Problem Behaviors 77

Key Aspects of Use 78

Summary 80

contents

I 1

I I

vii
Part II: Individual Factors 81

6 Individual Risk and Protective Factors 83

Demographics 65

Economics 105

Psychosocial/Behavioral 110

Summary 118

Part Ill: Activity Settings 119

7

8

9

Ethnographic Drug Studies 121

Ethnographic Studies of Alcohol and Other Drug

Use 121

Social Context of Drug Use 125

Poverty, Racism, and Cycle of Abuse 129

Future Research 132

Summary 133

Community Activity Settings 135

Homes and Families 137

Schools and Peers 145

Workplaces 153

Recreational Settings 157

Planning, Implementing, and Evaluating

Community-wide Programs 161

Summary 163

Policy Options 165

Federal Focus and Prevention Program Structure 166

Research Needs 170

Community Activity Settings 172

Availability 175

. . . Vlll
APPENDICES

A Drug Control Policy in the United States:

Historical Perspectives 177

B Federal Programs: Prevention and

Causation 164

C Perspectives on Defining Substance

Abuse 194

D List of Contracts 200

E List of Workshops and Participants 202

F Acknowledgments 206

G References 210

INDEX 236
Executive

Summary 1

T

he abuse of licit and illicit drugs represents a major public

health problem in the United States. The costs to society

of such abuse include thousands of premature deaths

annually due to drug-related illnesses, accidents, and

homicides; economic costs related to health care, criminal justice,

and lost productivity; and the mental and physical pain suffered

by millions of Americans. Many ills plaguing the nation today—

including the AIDS epidemic, increased crime and violence, and

homelessness—in some cases, may be linked to individuals’

physical dependence on a variety of abusable substances. The

consequences of substance abuse and addiction have been felt by

people within every economic, social, racial, religious, and politi -

cal boundary.

What are the root causes of substance abuse and addiction?

Why and how does addiction occur? Who are the substance abusers? What factors lead to addiction? What are the implications for

prevention and treatment?

ROOT CAUSES

The Office of Technology Assessment (OTA) was asked to identify the root causes of substance abuse and addiction. The term root

causes has been used in political discussions and debate. To

some, root causes of substance abuse and addiction are framed in

a moral context, in which decisions related to use, abuse, and addiction are the responsibility primarily of individuals. To others,

root causes include a multitude of social and economic problems,

such as homelessness, poverty, and racism. Many people have

strongly held opinions as to what constitutes the general root

A

.-

. . . . -. : :.:.:..

p~/~,

f

causes of substance abuse and addiction in populations, but no

II
2 I Technologies for Understanding and Preventing Substance Abuse and Addiction

consensus exists about the specific root causes of

substance abuse and addiction for particular individuals.

The OTA report has four parts: necessary preconditions, individual factors, community contexts, and policy options. The first part, Necessary

Preconditions, focuses on several factors that are

necessary for substance abuse and addiction to occur. The second part, Individual Factors, focuses

on risk and protective factors in individuals that

are thought to influence substance use, abuse, and

addiction. The third part, Community Contexts,

looks at how risk and protective factors play out

in subcultures and in major activity settings

(home, school, workplace, and recreation). The

fourth part, Policy Options addresses a range of

legislative issues and options for Congress.

NECESSARY PRECONDITIONS

No single or general set of variables explains

the misuse of alcohol and other drugs for every

individual; in other words there are no “root

causes” for substance abuse that universally

apply to everyone. Nevertheless, OTA has

identified three major sets of necessary preconditions that must be present in order for

substance abuse and addiction to occur:

■ biology and pharmacology,

~ availability, and

● use and transitions to abuse and dependency.

9 Biology and Pharmacology

The first major set of preconditions includes biological and pharmacological factors, without

which drug abuse and dependency would be impossible. Underlying all alcohol and drug problems are the actions and effects that drugs of abuse

exert on the brain. It is important to understand

how drugs work in the brain, why certain drugs

have the potential for being abused, and what, if

any, biological differences exist among individuals in their susceptibility to abuse drugs.

A wide range of psychoactive substances have

the potential for abuse (see box 1-1 ). The possession and use of several substances (e.g., marijuana, heroin, cocaine) are illegal in all 50 states.

Other addictive substances (e.g., tobacco and alcohol) may be legally purchased, possessed, and

consumed by many Americans. Some abusable

substances (e.g., a wide range of prescription

drugs) are available on a restricted basis, usually

by a physician’s order, while others (e.g., inhalants) may be legally purchased, possessed, and

consumed by anybody.

Biological factors that contribute to substance

abuse and addiction fall into two groups: the effects drugs of abuse exert on the individual in general, and the biological status of specific

individuals taking drugs. The effects the drugs

exert can be either acute or chronic and will vary

depending on the drug and its route of administration. Most drugs of abuse influence the brain’s reward system. The pleasurable sensations that drug

use can produce reinforce drug-seeking and drugtaking behaviors. These actions differ with different drugs; thus, some substances have greater

potential for abuse and addiction than others.

While growing evidence suggests that the brain

reward system plays a role in the reinforcing properties of most drugs of abuse, the precise mechanisms involved are complex and have yet to be

completely described (see figures 1-1 and 1-2).

Prolonged or chronic use of a substance or substances can produce both biological and behavioral changes (some long-lasting). Biological

changes can include sensitization and/or tolerance

to a substance and, if use is discontinued, withdrawal (see box 1-2). Behavioral changes also occur with continued drug use. An individual’s

drug-craving, drug-seeking, and drug-taking behaviors are reinforced through neuroadaptive

changes in the brain’s reward system.

Environmental cues also play a large role in

drug-seeking and drug-taking behavior. On encountering certain environmental stimuli (i.e.,

specific locations, smells, tastes), drug-craving

and drug withdrawal symptoms have been reported by former drug users who have been drugfree for months and even years.
Chapter 1 Executive Summary 13

Class of psychoactive substance

Description b

Examples

ALCOHOL (ethyl alcohol)

Alcohol, one of the most widely used of all drugs, is a

central nervous system depressant with effects similar to

those of sedatwe-hypnohc compounds (see below), At low

doses, alcohol may be associated with behavioral

excltahon thought to be due to the depression of inhibitory

neurons In the brain Alcohol differs from

sedatwe-hypnotic compounds in that it is used primarily

for recreation or social rather than medical purposes

SEDATIVES, HYPNOTICS, OR ANXIOLYTICS

Sedatwe-hypnotics are drugs of diverse chemical

structure that exert a nonselective general depressant on

the central nervous system In addltlon, they reduce

metabolism in a variety of tissues in the body, depressing

any system that uses energy. Depending on the dose, any

sedative hypnotic compound may be classified as a

sedatwe (an agent that allays excitement), a tranquilizer

(an antianxiety agent), a hypnotic (a sleep-inducing

agent), or an anesthetic (an agent that eliminates pain),

Sedatwe-hypnotics are used medically as sedatives,

anxlolytlcs (antianxiety agents), hypnotics, antiepileptics,

muscle relaxants, and general anesthetics.

CANNABIS (THC)

THC (tetrahydrocannabinol) the active agent in marijuana,

alters perceptions, concentration, emotions, and behavior,

though the mechanisms of action are not entirely clear

Researchers have found, however, that THC changes the

way in which sensory Information is processed by the

brain It can be used medically to relieve nausea and side

effects of chemotherapy in cancer patients, it is very rarely

used to treat glaucoma

NICOTINE

Nlcotlne, obtained naturally from tobacco, is a central

nervous system stimulant, c It exerts its action secondary to

stimulation of certain cholinergic (excitatory) synapses

both wlthln the brain and in the peripheral nervous system

1.

2,

3.

1

2,

3

1.

2

3

4

1

2

Beer.

Wine.

“Hard” liquor (e g,, whiskey, gin)

Barbiturates (“downers” or “barbs”)

pentobarbital sodium[NembutalR],

secobarbital sodium ISeconalR],

amobarbital IAmytalR]-taken orally

Nonbarbiturate hypnotics:

methaqualone

IQuaaludes R

]—taken orally

Tranquilizers diazepam IJ/allumR],

chlordiazepoxide hydrochloride

ILlbrlumR]—taken orally

Marijuana (’(pot” or “grass”)-

smoked or eaten

Hashish (’(hash’’ )—smoked or

eaten

Hashish oil (((hash oil’’ )—smoked

(mixed with tobacco.

Tetrahydrocannabinol (THC)—

taken orally in capsules

Cigarettes

Smokeless tobacco (e g , snuff or

chewing tobacco)

(continued)
4 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Class of psychoactive substanc+

Desoriptionb Examples

COCAINE

Cocaine, obtained naturally from coca leaves, is a potent

central nervous system stimulant.c It stimulates the

sympathetic nervous system, which regulates the activity

of cardiac muscle, smooth muscle, and glands It also

produces bronchodilation in the lungs It is used medically

as a topical anesthetic for surgical procedures.

AMPHETAMINES AND RELATED STIMULANTSf

1

2

Amphetamines

Amphetammes are a group of three closely related

compounds, all of which are potent central nervous

system and behavioral stimulants c Some amphetamines

are used medically to treat attention deficit disorder or

minimal brain dysfunction in children, narcolepsy

(recurrent, uncontrollable, brief episodes of sleep), or

(rarely) depression.

Nonamphetamlne stimulants

Like amphetamines, nonamphetamine stimulates are

central nervous and behavioral stimulants. Some

non-amphetamine stimulants (e g., PreludinR) are used for

weight control, and some (e. g., RitalinR and CylertR) are

used medically to treat hyperactivity, minimal brain

dysfunchon, narcolepsy, or (rarely) depression

HALLUCINOGENS

Hallucinogens, or psychedelics, are a heterogeneous

group of compounds that affect a person’s perceptions,

sensations, thinking, self-awareness, and emotions. ’

1

2

1.

2

3

1

2

3.

1,

2

3

4

Cocaine hydrochloride powder

(“coke” or “street

cocaine’’ )—usually snorted or

injected intravenously. d

Cocaine alkaloid (“freebase” or

“crack’ ’)-smoked e

Amphetamine (“speed” or “uppers”

(Benzedrine R

]–taken orally,

injected, or snorted, g

Methamphetamine (“speed” or

“crystal meth” or “ice”)

[Methadrine R

]—taken orally,

injected, or snorted, g’ h

Dextroamphetamine

[DexedrineR

]—taken orally, or

injected.

Pheumetrazine hydrochloride

IPreludin R

]–taken orally or

injected,d

Methylphenidate hydrochloride

injected d

Pemoline ICylertR]—taken orally.

IRitalin R

]—taken orally, or

injected, d

LSD (lysergic acid diethylamide) or

“acid’ ’-taken orally or put in the

eyes.

Mescaline (3,4,5 -trimethyloxphenylethyl amide) or “mesc” and

peyote-disks chewed,

swallowed, or smoked; tablets

taken orally.

Psilocybin (“magic

mushrooms’ ’)-chewed and

swallowed

MDMA (methylene

dioxymethamphetam ine)—taken

orally

(continued)
Chapterl Executive Summary 15

Class of psychoactive substanc@

Description b Examples

INHALANTS

Inhalants are chemicals that produce psychoactive

vapors Although different In makeup, nearly all of the

abused Inhalants produce effects similar to those of

anesthetics, which act to slow down the body’s

functions or produce feeltngs of dizziness At low

doses, users may feel sllghtly shmulated Amyl nitrite IS

used for heart patients because It dilates the blood

vessels and Increases blood supply to the heart There

are no medical Indlcatlons for most of the Inhalants

OPIATES (NARCOTICS) AND RELATED ANALGESICS

Opiates are natural or synthehc drugs that, Ilke

morphine, a substance derived from the opium poppy,

have analgesic (pain-reliewng) properties Heroin is not

approved for medical uses In the United States The

major medical use of other opiates IS for the rellef of

pain (I e , as analgesics), some narcotics are used to

relleve coughing (I e , as antltussives) or to treat

diarrhea Methadone IS used In the treatment of

narcotic abstinence syndromes and as an analgeslc In

terminal Illness

PCP (PHENCYCLIDINE) AND

SIMILARLY ACTING SYMPHATHOMIMETICS

Phencycyclldlne, commonly referred to as PCP, alters the

functions of the neocortex and has been called a

dlssoclatwe anesthetic It was developed In the 1950s as

an anesthetic but was subsequently taken off the market in

1967 when It was discovered that the drug caused

hallucinations In some people J PCP IS now used legally

only In veterinary medicine as an Immoblllzing agent

1

2.

3.

4

1

2

3

4,

Solvents (model airplane glue, nail

polish remover, lighter and

cleaning flulds, and

gasoline) —vapors Inhaled

Aerosols (e g , paints,

hairsprays)—vapors inhaled

Some anesthetics (e g ,nitrous

oxide) —vapors inhaled

Amyl nitrite (“snappers” or

“poppers”) and butyl nitrite

(“rush’ ’)-vapors Inhaled

Heroin (“smack” or ‘(horse”)-

Injected, smoked, or Inhaledd

Codeine (codeine sulfate) —taken

orally or Injectedd

Morphine (morphine

hydrochloride)—injected, smoked,

or inhaled.

Synthetic opiates (e g , methadone

IDolophlneR]), hydromorphone

hydrochloride IDilaudidR],

meperldme hydrochloride

IDemerolR], oxycodone and asprin

IPercodanR]—taken orally or

Injected

PCP (“angel dust” or ‘(lovely ’’)—taken

orally, or smoked (sprayed on joints

or cigarettes) d

aAccordlngto Jullen, one could concewably classlfy psychoachve drugs by at least three methods 1 ) mechamsm of action 2)

chemtcalstructure, and3) behaworal effects Probably the most useful approach would betoclasslfythem by mechanism of actton,

but knowledge of the brains physiology IS too hmlled forthls approach to be comprehenswe A Ilmtatlonof the second approach IS

that many drugs of apparently slmllar structure exert quite different effects, and many drugs of dlsslmltar structure exert quite s~mllar

effects The classlflcatlon Inthls table largely reflects the behavioral effects approach Theclasslflcatlon used here IS based on the

categories In the Amer[can Psych latrlc Assoclatlons D/agnosf/c and Statr’st/ca/ Manual of Menta/ Disorders, 3rd ed rewsed According to the American Psych latrlc Assoclahon, all of the classes of psychoactwe substances hsted m thrs box except mcotme are

associated with both abuse and dependence Nlcotme IS associated with dependence but not abuse

(continued,)

—
6 I Technologies for Understanding and Preventing Substance Abuse and Addiction

bThepOtentlal physiological, psychological, and behavioral effects of using the psychoachve substance shown are discussed

m the sources listed below The consequences depend m part on the speclflc drug used, the dosage level and mode of admmlstratlon

c Cenkr/ nervous system .sf/mu/ants are drugs that can elevate mood, increase alertness, reduce fahgue, provide a sense of

increased energy, decrease appetite, and Improve task performance They can also produce anxiety, msomma, and lrritablllfy. The

drugs ddfer widely m thew molecular structures and mechanisms of action.

d According to the American Psychlatrlc Association, the route of admimstrahon of a psychoactwe substance IS an important

variable m determmmg whether use WIII lead to dependence or abuse In general, routes of administration that produce more efflclent absorption of the substance m the blood stream (e g., intravenous injechon) tend to increase the hkelihood of an escalating

pattern of substance usesthat Ieadstodependence Routes that qulcklydeliver psychoactwe substances to the brain (e g , smokmgor intravenous InjectIon) are associated with higher Ievelsof consumption and with an increased Iikehhood of toxic effects. Use of

contaminated needles for intravenous admmlstratlon of amphetammes, cocaine, and opiates can cause hepatitis, HIV mfectlon,

and other Illnesses

‘Reebasecocaine IS a form of cocaine made by converting “street cocaine” (cocaine hydrochloride) to a punfled base that IS

smoked The effect of smokmg freebase E slmllar to that of intravenous mlection but smokmg provides a shorter more intense high

than smfhng or ingestion because of the rapid absorphon of the drug through the lungs “Crackcocaine ” IS the street name given to

freebase cocaine that has been processed from cocaine hydrochloride to a chemical base by cooking it with baking soda and

water The term crack refers to the cracking sound that is heard when the mixture w smoked (heated), presumably due to the sodum

bicarbonate

t Descrlblnga drug as a stimulant does not adequately describe Its prOpEYtlfX Drug Usesurveys typically meanamhetamlnes

when they use the word stimulants Some surveys regard asstlmulants both prescrlphon (amphetammes) andnonprescrlptlon substances (e g., caffeine-based compounds used In No-Doz, diet PIIIS, and “fake pep PIIIs”). Cocaine and mcotme (descrlbedabove)

are also central nervous system simulants

9 According to the FJatlonal Institute on Drug Abuse, desigrwdrug.s are structural analogs of substances scheduled under the

Controlled Substances Act that are prepared by underground chemists to mlmlc the psychoactwe effects of controlled substances

or produce other psychoactwe effects Because such analogs are not ldenhcal to their parent compound, thew manufacture and

dstrlbutlon does not wolate the law As of June 1986, there were synthetic analogs of PCP, fentanyl and meperldme, and amphetamine and methamphetamme.

h In the past, abuse of methamphetamme had been mtheform of tablets or intravenous mjechon More recently, “ice” (oneofthe

common street names for d-methamphetamine hydrochloride) has gained popularity m a form suitable for smoking

‘ Most of the agents m thrs class of drugs can induce hallucinations If the dose IS high enough But the term hallucinogen does not

adequately describe the range of pharmacological actions of the dwerse group of substances usually included m the class The

term psychedehc was proposed by Osmond m 1957 to Imply that these agents all have the abhty to alter the sensory percephon

and thus may be considered “mmd expanding “ The effects of hallucinogens are unpredictable and depend on the amount taken,

the users personality, mood and expectations, and the surroundings m which the drug IS used.

\ pcp IS considered a hallucinogen In some surveys of drug use

SOURCES Office of Technology Assessment, 1991, based on the following sources. American Psychlatrlc Association, DiagnosticandSfat/sf/ca/ Manua/o/Menfa/D/sordem, 3rd ed rewsed (Washington, DC 1987), R.M Jullen, A Prirnero/DrugAct/or?, 5th

ed (New York, NY W H Freeman and Co , 1988), J F Kauffman, H Shaffer, and M Burglass, “The Biological Basics Drugs and

Ther Effects, ’’A/coho/ismandSubsfanceAbuse C/mn&i/nterventiorrs (NewYork, NY” 1985), U S Department of Health and Human

Serwces, Public Health Service, Alcohol, Drug Abuse, and Mental Health Admmlstratlon, National Instltuteon Drug Abuse, “Hallucinogens and PCP, Inhalants, Marijuana, Opiates, Sedatwe-Hypnotics, Stimulants, and Cocaine,” Rockville, MD, 1983, U S Department of Health and Human Serwces, Pubhc Health Serwce, Alcohol, Drug Abuse, and Mental Health Admmwtration, National lnstltute on Drug Abuse, “Destgner Drugs, ” N/DA Capsu/es,Rockville, MD, June 1986, U S Department of Health and Human Serwces,

Pubhc Health Service, Alcohol, Drug Abuse, and Mental Health Admmwtratlon, National Institute on Drug Abuse, ‘(Marijuana Update, ” N/DA Capsu/es, Rockvllle, MD, May 1989, U S Department of Health and Human Services, Publlc Health Serwce, Alcohol,

Drug Abuse, and Mental Health Admmistrabon, National Institute on Drug Abuse, “Methamphetamme Abuse, ” N/DA Capw.des,

RockvNe, MD, January 1989, and U S Department of Education, Growing Up Drug Free A ParentS Guide to Prevent/on (Washington, DC 1989)

—
Chapter 1 Executive Summary I 7

Nerve Impulse

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/7’

Auto-

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k

receptor

m

4’4 b4 .4 ● ‘\\

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Q

4‘4 .4

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Re-uptake \

Neurotransmitters Receptors

Receiving cell

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Nerve Impulse

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—/

SOURCE Office of Technology Assessment, 1994

Through family, twin, and adoption studies,

most researchers agree that genetic factors

play some part in the acquisition of alcohol

problems and, although less clear, other drug

problems. However, no conclusive evidence

has been found to explain precisely what is inherited or the overall importance of this inherited material. It has been hypothesized that

numerous genes (as opposed to one) interact in

complex ways, and expression of those genes are

affected by a myriad of environmental factors.

Thus, the presence or absence of a genetic factor

neither ensures nor protects against drug addiction.

1 Availability

The second set of preconditions for drug abuse

and dependency includes availability. A person

cannot become a drug abuser unless a drug is

physically available. In addition, however, availability is affected by social norms (e.g., factors

SOURCE Off Ice of Technology Assessment 1994

within the community conducive to drug use, including level of parental or guardian supervision,

lack of consequences for alcohol and drug offenses, lack of alternative activities, and portrayals of alcohol and other drug use by friends and the

media as a glamorous and healthy activity), prices

(economic availability), and personal values (subjective availability) (see table 1 -1).

The primary focus of U.S. antidrug policy has

been to attack the physical availability of illicit

drugs through law enforcement efforts aimed at

disrupting the production, transport, and sale of

drugs. While this focus has increased drug-related

arrests-nearly half of newly sentenced federal

inmates in 1991 were imprisoned on drug

charges-illicit drugs are still widely available.

Marketing techniques for both licit and illicit

drugs can alter social, economic, and subjective

availability. Key components of marketing include the promotion and advertising of particular

product lines to appeal to particular subpopulations of the consuming public, development of a
8 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Tolerance to a drug develops when, following

a prolonged period of use, more of the drug is required to produce a given effect. Sensitization,

the opposite of tolerance, occurs when the effects of a given dose of a drug increase after repeated administration Dependence is a type of

neuroadaptation to drug exposure. With prolonged use of a drug, cells in the brain adapt to

Its presence such that the drug is required to

malntaln normal cell function On abrupt withdrawal of the drug, the cell behaves abnormally

and a withdrawal syndrome ensues Generally,

the withdrawal syndrome is characterized by a

series of signs and symptoms that are opposite

to those of the drug’s acute effects For example,

withdrawal of sedative drugs produce excitation

and Imitability Conversely, withdrawal of stimulants produces profound depression

SOURCE Off Ice of Technc)logy Assessment, 1994

product line that can be targeted to subpopulations

within the larger community of consumers, pricing strategies to attract new buyers, and identification of retail outlets for sales.

Federal law regulates the merchandising of licit

yet abusable substances such as tobacco, alcohol,

and prescription drugs by placing a variety of restrictions on how such products maybe marketed.

Despite current restrictions, debate continues as to

whether and how a variety of legal drugs should

be marketed.

~ Use and Transitions to Abuse and

Dependency

The third set of preconditions for drug abuse and

addiction is drug use, including the progression to

heavier and more harmful use. A person cannot

become drug-dependent without first using a drug

and then progressing to more harmful levels of

use. Researchers have focused on stages in the

progression of drug use in several ways. They

have studied stages in the initiation of the use of

Material from the ‘Just Say No” campaign

different drugs, finding a sequence that moves

from the use of cigarettes and wine or beer, to the

use of marijuana, then hard liquor, and finall y other illicit drugs. Because most individuals who use

drugs do not go on to abuse drugs, and because the

use of drugs at one level does not guarantee the use

of drugs at a higher level, these stages are descriptive but not predictive.

Initiation is the first step in the progression to

more serious levels of drug use. Because drug use

often begins during adolescence, most drug use

research has focused on drug use initiation among

adolescents. However, many individuals who initiate drug use do not progress to harmful drug use.

Also, the factors associated with such progression

may often differ from the factors associated with

initiation. Thus, the focus on the initiation of drug

use during adolescence is not sufficient for an understanding of the progression from use to abuse

and dependency.

In addition to initiation, research has focused

on other identifiable stages in the full cycle of drug

use and abuse, including continuation of drug use,

maintenance and progression of drug use within a

class of drugs, progression in drug use across drug

classes, and regression, cessation, and relapsecycles. Research has also been done on the co-
. .

Chapter 1 Executive Summary I 9

Category Primary question —

Physical availability Is a substance physically

available?

Economic availability Is the substance affordable?

Subjective availability Is the substance available in

a manner I would choose

to use?

Social availability Is the substance available in

my social setting?

SOURCE Off Ice of Technology Assessment, 1994

occurrence and possible sequences in drug abuse

and other problem behaviors, with some studies

finding that problem behaviors often precede the

onset of drug abuse.

INDIVIDUAL FACTORS

Much of the research on substance abuse and addiction has focused on identifying individual risk

factors for alcohol and other drug use, specifically y

among adolescents and young adults (see table

1 -2). Risk factors have been identified as those

cognitive, psychological, attitudinal, social, pharmacological, physiological, and developmental

characteristics that foster initiation of drug and alcohol use and/or abuse by an individual. Protective factors are those characteristics that reduce

the risk of substance use and abuse and promote

positive development, such as appropriate role

models, involvement in positive peer groups, and

a positive self-image and outlook for the future.

Because no individual risk or protective factor

can be categorized as a root cause of substance

abuse and addiction, a full analysis of each individual factor is beyond the scope of this report.

However, an overview of selected factors highlights associations often present in substance

abuse and addiction.

1 Demographic

Age

The preponderance of substance abuse research

points to the fact that children who use alcohol and

other drugs before the age of 15 have a greater

likelihood of becoming problem alcohol and

other drug users, versus those youth who begin

use at a later age.

While most substance use and abuse occur during the adolescent and young-adult years, older

persons are not immune to the addictive powers of

these substances. For example, among women, alcohol problems tend to appear on average several

years later than they do among men (although this

trend may be reversing). For black males, problem

drinking patterns typically occur after age 30, versus ages 18 to 25 for white males.

Although substance abuse problems are not exClusive to adolescence, most prevention programs

currently target youth. The importance of these

types of programs is obvious-to prevent or decrease the use of alcohol, tobacco, cigarettes, and

other drugs by youth. Yet, adults can also be exposed to stressful life situations, such as unemployment, divorce, or death of a spouse or child,

which could contribute to substance abuse problems. The adult population presents unique and

often overlooked challenges for the planning and

implementation of substance abuse prevention

programs.

Gender

Historically, the vast majority of biological and

behavioral studies were conducted on male participants; women substance abusers were not

commonly included in research studies. A distorted picture emerged, in which women were

assumed to misuse the same substances, and for

the same reasons, as men. Within the past 10 to 20

years, however, some researchers have focused on

the causes and consequences of substance abuse

problems among women, and are beginning to report differences based on gender. Basic gaps in

knowledge remain, however, regarding substance

use and abuse among women. Until these gaps are

addressed, the inaccurate and misleading practice

of transferring data garnered from studies on men

to women is likely to continue.

Race and Ethnicity

Historically, racial and ethnic minorities have

been linked with, and often blamed for, many of
10 I Technologies for Understanding and Preventing Substance Abuse and Addiction

RISK FACTORS

Ecological environment

Poverty

Living in an economically depressed area with

high unemployment

inadequate housing

poor schools

Inadequate health and social services

high prevalence of crime

high prevalence of illegal drug use

Minority status involving

racial discrimination

culture devalued in American society

differing generational levels of assimilation

cultural and language barriers to getting adequate

health care and other social services

low educational levels

low achievement expectations from society

Family environment

Alcohol and other drug dependency of parent(s)

Parental abuse and neglect of children

Antisocial, sexually deviant, or mentally III parents

High levels of family stress, including financial strain

Large, overcrowded family

Unemployed or underemployed parents

Parents with Iittle education

Socially isolated parents

Single female parent without family/other support

Family instability

High level of marital and family conflict and/or

family violence

Parental absenteeism due to separation, divorce,

or death

Lack of family rituals

Inadequate parenting and low parent/child contact

Frequent family moves

Constitutional vulnerability of the child

Child of an alcohol or other drug abuser

Less than two years between the child and

its older/younger siblings

Birth defects, including possible neurological

and neurochemical dysfunctions

Neuropsychological vulnerabilities

Physically handicapped

Physical or mental health problems

Learning disability

Early behavior problems

Aggressiveness combined with shyness

Aggressiveness

Decreased social Inhibition

Emotional problems

Inability to express feelings appropriately

Hypersensitivity

Hyperactivity

Inability to cope with stress

Problems with relationships

Cognitive problems

Low self-esteem

Difficult temperament

Personality characteristics of ego under control, rapid

tempo, inability to delay gratification, overacting, etc.

the substance abuse problems within the United

States (see box 1-3). Certainly, many urban areas

have high concentrations of minorities, and within

many of these areas the prevalence of substance

abuse may be high. Often overlooked, however, is

the prevalence of substance abuse problems in

suburban and rural areas throughout the United

States. In the minds of many, the link between minority populations and rampant substance abuse is

inaccurate and derogatory.

Adolescent research has documented substantial racial and ethnic differences in substance use

among high school seniors. On average, licit and

illicit substance use is highest among Native

American Indian youth, somewhat lower among

white and Hispanic youth, substantially lower
Chapter 1 Executive Summary I 11

Adolescent problems

School failure and dropout

At risk of dropping out

Delinquency

Violent acts

Gateway drug use

Other drug use and abuse

Early unprotected sexual activity

Teenage pregnancy/teen parenthood

Unemployed or underemployed

At risk of being unemployed

Mental health problems

Suicidal

Negative adolescent behavior and experiences

Lack of bonding to society (family, school, and

community)

Rebelliousness and nonconformity

Resistance to authority

Strong need for Independence

Cultural alienation

Fragile ego

Feelings of failure

Present versus future orientation

Hopelessness

Lack of self-esteem

Inability to form positive close relationships

Vulnerability to negative peer pressure

PROTECTIVE FACTORS

Ecological environment

Middle or upper class

Low unemployment

Adequate housing

Pleasant neighborhood

Low prevalence of neighborhood crime

Good schools

A school climate that promotes learning, participation,

and responsibility

High-quallty health care

Easy access to adequate social services

Flexible social service providers who put client’s

needs first

Family environment

Adequate family income

Structured and nurturing family

Parents promote learning

Fewer than four children in family

Siblings 2 or more years apart in age

Few chronic stressful life events

Multigenerational kinship network

Nonkin support network, e.g., supportive role models,

dependable substitute childcare

Warm, close personal relationship with parent(s)

and/or other adult(s)

Little marital conflict

Family stability and cohesiveness

Plenty of attention during first year of life

Sibling as caretaker/confidante

Constitutional strengths

Adequate early sensorimotor and language

development

High Intelligence

Physically robust

No emotional or temperamental impairments

Personality of the child

Affectionate/endearing

Easy temperament

Autonomous

Adaptable and flexible

Positive outlook

Health expectations

Self-esteem

Self-discipline

Internal locus of control

Problem-solving skills

Socially adept

Tolerant

SOURCE U S Department of Health and Human Services, Off Ice for Substance Abuse Prevention, Breaking New Ground for Youth at Risk: Program

Summaries OSAP Technical Report 1, DHHS Publication No. (ADM) 91-1858 (Washington, DC 1991)
12 I Technologies for Understanding and Preventing Substance Abuse and Addiction

among black youth, and lowest among Asian

youth. However, such findings do not include

populations most likely to be excluded from selfreporting studies (e.g., high school dropouts).

Until recently, much of the analysis of substance use and/or abuse data has concentrated on

the relationship between the use of a substance

and one or two variables such as race and ethnic it y

and/or educational level. Often a positive association was found between minority populations and

the use or abuse of certain substances. While statistically correct, these analyses can be simplistic

and misleading. Clearly many risk and protective

factors interact to produce substance use and

abuse. If the majority of these variables are excluded from the analysis, a skewed picture may

arise as to the importance of certain variables as

risk factors for substance use and abuse. Additional y, to simplify the data collection, racial and ethnic categories are often broad. The most popular

groupings are black, white non-Hispanic, Hispanic, and other. While each of these categories contains many distinct cultures, gross generalizations

are commonly made.

Race and ethnicity have not been shown to be

either biological or genetic risk factors for substance use or abuse. To date, the preponderance of

investigative studies has focused on racial and

ethnic differences in response specifically to alcohol. Few studies have been completed on differences in racial and ethnic biological responses to

other licit or illicit drugs.

1 Economic

Are poor individuals at greater risk of developing

problems related to substance abuse? While a relatively straight forward question, its resolution is

hampered by the fact that poverty is difficult to define and drawing conclusions concerning an individual potential for future substance abuse based

on one or two variables such as family income or

educational level is overly simplistic and deceptive.

In recent years, attention has been paid to the

plight of the urban poor, many of whom are minorities. These inner-city communities are often

riddled with high rates of crime, violence, unemployment, and inadequate social and medical services. For individuals living in these localities, the

consequences of these problems are serious and

far reaching.

To assess poverty and its relationship to substance abuse problems, some researchers have

used the federal guidelines for poverty, while others employ measures of socioeconomic status

(SES) such as educational level and household income. To date, the largest and most comprehensive analysis of SES variables and substance use

has been accomplished by the National Institute

on Drug Abuse (NIDA). While the analysis revealed associations between certain characteristics and patterns of substance use, it did not reveal

causality. From this analysis, a straightforward

“yes or no” response to the initial question linking

poverty to increased individual risk for substance

use or abuse is clearly impossible. The NIDA

analysis demonstrated that the type and quantity

of an individual’s substance use is correlated with

a variety of both individual as well as geographic

characteristics. Furthermore, while the NIDA

study was the largest and most comprehensive to

date, some segments of the population (e.g.,

homeless, dropouts, institutionalized), many of

whom were possible alcohol and drug abusers,

were excluded from the survey.

I Psychosocial and Behavioral

Many of the identified risk and protective factors

relate to psychological, social, and behavioral

characteristics. Conditions such as aggressiveness, delinquency, and mental disorders are often

linked with substance abuse and addiction. Experiences such as physical and sexual abuse have

also been identified as potential risk factors.

While relatively little research has been accomplished on protective factors, several elements

identified within the resiliency literature, as well

as religiosity and spirituality, have been

associated with decreased substance use.

However, the presence or absence of specific

risk factors neither predicates nor guarantees

protection from substance abuse. In addition,
Chapter 1 Executive Summary I 13

In America, tensions between the majority and various minorities often hinge on concerns raised by

drug use The groups change over time and place, but the dwidlng Issues remain remarkably slmllar

Those {n power decide which drugs are legal and how rules should be enforced Mlnonties charge that

unfair pollcles result from prejudice, Ignorance, and hypocrisy

When? 1850

Where? Boston

Who? Irish Immigrants

Impoverished Irish Immigrants brought the

tradltlon of drinking whiskey with them In

American cltles, people often blamed whiskey

for neighborhood quarrels In the mld-19th

century, clashes with Irish Immigrants occurred

so often that pollee vans came to be known by

the term “pa~~dy wagons “

I ILL’bA&iifii:!kED

,, II

When? 1880s

Where? San Francisco

Who? Chinese Immigrants

Fear of Immigrant Chinese often focused on

their recreational use of opium In 1875, San

Francisco outlawed opium smoking which most

residents associated exclusively with the

Chinese This cltywde ban became nationwide

In 1909

(confmued)
14 I Technologies for Understanding and Preventing Substance Abuse and Addiction

When? 1882

Where? Ohio

Who? German Immigrants

Beer drinking often brought Germans into

conflict with temperance advocates.

Cincinnati’s lively German community gathered

at beer gardens on Sundays to sing, dance,

drink, and argue politics. In 1882, Ohio’s

governor denounced Germans as “sabbath

breakers, criminals, and free thinkers “

Arrest for Burglary

Two Counts

MANUEL ONITI\:ERAS, t

MANUEL CHAVEZ:

m A Mexican;

‘w

Age about 30 years.

‘< height about 6 feet,

‘\ ‘

I \\ ”eight about 150 lb:

~ slender build,

snmoth sha~-en, 1

\“ medium sallow- corn”

1- imiik!i i , ‘#

plexion. black hair,

dark eyes,

ti marihut~na fiend.

When? 1930s

Where? Colorado, New Mexico

Who? Mexican Migrant Workers

The Southwest welcomed Mexican migrants

during labor shortages But during the

Depression, anxiety over competition for jobs

shifted to wildly exaggerated fears of the effects

of marijuana use customary among Mexicans

To placate fears, Congress passed the

Marijuana Tax Act of 1937, which prohibited

recreational use of the drug
Chapter 1 Executive Summary I 15

consensus is lacking within the substance abuse tors that can lead to a number of outcomes,

field as to the importance, interaction, or order of

the factors.

COMMUNITY CONTEXTS

A growing body of research is focusing on factors

and interventions relevant to the onset and prevention of substance use, abuse, and dependency in

the four principal community activity settings—

homes and families, schools and peers, workplaces, and recreational settings.

In framing prevention programs with divergent

populations, researchers are attempting to better

understand qualitative as well as quantitative research methods, and the variety of settings in

which substance abuse and addiction can take

place and can be combatted (see box 1-4).

Despite the promise of community-based research, several problems exist. First, much of the

research does not address substance abuse and addiction per se, but rather risk and protective facincluding substance abuse and addiction. Second,

research studies vary widely in methodology,

making it difficult to draw scientifically valid conclusions. Third, rigorous evaluation of many prevention research programs is missing, leaving the

effectiveness of such programs open to debate.

I Homes and Families

Although American society expects families in

their homes to take the lead in dealing with substance abuse and other problem behaviors, families in this country generally receive only limited

support in protecting themselves against substance abuse. This situation may result in part

from the belief that most nuclear families can raise

their children largely independently and therefore

do not need outside support, and in part from the

belief that teens and young adults are more influenced by their peers. The first belief, however,

is not supported by long-standing practices in
16 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Ethnographic techniques allow researchers to study how environmental and cultural factors affect

values, attitudes, and behaviors of individuals and groups, For three decades, researchers have documented societal and cultural influences on the patterns of substance use, abuse, and addiction; using

a range of methodologies and working in diverse contexts, ethnographers have contributed to the understanding of substance abuse Interacting with drug users under a wider set of circumstances than

do strict quantitative researchers, ethnographers have expanded the framework of substance abuse

research hypotheses They have also assisted m the evaluation and interpretation of clinical and survey

data to different subcultures and populations.

Ethnographies also prowde information on constantly changing substance use patterns By collecting data from substance users in their natural environments, ethnographers have been able to document who uses drugs and how drugs are used This type of methodology is essential to the historical

understanding of substance use and abuse.

Lastly, ethnographers have documented different styles of substance use within American society as

well as abroad. Differences are cited in experience and use patterns based on social class, cultural

background, gender, and geographic location

SOURCE Office of Technology Assessment, 1994.

most societies, where extended families and life- that include an addict’s family members also adlong neighbors have traditionally helped raise

children (although in the United States many parents do not have access to these additional childrearing resources because of urbanization, high

technology, and family mobility). And the second

belief is being questioned by growing evidence

that certain parenting practices and family intervention programs can significantly reduce the risk

of substance abuse among adolescents and young

adults.

A growing body of research has identified risk

and protective factors that may be particularly

relevant in home and family situations (see table

1-3). Programs that enhance protective factors include those providing parent education, prenatal

and infant care, preschool, and social support activities that help strengthen involved and responsive parenting. Programs that seek to decrease the

presence of risk factors include those designed to

reduce drug trafficking (e.g., community policing, clean sweeps of housing projects), physical

and sexual abuse, the impact of negative life

events (e.g., mental health counseling), and parental neglect. Substance abuse treatment programs

dress risk factors.

1 Schools and Peers

Schools have been the target for prevention programs to curtail drug use at school sites (e.g., Drug

Free School Zones) as well as curriculum-based

programs that target drug use in the community as

a whole. Because school-age youth are especially

likely to initiate the use of alcohol and other drugs,

much of the research has focused on use, rather

Protective factors

Close family relationships

Suflcient monitormg of children

Attractive alternatives to substance use and abuse

Risk factors

Parental neglect and rejection

Physical and sexual abuse

Substance abuse m the family

Major negahve Ilfe events

Drug-trafficking neighborhoods and drug-using friends

SOURCE Office of Technology Assessment, 1994
——— ——

Chapter 1 Executive Summary I 17

●

■

●

■

■

●

●

Prior Use

Drug Use by Others

Peer/friend use

Use and deviant behavior by a relative

Sibling use ■

Availability

Parental use

Intentions

Overt and Normative Pressures

Peer/friend attitudes about drug use ●

Offers to use

Others’ attitudes about use

Motivation to comply with pressure

Media Influences

Others’ attitudes about other issues

Cognitive Factors

Attitudes

■

Beliefs about psychological consequences

Value of achievement

Religious values

General values

Beliefs about health consequences

Demographic Factors

Age/grade

Race ■

Geographic identifiers

Gender

Personality Characteristics

Deviance

Independence

Affect

—

Personality traits

Social personality traits

Self-esteem

Locus of control

Peer Factors

Intimacy

Peer group characteristics

Peer bonding

Peer-parent relations

Competence

Self-efficacy

Stress management skills

School performance

Self-management skills

Intelligence

Institutional Influences

School bonding

Participation in nonstructured activities

Religious affiliation

Moral codes

Church attendance

Participation in structured activities

Academic expectations

Home Factors

Socioeconomic status

Parental relations

Parents’ psychological traits

Parents’ marriage

Parents’ education

Family composition

SOURCE Office of Technology Assessment, 1994

than on abuse and dependency. Such research is

nevertheless relevant to an understanding of abuse

and dependency, since use is a precondition and

contributor to abuse and dependency and because

even experimental use can be harmful.

OTA conducted the most extensive compilation and examination of survey research on

school-aged substance use to date—9,930 statistical analyses from 242 separate studies. The studies reported statistical relationships between

substance use and its postulated causes. Statistical

findings from the study reports were sorted into 11

major categories and 50 subcategories (see table

1 -4), and then analyzed to identify strong, moderate, and weak statistical relationships, as well as

those that had been insufficiently studied. The

four variables that dominated as correlates of and

possible contributors to substance abuse are: 1 )

prior and concurrent use of substances, 2) substance use by peers and friends, 3) perceived peer

attitudes about substance use, and 4) offers to use

substances. The prominence of prior and concurrent use is consistent with the reinforcing nature

of substance use itself. The prominence of the other three variables emphasizes the importance of

the social environment in contributing to and reinforcing substance use among school-age youth.

Schools primarily seek to prevent substance

use and abuse through curriculum-based drug prevention programs. Such programs have dominated the field, largely because they are relatively

simple to understand, implement, and replicate,

and because methods to evaluate them have become standardized. Curriculum-based prevention
18 I Technologies for Understanding and Preventing Substance Abuse and Addiction

programs have been hampered, however, by a lack

of good evaluation data needed to prove their effectiveness.

9 Workplaces

The prevalence of drug abuse among the

employed remains inadequately documented,

based on a small number of studies. Substance

abuse contributes to workplace problems, such as

accidents, injuries, absenteeism, turnover, lost

productivity, compensation claims, and insurance

costs. Substance abuse in workplaces can be affected by nonworkplace factors and workplace

factors. The primary interventions are employee

assistance programs that help employees with personal problems by providing services directly

(through the work organization) or indirectly

(through a provider in the community); health

promotion programs that typically seek to prevent

illness and promote wellness through behavior

change; and alterations to workplace environments that seek to reduce stress and strengthen

support for workers.

H Recreational Settings

Recreational activities and settings may also contribute to the prevention of substance use and

abuse or, by their absence, increase the risk. Examples of recreational activities and settings include Boys and Girls Clubs, Boy and Girl Scouts,

organized sports, and local park and recreation department programs.

Research on the impact of organized youth activities on substance use and abuse is limited, and

only a few studies have addressed the issue directly. However, existing research indicates that involvement in youth programs and activities is

associated with fewer at-risk behaviors, including

substance use among youth. The youth development field, including the resources of park and

recreation departments, provides opportunities

for broad-based prevention interventions.

Involvement in activities does not by itself protect against substance abuse. Some activities,

such as those that are unstructured and unsupervised, may even increase the risks of substance

use and abuse through association with a wider

range of peers, some of whom are using substances. In addition, activities perceived as boring

may not protect against substance use and abuse.

More research is needed to clarify the aspects of

recreational and other leisure activities that may

protect against substance use and abuse. Research

might focus on whether activities that are supervised, structured, drug-free, empowering, skillsbuilding, self-esteem-promoting, active, shared,

and nonboring (or some combination of those) are

associated with lower levels of substance use and

abuse.

POLICY OPTIONS

Issues related to substance abuse and addiction

have long occupied the attention of the American

public (see table 1-5). Congress has authorized a

multitude of federal programs aimed at reducing

or preventing the supply and demand of illicit

drugs and regulating the availability of illicit substances, and has appropriated billions of dollars

each year to federal agencies, provided oversight

of federal programs, and passed broad-based legislation to coordinate programs as part of the war

on drugs. In addressing what some policy makers

term as the root causes of substance abuse and addiction, the list of relevant statutes expands significantly, as many domestic and social programs can

influence the risk and protective factors that can

lead an individual into or away from substance

abuse and addiction.

A total of 12 executive branch departments,

four independent agencies, one multiagency program (Weed and Seed), one White House office

(the Office of National Drug Control Policy—

ONDCP), and the Judiciary, all receive federal

funding as part of national drug control strategy.

These efforts include interdiction, treatment, and

prevention programs.

The federal substance abuse control policy has

as its primary focus the eradication of the supply

of drugs. Congress currently appropriates more

than $12 billion annually on antidrug efforts, with

approximately two-thirds of this amount supporting drug interdiction and law enforcement activi-
Chapter 1 Executive Summary I 19

1900–20s The first drug bans are enacted in the United States.

1906: The Pure Food and Drug Act requires labeling of over-the-counter medicines containing psychoactive

Ingredients such as alcohol, cocaine, opiates, and cannabis,

1909: Congress bans opium imports

1914: Congress passes the Harrison Narcotics Act regulating the production and sale of opiates and cocaine

1919: The U S. Supreme Court rules in Webb et al. v. United States that doctors may not prescribe maintenance

supplies of narcotics to addicts. The decision effectively criminalizes the drug-consuming behavior of

addicts.

1920s-30s Prohibition of alcohol gives rise to a booming underground market in alcohol, while the

Depression inreases xenophobia against immigrants and pressure to ban the drugs associated with

them.

1920: The 18th Amendment to the Constitution, prohibiting the production and sale of alcohol, takes effect

1933: The 21st Amendment repealing Prohibition iS ratified.

1937: Congress passes the Marijuana Tax Act, making registration and taxation of marijuana buyers and sellers

mandatory, and Imposing criminal penalties.

1960s-70s The drug culture that flourished in the 1960s is followed by a crackdown on drug use.

1970: The Comprehensive Drug Abuse Prevention and Control Act consolidates drug laws and sets penalties for

trafficking according to each illegal substance’s perceived harmfulness

1971: President Richard M Nixon declares the nation’s first “war on drugs” and creates an executive branch office

to coordinate drug policy.

1973: The Federal Drug Enforcement Administration (DEA) IS established.

1978: Law enforcement agencies are authorized by Congress to seize the assets of drug dealers, including

money, real estate, and vehicles

1980s Harsher antidrug policies are enacted.

1984: Congress enacts mandatory minimum prison sentences for certain drug offenses

1986: President Ronald Reagan declares a “war on drugs” and announces he wiII seek stricter laws against the

sale and use of illegal drugs, Congress enacts legislation Iinking the length of mandatory prison sentences

to the types of Illegal drugs Involved.

1988: Congress passes the Anti-Drug Abuse Act, which stiffens penalties for drug possession and requires the

President to issue an annual drug control strategy,

1989: Worldwide heroin production reaches an all-time record Calling drugs ‘(the gravest threat facing our nation

today, ” President George Bush appoints William J. Bennett as the first ‘(drug czar, ” or director of the new

Off Ice of National Drug Control Policy U S forces invade Panama and capture Gen. Manuel Antonio

Noriega, a reputed key figure in the cocaine trade

1990s Statistics show a fall in consumption of most illegal drugs.

1991: The U.S. Supreme Court upholds a Michigan law imposing a mandatory life sentence without the possibility

of parole to anyone convicted of possessing more than 650 grams of cocaine

1993: The U S Supreme Court rules that officials may not seize property acquired with the proceeds of illegal

drug sales if the owner is unaware of the source of those funds. The ruling weakens one of the governments

main weapons in the drug war

—. —

SOURCE Off Ice of Technology Assessment, 1994, based on “War on Drugs, ” The CQ Researcher, Mar 19 1993, vol. 3, No. 11.
20 I Technologies for Understanding and Preventing Substance Abuse and Addiction

ties, and the remainder supporting demand-side

activities, such as drug treatment, research, and

prevention programs.

Drug demand reduction efforts focus on providing treatment for abusers and addicts, prevention programs for various populations, and

biomedical and behavioral research on the causes

of substance use, abuse, and addiction. Of these,

the federal government spends the most on treatment, followed by prevention and causality research. Drug treatment and prevention programs

are funded at both the federal and state levels,

while causation research is funded primarily by

the federal government. A recent General Accounting Office (GAO) study revealed that for

studying the causes of drug abuse, funding has remained comparatively tiny. In 1990, for example,

such research was funded at a level of $6 million,

about one-tenth of one percent of the nation’s drug

control budget for that year.

OTA, in conjunction with GAO, surveyed federal agencies identified as having substance abuse

prevention efforts. OTA finds that substance

abuse prevention efforts are scattered over a

number of federal agencies, and that federal

prevention efforts are dictated by statutory

mandates, rather than directed at identifying

causes of substance abuse and addiction per se.

The White House ONDCP, charged with coordinating federal antidrug efforts, lacks the

statutory mandate to forcibly integrate or alter

the multitude of programs that make up the

federal government’s war on drugs.

Congress faces several fundamental difficulties in addressing the causes of substance abuse

and addiction:

No scientific consensus exists as to what is

the driving cause of substance abuse and addiction. A range of risk and protective factors

have been associated with drug use, abuse, and

addiction.

Federal antidrug efforts, though coordinated by ONDCP, are spread among many

federal agencies, whose authorization and

appropriations fall under the jurisdiction of

Federal Focus and Prevention Program Structure

Supply Versus Demand Reduction

Structure of the Off Ice of National Drug Control Policy

Structure of Federal Substance Abuse Prevention

Programs

Evaluation of Prevention Programs

Research Needs

Data Collection

Individual Risk and Protective Factors

Biomedical Research

Community Activity Settings

Schools and Peers

Homes and Families

Workplaces

Recreational and Community Settings

Availability

Taxes

Alcohol Labeling —

SOURCE Office of Technology Assessment, 1994

■

numerous congressional committees and

subcommittees. ONDCP efforts in drug demand reduction efforts alone involved federal

agencies across at least 11 Cabinet-level departments. This makes coordinated legislative

action difficult to achieve.

The federal budget deficit is an obstacle to

the creation of new domestic programs or

the enhancement of existing programs that

target known risk and protective factors in

individuals and communities. The framework and literature reviews presented in this report make clear that substance abuse and

addiction can arise and be influenced by multiple factors in individuals, groups, and communities. Thus, effective intervention requires

prevention practitioners to select from a variety

of options, so they can target the specific factors that are especially important for the particular populations and communities they are

addressing. This does not mean that everything

must be done at once nor that everything be

known in advance of taking action. To the contrary, policy makers and practitioners can take

small steps at a time, and then, as resources and

new knowledge permit, take additional steps
Chapter 1 Executive Summary I 121

Federal Focus and Prevention Program Structure

How much should federal substance abuse control o/icy focus on the supply of substances versus

the demand for substances?

Opt/ens include

—Increase appropriations for treatment and prevention programs,

—Redirect some of the interdiction funds to increase support for treatment and prevention programs

—Require that assets forfeited in drug seizures be Increasingly used to support treatment and

prevention programs

Should the White House Office of National Drug Control Policy (ONDCP) be reauthorized and, if so,

should its authority be modified?

Options include

—Direct ONDCP to address the full range of the most harmful abusable substances, including alcohol,

tobacco, and Inhalants

—Alter ONDCP’S leadership structure,

—Give ONDCP Increased authority over federal agency antidrug programs

—Mandate the size of ONDCP

—Allow the authorization for ONDCP to expire

Should federal substance abuse prevention programs be more fully integrated into a single agency?

Options include

—Merge the National institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and

Alcoholism (NIAA) into a single National Institute on Substance Abuse and Addiction

—Place CSAP in the Center for Disease Control and Prevention or in the Health Resources and Services

Administration

—Merge federal substance abuse prevention efforts into a single agency, such as the Center for

substance Abuse Prevention (CSAP)

How should evaluation of substance abuse prevention programs be improved?

Options include:

—Allow the current level of process and outcome evaluation related to substance abuse programs to

continue

—Direct NIDA, NIAAA, or CSAP to lead a national process to forge consensus on standardized

definitions and outcome measures,

—Require states to use a portion of their 20 percent prevention set-asides (under the Alcohol and Drug

Abuse Block Grant program) and a portion of their Drug-Free Schools funds for evaluation of

substance abuse prevention programs

(continued)

that address a fuller range of factors and contexts in greater depth.

= Current drug prevention programs lack

scientifically accepted standards for determining their success or failure. Whatever

methods are developed, tested, and incorporated into prevention programs, a critical component of success is careful, rigorous

evaluation. Answering “what works?” is essential in making advances in preventing substance abuse.

In choosing which policy issues to address,

OTA focused on those areas directly addressed in

this study. OTA identified a series of policy issues

in four broad categories: federal focus and prevention program structure, research needs, community activity settings, and availability (see table

1-6). A number of policy questions and options

for congressional action emerge from these four

categories (see table 1-7). A full discussion of the

policy issues and options for congressional action

can be found in chapter 9 of the full report. Given

the broad nature of federal antidrug efforts, many

important issues relating to federal antidrug efforts remain beyond the scope of this report. Such

topics include drug treatment, interdiction and enforcement, and drug legalization.
22 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Research Needs

Do national surveys adequately document substance use, abuse, and addiction?

Options include:

—Continue with no substantial changes.

—Direct that the Household and High School Seniors surveys be conducted less intensely or less

frequently.

—Direct NIDA to develop and support survey methodology that reaches populations missed by current

surveys.

—Create a mechanism for the regular and nonpolitical release of survey data.

/s an adequate proportion of federal research being conducted on the underlying risk and protective

factors that can lead to substance abuse and addiction?

Options include

—Monitor the amount and scope of risk and protective factor research that IS being conducted, and

redirect federal efforts toward more extensive multifactor research and analysis as needed.

Should current levels of federal funding for drug-related biomedical research be altered?

Options include

—Continue to increase annual appropriations for biomedical research at NIH.

—Substantially raise appropriations levels for NIDA and NIAAA.

—Reduce funding for NIH research,

Community Activity Setting

Do Federal programs affecting homes and families, schools and peer groups, workplaces, and

recreation settings adequately address issues of substance abuse and addiction?

Options include:

—Continue to fund school-based prevention programs, with a continued emphasis on prevention

curricula and evaluations that are Iimited to substance use prevention.

—Require the Department of Education (DOE) to spend a set percent of its Drug-Free Schools monies

on research and evaluation of prevention curricula and the dissemination of findings.

—Require DOE to set aside a certain percentage of Drug-Free Schools funds for a variety of activities

that target high-risk youth and to work individually with them and their families.

—Encourage the support of school-based clinics.

—Create a Presidential commission or task force to formulate a national family policy.

—Mandate that federal agencies increase the reformation that is made available to workplaces about

drug-free workplace programs and policies.

—Direct CSAP to expand technical assistance and outcome evaluation measures to the community

partnership demonstration programs.

—Establish an information clearinghouse about federal and nonfederal recreational and youth

development activites.

Availability

is alcohol and/or tobacco taxed at an appropriate level?

Options include:

—Continue current levels of taxation,

—Raise federal excise tax on a variety of tobacco and alcohol products

Is current alcohol labeling appropriate?

Options include

—Continue to require each alcoholic beverage container bear a specific warning statement.

—Require warnings on all alcohol beverage advertising.

SOURCE Off Ice of Technology Assessment, 1994
Introduction

s

ubstance abuse and addiction are pervasive in our society,

with their consequences felt by people in every economic,

social, racial, and political boundary.

The United States has grappled with problems associated with substance abuse and addiction for over a century (see

appendix A and table 2-1). In 1986, then-President Ronald Reagan launched what has become known as the war on drugs. Federal spending to combat drugs increased from $1.5 billion in 1981

to more than $12 billion in 1994, with spending in 1995 projected

to pass the $13 billion mark (see table 2-2). Nearly two-thirds of

the federal antidrug budget goes toward efforts to curb the supply

of drugs (e.g., border interdiction, law enforcement), with the remainder being spent on drug treatment and prevention programs.

While the use of illegal drugs has declined in the United States in

recent years, a vigorous debate continues as to whether the nation

is indeed winning the war on drugs, and what the balance of federal effort should be in formulating programs to decrease the supply

of drugs, treat drug abusers and addicts, and educate Americans

about problems associated with drug abuse and addiction.

Congress has enacted a number of laws in an attempt to create a

national policy to fight the scourge of drug abuse and addiction.

As part of oversight responsibility for national drug policy, several committees of Congress have requested the Office of

Technology Assessment (OTA) to undertake a study addressing

the socioeconomic, psychological, physiological, and genetic underpinnings of substance abuse and addiction (see table 2-3).

2

I 23
24 I Technologies for Understanding and Preventing Substance Abuse and Addiction

1900-20s The first drug bans are enacted in the United States.

1906: The Pure Food and Drug Act requires labeling of over-the-counter medicines containing psychoactive

Ingredients such as alcohol, cocaine, opiates, and cannabis,

1909: Congress bans opium Imports.

1914: Congress passes the Harrison Narcotics Act regulating the production and sale of opiates and cocaine,

1919: The U.S. Supreme Court rules in Webb et al. v. United States that doctors may not prescribe maintenance

supplies of narcotics to addicts The decision effectively criminalizes the drug-consuming behavior of

addicts.

1920s-30s Prohibition of alcohol gives rise to a booming underground market in alcohol, while the

Depression increases xenophobia against immigrants and pressure to ban the drugs associated with

them.

1920: The 18th Amendment to the Constitution, prohibiting the production and sale of alcohol, takes effect

1933: The 21st Amendment repealing Prohibition iS ratified

1937: Congress passes the Marijuana Tax Act, making registration and taxation of marijuana buyers and sellers

mandatory, and imposing criminal penalties.

1960s-70s The drug culture that flourished in the 1960s is followed by a crackdown on drug use.

1970: The Comprehensive Drug Abuse Prevention and Control Act consolidates drug laws and sets penalties for

trafficking according to each illegal substance’s perceived harmfulness.

1971: President Richard M. Nixon declares the nation’s first “war on drugs” and creates an executive branch office

to coordinate drug policy.

1973: The Federal Drug Enforcement Administration (DEA) is established.

1978: Law enforcement agencies are authorized by Congress to seize the assets of drug dealers, including

money, real estate, and vehicles.

1980s Harsher antidrug policies are enacted.

1984: Congress enacts mandatory minimum prison sentences for certain drug offenses

1986: President Ronald Reagan declares a “war on drugs” and announces he will seek stricter laws against the

sale and use of illegal drugs. Congress enacts Iegislation Iinking the length of mandatory prison sentences

to the types of illegal drugs Involved.

1988: Congress passes the Anti-Drug Abuse Act, which stiffens penalties for drug possession and requires the

President to issue an annual drug control strategy,

1989: Worldwide heroin production reaches an all-time record. Calling drugs ‘(the gravest threat facing our nation

today, ” President George Bush appoints William J. Bennett as the first “drug czar, ” or director of the new

Off Ice of National Drug Control Policy. U.S. forces invade Panama and capture Gen. Manuel Antonio

Noriega, a reputed key figure in the cocaine trade,

1990s Statistics show a fall in consumption of most illegal drugs.

1991: The U.S. Supreme Court upholds a Michigan law imposing a mandatory Iife sentence without the possibility

of parole to anyone convicted of possessing more than 650 grams of cocaine,

1993: The U.S. Supreme Court rules that officials may not seize property acquired with the proceeds of illegal

drug sales if the owner iS unaware of the source of those funds The ruling weakens one of the government’s

main weapons in the drug war

— -—... —

SOURCE Office of Technology Assessment, 1994, based on “War on Drugs, ” The CQ Researcher, Mar 19, 1993, vol. 3, No 11
Chapter 2 Introduction I 25

Fiscal year 1995

Fiscal year 1993 Fiscal year 1994 President’s

actual enacted request

(Budget authority in millions)

Drug treatment 2,339.1 2,5141 2,874 4

Education, community action, and the workplace 1,556.5 1,602,4 2,050 7

Criminal justice system 5,685.1 5,700.4 5,926 9

International 523 4 351.4 427 8

Interdiction 1,511 1 1,299,9 1,205 6

Research 499.1 504 6 531 6

Intelligence 150,9 163 4 162 8

Total 12,265.2 12,136 2 13,179 8

.— —

SOURCE The White House Off Ice of National Drug Control POIiCY, 1994

OTA has been asked to address a number of

questions:

■

■

m

■

■

What are the root causes of substance abuse and

addiction?

Why and how does addiction occur?

Who are the substance abusers?

What factors, scientific and social, lead to addiction?

What are the implications for prevention?

ROOT CAUSES

At the outset, OTA was asked to address the root

causes of substance abuse and addiction. The term

root causes has been used in political discussions

and debate (see box 2-1 ), and although many

people have strongly held opinions as to what

constitutes the root causes of drug abuse, no consensus exists as to what, if anything, is inherent in

every case of substance abuse and addiction. OTA

conducted a search of various bibliographic databases, which revealed only limited discussion

about root causes of drug abuse (2).

Research into drug abuse looks not at root

causes per se, but rather at risk and protective factors that increase or decrease the possibility that

substance abuse and addiction will occur (see

table 2-4), and how these risk and protective factors affect various subpopulations in different settings.

WHAT ARE SUBSTANCE ABUSE

AND ADDICTION?

Drug consumption is divided into three levels or

stages commonly distinguished by clinicians and

researchers: use, abuse, and dependence (see figure 2-1 ). Each of these stages is, on average, more

hazardous, more obtrusive, and more likely to

provoke or induce social interventions (e.g., punitive sanctions, attention by prevention programs,

admission to treatment) than the one before (4). A

substance is abusable if it has the capacity to induce dependence in those who use it. Dependence,

a term that is often used interchangeably with the

term addiction, can include psychological dependence (a form of obsessive behavior whose objective is the attainment of pleasure or the avoidance

of unpleasantness) and physical dependence (development of tolerance, causing the user to need

increasing amounts of the drug for it to have its desired effect, and withdrawal symptoms if drug use

is stopped) (5).

House

Committee on Government Operations

Senate

Committee on Labor and Human Resources

Committee on Governmental Affairs

SOURCE Off Ice of Technology Assessment, 1994
26 I Technologies for Understanding and Preventing Substance Abuse and Addiction

RISK FACTORS

Ecological environment

Poverty

Living in an economically depressed area with

high unemployment

inadequate housing

poor schools

inadequate health and social services

high prevalence of crime

high prevalence of Illegal drug use

Minority status involving.

racial discrimination

culture devalued in American society

differing generational levels of assimilation

cultural and language barriers to getting adequate

health care and other social services

low educational levels

low achievement expectations from society

Family environment

Alcohol and other drug dependency of parent(s)

Parental abuse and neglect of children

Antisocial, sexually deviant, or mentally ill parents

High levels of family stress, including financial strain

Large, overcrowded family

Unemployed or underemployed parents

Parents with little education

Socially isolated parents

Single female parent without family/other support

Family instability

High level of marital and family conflict and/or

family violence

Parental absenteeism due to separation, divorce,

or death

Lack of family rituals

Inadequate parenting and low parent/child contact

Frequent family moves

Constitutional vulnerability of the child

Child of an alcohol or other drug abuser

Less than two years between the child and

its older/younger siblings

Birth defects, including possible neurological

and neurochemical dysfunctions

Neuropsychological vulnerabilities

Physically handicapped

Physical or mental health problems

Learning disability

Early behavior problems

Aggressiveness combined with shyness

Aggressiveness

Decreased social inhibition

Emotional problems

Inability to express feelings appropriately

Hypersensitivity

Hyperactivity

Inability to cope with stress

Problems with relationships

Cognitive problems

Low self-esteem

Difficult temperament

Personality characteristics of ego under control, rapid

tempo, inability to delay gratification, overacting, etc.

Nevertheless, there is considerable controversy several substances—such as marijuana, heroin,

about what constitutes substance abuse and addic- cocaine—are illegal in all 50 states. Other adtion. A number of issues come into play, such as: dictive substances—such as tobacco and alcohol—may be legally purchased, possessed, and D What substance is being used? A wide range of

psychoactive substances has the potential for consumed by a majority of Americans. Other

abuse (see box 2-2). The possession and use of abusable substances—such as inhalants—may
Chapter 2 Introduction I 27

Adolescent problems

School failure and dropout

At risk of dropping out

Delinquency

Violent acts

Gateway drug use

Other drug use and abuse

Early unprotected sexual activity

Teenage pregnancy/teen parenthood

Unemployed or underemployed

At risk of being unemployed

Mental health problems

Suicidal

Negative adolescent behavior and experiences

Lack of bonding to society (family, school, and

community)

Rebelliousness and nonconformity

Resistance to authority

Strong need for Independence

Cultural alienation

Fragile ego

Feelings of failure

Present versus future orientation

Hopelessness

Lack of self-esteem

Inability to form positive close relationships

Vulnerability to negative peer pressure

PROTECTIVE FACTORS

Ecological environment

Middle or upper class

Low unemployment

Adequate housing

Pleasant neighborhood

Low prevalence of neighborhood crime

Good schools

A school climate that promotes Iearning, participation,

and responsibility

High-qualty health care

Easy access to adequate social services

Flexible social service providers who put client’s

needs first

Family environment

Adequate family income

Structured and nurturing family

Parents promote Iearning

Fewer than four children in family

Siblings 2 or more years apart in age

Few chronic stressful Iife events

Multigenerational kinship network

Nonkin support network, e.g., supportive role models,

dependable substitute childcare

Warm, close personal relationship with parent(s)

and/or other adult(s)

Little marital conflict

Family stability and cohesiveness

Plenty of attention during first year of Iife

Sibling as caretaker/confidante

Constitutional strengths

Adequate early sensorimotor and language

development

High intelligence

Physically robust

No emotional or temperamental Impairments

Personality of the child

Affectionate/endearing

Easy temperament

Autonomous

Adaptable and flexible

Positive outlook

Health expectations

Self-esteem

Self-discipline

Internal locus of control

Problem-solving skills

Socially adept

Tolerant

SOURCE U S Department of Health and Human Services, Office for Substance Abuse Prevention, Breaking New Ground for Youth at Risk: Program

Summaries, OSAP Technical Report 1, DHHS Publication No. (ADM) 91-1658 (Washington, DC 1991)

be legally purchased, possessed, and consumed ■ Does experimental use constitute abuse? Some

by anybody. maintain that any use of an abusable or addic-
28 I Technologies for Understanding and Preventing Substance Abuse and Addiction

“Many states and cities are on shoe-string budgets and must provide services and alternatives to substance abuse in local communizes. The failure to address the fundamental causes of substance abuse and

to provide Immediate intervention strategies will impact city residents most The committee recommends

that the National Drug Control Strategy be framed by broader social and economic problems which require

dramatic reforms m order to attack the root causes of substance abuse We need to begin to build the infrastructure necessary to Improve the quality of treatment services by requiring medtcal schools to prowde

comprehensive trammg to identify and treat substance abusers, prowde adequate treatment services at the

commumty level, including after care, vocational, educational, and psychiatric assessments, and develop

alternate leisure achvlties for youth and adults to replace ‘street Ilfe’ and assist indiwduals to escape the

drug culture “

House Committee on Government Operations committee report

“One of [the Democrats’] tactics was to talk about the root causes of drug use, the ‘deeper and more

profound problems, ’ as they put It, of hopelessness, poverty, helplessness, and the like The elites Ilked this

shift m emphasis, too. It took the discussion away from moral considerahons to the (for them) more comfortable ground of social theory They wanted to talk about ‘hopelessness’ as a condition caused by lack of

government involvement. We talked about hopelessness, too, but talked about It as a condition caused by

social decomposition and the breakdown of the family and a lack of law and order m these commumtles I

found It shocking and disappointing that when we argued for more police, jails, courts, and prisons because

of the exploding crime epidemic m some of America’s inner cltles, some people responded by saying, ‘But

what are the root causes of thlsv ‘That’s an mterestmg debate which should go on at an ellte university But If

there are drug dealers gong around shooting people in the affluent suburbs, the cllzenry WIII not call for a

seminar on root causes. They WIII raise hell and demand that the dealers be arrested And they are right to

do SO. ”

William Bennett

Former dtrector, U.S Office of National Drug Control Policy

SOURCES U S House of Representatives, Commitee on Government Operations, H.Rept 101-992, “The Role of Demand Reduction {n the National Drug Control Strategy”, Bennett, W, The De-Va/umg otArner/ca The Fight for Our Cu/ture and Our Ch//dren (New

York, NY Summlft Books, 1992)

tive substance constitutes abuse. Others sug- ing the use of illicit substances or the illegal use

gest that experimentation—particularly with

such psychoactive substances as alcohol or tobacco that are available for purchase by adults

of legal age—is part of normal development

and does not necessarily have harmful consequences.

In what context are substance abuse and addiction being addressed? Four broad arenas that

encounter substance abuse related issues include: mass communications, criminal justice,

medicine, and public health. These entities

often operate independently of one another, and

use substantially different terms when describof licit substances (see appendix C).

1 Public Health Model

The traditional public health model incorporates

the host-agent-environment relationship. Each of

these factors has an individual, as well as an interrelated role in the potential use and/or harmful use

of a substance. Host factors may include possible

genetic, psychological, and biological susceptibility. Agent factors incorporate the substance’s

abuse liability capacity, as well as how the substance is marketed. Lastly, environmental factors
Chapter 2 Introduction I 29

Abstinence ‘—7

Cessation

* USE Low or infrequent doses:

*

experimental, occasional,

+ “social. ” Damaging consequences

are rare or minor.

,

+— Mild sanctions

+— Prevention programs

A

(Early/light

stage

+ Intensification

F

responses)

*

ABUSE Higher doses and/or

-> frequencies: sporadically heavy,

[-- ‘-

— intensive. Effects are unpredictable,

● sometimes severe. ● 1 1 I I

I I

“7 DEPENDENCE High, frequent doses:

~–– — compulsion, craving, withdrawal. 1

I I Severe consequences are very

“Self -help~

*

likely.

remission

v 1

Late/heavy

stage

responses)

v

+-- -- Severe sanctions

<-– - TREATMENT

PROGRAMS

I

*

‘indicates the influence of biological, physiological, and

RELAPSE- ]

social factors that condition changes in behavior.

SOURCE: Institute of Medicine 1993

encompass not only the availability of the substance, but the social, cultural, political, and economic climate as well. The focus of the public

health perspective is to understand the importance

social norms, environment, and availability play

in the shaping of alcohol- and drug-related problems both on an individual and societal level.

The public health approach toward substance

abuse has several defining characteristics:

● The substance abuse problem is primarily one

of health, and risks for ill-health. In every recreational, mood-altering drug user, use increases

the risk of contracting one or more diseases or

conditions damaging to one’s health. Drug use

always creates the potential, from great to

small, for developing one or more drug-related

■

■

✘

health problems.

The legality or illegality of a drug is an artificial

barrier that is not as relevant as the healthrelated considerations stemming from all types

of drug use. Rather than using legal/illegal, the

public health approach categorizes drugs by

such characteristics as addictive potential and

long-term health risks.

The drug abuse problem and the drug-related

crime problem are not one and the same. As two

distinct, interrelated problems, they have different, interrelated solutions.

Dealing with the drug problem primarily as a

moral problem is considered inappropriate and

counterproductive.
30 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Class of psychoactive substanc@

Descriptionb Examples

ALCOHOL (ethyl alcohol)

Alcohol, one of the most widely used of all drugs, is a

central nervous system depressant with effects similar to

those of sedative-hypnotic compounds (see below). At low

doses, alcohol may be associated with behavioral

excitation thought to be due to the depression of inhibitory

neurons in the brain. Alcohol differs from

sedative-hypnotic compounds in that it is used primarily

for recreation or social rather than medical purposes.

SEDATIVES, HYPNOTICS, OR ANXIOLYTICS

Sedative-hypnotics are drugs of diverse chemical

structure that exert a nonselective general depressant on

the central nervous system In addition, they reduce

metabolism in a variety of tissues in the body, depressing

any system that uses energy. Depending on the dose, any

sedative hypnotic compound may be classified as a

sedative (an agent that allays excitement), a tranquilizer

(an antianxiety agent), a hypnotic (a sleep-inducing

agent), or an anesthetic (an agent that eliminates pain).

Sedative-hypnotics are used medically as sedatives,

anxiolytics (antianxiety agents), hypnotics, antiepileptics,

muscle relaxants, and general anesthetics.

CANNABIS (THC)

THC (tetrahydrocannabinol) the active agent in marijuana,

alters perceptions, concentration, emotions, and behavior,

though the mechanisms of action are not entirely clear.

Researchers have found, however, that THC changes the

way in which sensory information is processed by the

brain. It can be used medically to relieve nausea and side

effects of chemotherapy in cancer patients; it is very rarely

used to treat glaucoma.

NICOTINE

Nicotine, obtained naturally from tobacco, is a central

nervous system stimulant.c It exerts its action secondary to

stimulation of certain cholinergic (excitatory) synapses

both within the brain and in the peripheral newous system.

1

2

3

1

2

3.

1,

2

3

4.

1.

2,

Beer.

Wine.

“Hard” liquor (e.g , whiskey, gin)

Barbiturates (“downers” or “barbs”):

pentobarbital sodium [NembutalR],

secobarbital sodium ISeconalR],

amobarbital IAmytalR]—taken orally.

Nonbarbiturate hypnotics:

methaqualone

IQuaaludesR]—taken orally.

Tranquilizers: diazepam ~aliumR],

chlordiazepoxide hydrochloride

[Librium R

]–taken orally.

Marijuana (“pot” or “grass”)-

smoked or eaten.

Hashish (“hash’ ’)-smoked or

eaten.

Hashish oil (“hash oil’’ )—smoked

(mixed with tobacco.

Tetrahydrocannabinol (THC)—

taken orally in capsules.

Cigarettes.

Smokeless tobacco (e g , snuff or

chewing tobacco).

(continued)
Chapter2 Introduction 131

Class of psychoactive substanc@

Descfiptfonb Examples

COCAINE

Cocaine, obtained naturally from coca leaves, is a potent

central nervous system stimulant c It stimulates the

sympathetic nervous system, which regulates the activity

of cardiac muscle, smooth muscle, and glands It also

produces bronchoddatlon in the lungs It is used medically

as a topical anesthetic for surgical procedures

AMPHETAMINES AND RELATED STIMULANTSf

1

2

Amphetammes

Amphetamines are a group of three closely related

compounds, all of which are potent central nervous

system and behavioral stimulants c Some amphetamines

are used medically to treat attention deficit disorder or

mlnlmal brain dysfunchon in children, narcolepsy

(recurrent, uncontrollable, brief epmdes of sleep), or

(rarely) depression

Nonamphetamme stimulants

Like amphetamines, nonamphetamine stimulates are

central nervous and behavioral stimulants Some

non-amphetamine stimulants (e g , PreludinR) are used for

weight control, and some (e g , RitalinR and CylertR) are

used medically to treat hyperactivity, mmimal brain

dysfunchon, narcolepsy, or (rarely) depression.

HALLUCINOGENS

Hallucinogens, or psychedelics, are a heterogeneous

group of compounds that affect a person’s perceptions,

sensahons, thinking, self-awareness, and emotions. ’

1

2.

1

2,

3.

1

2

3

1

2.

3

4

Cocaine hydrochloride powder

(“coke” or “street

cocaine’’ )—usually snorted or

injected intravenously. d

Cocaine alkaloid (“freebase” or

“crack’ ’)-smoked e

Amphetamine (“speed” or “uppers”

(BenzedrmeR]-taken orally,

injected, or snorted 9

Methamphetamine (“speed” or

“crystal meth” or “ice”)

[Methadrine R

]–taken orally,

injected, or snorted 9

 h

Dextroamphetamine

[DexedrmeR]-taken orally, or

rejected

Pheumetrazine hydrochloride

IPreludin R

]—taken orally or

injected d

Methylphenidate hydrochloride

injected d

Pemollne ICylertR]—taken orally

IRitallnR]—taken orally, or

injected d

LSD (lysergic acid diethylamide) or

“acid’ ’-taken orally or put in the

eyes.

Mescaline (3,4,5-trlmethy loxphenylethyl amide) or “mesc” and

peyote-disks chewed,

swallowed, or smoked, tablets

taken orally.

Psilocybln (“magic

mushrooms’’ )-chewed and

swallowed.

MDMA (methylene

dloxymethamphetamme) —taken

orally.

(continued)
32 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Class of psychoactive substanc@

Descriptionb Examplee

INHALANTS

Inhalants are chemicals that produce psychoactive

vapors, Although different in makeup, nearly all of the

abused inhalants produce effects similar to those of

anesthetics, which act to slow down the body’s

functions or produce feelings of dizziness. At low

doses, users may feel slightly stimulated. Amyl nitrite is

used for heart patients because it dilates the blood

vessels and increases blood supply to the heart. There

are no medical indications for most of the inhalants

OPIATES (NARCOTICS) AND RELATED ANALGESICS

Opiates are natural or synthetic drugs that, like

morphine, a substance derived from the opium poppy,

have analgesic (pain-relieving) properties Heroin is not

approved for medical uses in the United States. The

major medical use of other opiates is for the relief of

pain (i e , as analgesics); some narcotics are used to

relieve coughing (i. e., as antitussives) or to treat

diarrhea Methadone is used in the treatment of

narcotic abstinence syndromes and as an analgesic in

terminal illness

PCP (PHENCYCLIDINE) AND

SIMILARLY ACTING SYMPHATHOMIMETICS

Phencycyclidine, commonly referred to as PCP, alters the

functions of the neocortex and has been called a

dissociative anesthetic. It was developed in the 1950s as

an anesthetic but was subsequently taken off the market in

1967 when it was discovered that the drug caused

hallucinations in some people,] PCP is now used legally

only m veterinary medicine as an immobilizing agent.

1.

2,

3.

4,

1,

2,

3

4

Solvents (model airplane glue, nail

polish remover, Ilghter and

cleaning fluids, and

gasoline) —vapors inhaled,

Aerosols (e,g , paints,

hairsprays)—vapors inhaled

Some anesthetics (e.g ,nitrous

oxide) —vapors inhaled

Amyl nitrite (“snappers” or

“poppers”) and butyl nitrite

(“rush’ ’)-vapors inhaled.

Heroin (“smack” or “horse”)-

injected, smoked, or inhaledd,

Codeine (codeine sulfate) —taken

orally or injected d

Morphine (morphme

hydrochloride)—injected, smoked,

or inhaled.

Synthetic opiates (e g., methadone

IDolophineR]); hydromorphone

hydrochloride IDilaudidR],

meperidine hydrochloride

IDemerolR], oxycodone and asprin

IPercodanR]—taken orally or

injected,

PCP (“angel dust” or “lovely ’’)-taken

orally, or smoked (sprayed on joints

or cigarettes) d

aAccordmg to Juhen, one could concewably classdy psychoactive drugs by at least three methods 1 ) mechanism of action, 2)

chemical structure, and3) behaworal effects Probably the most useful approach would be toclassdy them by mechamsm of achon,

but knowledge of the brain’s physiology IS too hmtted forthrs. approach to be comprehensive A Ilm[tation of the second approach ts

that many drugs of apparently slmllar structure exert qultedlfferent effects, and many drugs of dlsslmllar structure exert quite slmllar

effects The classlflcatlon m thrs table largely reflects the behavioral effects approach. The classlflcahon used here IS based on the

categories In the American Psychlatrlc Assoclatlon’s LJagnosf/c and StaOs/ica/ Manua/ of Menfa/ Dsorders, 3rd ed , rewsed According to the American Psych latnc Assoclatlon, all of the classes of psychoactwe substances Itsted m this box except rucotme are

associated with both abuse and dependence Nlcotme IS associated with dependence but not abuse

(confinued)
Chapter2 Introduction 133

bThe potentla[physlologlcal, psychological, and behaworal effects of using the psychoactwe substance shown are discussed

In the sources hsted below The consequences depend m part on the speclflc drug used, the dosage level and mode of admlnlstratlon

c Centra/ nervous system sMnukmk are drugs that can elevate mood, Increase alertness, reduce fat[gue, prowde a sense of

Increased energy, decrease appetite, and improve task performance They can also produce anxfety lnsomma, and Irritablllty The

drugs differ widely n their molecular structures and mechanisms of action

d According to the American Psychlatrlc Assoc[atlon, the route of admmtstration of a psychoachve substance IS an lmPortant

variable In determining whether use WIII lead to dependence or abuse In general, routes of admlnlstratlon that produce more efflclent absorption of the substance n the blood stream (e g , Intravenous In\ectlon) tend to Increase the likelihood of an escalating

pattern of substance uses that leads to dependence Routes that qulcklydelwer psychoactive substances to the brain (e g , smoking or Intravenous lnlectlon) are associated wlfh higher levels of consumption and with an Increased Ilkellhood of toxic effects Use of

contaminated needles for intravenous admmlstratlon of amphetamines, cocaine, and opiates can cause hepatltls, HIV Infection,

and other Illnesses

‘Freebase cocaine IS a form of cocaine made by converting “street cocaine” (coca[ne hydrochloride) to a purlfled base that IS

smoked The effect of smoking freebase IS slmllar to that of Intravenous InjectIon but smoking provides a shorter more Intense high

than sn[fflng or IngestIon because of the rapid absorption of the drug through the lungs “Crack cocaine” IS the street name gwen to

freebase cocaine that has been processed from cocaine hydrochloride to a chemical base by cmk(ng It with baking soda and

water The term crack refers to the cracking sound that IS heard when the mixture IS smoked (heated), presumably due to the sodium

bicarbonate

t Descrlblng a drug as a Stlfnulant does not adequately describe Its properties Drug use surveys typically mean amphetamines

when they use the word stimulants Some surveys regard as stimulants both prescription (amphetammes) and nonprescription substances (e g caffeine-based compounds used m No-Doz, det pills, and “fake pep pills”) Cocaine and ntcotlne (described above)

are also central nervous system slmulants

9 According to the National Institute on Drug Abuse, ~es/gnerdrugs are structural analogs of substances scheduled under the

Controlled Substances Act that are prepared by underground chemists to mimic the psychoactive effects of controlled substances

or produce other psychoactwe effects Because such analogs are not ldentlcal to their parent compound, their manufacture and

dlstrlbutlon does not violate the law As of June 1986, there were synthetic analogs of PCP, fentanyl and mependtne, and amphetamine and methamphetamme

h In the past, abuse of methamphetamlne had been m the form of tablets or Intravenous InjectIon More recently, “Ice” (one of the

common street names for d-methamphetamlne hydrochloride) has gained popularity In a form suitable for smoking

‘ Most of the agents In this class of drugs can Induce hallucinations If the dose IS high enough But the term hallucinogen does not

adequately describe the range of pharmacological actions of the dwerse group of substances usually Included m the class The

term psychedehc was proposed by Osmond n 1957 to Imply that these agents all have the abhty to alter the sensory perception

and thus may be considered “mind expanding “ The effects of hallucinogens are unpredictable and depend on the amount taken,

the user’s personahfy, mood and expectations, and the surroundings m which the drug IS used

I PCP IS considered a hallucinogen m some surveys of drug use

SOURCES Off Ice of Technology Assessment, 1991, based on the following sources American Psychlatnc Assoclatlon, D/agnosflc and Sfat/s//ca/ Manual of Menta/ D/sorders, 3rd ed rewsed @Vashlngton, DC 1987), R M Jullen, A Pnmerof Drug Act/on, 5th

ed (New York, NY W H Freeman and Co , 1988), J F Kauffman, H Shaffer, and M Burglass, “The Blologlcal Basics Drugs and

Their Effects, ’’flcoho//smar? dSubsfance Abuse C//n/ca//nterverWorts (New York, NY 1985), U S Department of Health and Human

SewIces Pubhc Health Serwce, Alcohol, Drug Abuse and Mental Health Admmlstratlon, National Instltuteon Drug Abuse, “Hallucinogens and PCP Inhalants, Marlluana, Opiates, Sedattve-Hypnotics, Stimulants, and Cocaine, ” Rockvtlle, MD, 1983, U S Department of Health and Human Services, Pubhc Health Service, Alcohol, Drug Abuse, and Mental Health Admlnlstratlon, National lnstltute on Drug Abuse, “Designer Drugs, ” N/DA Capsu/es,Rockvllle, MD, June 1986, U S Department of Health and Human Serwces,

Public Health Serv!ce, Alcohol, Drug Abuse, and Mental Health Admlnlstratlon, National Institute on Drug Abuse, “Marijuana Update “ N/DA Capsu/es, Rockvllle, MD, May 1989, U S Department of Health and Human Services, Publtc Health Serwce, Alcohol,

Drug Abuse, and Mental Health Admm[stratlon, Nahonal Institute on Drug Abuse, “Methamphetamme Abuse, ” N/DA Capsu/es,

Rockvllle MD, January 1989, and U S Department of Education, Growing Up Drug Free A Parentk Gwde to Prevent/on (VVashington, DC 1989)
34 I Technologies for Understanding and Preventing Substance Abuse and Addiction

1 Medical Model

Within the fields of medicine, the two most frequently cited texts for the definitions of substance

abuse and dependence are the Diagnostic and Statistical Manual of Mental Disorders (DSM) issued by the American Psychiatric Association and

used widely in American medical practice, and the

International Classification of Diseases (ICD)

published by the World Health Organization

(WHO).

The current ICD and DSM definitions of substance dependence are nearly identical. However,

the two manuals differ sharply on the concepts of

abuse, which DSM classifies as a maladaptive pattern of substance use leading to impairment or distress, as manifested by one or more of several

events occurring over the same 12-month period

(e.g., failure to fulfill major role obligations at

work, school, or home; recurrent substancerelated legal problems, such as arrests for substance-related disorderly conduct. The current

ICD- 10 category of harmful use, while applicable

cross-culturally, is limited to a pattern of psychoactive substance use that is causing damage to

health. The damage may be physical, as in cases

of hepatitis from the self-administration of injected drugs, or mental, such as episodes of

depressive disorder secondary to heavy consumption of alcohol (see appendix C for a full discussion of DSM and ICD definitions).

D Criminal Justice Model

While it is well-known that many crimes are committed by persons with substance use disorders

and that these disorders can be major contributors

to their crimes, the criminal justice system has no

systematic policy for the evaluation of these disorders. In many jurisdictions, whether federal, state,

or local, the prevailing sentiment is that any use of

an illicit substance and/or use of a licit substance

in an illegal manner is considered criminal abuse.

A limited set of quantitative analyses including

blood, urine, and breath tests can be performed to

detect illegal levels of alcohol and/or the presence

of illicit substances. Besides the limited amount

of testing and evaluation, psychological screening

examinations or structured interviews are used infrequently to determine the level and severity of

use, abuse, or dependence.

For purposes of this report, OTA does not adopt

any single definition for the terms substance

abuse or substance addiction/dependence. The

focus of this report, the underlying causes of substance abuse and addiction, relates to each of the

definitions discussed above.

MAGNITUDE OF THE PROBLEM

The abuse of licit and illicit drugs represents a major public health problem in the United States.

Abuse of alcohol and other drugs has been associated with many problems (see figure 2-2)

costing Americans an estimated $144.1 billion

annually.

Federal survey data estimate that 11.4 million

Americans aged 12 and older used illegal drugs in

1992, continuing a steady decline from a peak of

24 million in 1979. Findings from the 1992 National Household Survey found the following

about specific drugs:

Illegal drugs. Since 1979, overall rates of current use (defined as use within the last 30 days)

have dropped in all age groups, except those

aged 35 and older, whose use of drugs has remained level. This has resulted in a general

shift in the age distribution of illegal drug users. In 1992, 23 percent of illegal drug users

were aged 35 and older, compared with only 10

percent in 1979.

Cocaine. The number of cocaine users decreased 31 percent from 1.9 million users in

1991 to 1.3 million in 1992. This is down from

a peak of 5.8 million in 1985. The number of

occasional users (defined as those who used the

drug in 1992 but less often than monthly) also

continued a sharp decline from 4.3 million in

1991 to 3.4 million in 1992. This is down from

a peak of 8.6 million in 1985. Frequent use of

cocaine (defined as use on a weekly basis) remained unchanged between 1991 and 1992. In

fact, no significant change has occurred in this

number since it was first estimated in 1985.
Chapter 2 Introduction I 35

up to 50%0

Spousal abuse

20-350/o T

‘uicide’*zTraff::;;a’i’ies

52°/0

Rapes Manslaughter

380/o 690/o

Child abuse Drownings

SOURCE Off Ice of Substance Abuse Prevention, 1991

Marijuana. This is the most common illegal

drug—used by 78 percent of all illegal drug users in 1992.

Other illegal drugs. No major changes in the

prevalence of the use of hallucinogens, such as

lysergic acid diethylamide (LSD) and phencyclidine (PCP), between 1991 and 1992. The

survey estimates that approximately 1.8 million Americans have used heroin at least once.

However, the data on these categories are

somewhat unreliable, as these users are less

likely to be contacted and reported in a household survey.

Alcohol. In 1992, approximately 98 million

persons over the age of 12 had used alcohol in

the last month, which is approximately 48 percent of the population aged 12 and older. This

number is down from an estimated high of 106

million drinkers in 1988. The number of heavy

drinkers (defined as having five or more drinks

per occasion on five or more days in the past

month) has remained steady at an estimated 9

million people.

Tobacco. An estimated 54 million Americans

were smokers in 1992, a rate of 26 percent of

■

●

■

the population aged 12 and older. Cigarette

smoking has declined since 1988, when an estimated 57 million Americans smoked cigarettes.

Smokeless tobacco. An estimated 7.5 million

Americans used smokeless tobacco in 1992,

the vast majority of whom (7.1 million) were

males.

Inhalants. The use of inhalants (e.g., gasoline,

glue, and nitrites) dropped slightly in 1992 as

compared to 1991.

Prescription drugs. The estimated current

nonmedical use of psychotherapeutics (sedatives, tranquilizers, stimulants, or analgesics)

dropped from 1991 to 1992.

The survey also provides demographic variables useful to understanding substance use and

abuse in the United States (see box 2-3). However,

these figures, as all data on drug use, are suspect.

Most surveys have strengths and weaknesses,

which have led stakeholders and policy makers to

make widely divergent conclusions based on the

same sets of data.

MEASURING SUBSTANCE

USE AND ABUSE

Like the old fable about blind men describing an

elephant, individual drug statistics usually tell us

only part of the story (13). Each survey provides

useful information, but at the same time, each survey is flawed. Currently, no single measurement

can by itself describe drug use and abuse in all its

complexity. Nonetheless, several useful indicators do provide information to policy makers.

Three major national drug monitoring systems

are the primary data source for this review: The

National Household Survey on Drug Abuse (the

Household Survey), the National Survey of High

School Seniors (the Seniors Survey), and the Drug

Abuse Warning Network (DAWN). These continuing data series have been sponsored by the National Institute on Drug Abuse (NIDA) since the

1970s. Supplementary data sources include the

few small area studies that compare drug use by

poverty or income status and the Drug Use Forecasting System (DUF), sponsored by the National
36 I Technologies for Understanding and Preventing Substance Abuse and Addiction

According to the 1992 National Household

Survey on Drug Abuse

■

9

■

●

■

■

Illegal drug use IS most prevalent In the 18- to

25-year age group

Most Illegal drug users are m the white population (76 percent of all current users or 87 million people)

Men have a higher rate of current illegal drug

use than women

Illegal drug use is highly correlated with

educational status Those who had not completed high school had the highest rate of use

Unemployed people are twice as Ilkely as

employed people to be using Illegal drugs.

The prevalence of Illegal drug use m large metropolitan cities IS sllghtly higher than in nonmetropolltan areas

SOURCE Off Ice of Technology Assessment, 1994, based on

U S Department of Health and Human Serwces data

Institute of Justice, which provides quarterly esti

mates of drug use among the criminal population

in selected cities.

1 National Household Survey on Drug

Abuse

Since 1974, NIDA has commissioned the Household Survey every one to three years. The survey

is based on a multistage random sample of the

household population in the 48 contiguous United

States. The sample excludes persons living in

group quarters, including institutions, prisons,

military quarters, and college dormitories, and

those with no permanent address, including the

homeless.

Since 1985, a number of enhancements have

been made to the Household Survey. In 1985,

blacks and Hispanics were oversampled to provide additional cases for subgroup analyses, and

new measures of drug use frequency were

introduced to identify persons who used drugs

monthly and weekly during the previous year. In

1991, special supplementary samples were added

for six metropolitan areas with highly publicized

drug problems. Similarly, reports published since

the early 1980s provide greater detail on the demographic characteristics of users by frequency of

use.

I National Survey of High School Seniors

Every year since 1975 researchers at the University of Michigan have surveyed a nationally representative sample of approximately 16,000 high

school seniors. Beginning in 1976, a followup

survey of members from each graduating class, including an over-sampling of drug users, has been

conducted by mail. In 1990, the followup sample

included young adults aged 19 to 32.

1 Drug Abuse Warning Network

DAWN, established in 1972, is the federal government major data system for tracking patterns and

trends in the serious health consequences of drug

use. DAWN reports include statistics on the total

number of hospital emergency room visits (episodes), separate counts of the number of drugs

mentioned per episode (drug mentions), and drugrelated deaths.

Throughout the 1970s and 1980s, the DAWN

program focused primarily on data from emergency rooms and medical examiners in 27 metropolitan areas. The selection of reporting facilities,

over 700 emergency rooms and 87 medical examiners by 1989, was not random, however, and

the number of facilities reporting varied from year

to year, with facilities in metropolitan areas being

overrepresented. Beginning in 1990, DAWN implemented a national probability sample for the

collection of drug-related emergency room visit

data to allow reporting of national as well as metropolitan area information.

1 Drug Use Forecasting System

DUF, initiated in 1988 by the Department of Justice, provides estimates of drug use among

booked arrestees in selected cities based on urinalysis tests. The tests, administered shortly after arrest, measure very recent drug use among
Chapter 2 Introduction I 37

lawbreakers. Four times a year, samples of about

250 male adult arrestees in participating cities are

tested; some areas also test female arrestees and

juveniles. The proportion of persons arrested explicitly on drug charges is limited to 25 percent of

the total sample.

I Limitations of the Data

The national drug monitoring surveys have several limitations for studying drug use, abuse, and addiction:

● Most surveys rely on self-reporting. The results

of such surveys rely on the veracity of the person responding to the survey. A major, and

widely recognized, limitation in the national

surveys is that respondents may be unwilling or

unable to report their drug use accurately. Comparisons of self-report and urinalysis results

based on DUF data indicate that, among arrestees, the tendency to underreport drug use is

substantial ( 12). As one Member of Congress

noted, “how in the hell can you expect people

who live in households to share with anybody,

let alone the government, how often they use

drugs?” (3).

■ Surveys miss populations at risk for drug abuse.

The Household Survey, by definition, excludes

certain groups who do not reside in households,

such as the homeless and persons in jail or prison. Although the excluded groups represent

only 2 percent of the total population, drug use

may be higher, or different, among excluded

groups such as the homeless and jail or prison

inmates. The Household Survey may also fail

to capture drug users within the target population. Although overall survey response rates

are high (82 percent in 1990), drugs users may

have been more difficult to locate and interview

because their lifestyles may involve irregular

hours, avoiding authority, and other behaviors

that reduce the likelihood of survey response.

In addition, response rates tend to be generally

lower among young adults and residents of

metropolitan and low-income areas, and those

not interviewed may be more likely to use

drugs than those who respond to the survey.

■ Poverty indicators per se are not available.

The national drug monitoring systems contain

very limited data on poverty, and none that

meet the official poverty definition (in 1991,

the poverty thresholds varied from $6,932 for

a person living alone to $27,942 for a family of

nine or more members (6). The proxy variables

relating to employment, education, place of

residence, and race and ethnic it y unsuccessfully separate the effects of income from the effects of other correlated factors. Information on

drug use by income status is available only in

the most recent Household Surveys, and then

only by family income without regard to household size. More information is provided by the

Household Survey on other variables related to

poverty, including employment status, race and

ethnicity, and neighborhood characteristics.

The Seniors Survey provides no income data.

For high school seniors, the only regularly reported indicators of socioeconomic status are

college plans and parental education. No socioeconomic indicators are available for the followup sample of young adults except current

enrollment in college. Race and ethnic status

are not regularly reported for either sample, but

for high school seniors racial and ethnic patterns of drug use are analyzed and published

separately. DAWN has severe limitations for an

analysis of poverty and drug use. The only indicators in DAWN related to poverty are race and

ethnicity. No data are available on income status of patients or the economic status of areas

served by the facility.

■ Surveys may over- and underrepresent findings

regarding populations at risk for drug abuse.

Populations at risk for both poverty and drug

abuse, for example, are excluded or underrepresented in the major surveys and overrepresented in reports from hospital emergency rooms.

These problems mean that the findings from

these surveys are suggestive rather than definitive (see box 2-4).

■ Drug measures focus on use, rather than abuse

or addiction. The common measures of drug

use employed by the Household and Seniors

Surveys-lifetime, past year, and past month
38 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Because of populations not represented in the Household Surveys (including homeless, run-away

children, and institutionalized populations such as the incarcerated), the surveys may greatly underestimate the involvement of the poor in drug use. Two years ago, for example, Abt Associates conducted a

study to determine the number of heavy cocaine users in the United States. Two measures of heavy

cocaine use were employed, both of which measured use of cocaine in the very recent past Estimates

of the number of regular weekly cocaine users from the 1990 Household Survey were compared to estimates of the number of recent cocaine users based on urinalysis tests of arrestees from the Drug Use

Forecasting (DUF) program. DUF urinalysis tests were conducted at the time of booking, and the results

measured cocaine use during the day or two before arrest. DUF estimates therefore measured the prevalence of very recent drug use among those involved with the criminal justice system in selected major

cities

The two data systems generated significantly different estimates. From the Household Survey, Abt

estimated that there were about 662,000 heavy cocaine users in this country in 1990. This is substantially lower than the Abt estimate of 1.709 million heavy cocaine users derived from DUF data. Reasons

for the differences include both possible underreporting on the Household Survey and the fact that

many heavy cocaine users may be excluded from the household population or may be exceedingly

difficult to locate and interview. Overall, the study indicated that approximately two-thirds of the heavy

cocaine users in this country are not counted by the Household Survey and that approximately 87 percent of all heavy cocaine users are involved with the criminal justice system

SOURCE Office of Technology Assessment, 1994, based on Abt Associates, Heavy Cocaine Use m the Un/fed S[afes The Number

of Users (Washington, DC Abt Associates, 1991)

■

use—are insufllciently refined to distinguish

between casual and dependent drug use. Definitions of alcohol, drug abuse, and dependency

—such as those set forth in DSM ( 1 )—link the

quantity and frequency of use to indications of

persistent, uncontrolled consumption, impaired social and psychological functioning as

a result of use, and physical problems including

withdrawal symptoms. No published estimates

of the number of drug users meeting medical

criteria for abuse or dependence by poverty indicators are available, with the single exception

of the DAWN estimates of emergency room

contacts for dependency, which are reported by

race and ethnicity.

The surveys include few multivariate analyses.

Since the surveys do not examine variables

while controlling for factors related to drug use,

an accurate link of drug use with the role of income, race, education, and place of residence is

impossible. The dearth of such analyses results

in part from sample size limitations and in part

from the fact that secondary analyses of the national survey data have not been encouraged.

ORGANIZATION AND SCOPE

OF THE REPORT

This report has four parts: necessary preconditions, individual factors, community contexts,

and policy options.

The first part, Necessa~ Preconditions (chs.

3-5), focuses on several factors necessary for substance abuse to occur. The second part, Individual

Fac?ors (ch. 6), explores research conducted on

risk and protective factors thought to be indicators

in assessing an individual’s substance use, abuse,

and addiction. The third part, Activi~ Settings

(chs. 7 and 8), looks at how risk and protective

factors play out in various population subgroups

and in various community settings (home, school,

workplace, recreation, and neighborhood). The

fourth section, Policy Options (ch. 9), addresses
Chapter 2 Introduction I 39

the range of legislative issues and options for Congress arising from chapters 3 through 8.

This report focuses on factors that contribute to

or protect against substance abuse and addiction,

and the implications for prevention. It does not address in any depth drug treatment or law enforcement issues and interventions. Based on the

literatures reviewed by OTA about causes and prevention, however, it is clear that comprehensive

prevention strategies will generally need drug

treatment and law enforcement components, if

they are to be effective. While drawing on data

from federal antidrug prevention programs, the effectiveness of such approaches needs to be studied

in greater depth than was possible in this report.

This report is the second and final publication

of this assessment, The first publication, a

background report on Biological Components of

Substance Abuse and Addiction, described genetic, pharmacological, and abuse liability research

issues (9). Readers are also referred to earlier OTA

reports that address issues related to drug interdiction efforts (10); alcohol, tobacco, and drug abuse

prevention and services issues in adolescent

health (7); the effectiveness of drug abuse treatment in controlling AIDS/HIV infection (11); and

alternative coca reduction strategies (8).
Part I:

Necessary

Preconditions

N

o single or generic set of variables explains the misuse of

alcohol and other drugs for every individual; in other

words there are no “root causes” for substance abuse

which universally apply to everyone. However, three major preconditions must be present in order for substance abuse and

addiction to occur:

■ biology and pharmacology;

● availability; and,

= drug use, with transitions to abuse and dependency.

Chapters 3,4, and 5 discuss these three preconditions in greater

detail.

I 41
Biology

and

Pharmacology

s

ubstance abuse and addiction are complex phenomena that

defy simple explanation or description. A tangled interaction of factors contribute to an individual’s seeking out,

use, and perhaps subsequent abuse of drugs. Since more individuals experiment with drugs than eventually develop substance abuse problems, great interest persists in understanding

what differentiates these groups. Factors that can play a role in

drug abuse susceptibility include a person’s psychological makeup (e.g., self-esteem, propensity to take risks, impulsivity, depression), biological response to drugs, environmental situation

(e.g., peer groups, family organization, socioeconomic status),

and the availability of drugs. The exact combination of elements

that lead to substance abuse varies among individuals.

Underlying all substance use, abuse and addiction are the actions and effects that drugs of abuse exert. For a complete understanding of drug abuse and addiction one must address how drugs

affect the brain, why certain drugs have the potential for being

abused, and what, if any, biological differences exist among individuals in their susceptibility to abuse drugs. While many other

factors ultimately contribute to an individual’s drug-taking behavior, understanding the biological components is crucial in understanding substance abuse, addiction, and dependency.

Two biological factors contribute to substance use, abuse, and

addiction: the effects drugs of abuse exert on a person; and the biological status of the individual taking drugs. The former relates

to the acute mechanisms of action of drugs in the brain and the

long-term effects that occur after chronic exposure. The latter pertains to an individual’s biological constitution, most importantly

the presence of inherited characteristics that affect that person’s

response to a drug.

3

I 43
44 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Neurons are the cells that process information m the brain. NeurotransmNers are chemicals released by

neurons to communicate with other neurons. When a neuron is actwated It releases a neurotransmitter mto

the gap between two neurons (see figure 3-1 ). The molecules of the neurotransmltter move across the gap

and attach to proteins, called receptors, in the outer wall of an adjacent cell. Once the receptor is activated, the neurotransmltter is removed from the gap, either by reabsorphon Into the neuron that released it

or by being broken down chemically.

For each neurotransmltter m the brain, there are speclflc receptors to which it can attach Receptors

and receptor subtypes can achvate a variety of membrane and cellular mechanisms. In this way, one

chemical can have dwerse effects m different areas of the brain. Many chemicals have been Identified as

neurotransmltters. Some particularly relevant to the reported pleasurable sensahons associated with drug

abuse include dopamme, norepmephrme, serotonln, oploids and other neuropeptides, gamma ammo butyrlc acid (GABA), and glutamate.

A neuron can have thousands of receptors for many ddferent neurotransmltters. Some neurotransmltters

actwate neurons (excitatory neurotransmltters), while others decrease neuron actWy (mhlbltory neurotransmltters) Some receptors are biochemically coupled the actwahon of one modulates the funchon of

the other, either mcreasmg or decreasing its actiwty. A neuron can also have receptors for the chemical It

releases, In this way, neurons can regulate their release of a parhcular neurotransmitter. Thus, these socalled autoreceptors act as a feedback mechanism. The actwlty of a neuron WIII be determmed by the

cumulatwe achvhy of all Its various receptors.

Drugs that work In the brain, Includlng drugs of abuse, alter normal neuropharmacologlcal actwity

through a variety of ddferent mechanisms. They can affect the production, release, or reuptake of a chemical, they can mlmlc or block the action of a chemical at a receptor. or they can interfere with or enhance

the actwlty of a membrane or cellular mechanism associated with a receptor. Prolonged drug use has the

potential to alter each of these processes.

SOURCE Off Ice of Technology Assessment, 1994

The biological mechanisms of substance abuse

are complex and interactive. A previously published background paper by the Office of Technology Assessment (OTA) entitled Biological

Components of Substance Abuse and Addiction

thoroughly discusses the basic concepts, neuropharmacology, and genetics of drug abuse. This

chapter is a synopsis of the background paper.

DRUG ACTION

1 Acute Actions

Drugs of abuse alter the brain’s normal balance

and level of biochemical activity (see box 3-1). In

order to have these affects, a drug must first reach

the brain. This is accomplished by the drug diffusing from the circulatory system into the brain. The

routes of administration, methods by which a drug

enters the bloodstream, affect how quickly a drug

penetrates the brain. The chemical structure of a

drug plays an important role in the ability of a drug

to cross from the circulatory system into the brain.

The four main routes of administration for drugs

of abuse are oral, nasal, intravenous, and inhalation. With oral ingestion, the drug must be absorbed by the stomach or gut which results in a

delay before effects become apparent. When the

nasal route of administration is used, effects are

usually felt within 3 minutes, as the capillary rich

mucous membranes of the nose rapidly absorb

substances into the bloodstream. Intravenous administration usually produces effects in 1/2 to 2
Chapter 3 Biology and Pharmacology 45

Nerve impulse

‘\ ‘\ ///

Neurotransmitters Receptors

Receiving cell

—

SOURCE Off Ice of Technology Assessment, 1994

minutes and is slowed only by the detour back

through the lungs that venous blood must take to

reach the brain. Lastly, the inhalation method bypasses the venous system completely because the

drug is absorbed into the pulmonary circulation

which goes directly from the 1ungs to the heart and

then to the brain. As a result, effects are felt within

5 to 10 seconds, making inhalation the fastest

route of administration. The route of administration can determine the drug’s potency and the efficacy the drug will have on affecting brain activity,

thereby contributing to the abuse potential of the

drug.

Distinct from other psychoactive agents, drugs

of abuse, in part, affect those areas of the brain that

mediate feelings of pleasure and reward (see box

3-2). Evidence is accumulating that positive

sensations experienced during these activities are

mediated by the brain reward system. Studies

have shown that direct stimulation of the areas of

the brain involved in the reward system, in the absence of any goal-seeking behavior, produces extreme pleasure that has strong reinforcing

properties in its own right (48,60). Animals with

electrodes implanted in these areas in such a way

that electrical impulses produce a pleasurable

sensation will repeatedly press a bar, or do any

other required task, to receive electrical stimulation. The fact that animals will forego food and

drink or will willingly experience a painful stimulus to receive stimulation of the reward system attests to the powerful reinforcing characteristics of

the reward system. Most drugs of abuse, either directly or indirectly, are presumed to affect the

brain reward system.

Inducing activity in the brain reward system

gives drugs of abuse positive reinforcing actions

that support their continued use and abuse. Drug

reinforcement is defined as increasing the behavior that led to the taking of the drug. Put more simply, individuals who use drugs experience some

effect, such as pleasure, detachment, or relief from

distress which initially establishes and then maintains drug self-administration. The consequence

of taking the drug enhances the probability that it

will continue to be used for some real or perceived

effect and, hence, tends to lead to continued compulsive self-administration. In fact, the ability of

a drug to support self-administration in experimental animals is a measure of the drug’s strength

as a reinforcer.

While growing evidence suggests that the brain

reward system plays a role in the reinforcing properties of most drugs of abuse, the precise mechanisms involved are complex, vary among

substances, and have yet to be completely described (41 ,42,43). For example, while some

drugs of abuse directly affect the chemical release

of dopamine (see box 3-3), the interactions of other neurotransmitters such as gamma amino butyric acid (GABA), opioid peptides, and serotonin

may also be important.

I Chronic Actions

Chronic, long-term exposure to drugs of abuse can

cause changes in the brain that may take weeks,
46 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Eating, drinking, sexual, and maternal behaviors are actwities essential for the survival of the indwidual

and the species. Natural selection, in order to ensure that these behaviors occur, has Imbued them with

powerful rewarding properties. The brain reward system evolved to process these natural reinforcers.

The reward system IS made up of various brain structures. A key part of this system for drug reward

appears to be the mesocorticolimbic pathway (MCLP). The MCLP IS composed of the axons of neuronal

cell bodies in the middle part of the brain (i.e., ventral tegmental area) projecting to areas m the front part

of the brain (I. e., the nucleus accumbens, a nucleus in the Ilmblc system, a network of brain structures

associated with control of emotion, perception, motivation, grahf ication, and memory; medial prefrontal cortex, part of the front of the brain revolved with higher ordered thmklng) (see figure 3-2). Ventral tegmental

neurons release the neurotransmltter dopamine to regulate the activity of the cells In the nucleus accumbens and the medial prefrontal cortex. Other parts of the reward system include the nucleus accumbens

and Its connections with other Iimblc structures, and other regions in the front part of the brain (I.e., substantla mnommata-ventral palladlum) The nucleus accumbens also sends signals back to the ventral tegmental area, Finally, other neuronal pathways containing different neurotransmltters regulate the activity of

the mesocortlcollmblc dopamine system and may also be revolved In medlatmg the rewarding properties

of drugs of abuse.

SOURCE Koob, G F, “Drugs of Abuse Anatomy, Pharmacology, and Function of Reward Pathway s,” Trends m Pharmacological

Sciences 13177-184, 1992, Kcmb, G F, “Neural Mechamsms of Drug Reinforcement,” PW Kalwas and H H Samson (eds ), The

Neurobiology of Drug and Alcohol Addlctlon, Annals of the American Academy of Sciences 654171-191, 1992

months, and possibly years, to reverse once drug and amphetamines, sensitization can also occur to

use has stopped.

Most drugs of abuse have complex actions in

the brain and other parts of the body resulting in

a variety of behavioral effects. In general, tolerance develops to many of the effects of drugs of

abuse and a withdrawal syndrome occurs on

cessation after prolonged use. However, the details of these phenomena vary from drug to drug,

and the specific details of the biological mechanisms that underlie these phenomena are not completely understood. Recent advances in neuroscience research have begun to unravel how

neuroadaptive responses manifest themselves for

various drugs of abuse.

Tolerance to a drug develops when, following a prolonged period of use, more of the drug

is required to produce a given effect (33,38).

This response occurs with many types of drugs. It

is a common, but unnecessary, characteristic of

drug abuse (see box 3-4). For example, while tolerance develops to some of the effects of cocaine

some of their other effects. Also, while it is unclear from available data whether tolerance develops to cocaine’s reinforcing effects, the notion is

supported by some experimental evidence and

Frontal —

cortex

Nucleus —

accumbens

Ventral / \\wv

\

tegmental

area

SOURCE Off Ice of Technology Assessment, 1994
Chapter3 Biology and Pharmacology 47

The rewarding properties of stimulant drugs

such as cocaine and amphetamines are due directly to the effects of the chemical dopamlne,

Opiates, on the other hand, Indirectly stimulate dopam(ne by actwatlng other chemical pathways,

which in turn Increase dopamlne achwty SImllarly,

alcohol, barbiturates, and benzodlazeplnes Ilkely

have an Indirect achon which Increases dopamlne

achwty All of these drugs have reinforcing properties Phencyclldlne (PCP) IS also a strong reinforcer but Its relatlonshlp, If any, to actwlty m the dopamlne pathway has yet to be established. Other

drugs are either weak reinforcers or have not been

shown to support self -admlnlstratlon In animal experiments. Nlcotlne stimulates dopamlne neurons,

however, Its effect IS modest when compared with

cocaine or amphetamine Llkewlse, caffeine IS a

weak reinforcer, but the precise mechanisms of Its

reinforcement are unclear. Finally, cannabis and

Iyserglc acid dlethylamlde (LSD) also produce

poslhve effects that clearly support their use

SOURCE Off:ce of Technology Assessment 1994

anecdotal reports from cocaine users that the

drug’s euphoric action diminishes with repeated

use. In a recent study, it has been shown that acute

tolerance to dopamine response is induced by

binge patterns of cocaine administration in male

rats (51 ). Tolerance develops to most of the effects, including the reinforcing properties, of opiates, barbiturates, and alcohol.

Sensitization, the opposite of tolerance, occurs when the effects of a given dose of a drug

increase afler repeated, but intermittent, administration. Sensitization to a drug’s effects can

play a significant role in supporting drug-taking

behavior.

Dependence is a type of neuroadaptation to

drug exposure. With prolonged use of a drug,

cells in the brain adapt to its presence such that the

drug is required to maintain normal cell function.

On abrupt withdrawal of the drug, the cell behaves

abnormally and a withdrawal syndrome ensues.

Generally, the withdrawal syndrome is characterized by a series of signs and symptoms that are opposite to those of the drug’s acute effects. For

example, withdrawal of sedative drugs produce

excitation and irritability. Conversely, withdrawal

of stimulants produces profound depression.

The magnitude of the withdrawal syndrome

varies from drug to drug. Although the severity

varies, withdrawal is associated with the cessation

of use of most drugs of abuse. Opiates, cocaine,

amphetamines, barbiturates, alcohol, and benzodiazepines produce pronounced and sometimes

severe withdrawal symptoms (20,24,56,68,74)

while those for nicotine and caffeine are less intense (1,3 1). A mild withdrawal episode is

associated with discontinued cannabis use, while

none is associated with lysergic acid diethylamide

(LSD) use (12,63). No matter the severity of the

physical withdrawal syndrome, its existence can

create a craving or desire for the drug and dependence can play a very strong role in recurrent patterns of relapse and maintaining drug-seeking

behavior to forestall withdrawal.

At one time, withdrawal was believed to peak

within several hours after drug-taking was discontinued and then dissipate; similarly, common

knowledge held that tolerance to most drugs was

thought to dissipate gradually with time, as the

brain readapted to the drug’s disappearance. Substantial evidence now indicates that persistent, residual neuroadaptations are present, which can

last for months or possibly years, and mayor may

not be associated with the pathways that mediate

physical dependence (33,44,45,77). An important

component of this phenomena maybe the learning

which takes place during drug-taking behavior.

Moreover, with repeated cycles of abstinence and

reinitiation of drug use, the time required to elicit

drug dependence grows shorter and shorter. Evidence also indicates that the administration of naloxone, a drug that blocks the actions of opiates,

may elicit a withdrawal syndrome in individuals

who have abstained from use for extended periods

of time. These data indicate the existence of long-

-lasting, drug-induced neuroadaptive changes that
48 I Technologies for Understanding and Preventing Substance Abuse and Addiction

The two types of tolerance are: dispositional (pharmacokmehc) and pharmacodynamfc. Dispositional

tolerance develops when the amount of drug reaching active sites m the brain is reduced in some way

Generally, this arises from an Increased breakdown of the drug or a change m Its drstrlbution m the rest of

the body Thus, more drug must be taken to achieve the same blood levels or concentrations at the achve

sites in the brain.

Pharmacodynamic tolerance represents a reduced response of the brain to the same level of drug It

develops during the continued and sustained presence of the drug. It may be that the mechanism of

adaptation may differ from drug to drug and depend on the original mechamsm of achon of a gwen drug.

The net effect IS that more drug is required to overcome this new neuronal adaptation to produce an equwalent pharmacologic effect.

Although dispositional tolerance represents a component of tolerance to some drugs (e g., alcohol, barbiturates), in most cases much or all of the tolerance which develops to drugs wth slgmflcant abuse potential can be attributed to pharmacodynamic tolerance, Tolerance can contribute to drug-taking behavior by

requlrlng that an Individual take larger and larger doses of a drug to achieve a desired effect.

SOURCES Jaffe, J.H “Drug Addlctlon and Drug Abuse, ” The Pharmacological Basis of Therapeutics, A G Gllman, TW Rail, A S

N[es, and P Taylor (eds ), (New York Pergammon Press, 1990) Kalant, H , “The Nature of Addlct[on An Analysls of the Problem, ”

Molecular and Cellular Aspects of the Drug Add[chons, A Goldstein, (cd) , (New York, NY Springer Verlag, 1989)

persist for as yet undefined periods of time. Al- from NIDA, and input from FDA and DEA, the

though information explaining this effect is lacking, these changes may help account for the

relapses that sometimes occur in long-term abstinent, drug-dependent individuals.

I Abuse Liability

The Comprehensive Drug Abuse Prevention and

Control Act (Public Law 91-5 13) and the Psychotropic Substances Act of 1978 (Public Law

95-633) gives exclusive authority to the Secretary

of the Department of Health and Human Services

to determine the abuse liability of substances and

to make recommendations concerning substance

regulation and other drug policy decisions. Although the Secretary receives advice from the

Drug Enforcement Administration (DEA), the

Food and Drug Administration (FDA), and various other regulatory agencies, these laws explicitly state that the National Institute on Drug Abuse

(NIDA) must provide to the Secretary information

relevant to the abuse potential of suspected drugs

of abuse and all facts key to an assessment of their

abuse potential. On the basis of this information

Secretary makes a judgment as to the dependence

potential of new drugs. NIDA supports a variety

of activities in commercial and private laboratories around the country to provide this information.

A drug’s abuse liability is measured by the likelihood that its use will result in drug addiction.

Many factors ultimately play a role in an individual drug-taking behavior; nevertheless, the abuse

potential of a drug is related to its intrinsic rewarding properties and/or the presumed neuroadaptive

motivational effects that result from its prolonged

use. Drugs can be tested and screened for their

abuse liability in animals. Four criteria can be

evaluated to classify a drug as having significant

abuse potential:

pharmacological equivalence to known drugs

of abuse,

demonstration of reinforcing effects,

tolerance, and

physical dependence.
Chapter 3 Biology and Pharmacology! 49

The capacity to produce reinforcing effects is

essential to any drug with significant abuse potential, whereas tolerance and physical dependence

often occur but are not absolutely required to

make such a determination.

Testing new pharmaceuticals for their abuse

potential is an important step in new drug development. Many major pharmaceutical firms today

emphasize the development of new and safer

drugs for pain reduction and in the development

of psychoactive compounds for treatment of brain

disorders. In particular, scientific strides in understanding the brain, neurological disease, psychiatric disturbances, and aging are fueling research

into treatment of brain disorders. As psychoactive

compounds become available, they must be

screened for abuse potential. The abuse liability

assessment of new products is not simply at the

discretions of the manufacturer. Various federal

regulatory laws mandate such testing and federal

regulatory agencies are charged with seeing that

testing is carried out. The College on Problems of

Drug Dependence (CPDD), and, specifically, its

Drug Evaluation Committee (DEC), provides the

majority of abuse liability testing information to

NIDA.

Animal models are generally used to screen for

the abuse potential of new drugs in earlier stages

of drug development or to evaluate abuse potential in drugs that cannot be readily studied in humans (2). Laboratory methods for abuse potential

evaluation in humans are also well developed and

is an area of active research (21). However, factors

such as the heterogeneity of drug-using populations, the use of multiple drugs, and the other biological, social, and environmental factors

involved in human drug use make human studies

complex.

In terms of the validity of animal models as a

means of studying human drug addiction, an excellent correlation exists between predicting the

abuse liability of specific classes of drugs in animals and humans (34). However, it is recognized

that animal models are imperfect and, in fact, there

are examples of drugs that proved to have significant abuse potential in humans, whereas the preclinical testing in animals revealed relatively

minimal abuse potential (9,33,38). The ultimate

answer to the issue of whether a drug has significant abuse potential is long-term experience with

the drug once it has become available, either legally or illegally. Nevertheless, animal models serve

as the only practical means of initially screening

drugs for abuse liability and have proven to be the

most effective means of detecting whether there is

likely to be a problem in humans.

Self-Administration

The predominant feature of all drugs with significant addiction-producing properties is that they

are self-administered. In fact, self-administration

of a drug to the point when the behavior becomes

detrimental to the individual is the primary criterion for classifying a drug as having significant

abuse potential for addiction. In addition to selfadministration, another contributing factor to

abuse liability is the notion of craving (9.33,38).

Although craving is a difficult term to quantify,

once a drug is voluntarily or involuntarily withdrawn, the increased desire to take the drug can

play a role in the relapse to substance abuse. As

previously mentioned, the reinforcing properties

of the drug may shift the pattern of administration

established during the initial, early phase of

drug addiction. Specifically, the drug may have

initial] y been self-administered for its pleasurable

effects but may eventually be self-administered

to relieve the discomfort associated with withdrawal.

Animals can be readily trained to self-administer drugs in a variety of settings (9). Animal models of self-administration provide a powerful tool

that can give a good indication of the abuse liability of new or unknown drugs. These models also

permit examination of the behavioral, physiological, and biological factors leading to sustained

self-administration.

Drug Discrimination

Another tool in the assessment of abuse liability of drugs is drug discrimination, which refers to

the perception of the effects of drugs (3,9). Specifically, animals or humans trained to discriminate

a drug from a placebo show a remarkable ability
50 I Technologies for Understanding and Preventing Substance Abuse and Addiction

to discriminate it from other drugs with different

properties. These procedures also permit a determination of whether the subject considers the drug

to be the pharmacological equivalent of another

drug. Pharmacological equivalence refers to the

fact that drugs of particular classes, such as opiates, stimulants, and depressants cause a series of

affects on the brain and other organs which collectively constitute their pharmacological profile.

Drug discrimination provides a useful measure in

animals to assess the subjective effects of drugs in

humans.

Dependence and Tolerance

Physical dependence and tolerance to drugs of

abuse can readily be induced in animals by chronic administration of these drugs (37,38). Following abrupt cessation of these drugs, a withdrawal

syndrome will often develop and, if given the opportunity, self-administration rates will be increased. Furthermore, since the understanding of

the biological changes which take place during the

development of physical dependence and tolerance are poorly understood in humans, with the

possible exception of opiate dependency (45), animal models offer a unique opportunity to carry out

experiments designed to address these issues.

GENETIC FACTORS

Why does one person abuse or become dependent

on drugs while another, exposed to a similar environment and experiences, does not? To date, the

majority of biomedical research has focused on

the role, if any, that genetics plays in individual

susceptibility to substance abuse and dependence.

There is growing interest, however, in researching

other factors that effect a person’s biological status. For example, nutrition, biological development, in utero experiences, early exposure to

environmental lead, head injuries, and other environmental components,

neurophysiology. Thus,

tures genetics, there are

can influence individual

to the effects of a drug.

can modify individual

while this section feamany other factors that

biological susceptibility

Progress in understanding the genetics of various conditions and diseases has brought with it a

realization that substance abuse and addiction

probably involve a genetic component. That is,

hereditary biological differences among individuals may make some more or less susceptible to

drug dependency than others. However, a genetic

component alone is undoubtedly insufficient to

precipitate substance abuse and addiction. Unlike

disorders such as Huntington’s disease and cystic

fibrosis that result from the presence of alterations

in a single gene, any genetic component of substance abuse is likely to involve multiple genes

that control various aspects of the biological response to drugs, individual temperament, and the

propensity to engage in risk-taking behaviors, or

physiological predisposition to become an abuser.

In addition, the involvement of many behavioral

and environmental factors indicates that any

genetic component acts in consort with other nongenetic risk factors to contribute to the development of substance abuse and addiction. Thus, the

presence or absence of a genetic factor neither ensures drug addiction nor precludes it.

Two questions arise when considering a genetic

component to substance abuse and addiction. Do

inherited factors exist? If so, what are they? To

date, most of the work done in this field is related

to alcoholism; much less is known about the genetics of other drugs of abuse.

1 Do Inherited Factors Exist?

Results from family, twin, and adoption studies as

well as extensive research on animal models indicate that there are heritable influences on patterns

of alcohol use. Animal studies using selective

breeding techniques have established that alcohol

preference, the reinforcing actions of alcohol, alcohol tolerance, and alcohol physical dependence

can be affected by genetic factors. Although fewer

studies have examined the genetic component of

vulnerability to the addictive properties of other

drugs of abuse, evidence from animal studies confirms the role of a genetic influence on the use and

abuse of drugs other than alcohol. To study non-
Chapter 3 Biology and Pharmacology 51

alcoholic drug abuse in humans has been difficult

because of substantially lower population prevalence and marked changes in availability and,

hence, exposure to these substances. Investigation

in this area is further hampered by the complexity

of subjects’ drug use—most drug abusers have

used (and had problems from using) multiple substances. This has led researchers either to concentrate on one class of drug or to treat all illicit drug

use as equivalent. The tendency to lump all illicit

drugs into one category makes results difficult to

interpret or compare.

1 Family Studies: Alcoholism

References to a familial tendency or hereditary

“taint” of alcoholism date back to classical times

(23). Family studies have repeatedly confirmed

that the risk of alcoholism is higher among firstdegree relatives (i.e., parents, siblings, children)

of alcoholics as compared with the general population (54). Moreover, while family studies can establish that a disorder (or liability to a disorder) is

transmitted, in general they fail to distinguish between biological and environmental transmission.

This issue, however, can be evaluated in large

family studies by analyzing multiple classes of

relatives with differing degrees of genetic relatedness.

Results of numerous family studies indicate

that alcoholism segregates within families, with

male first-degree relatives of alcoholics having a

higher incidence (ranging from 27 to 54 percent)

than female first-degree relatives (6 to 17 percent)

as compared to first-degree relatives of nonalcoholics (20 percent of males, 4 percent of females)

(26,66,76). In fitting models of inheritance to

family data, researchers concluded that observed

patterns of inheritance were consistent with the

hypothesis that familial factors predisposing to alcoholism were the same in men and women, but

that nonfamilial environmental factors exerted

more influence in the development of alcoholism

in women (14). However, a review of drug abuse

research on women presented several comparative

studies of men and women showing that alcoholism among some women appeared more highly

correlated with a family history of alcohol problems. Compared to alcoholic men in various studies, alcoholic women had a greater likelihood of

having an alcoholic father and/or parents, as well

as alcoholic siblings (47). Additionally, while perhaps not genetically influenced, familial alcoholics (those with at least one relative with

alcoholism) appear to have earlier onset, more

antisocial symptoms, more social complications

of alcohol use, and worse treatment outcome than

nonfamilial alcoholics (22,62,70).

Familial is not identical to genetic, and in the

case of alcoholism, the familial patterns of inheritance are not consistent with those of a purely genetic condition (36,79). In addition, researchers

suggest that the transmissibility of alcoholism has

increased over time (65). Thus, any genetic factors

promoting the development of alcoholism are significantly moderated by nongenetic influences.

h Family Studies: Other Drugs

Although fewer family studies have been conducted on the genetic transmission of liability to

other drugs of abuse, researchers suggest that, as

in the case of alcohol, addiction to other psychoactive substances appears to run in families.

One study found evidence of drug use running

in families, based on family history obtained from

individuals admitted for substance abuse treatment (53). However, this study combined use of

all illicit drugs into one category and relied on

self-reports by the subject on his or her drug use

as well as that of family members. A large family

interview of opiate addicts found that the relatives

of opiate users had elevated rates of drug addiction

as compared with the controls (67). In addition, an

association was found between opiate use and the

presence of antisocial personality disorder

(ASPD). Further analysis of these data revealed

that the incidence of both drug abuse and ASPD

was higher among the siblings of the opiate subjects than among their parents (49,50).

A familial association between opiate addiction and alcoholism has been noted in some studies (46). However, another family history study

found that while both opiate addiction and alco-
52 I Technologies for Understanding and Preventing Substance Abuse and Addiction

holism clustered within families, co-occurrence

of the disorders within families occurred only as

frequently as expected by chance, thus supporting

the hypothesis of independent transmission (29).

Little has been done to test hypotheses regarding familial transmission of liability to addiction

to specific substances other than opiates or alcohol. One study examining treated drug abusers

and their relatives found that alcoholism was

equally common among relatives of individuals

who preferentially abused opiates, cocaine, or

sedative-hypnotics (27 percent, 31 percent, and 24

percent of male relatives, respectively), whereas

relatives of sedative-hypnotic users were subject

to diagnoses of other substance abuses (2 percent

of male relatives, versus 11 percent of male relatives of opiate abusers and 16 percent of male relatives of cocaine abusers) (55).

9 Twin and Adoption Studies

Twin and adoption studies provide information to

distinguish between biological and cultural transmission. Twin studies observe siblings raised in

the same environment, but compare how often

identical twins, who are genetically identical, and

fraternal twins, who have the genetic similarity of

nontwin siblings are concordant for a trait. A high

concordance rate for a trait among identical twins

versus fraternal twins usually indicates a genetic

component for the trait. Adoption studies, by contrast, compare the presence of a trait among biological versus adoptive family members or other

control groups. In this way individuals sharing the

same environment but having different genetic

heritages, or vice versa, can be compared.

Evidence from twin studies suggests genetic

influences on drinking patterns as well as alcoholrelated problems. Results from twin studies demonstrate genetic influences on measures of alcohol

consumption such as abstention, average alcohol

intake, and heavy alcohol use (28,39,61 ). Twin

studies also indicate an inherited risk for smoking

(16).

When evaluating the development of alcoholism, twin studies have generally supported the existence of genetic influences over the disorder’s

development. One early study found a higher concordance rate for alcohol abuse between identical

twins (54 percent) than in fraternal twins (28 percent) (35), while two other studies did not find

such a relationship (25,61). A 1991 study examined male and female identical twin pairs, and

male and female fraternal twin pairs, with one

member of the pair meeting the criteria for alcohol

abuse or dependence (64). Researchers found that

identical male twins differed from fraternal male

twins in the frequencies of both alcohol abuse and

dependence as well as other substance abuse and/

or dependence. On the other hand, female identical and fraternal twins were equally likel y to abuse

alcohol and/or become dependent on other substances, but identical female twins were more

likely to become alcohol dependent. Another

study of 356 twin pairs also found higher identical

than fraternal rates of concordance for problems

related to alcohol and drug use as well as conduct

disorder (52). The same study also noted that

among men, heritability played a greater role in

the early rather than late onset of alcohol problems, whereas no such effect was seen among

women. However, a study of 1,030 female twin

pairs found evidence for substantial heritability of

liability to alcoholism, ranging from 50 to 60 percent (40).

Thus, twin studies provide general agreement

that genetic factors influence certain aspects of

drinking. Most twin studies also show genetic influence over pathological drinking, including the

diagnosis of alcoholism, which appears (like

many other psychiatric disorders) to be moderately heritable. Whether genetic factors operate

comparably in men and women, and whether severity of alcoholism influences twin concordance

is less clear. How psychiatric comorbidity may affect heritability of alcoholism also remains to be

clarified.

Adoption studies have supported the role of

heritable factors in risk for alcoholism (6,1 1,71).

The results from a series of studies conducted in

Denmark during the 1970s are typical. Researchers studied male adoptees, later comparing them

with nonadopted brothers; female adoptees, later
comparing them with nonadopted daughters of alcoholics, comparisons were also made with

matched control adoptees. Sons of alcoholic and

nonalcoholic parents who were put up for adoption were compared for the development of alcoholism. Sons of alcoholic parents were found to be

four times as likely as sons of nonalcoholic parents to have developed alcoholism; evidence also

suggested that the alcoholism in these cases was

more severe. The groups differed little on other

variables, including prevalence of other psychiatric illness or “heavy drinking.” Being raised by an

alcoholic biological parent did not further increase the likelihood of developing alcoholism;

that is, rates of alcoholism did not differ between

the adopted-away children and their nonadopted

brothers. In contrast, a study of daughters of alcoholics revealed no elevated risk of alcoholism

(23).

Another analysis examined factors promoting

drug abuse as well as alcoholism (10). In this

study, all classes of illicit drug use were categorized into a single category of drug abuse. Most of

the 40 adopted drug abusers examined had coexisting ASPD and alcoholism; the presence of

ASPD correlated highly with drug abuse. Among

those without ASPD, a biological background of

alcoholism (i.e., alcoholism in a biological parent) was associated with drug abuse. Also, turmoil

in the adoptive family (divorce or psychiatric disturbance) was associated with increased odds for

drug abuse in the adoptee.

Finally, results from other adoption studies

suggest two forms of alcohol abuse (7,13). The

two forms were originally classified by C.R. Cloninger as “milieu-limited” or type 1 alcohol abuse

and “male-limited” or type 2 alcohol abuse (15).

Type 1 alcohol abuse is characterized by moderate

alcohol problems and minimal criminal behavior

in the parents, and is generally mild, but occasionally severe, depending on presence of a provocative environment. Type 2 is associated with severe

alcohol abuse and criminality in the biological fathers. In the adoptees, it is associated with recurrent problems and appears to be unaffected by

postnatal environment.

Chapter 3 Biology and Pharmacology I 53

While the appropriateness of the biological and

environmental parameters used in the Cloninger

study have been challenged, the discriminating

characteristics used to classify individuals as type

1 or 2 alcohol abusers have not been-until recently. A new study of familial and nonfamilial

male alcoholics has investigated the type 1 and 2

classifications by analyzing the importance of age

differences and cohort distributions (19). The researchers showed that among the male alcoholics,

there was not a clear distinction between familial

and nonfamilial based alcohol abuse problems

and type 1 or 2 characteristics, as reported in previous studies. Additionally, another recent publication discusses the absence of paternal sociopathy in the etiology of severe alcoholism, and the

possibility of a type 3 alcoholism (30). This type

of research raises obvious questions as to the validity of the discriminating characteristics originally outlined by Cloninger and currently used in

the classification of individual alcohol abusers.

In summary, adoption studies of alcoholism

clearly indicate the role of biological, presumably

genetic, factors in the genesis of alcoholism. They

do not exclude, however, a possible role for nongenetic, environmental factors as well. Moreover,

researchers have suggested more than one kind of

biological background may be conducive to alcoholism. In particular, one pattern of inheritance

suggests a relationship between parental antisocial behavior and alcoholism in the next generation. Thus, adoption studies, like other designs,

suggest that even at the genetic level, alcoholism

is not a homogeneous construct.

9 What Is Inherited?

While study results indicate a probable genetic

component to alcoholism and probably other drug

abuse, they lack information about what exactly is

inherited. For example, do individuals with a family history of drug abuse have an increased susceptibility or sensitivity to the effects of drugs with

reinforcing properties? If a susceptibility exists,

what are its underlying biological mechanisms?

To understand what might be inherited, both indi-
54 I Technologies for Understanding and Preventing Substance Abuse and Addiction

viduals who have a substance abuse problem and

animals models of substance abuse are studied.

Various types of information can be derived from

these studies. As with family, twin, and adoption

studies, much more information is available about

alcoholism as compared with other drugs of

abuse.

First, it maybe possible to identify specific inherited risk markers for alcoholism and other substance abuse. A risk marker is a biological traitor

characteristic associated with a given condition.

Thus, if an individual is found to have an identified marker for substance abuse, he or she is at risk

for developing a drug dependency. To date, no biological characteristic has been clearly identified

as being a risk marker for either alcoholism or substance abuse, although evidence suggests some

possible candidates. The identification of a valid

and reliable risk marker could provide important

information about the fundamental mechanisms

underlying substance abuse and addiction and

would be an invaluable aid in diagnosis and treatment.

Second, inherited differences in biochemical,

physiological, and anatomical processes related to

differences in drug responses might be identified

and studied. Animal models of substance abuse

allow thorough biological assays to be carried out.

Animal genetic models of substance abuse consist

of strains of animals (usually rodents) that have

been selectively bred to either exhibit a preference

for taking or refusing a drug, or to differ in some

way in their behavioral or physiological response

to a drug. In the case of alcohol, studies suggest

that low doses of alcohol are more stimulating and

produce a stronger positive reward in rats bred to

have a high preference for alcohol as compared

with normal rats. Experimental data indicate that

this may be due to inherited differences in the dopamine, GABA, and serotonin systems (27,32,

57,73). These differences represent inherited

traits related to drug taking behavior, and these

animals can be examined to determine what biological mechanisms are involved in the expression

of these traits.

Third, the genetic technique of linkage analysis

can narrow the area on a chromosome where a

gene may be located. It can lead to the identification of the gene itself which in turn can improve

the understanding of the molecular events that underlie the expression of the gene. There have been

few genetic linkage studies related to substance

abuse since few specific biological traits associated with drug dependency have been identified.

Some studies in humans have been carried out related to alcoholism but the findings of these studies are contradictory and inconclusive.

Several studies have reported an association

between alcoholism and a gene that regulates the

number of a type of dopamine receptor in the

brain; other studies have found no such link

(4,5,8,18,58). The reason for this discrepancy is

unclear. One study revealed a relationship between the presence of the gene not only in alcoholics, but in other disorders such as autism, attention

deficit hyperactivity disorder, and Tourette’s syndrome (17). Thus, the presence of this particular

gene, while not uniquely specific for alcoholism,

may cause an alteration in the brain’s dopamine

system that somehow exacerbates or contributes

to alcohol abuse.

Few studies have examined possible inherited

biological mechanisms associated with the abuse

of other drugs. For example, strains of rats and

mice that differ in their sensitivity to the reinforcing effects of cocaine and in their cocaine-seeking

behavior have been observed to also have differences in the actual number of dopamine-containing neurons and receptors in certain brain areas.

Also, a comparison of one strain of rat that self-administers drugs of abuse at higher rates than

another strain, found that the higher self-administering strain exhibited differences in the intracellular mechanisms that control activity in some

of the neurons in the brain reward system (see box

3-2) as compared with the low self-administering

strain. Additional studies exploring the role of

genes in drug response are needed to more fully

understand the full range of biological factors

associated with drug abuse. The recent develop-
Chapter 3 Biology and Pharmacology 55

ment of new and more sensitive techniques to analyze brain activity and processes will facilitate

these studies.

ROLE OF LEARNING

The learning that occurs during drug-taking activities is an important force in the continued use

and craving of drugs (59,72). Drugs of abuse often

produce feelings of intense pleasure in the user. In

addition, such drugs produce changes in numerous organ systems (e.g., cardiovascular, digestive,

endocrine). Both the behavioral and physiological

effects of a drug occur in the context of the individual’s drug-seeking and drug-using environment. As a result, environmental cues are present

before and during an individual drug use that are

consistently associated with a drug’s behavioral

and physiological effects. With repetition the cues

become conditioned stimuli, that on presentation,

even in the absence of the drug, evoke automatic

changes in organ systems and sensations that the

individual reports as drug craving. This is analogous to Pavlov’s classical conditioning experiments in which dogs salivated at the cue of a bell

following repeated pairing of food presentation

with a ringing bell. Evidence for this effect is seen

in numerous studies showing that animals seek

out places associated with reinforcing drugs and

that the physiological effects of drugs can be classically conditioned in both animals and humans

(72).

Conditioning also occurs in relation to the

withdrawal effects of drugs (75). It was observed

that opiate addicts who were drug free for months

and thus should not have had any signs of opiate

withdrawal, developed withdrawal symptoms

(e.g., yawning, sniffling, tearing of the eyes) when

talking about drugs in group therapy sessions.

This phenomenon, termed conditioned withdrawal, results from environmental stimuli acquiring

the ability, through classical conditioning, to elicit

signs and symptoms of pharmacological withdrawal. Conditioned withdrawal can also play a

role in relapse to drug use in abstinent individuals.

The emergence of withdrawal symptoms as a result of exposure to conditioned cues can motivate

an individual to seek out and use drugs.

These associations are difficult to reverse. In

theory, repeated presentation of the environmental cues, without the drug should extinguish the

conditioned association. Animal studies indicate

that stopping the conditioned response is difficult

to achieve and does not erase the original learning.

These types of studies examining drug conditioning have found that various aspects of extinguished responses can either be reinstated with a

single pairing of the drug and environmental cue,

can be reinstated with a single dose of drug in the

absence of the environmental cue, or can spontaneously recover (72).

Thus, exposure to environmental cues

associated with drug use in the past can act as a

stimulus for voluntary drug-seeking behavior. If

the individual succeeds in finding and taking the

drug, the chain of behaviors is further reinforced

by the drug-induced, rewarding feelings and the

effects of the drug on other organ systems (59).

The effects of the environmental stimuli can be

similar to the priming effects of a dose of the drug.

The complexity of human responses to drugs of

abuse, coupled with the number of drugs that are

abused, complicates understanding of the role of

biology in drug use and abuse. Nevertheless, scientists know the site of action of many drugs in the

brain, and sophisticated new devices are expected

to improve that understanding. A genetic component to drug use and abuse is likely, but it has not

been fully characterized.

SUMMARY

Underlying all alcohol and drug problems are the

actions and effects that drugs of abuse exert. It is

important to understand how drugs work in the

brain, why certain drugs have the potential for

being abused, and what, if any, biological differences exist among individuals in their susceptibility to abuse drugs.

Two biological factors contribute to substance

abuse and addiction: the effects drugs of abuse exert on the individual, and the biological status of
56 I Technologies for Understanding and Preventing Substance Abuse and Addiction

the individual taking drugs. The effects the drugs

exert can be either acute or chronic and will vary

depending on the drug and its route of administration. Most drugs of abuse influence the brain’s reward system. The pleasurable sensations that drug

use can produce reinforce drug-seeking and -taking behaviors. These actions differ with different

drugs: and, thus, some substances have greater potential for abuse and addiction than others.

Prolonged or chronic use of a substance or substances can produce both biological and behavioral changes (some long-lasting). Biological

changes can include sensitization and/or tolerance

and, if use is discontinued, withdrawal. The behavioral changes from continued drug use are directly related to these biological changes. An

individual’s drug-craving, -seeking, and -taking

behaviors are amplified through the neuroadaptive changes in the brain reward system that occur

with chronic administration.

Environmental cues also play a large role in

drug-seeking and -taking behavior. On encountering certain environmental stimuli (i.e., specific

locations, smells, tastes), drug-craving and drug

withdrawal symptoms have been reported by former drug users who have been drug-free for

months, even years.

Through family, twin, and adoption studies,

most researchers agree that genetic factors play

some part in the heritability of alcohol problems

and, although less clear, other drug problems. No

conclusive evidence has been found to explain

precisely what is inherited or the overall importance of this inherited material. It has been hypothesized that there are probably numerous

genes (as opposed to one) that interact in complex

ways, and whose expressions are affected by a

myriad of environmental factors. Thus, the presence or absence of a genetic factor neither ensures

nor protects against drug dependency.
A

vail ability is a precondition for drug abuse and dependency. A person cannot become a drug abuser unless a drug is

available to be used.

Drug availability is often thought of as mere physical

presence of an abusable substance. In addition, however, availability is affected by social norms (social availability), prices

(economic availability), and personal values (subjective availability y) (see table 4-1). Marketing techniques for both licit and illicit drugs can alter social, economic, and subjective availability,

and thus are addressed in this chapter (see box 4-1).

A substantial body of literature addressing the relationship between drug availability and drug demand does exist. However,

most of this information addresses tobacco and alcohol, rather

than illicit drugs. In addition to conducting a literature search (primarily of mass media), the Office of Technology Assessment

(OTA) contracted with the National Center for Juvenile Justice

(NCJJ) to conduct a survey of juvenile probation officers on the

perceived availability of drugs and to conduct a workshop on

availability issues (see appendix F for a list of participants).

AVAILABILITY

Availability is a concept usually reserved for the supply-side of

the substance abuse policy equation (i.e., making drugs available

to supply an already existing demand). However, the proximity of

drugs and drug dealers to potential users, and the ease with which

these substances can be purchased or otherwise obtained can affect demand, use, and abuse. This is especially true when one considers aggressive marketing efforts by suppliers, who seek to

create or expand the demand for drugs by convincing potential

Availability 4

1

 I 57
58 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Category Primary question

Physical availability Is a substance physically

available?

Economic availability Is the substance affordable?

Subjectwe availability Is the substance available In

a manner I would choose to

use?

Social availability Is the substance available In

my social setting?

SOURCE Off Ice of Technology Assessment, 1994

consumers of the benefits, acceptability, and

availability of these substances. While availability is a concept that applies to the whole range of

drugs, most of what we know about its role in drug

use and abuse comes from research in the arena of

alcohol and tobacco abuse (1 ,9,10, 14) (see box

4-2 and figure 4-1 ).

Research has shown that when alcohol is more

available, the prevalence of drinking, the amount

of alcohol consumed, and the heavy use of alcohol

all increase (5). Alternatively, the literature also

suggests that physical conditions that restrict

alcohol availability reduce rates of alcohol consumption (1). A review of alcohol-related literature reveals that availability y can be conceptualized

in four different, yet related categories.

@ Physical Availability

Physical availability refers to a basic element—

the proximity and accessibility of an abusable

substance. Simple logic dictates that if a substance

is absent, it cannot be used. Government interdiction and law enforcement policies target the physical availability of illicit drugs. Other policies,

such as limitations on the point-of-sale, hours, or

age of purchasers, target the physical availability

of other abusable drugs, such as tobacco and alcohol products.

Responses to the OTA survey of juvenile

probation administrators indicated that respondents perceived two ways in which physical availability is increased: through contamination by

outsiders (e.g., youth gangs, tourists, foreigners)

Marketing includes any activity involved m

moving goods from producer to consumer In the

context of drugs, marketing includes a variety of

activities covering a wide range of licit and Illlcit

substances

For Iiclt substances, such as alcohol, tobacco, and inhalants, it includes market research,

advertwng, pricing, and taxation A number of

government policies in the marketing arena—

taxes, advertising restrictions, point-of-sale controls, and age restrictions on certain products—

directly affects the availability of licit, yet abusable, substances

For illicit drugs, such as marijuana, cocaine,

and hallucinogens, marketmg techniques can include street markets, gang achwty, and prwate,

closely controlled distribution and sales systems

Government control in this area—prohiblhng the

possession, use, and sale of such substances—

Ilkewlse affects the availability of these substances.

SOURCE Off Ice of Technology Assessment, 1994

bringing drugs into the community, and through

proximity to a source of drugs or alcohol.

Gangs and organized drug trafficking were

mentioned often by respondents as reasons for increases in the availability of drugs. Respondents

from all over the country, representing both rural

and urban areas, registered concerns about gangs

and their role in marketing and trafficking drugs.

A respondent from Canton, Mississippi, for example, attributed the increase in drug availability

simply to “gang leaders from California.” A respondent from Waterbury, Connecticut, was more

explicit about the age and ethnicity of the gang influences, attributing the observed increase in

drugs to the “emergence of gang activity for the

12-to-1 5-year-old age group, particularly in the

Hispanic and black ethnic groupings.” A respondent from Paducah, Kentucky, said that the “increase in drugs has been from gangs entering the

community from Memphis, Tennessee, Arkansas,
Chapter4 Availability 159

The evolutlon of tobacco from a relatwely rare product requiring preparation, thought, and ritual to a

product that IS ubiquitous, prepackaged, and consumed without much fanfare provides a graphic illustration of how Increased physical avallablllty of a product can dramatically Increase drug use, abuse,

and addlctlon Three major developments [n the history of tobacco use paved the way for mak[ng this

drug Imminently available for use by consumers the invention of the cigarette manufacturing machine,

the InventIon and perfechon of matches, and the proliferation of the use of vending machines to sell

tobacco products

The first successful cigarette manufacturing machine was developed in 1881 by James A Bonsack

This machine had the capacity to produce more than 200 cigarettes per minute Prior to the advent of

this machine, smokers had to roll each cigarette by hand, a time-consuming and often ntuallstic process

Once rolled, a cigarette must be Ilt to be consumed This was no easy task prior to the Introduction

of the safety match, first invented In 1896 but not perfected until 1912 Without matches, smokers were

required to enter cigar stores to Ilght cigarettes from gas or oil lamps provided specifically for the purpose of Ilghtlng tobacco products These developments changed forever the way that cigarettes were

consumed by mak(ng them read(ly available for consumption at any moment during the day Instead of

a thoughtful, often ntuallstic exercise, cigarette consumption has evolved for some Into an almost unconscious habit Following the invention of the manufacturing machine and the safety match, the rate of

cigarette consumption soared during the late 19th and early 20th century

The use of vending machines may be the most revolutionary aspect of tobacco availability First

Introduced In 1926, vending machines require no sales person, are not restricted by selected hours of

operation, and are not concerned with the age or legality of the purchaser Vending machines make

cigarettes available almost anywhere, appearing In bars, hotels, train and bus stations, airports, hotels,

and restaurants By 1953, nearly half a million cigarette machines existed and were responsible for

sales of more than 3 bllllon packs of cigarettes a year The upward trend in sales from cigarette machines continued through the mid-1 970s by 1973 more than 900,000 vending machines were in operation, selllng almost 5 bllllon packs per year Some early research indicated that the existence of vending

machines throughout the physical environment is a major inducement to Impulse smoking

SOURCE Office of Technology Assessment, 1994, based on J Mosher, “The Environmental Approach to Prevention, ” The California

PreventIon Network Journal 3, 42-44 (1 990), R Tenant, The American Cigarette Industry A Study In Economic Analysis and Publlc

Policy (New Haven CT Yale U~werslty Press, 1950), R Sobel, They Sat@ The Cigarette In American Ilfe (Garden City, NJ Anchor

Press/Doubleday, 1978), Marshall, M V, Automatic Merchandlslng, A Study of the Problems and Llmltations of Vending (Cambridge,

MA The Rwerslde Press, 1954)

and Chicago, Illinois.” The respondent from Dav - However, gangs were not the only phenomena

enport, Iowa, attributed the increase to attempts

by “Chicago gang members to establish crack

markets in Quad Cities—lots of arrests of Chicago

residents including juveniles. ” Even cities with an

established history of youth gangs identified

gangs as being responsible for increases in drugs.

For example, a respondent from Philadelphia,

Pennsylvania, attributed the observed increase to

the fact that ● ’gang participation has become increasingly sophisticated. ”

associated with increasing the physical availability of drugs and alcohol. Many respondents were

concerned with the potential for contamination

due to proximity to areas thought to be established

drug markets or through proximity to the means

for widespread drug distribution (e.g., major highways and roads, prisons).

Physical availability is necessary but not solely

responsible for drug use. For example, drugs often

are physically available but are not always used.
60 I Technologies for Understanding and Preventing Substance Abuse and Addiction

The cigarette rolling machine was patented in 1881 by James Albert BonSack, a Lynchburg, Virginia, teenager

Also, seeking to prevent or reduce drug use solely

by eliminating or reducing physical availability

may be doomed to failure, since it has proven to

be very difficult to keep drugs out of communities.

So although the concept of physical availability is

important, it is limited, both as a cause and a cure

to drug use and abuse.

1 Economic Availability

Economic availability may be increased when a

person has access to surplus income or the costs of

drugs are low, illegal drug sales are a key component of the local economy, or the price per unit of a

drug or drugs in general is reduced. In describing

the difference between “private” and “flagrant”

drug markets, one article specified some of the dimensions of the changing economics of addiction:

If cigarettes were sold only by the carton and

whiskey only by the case, the effect would be to

decrease the total consumption of tobacco and

whiskey. Presumably, few people would start

smoking cigarettes if the first experimental purchase were a $20 carton rather than a $1 pack.

Similarly, fewer poor people would drink if they

were required to buy whiskey by the case. A

similar effect would, in all likelihood, hold true

if open air and flagrant drug markets were eliminated (3),

In addition to overall conditions, economic

availability of all substances can be affected by the

pricing of products. For licit products such as alcohol and tobacco, economic availability is also

affected by taxes levied by federal, state, and local

authorities.

In 1989, federal excise taxes on tobacco, alcoholic beverages, and motor fuels raised $24.4 billion in revenue—about 2.5 percent of total federal

revenues (11 ). Excise taxes—taxes on specific

products—while representing a small part of total

taxes, are an important consideration in the economic availability of licit substances.

Excise taxes are seen by many as having three

impacts:

● to raise revenue for government programs;

■ to make certain harmful substances less affordable and, hence, less used and abused; and
——.

Chapter 4 Availability I 61

$

.,

. . >:V’

7:-- ‘-- .y --1925

7001yr.

.

.;: --192 0

>

426/yr.

i$— 1915

3101yr.

J ‘--

~ ., -1910

134iyr.

;:: .:.<:

. .

y.,

Americans consumed.5 billlon cigarettes m 1880, 2.2 billlon

m 1888, 18 bdhon m 1914, and 54 billion m 1919. The annual

per-capla consumption of cigarettes ref/ected the tota/

production figures

SOURCE R Sobel, They Satisfy The Cigarette m American bfe (New

York NY Anchor Press/Doubleday, 1978)

= to cover societal costs that accrue from the use

of various subtances (e.g., environmental costs

from the use of gasoline, health costs resulting

from smoking and drinking).

Whether taxation of alcoholic beverages and

tobacco products is an appropriate means of

reducing societal costs caused by their use is a

continuing public debate. Some argue that the

public health costs and other external costs are so

significant as to justify substantial excise taxes.

Others counter that such taxes are regressive—impacting the poor more than the rich—and reduce

the satisfaction experienced by millions of sensible drinkers without necessarily reducing the

harm caused by excessive drinkers (8).

1 Social Availability

Social availability refers to those factors within

the community conducive to drug use. One study

explored alternative explanations for reported declines in cocaine use among high school seniors,

using questionnaire data from annual nationwide

surveys conducted from 1976 to 1988 (2). Results

of this analysis indicated that although lifestyle

factors showed strong links with the use of marijuana and cocaine, these factors had not developed

trends in ways that could account for declines in

the use of either drug. Reported physical availability of either drug had not been reduced.

Instead, increases in perceived risks and disapproval appear to have contributed substantially to

the recent declines in the use of marijuana and cocaine. The study concluded that it was important

to lower demand by reducing social availability,

as opposed to trying to reduce supply by reducing

physical availability.

Increasingly, grass roots community action

groups are working to diminish both the subjective and social domains of availability. These efforts usually entail developing and presenting

public awareness and fact-based education to consumers and potential consumers, decreasing community tolerance for drug use while increasing

collective pride in the community, and developing

or otherwise demonstrating alternatives to substance use and abuse.

1 Subjective Availability

Subjective availability encompasses individual

differences in how people perceive their access to

substances. For example, an individual may

choose to use one type of abusable substance, but

not another. Or, an individual may choose to use a

drug (e.g., cocaine), but only in certain forms (i.e.,

a person may choose to snort a line of cocaine but

refuse to smoke or inject it). The person who refuses to use illicit drugs has interjected his or her

personal values in a way to make illicit drugs unavailable, even if they are physically and economically available.
62 I Technologies for Understanding and Preventing Substance Abuse and Addiction

One reviewer identified four components of

subjective availability as it relates to alcohol:

1) willingness to go out of one’s way to purchase

alcohol, 2) perceived convenience of buying alcohol, 3) discomfort about buying alcohol, and

4) importance of the price of alcohol. Subjective

and social availability were demonstrated to have

direct influences on alcohol consumption, and

subjective and social aspects of availability can

mediate and outweigh the influence of physical

availability (1).

Subjective availability is likely to increase

when an individual holds attitudes or values favorable toward use; lives in a community that condones, or even celebrates, drug use; and has ready

access to drugs that are highly valued, particularly

if those agents are addictive.

ARE DRUGS READILY

AVAILABLE?

A number of surveys exists for measuring drug

use (see chapter 2). In addressing the question of

whether drugs are readily available, several measures exist (e.g., marketing figures related to alcohol and tobacco sales, tallies of illegal drugs

seized by law enforcement authorities). In addition to quantitative measures of drug use, many

people perceive various drugs to be widely available. In an attempt to measure these anecdotal

perceptions, OTA surveyed juvenile probation administrators randomly selected from a database

maintained by NCJJ.

The purpose of the survey was to identify communities that have experienced a sudden, observable change in the abuse of drugs or alcohol in the

past 12 months and to collect preliminary data

about the events and circumstances leading to the

change in abuse. Such anecdotal evidence could

be gathered from a number of groups; OTA chose

to survey juvenile justice officials because of their

involvement in drug issues and the availability of

a nationwide database of such officials who could

be accessed.

Influx of Illegal drug marketeers in

the community.

Increase in gang activity.

Increase of illegal sales of alcoholic

beverages to minors.

Establishment of new drug

distribution routes.

Increased community tolerance of

illegal drugs and illicit alcohol

use.

Development or introduction of

“new” or ‘(designer” drugs.

Establishment of businesses or

other entities that attract wide

diversity of youths (i.e., shopping

mall, under 21 dance clubs, etc. )

Decreased law enforcement

presence in the community,

64.0

63.7

60.1

53.8

41.9

35.9

33.2

26,6

36.0

36.3

39.9

46.2

58.1

64.1

6 6 8

734

SOURCE Off Ice of Technology Assessment, 1994

Responses were received from 246 juvenile

justice administrators across 38 States. The data

provide a glimpse at some of the drug and alcohol availability issues being addressed by juvenile courts and probation departments across

the United States. Seven findings resulted from

the survey:

Most respondents consider substance abuse to

be a serious problem in their communities. Using a scale of 1 (not serious) to 10 (very serious), the respondents, on average, rated the

problem of substance abuse among juveniles in

their communities at 7.4. In addition, 85.8 percent of the respondents rated substance abuse

seriousness at six or above.

Almost half of the respondents indicated a dramatic increase in availability of drugs and/oralcohol in their communities. A total of 46.7

percent of the survey respondents reported a

dramatic increase in the availability of drugs

and/or alcohol in their communities. Some

50.8 percent of the respondents indicated “no

dramatic changes” in perceived availability of

drugs and/or alcohol. Only 2.4 percent indicated a dramatic decrease in availability.
Chapter 4 Availability I 63

Dramatic Dramatic

decrease Decrease No change Increase increase Don’t know

Alcohol

Marijuana

Psychedelics

Amphetamines

Barbituates

TranquiIizers

Heroin

Cocaine

Cocaine (Crack)

Other Narcotics

Inhalants

0.4

1 6

0.8

2.0

0.8

0.8

1.2

1,2

0.8

09

08

2.1

4.9

5.8

6.7

8.3

6.2

4.6

3.7

2.5

1.8

4 2

42.0

50.2

41,7

56.7

61.4

59.3

48,1

28,1

27,4

51,3

46,3

44.4

34.2

24.0

15,4

4.6

8.3

20.7

39.7

35.3

10.1

23.8

9.9

7 4

6.2

2.1

0.4

0.4

2.5

17.8

24,5

2.2

14.6

1.2

1.6

21.5

17,1

24.5

2 4 9

22,8

9.5

9.5

33.7

10.3

SOURCE Off Ice of Technology Assessment, 1994

8

■

■

m

Factors affecting physical availability (i.e.,

sales and/or distribution of drugs) were selected most often and were rated highest in

terms of increasing availability y of drugs. Given

an opportunity to select and rate commonly

cited reasons for increased availability of drugs

and alcohol, the respondents selected items that

were strongly associated with the sales and distribution of drugs and alcohol (see table 4-2).

Crack cocaine and cocaine were much more

likely than other drugs to show dramatic increases in availability. Respondents were given

an opportunity to report whether they had noticed a change (ranging from a dramatic decrease to a dramatic increase) in the availability

of a range of drugs, including alcohol. Crack

(24.5 percent) and cocaine (17.8 percent) had

the highest percentage of respondents indicating a “dramatic increase” in availability. The

next closest were inhalants at 14.6 percent (see

table 4-3).

Economic conditions and the perceived lack of

real opportunities for many youths were frequently cited as factors contributing to the increased availability of drugs in many

communities (see box 4-3).

Survey respondents listed several factors contributing to a sense of social availability, including lack of parental/guardian supervision,

consequences for alcohol and drug offenses, al9

ternative activities, as well as portrayals of alcohol and drug use by the mass media as a

glamorous and healthy activity (see box 4-4).

Substance abuse prevention and early intervention efforts were rated highest as important

community responses to increases in the availability of drugs and alcohol. Over 80 percent of

respondents agreed that an increase in prevention and intervention efforts was an important

response to an increase in the availability of

drugs. Trailing behind prevention and early intervention were increased law enforcement

(68.4 percent), increased treatment (68.2 percent), and stiffer judicial penalties (68.0 percent). Respondents were also asked to rate the

relative effectiveness of the listed responses to

availability on a scale of 1 (not effective) to 10

(very effective). Prevention and early intervention (6.4 percent) was rated the highest in terms

of perceived effectiveness, but not much higher

than law enforcement (6.2 percent), increased

treatment (6.0 percent), and stiffer judicial penalties (6.2 percent) (see table 4-4).

MARKETING

Standard marketing strategies used to increase

consumption of legal goods are used in equally effective ways to increase consumption of illicit

drugs. Marketing refers to efforts by individuals
64 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Economic factors impact on perceptions of availability in a number of ways. For example, because

Sioux Falls, South Dakota, was experiencing a “strong economy juveniles have had an abundance

of cash available for alcohol/drug usage. ” More frequent, however, were comments stating the opinion

that a poor economy increased the economic availability of drugs and alcohol:

Frankfort, Kentucky: “Profit motive due to national economy and lack of job training/jobs Lack of

hope and opportunity for some causes increased sale of drugs due to high profit. ”

Barbounrille, Kentucky: “Drug dealers that cannot make it flipping hamburgers, but are successful

at selling drugs and have a lot of material evidence of their success. Law enforcement needs to confiscate these material items in prosecution of case. Also, involvement of drug dealing by law enforcement

and politicians is a problem. “

Harrisburg, Pennsylvania: “Teenaged drug dealers have status, money, jewelry, cars, designer

clothes, etc , which many of their peers cannot afford. ”

Fort Worth, Texas. “Depressed economic conditions—Lack of legitimate means to obtain income

It’s easy money with minimal consequences for conviction. ”

SOURCE Office of Technology Assessment, 1994

interested in the sale or trade of a product to main- ● Bottles, concert kits, brass straws, spoons

tain or increase sales by maintaining market

shares and opening new markets. Marketing includes efforts to increase the perceived availability of a product or products by enhancing the sense

of both subjective and social availability in prospective consumers. To the extent that those efforts are successful, then purveyors of consumer

products will attempt to make the supply match

the demand (physical availability) at a cost that

maximizes both sales to consumers (economic

availability) and profits to the sellers.

1 Illegal Drugs

Illegal drugs are marketed aggressively in the

United States. Some of the strategies for marketing illicit drugs are very similar to those strategies

for marketing licit products. Sometimes the distinction between licit and illicit products is difficult to determine. Take, for example, the case of

so-called head shops. Drug paraphernalia are

items sold specifically to promote the preparation,

manufacture, or marketing of drugs. Head shops

may sell a wide variety of products that are often

associated with specific drugs, for example:

■ Stash cases, rolling machines, pipes, bongs

(marijuana).

(cocaine).

Head shop paraphernalia that some patrons might use in

consuming crack cocaine. They include, clockwise from the

top, a snuff inhalec a plastic coke card, a gold plated set at

center composed of a spoon, nasal straw, razor blade, and

mirroc Users cut any large particles of cocaine on the mwror

with the blade and shape the drug into thin lines before

inhaling them. The gold plating prevents the acid in cocaine

hydrochloride from rusting the equipment. Prefoldedpapers

make neat and efficient packets for storing cocaine. The

necklace at the top doubles as a cocaine spoon.
. .

Chapter4 Availability 165

Conway, New Hampshire. “Our law enforcers are known and make little inroads towards prosecuting drug traffickers or sellers. Many young adults supply liquor and drugs to underage kids in our area. ”

Mount Holly, New Jersey ‘

i

The legal system does not fairly prosecute offenders It gives some juveniles the message that depending upon your circumstances lt is OK to use and sell drugs “

Muskogee, Oklahoma “The lack of prosecutive vigor in alcohol-related offenses (Minor in possession, publlc intoxication, D U I ). District attorney does not vigorously pursue and law enforcement treats

D U I as publlc intoxication “

Prineville, Oregon “This community IS basically a blue collar community. There ts an attitude of

acceptance of juveniles using alcohol Kind of a boys will be boys attitude “

South Bend, Indiana “We have seen an Increase in alcohol consumption that appears to be tolerated or even encouraged by adults (primarily parents) “

Hillsboro, Illinois “Lack of education, Interest, cooperation of parents Not enough interest with

higher offlclals (e g , school teachers, church members, government officials, businesses, and senior

clhzens) “

Baraboo, Michigan “Lack of appropriate teen activities Lack of parental interest “

Jacksonville, Illinois “Decrease in the ability and willingness of individual family units to educate,

Instruct, and monitor juvenile behaviors “

Nicholasville, Kentucky ‘(Alcohol is supplled wllllngly to Juveniles by a large number of adults inhalants are available at any department store “

Brownstown, Indiana “Children, mostly high school age, come in contact wdh adults, ages 18-23,

who are very willlng to buy alcohol or sell drugs to their younger friends In addition, these children who

do not have money on hand are likely to steal items and trade them for drugs or cash to buy alcohol

and drugs “

SOURCE Off Ice of Technology Assessment, 1994

■ Glass pipes, viles, stems, screens, shaker poses. Specifically, head shops contribute to the

bottles (crack cocaine).

■ Testing kits, scales, adulterants (heroin).

■ Canisters, balloons, tanks (inhalants).

Head shops represent the most shrewd form of

pro-drug marketing by targeting mostly young

customers and providing the technology and products required to increase the ability of users to procure, prepare, hide, and ingest drugs. Despite

Federal legislation prohibiting the sale of drug

paraphernalia (18 USC Ap4), heads shops continue to flourish. These shops can avoid the intention

of the law because the definition of what constitutes drug paraphernalia is ambiguous and open to

interpretation. Head shop owners will simply emphasize the legitimate use of their products. For

example, they may sell a scale designed to weigh

drugs as a product to weigh food for dieting purdrug abuse problem by:

8

■

✘

■

●

sending a double message—if drugs are so bad,

why is drug paraphernalia sold openly?

operating, in some cases, in the guise of candy

stores, exposing children to drug paraphernalia

and stimulating curiosity about drugs;

serving to facilitate the use, marketing, and sale

of drugs;

selling items designed as conversation pieces

which serve to glamorize drug use; and

becoming hubs for drug abusers, indirectly

serving to increase crime in the neighborhoods

in which they operate.

Another example of a marketing strategy used

for licit substances and now being adapted for illicit substances is total marketing, which consists
66 I Technologies for Understanding and Preventing Substance Abuse and Addiction

of four basic strategies-promotion, product,

price, and place—to maximize the exposure of a

product in a positive light to the most likely consumer groups (4).

A key component of total marketing is promotion, or advertising particular product lines to appeal to particular subpopulations of the

consuming public. Promotion is a standard practice in the marketing of legitimate products—it is

also a very powerful force for manipulating consumer habits.

Promotion includes activities like advertising

and sponsorship of sporting and entertainment

events (7). For illicit drugs, promotional activities

may include sponsoring a party in which the illegal drug is dispensed free or at a dramatic discount

along with other attractions (e.g., sex, drug paraphernalia) (15).

Total marketing also entails the development of

a product line that can be targeted to subpopulations within the larger consumer community. For

example, alcohol and tobacco manufacturers will

produce an array of products targeted at several

consumer groups—premium beers for one group,

wine coolers for another, rugged masculine cigarettes for one group, thin feminine cigarettes for

another. Similarly, purveyors of illegal drugs have

begun to develop product lines—powdered cocaine for one group, crack cocaine for another. The

use of brand names is one technique used by marketers to establish a niche in the larger market,

which is one reason people become unwilling participants in the marketing wars between Coke and

Pepsi or Visa and American Express or even Bud

and Bud Light.

A great deal of uniformity exists in the price,

quantity, and quality of drugs sold in the same city,

especially in the same neighborhood or street market. As a result, a dealer will occasionally try to

capture a larger share of the market by increasing

the weight or strength of the product and applying

a brand name for recognition (3).

In Washington, DC, for example, brand name

heroin is sold under the name of “Smurf,” “Mr. T,”

“Brown Wrapper,” and “Black Poison.” Phency -

clidine (PCP) is occasionally sold under the brand

name “Hinkley” (after John Hinkley, the man who

Glycerine bags bearing the trademark “D, O. A.” for Dead on

Arrival, one brand of heroin sold in Rochester, New York.

shot Ronald Reagan), ● ’Gofer” (a reference to a

television character on the “Love Boat,” which is

a popular street name for PCP), and “Keys to St.

E’s” (a reference to a local mental institution).

Crack cocaine is sometimes hawked under the

brand names of “Conan,” “007,” and “Baseball. ”

Pricing is the process of assigning a retail cost

to each item in a given product-line that matches

the ability of the targeted subgroup to pay. By producing a line of products at a wide range of prices,

the purveyor of the goods can maximize the consumer population. For example, whether a consumer of tobacco products is smoking low-priced

generic cigarettes from the supermarket or highpriced cigarettes from the tobacconist, that individual is included in the range of consumers.

Illegal drug sellers also price their particular products to move. For example, while powdered cocaine may be too expensive for some

economically disadvantaged consumers to pur-
Chapter 4 Availability I 67

BAYER send far

PH@tM#CWTK/4L samphzs mid

p~ODUCTiikI’ahJI’? tl

F~I?BENF~IUI@N

-,TO,B OF

EIJBIRFEIJD CO. NIX? YOR

ST

:K.

Tetracetylmorphma, a derivation of morphme, was first

synthesized m 1874, but the substance remamed //tt/e known

ur)td (he Bayer Company marketed the substance as heroin in

1898

chase regularly, almost everyone can afford a $5

vial of crack cocaine. Drug dealers also manipulate the cost for their goods to attract customers.

Once a product has been developed, promoted,

and priced to move, a place must be found to most

effectively sell the product. Legal nonmedical

drugs are packaged and made available at retail

outlets in such a way as to make their purchase as

convenient as possible.

Wine coolers, for example, are a type of beverage aimed particularly at women and young

people. With its sweet, light taste, low prices, and

convenient packaging, the wine cooler competes

with beer and soft drinks for occasions such as picnics and sports events, where traditional wine

products are unlikely to be consumed. Wine cooler ads promote just these types of uses. Packaging

has taken on a beer or soft drink look, and the industry is successfully obtaining access to convenience stores and supermarket outlets to make

purchases easier (6).

Illicit drugs can also be packaged and made

available at “retail” outlets where purchasers can

conveniently obtain the product(s) of their choice.

One news account suggests that “mass marketing

that would have made McDonald’s proud” is responsible for the evolution of crack cocaine from

a drug derided as “garbage rock” just a few years

ago into a national craze.

Crack was not invented, it was creatcd by a

sharp crowd of sinister geniuses who took a simple production technique to make a packaged,

ready to consume form of the product with low

unit price to entice massive numbers of consumers. Cocaine powder required an investment of

nearly $75 for a gram, but a hit of crack costs as

little as $5. Equally alluring was crack’s incredible “high’’ -an instantaneous euphoria because

it was smoked-that could create addicts in

weeks (16).

Two kinds of retail drug markets exist in the

United States: the private market place and the

open-air or flagrant drug markets (3). The private

drug market involves transactions that occur between people who are known to one another or are

referred by a trusted acquaintance. Referrals in the

private marketplace are usually not very far removed from the original connection; they may be

classmates in college, business associates, relatives, or persons belonging to the same club.

The familiarity of the parties in the private drug

market usually means that there is a reduced level

of public exposure and violence. The desire to

keep the flow of traffic to the site of transactions

at a minimum means that sales in the private marketplace tend to be of larger quantities of drugs

than those in street transactions. Because most of

the transactions take place “behind closed doors”

or in some other clandestine fashion, a high degree

of impermeability exists in the dealer-customer

relationship (3). Examples of private drug markets include “speakeasies” during prohibition and

the “traditional” (i.e., before crack) cocaine markets.

Another aspect of the private drug market is the

ritualistic aspect of procuring the product. Consider, for example, the ritual associated with pur-
68 I Technologies for Understanding and Preventing Substance Abuse and Addiction

chasing cocaine. One author describes “a day in

the office” of a street-level cocaine distribution

network. The office itself is a highly structured

operation, complete with receptionists to screen

potential customers, guards, a “catcher’’--held on

retainer to retrieve cocaine thrown out of a window during a bust—and the merchant who sets

prices, arranges to barter goods and services, gives

credit, and makes day-to-day decisions regarding

sales (15).

A typical transaction involves a positive identification of the buyer, a greeting and brief social

contact (e.g., handshake, hug, kiss) between the

merchant and the buyer, a formal request for an

amount of cocaine, and a discussion of method of

payment (e.g., cash, barter). Sometimes the transaction involves a brief discussion of the relative

quality of the drugs in the street, a sample of the

drug available from this particular merchant, and

possibly some haggling over price. The public

weighing and packaging of the cocaine is central

to this type of transaction. The scale, in fact, becomes a central point of power and authority in the

business; only those with the highest level of trust

and respect can operate the scale (15).

Open air and flagrant drug markets, on the other

hand, tend to be far more impersonal and much

less ritualistic than the private marketplace. Many

of the concepts used by mass marketers of licit

products are used in the flagrant marketplace—

targeted consumer groups, small and widely affordable units of sale, prepackaged goods with

fixed prices, convenient retail outlets. One research team describes the mechanics of a typical

open-air drug market transaction:

A car drives down a residential street with

enormous apartment buildings on either side.

Young men wave to the car; a few of the more

aggressive dealers step into traffic to signal autos to stop. Even before the wheels have stopped

rolling, several young men are at the window;

“You looking?” says one. “Smoke, smoke. I’ve

got crack. Whatever you want” says the other

peering over his shoulder. The answer from the

driver is simple and short: “Two dimes.” Two

small brown glass vials are exchanged for a 20

dollar bill and the transaction is over in a matter

of seconds (3).

Although the exact method for conducting a

transaction may vary slightly from place to place

around the country, the essence of the transaction

is remarkably similar across the United States.

Flagrant or open-air drug markets have many of

the same structural characteristics as legal marketplaces: demographic and product segmentation,

brand loyalty, cartel pricing, aggressive salesmen

working on commission, and careful recruitment

of loyal and productive employees (3).

1 Alcohol and Tobacco

The marketing of legal yet addictive substances, especially tobacco and alcohol, has become controversial in recent years. Issues

stemming from the marketing of licit substances

include advertising, taxation, and labeling.

Advertising

Alcohol and tobacco products have long been advertised in the United States. In the 1950s and

1960s, these products were advertised with minimal restrictions. Following the Surgeon General

report on the hazards of smoking in 1964 (1 3),

public sentiment against cigarette advertising increased. The most famous example of Federal regulation is the ban on broadcast cigarette

advertising in January 1971 resulting from the

passage by Congress of the Public Health Cigarette Smoking Act of 1969 (Public Law 91-222).

In recent years, attention has focused on legislative proposals to ban all forms of cigarette advertising, and to control the advertising of alcoholic

products.

Taxation

The federal government currently levies excise

taxes on alcoholic beverages and tobacco products. Excise taxes on all types of alcoholic beverages were raised in 1990 to their current levels.

Currently, for example, beer (six pack 12-ounce

cans) carries a 33 cent federal excise tax, a 750 ml

bottle of wine carries a 21 cent federal excise tax.
Chapter4 Availability 169

It ts unlawful for any person to manufacture, package, or import for sale or distrlbuhon within the

Umted States any cigarettes the package of which falls to bear one of the followlng labels

SURGEON GENERAL’S WARNING Smoking Causes Lung Cancer, Heart Disease, Emphysema,

And May Complicate Pregnancy

SURGEON GENERAL’S WARNING Qulttlng Smoking Now Greatly

Health

SURGEON GENERAL’S WARNING Smoking By Pregnant Women

mature Birth, And Low Birth Weight

Reduces Serious Risks to Your

May Result In Fetal Injury, PreSURGEON GENERAL’S WARNING Cigarette Smoke Contains Carbon Monoxide

It IS unlawful for any person to manufacture, Import, or bottle for sale or distribution in the United

States any alcohollc beverage unless the container of such beverage bears the followlng statement

GOVERNMENT WARNING (1) According to the Surgeon General, women should not drink alcoholIC beverages during pregnancy because of the risk of birth defects (2) Consumption of alcohollc beverages Impairs your ablllty to drive a car or operate machinery, and may cause health problems

SOURCE 36 USC 1331 27 USC 213

A pack of cigarettes carries a federal excise tax of

24 cents.

A number of studies in the 1980s focused on the

impact of federal excise taxes on cigarette consumption. A 1986 study concluded that an 8- to

16-cent increase in the federal cigarette excise tax

would encourage from 1 to 2 million young persons and 8,000 to 1.5 million adults to quit smoking or not to start. Thus, a tax increase could

prevent hundreds of thousands of premature

smoking-related deaths, while a tax decrease

would contribute to the disease burden of tobacco

(14). The General Accounting Office, in a review

of the literature on teenage smoking and excise

taxes, concluded that an increase in the cigarette

excise tax would be an effective way to reduce

teenage smoking ( 12).

Labeling

Federal law addresses the labeling of both cigarettes and alcoholic beverages. In both cases, Congress declared that the purpose of such labeling is

to make sure the American public is informed

about the potential health hazards that may result

from consumption (36 USC 1331; 27 USC 213).

Manufacturers of cigarettes must use one of four

rotating warnings on each package, while

manufacturers of alcoholic beverages must post a

prescribed warning (see box 4-5). Proponents of

labeling have stated that such warnings do not

create legal restrictions, but only help to inform

the consumer about possible health risks. Opponents of labeling have argued that no scientific

proof exists to link labeling with reduced use or

improved health.

SUMMARY

The second set of preconditions for drug abuse

and dependency includes availability and marketing. A person cannot become a drug abuser unless

a drug is physically available to be used. In addition, however, availability is affected by social

norms (e.g., factors within the community conducive to drug use, including level of parental or

guardian supervision, lack of consequences for alcohol and drug offenses, lack of alternative activities, portrayals of alcohol and other drug use by

friends and the media as a glamorous and healthy

activity), prices (economic availability), and personal values (subjective availability).

The primary focus of U.S. antidrug policy has

been to attack the physical availability of illicit

drugs through law enforcement efforts aimed at

disrupting the production, transport, and sale of

drugs. While this focus has increased drug-related

arrests-nearly half of newly sentenced federal
70 I Technologies for Understanding and Preventing Substance Abuse and Addiction

inmates in 1991 were imprisoned on drug

charges-illicit drugs are still widely available.

Marketing techniques for both licit and illicit

drugs can alter social, economic, and subjective

availability. Key components of marketing include the promotion and advertising of particular

product lines to appeal to particular subpopulations of the consuming public; development of a

product line that can be targeted to subpopulations

within the larger community of consumers; pricing strategies to attract new buyers; and identification of retail outlets for sales.

Federal law regulates the merchandising of licit

yet abusable substances such as tobacco, alcohol,

and prescription drugs by placing a variety of restrictions on how such products maybe marketed.

Despite current restrictions, debate continues as to

whether and how a variety of legal drugs should

be marketed.
Substance

Use and

Transitions to

Abuse and

s

ubstance use is another precondition and contributor to addiction, since one cannot become dependent on a substance

without first using it, continuing its use, and passing

through stages of progressively more serious use.

Patterns of progression from use to addiction are not, however,

consistent or predictable for all individuals. They can vary widely, depending on numerous individual and contextual factors and

on characteristics of the use itself, such as age of onset and the

type, frequency, and quantity of substance used. While other

chapters in this report focus on individual and contextual factors,

this chapter focuses only on the characteristics of drug use itself

that can contribute to the progression to abuse and addiction.

Researchers have failed to identify specific levels of substance

use or of substance-related problems that clearly distinguish use

from abuse (16). This is the case, in part, because substances can

differ greatly in their abuse liability and, in part, because the same

levels of use of a particular substance can affect the functioning of

various individuals differently. For example, for some individuals, the initial use of certain substances may constitute substance

abuse, because of the severe adverse consequences of the initial

use itself. (Although abuse is usually associated with large quantities of substance use per occasion, resulting in either the risk of

harm to others (e.g., drunk driving) or to self (e.g., blackouts),

some in the prevention field define any initial use of an illicit substance as substance abuse, because the substance being used is illicit and should not be used.)

Although the distinction between use and abuse is unclear, the

causes of substance use--especially initial or casual use—are

thought to differ in man y cases from the causes of substance abuse

Addiction 5

171
72 I Technologies for Understanding and Preventing Substance Abuse and Addiction

and addiction. Some researchers have asserted

that substance use results primarily from social influences (e.g., peer pressure), while abuse results

more from internal psychological and physiological processes (13). Others have reported, based on

longitudinal data, that current substance use was

related more to the early modeling of use by adults

and to one’s own prior use, whereas problem use

was related more to early rebelliousness (22). A

review of prevention programs also supports the

conclusion that the factors associated with the initiation of use differ from the factors associated

with escalation to abuse (23).

SUBSTANCE USE

Because substance use is necessary as a precondition to abuse and addiction, prevention efforts can

be directed at initial use, continuing use, or progression in use to block the later development of

addiction.

Possible goals are:

Prevent initial use. One way to prevent substance abuse and addiction is to prevent any initial use. The surest way to succeed would be to

keep abusable substances out of the community, since, if they are unavailable, they cannot be

used. However, once the substances are available in a community, other preventive approaches can be tried, including scare tactics

(as with a policy of zero tolerance, backed up

by stem parental, school, and legal penalties for

use), educational efforts (through media campaigns or prevention curricula in the schools),

training in refusal skills, and promotion of safe

nonsubstance-using activities. The lack of clear

standards and penalties, credible information,

and alternative activities may certainly increase

the vulnerability of youth to the appeals of

abusable substances, but the presence of such

efforts has not guaranteed success in preventing initial use among all youth.

Delay initial use. Another goal is to delay initial

use as long as possible, thus delaying the point

at which any progression from use to abuse to

addiction can begin. Such an approach can provide at least some protection for some chilMaterial from the “Just Say No” campaign.

m

dren—i.e., those who might otherwise initiate

use at earlier ages and then more rapidly progress to abuse and possibly addiction. Early onset of substance use is often more severe than

late onset and, as is discussed later in this chapter, early use of substances is one of the better

predictors of subsequent problems. Thus, a

delay in initial use may offer significant protection even if substances are used later on.

Prevent, reduce, or control continued use.

Another approach is to try to prevent current

users from continuing or escalating their use of

one substance or moving on to other substances

with greater abuse liability. Many youth experiment with cigarettes, alcohol, and marijuana,

but do not progress to problematic use of these

or other substances. Others, however, do progress. Efforts to reduce, prevent, or control continued and progressive use, if successful, can

protect individuals from the problems of abuse

and addiction.

Preventing, delaying, reducing, or controlling

the use of substances can help prevent abuse and

addiction. Because of their directness and apparent simplicity, these goals can be very appealing.

Detracting from their appeal, however, is that they

can be difficult to achieve, especially for multi-
.

Chapter 5 Substance Use and Transitions to Abuse and Addiction I 73

problem individuals in communities where abusable substances are widely available and

aggressively marketed, and for individuals who

may be physiologically predisposed to the continued and escalating use of substances.

In addition to being a precondition (without

which abuse and addiction become impossible),

substance use can also be an important contributor

to later abuse and addiction, by affecting individuals physiologically, psychologically, and socioculturally.

1 Physiological Effects

Addictive substances affect processes in the brain,

some of them operating through reward systems,

and can produce drug tolerance and dependence.

Tolerance manifests itself when, to produce a given response (e.g., a high), an individual must ingest more of a substance. Physiological drug

dependence has at least two defining characteristics: the development of tolerance to the effects of

the drug and the manifestation of symptoms of

withdrawal on abrupt discontinuation or reduction in dosage. The development of physiological

tolerance and dependence can contribute to the

progression from use to abuse and addiction: as

tolerance to a substance increases, an individual

must ingest more of the substance to continue to

obtain a given desired response; as dependency

develops, an individual must continue to ingest

the substance to avoid the unpleasant experience

of withdrawal.

I Psychological Effects

Substance use may contribute to further use and

abuse through psychological means as well. For

example, an initial successful experience of use

may reduce an individual’s fear about the substance, thus opening the way to continued use that

can lead to growing tolerance and dependence.

Changes in expectations about the consequences of alcohol use have also been associated

with increases in behavioral tolerance. Specifically, less impairment from drinking alcohol occurred when, after the ingestion, successfully

performing certain tasks was rewarded, while all

Buttons urging the use of a designated driver, developed by

Mothers Against Drunk Driving (MADD) in conjunction with

AAMCO Transmissions. The joint campaign targets specific

times identified by MADD as especially susceptible to

drinking and driving—summer, Labor Day, New Year's Eve,

and St. Patrick's Day.

other variables that increase tolerance were controlled. Several recent studies and a literature review have found that the ingestion of alcohol

increased when the rewards for alternative behaviors were constrained (24). Also, social drinkers

who expect the effects of alcohol to be better than

the outcomes of other activities may well be more

likely to make the transition to abusive drinking.

Such a hypothesis is supported by several studies

that found that alcohol abusers identify a greater

number of favorable consequences of alcohol consumption than do nonabusers (24).

Continued use of substances can also impair

the learning of skills, especially among the young,

and the ability to remember lessons once learned.

Developmental processes may be slowed, which

may hamper decisionmaking, in general, and

about the use of substances, in particular. However, the progression from use to abuse may also,

in many cases, not be simply linear, as when individuals move in and out of substance abusing patterns, depending on the developmental stages and

social and cultural situations and contexts that

may be affecting them.
74 I Technologies for Understanding and Preventing Substance Abuse and Addiction

[ Sociocultural Effects

Sociocultural factors, triggered by substance use,

can also contribute to progression in use. An individual who initiates use, for example, may begin

to participate in a subgroup that encourages use,

such as the patrons of crack houses, groups of heroin users, members of substance-using motorcycle gangs, adolescent peer groups, cocktail

party groups, after-work beer groups, and groupies who follow certain rock bands. (In some cases,

too, such groups and subcultures may provide the

impetus for the initiation of use as well.) Such social and cultural environments encourage, reinforce, maintain, and increase substance use and

abuse—all of which can develop after the initiation of use outside the group. Conversely, the lack

of rewarding, substance-free alternative groups

and activities may render individuals more vulnerable to the appeals of substance-using groups

and subcultures.

STAGES IN THE INITIATION OF USE

Do individuals first use one substance (e.g., alcohol or tobacco) and only later use another (e.g., cocaine or heroin)? Are stages in the first use of

different substances similar across cultures? Does

the use of one substance (e.g., marijuana) directly

increase the likelihood of later use of another substance (e.g., heroin)? Or is progression in use

caused more by other mediating factors, such as

multiple behavior problems? If so, might these

other problems contribute to later use of certain

substances even in the absence of the use of other

substances earlier on?

The basic question about whether there are

stages in the initiation of the use of different substances has been studied in the United States

(9,11,12,21,27) and in Israel and France (l).

While study results vary somewhat, the sequence

most often reported is that alcohol and cigarette

use come first, followed by marijuana use and

then by the use of other illicit substances. Some

variations in this sequence have been found for individuals of different sexes, racial and ethnic

groups, and cultures. The idea that the use of some

substances increases the likelihood of the use of

other substances has led to several hypotheses.

1 The Stepping Stone Hypothesis

In its strongest form, the so-called “stepping

stone” hypothesis asserted that the use of marijuana often or almost always led to violent crime

and to the use of other illicit substances (28). This

hypothesis has never been proved. An even earlier

version of the steppingstone hypothesis goes back

to the beginning of the 20th century, when the presumed progression from tobacco to alcohol to

morphine use was presented as an argument for

prohibiting both alcohol and tobacco. One observer commented that there was no strong evidence

that the use of these substances causes progression

from one to another; rather, some individuals are

more prone to the use of multiple substances.

Also, the criminalization of marijuana may have

caused some marijuana users to move on to other

illicit substances through contact with the subculture of illicit users (14).

I The Gateway Hypothesis

More recently, a more moderate hypothesis, the

gateway hypothesis, has been put forward. It asserts that use of certain substances increases

somewhat the chances of progression to the use of

other substances. For example, in one longitudinal study, men who had used both alcohol and cigarettes by age 15 had a 52 percent greater chance

of using marijuana, compared to men who had

never used alcohol or cigarettes by age 25 (26).

For women, the increased chance of marijuana use

among alcohol and cigarette users was 46 percent.

Similarly, for the next stage, men who had used

marijuana by age 15 had a 68 percent greater

chance of initiating the use of other illicit substances, compared with those who had never used

marijuana. For women, the increased probability

was 53 percent.
Chapter 5 Substance Use and Transitions to Abuse and Addiction I 75

I Early and Frequent Use

A still more constrained version, but one that may

be more predictive, suggests that early and frequent use increases the probability of movement

to later levels in the sequence (12). For example,

researchers have reported that early use of substances is associated with later problematic use

(7,20).

1 Nonuse of a Substance at

an Earlier Stage

Another hypothesis proposes that the nonuse of a

substance at an earlier age reduces the chances of

later use of other substances. A longitudinal study

has found that the chance that an individual who

had never used marijuana would move up a level

to use other illicit substances was very low (26).

This finding corroborated conclusions reached

earlier based on a cross-sectional study ( 18).

Because of variations among communities and

cultures, the search for a universal y applicable sequence in the initiation of the use of different substances may be less fruitful than the study of why

there may be somewhat different sequences, depending on factors such as availability and social

norms. The relative ease of availability of some

substances (e.g., cigarettes, beer, wine) may well

account for their frequent appearance at an early

stage in the sequence of use. However, this may

vary among cultures. In France, for example, wine

is widely available and used both at an early age

and at an early stage in the sequence. In other cultures, where wine is less available but inhalants

are widely available and inexpensive, inhalants

are used at an early age and early in the sequence.

Use at a young age may be a marker, at least in

some cultures, for other risk factors, such as parental substance abuse and other family problems,

which can contribute to later substance abuse

problems, independently of early and frequent

use. For example, one study found that, irrespective of the age of onset of use, individuals who exhibited numerous behavioral problems in their

youth moved on to problem substance use, no

matter how early or late in their youth they began

to use substances (20).

9 Limitations in the Research

Research into stages in the initiation of the use of

different substances has itself evolved through

stages. A number of issues, which have not been

thoroughly addressed, remain:

The identification of stages in the progression

from use to abuse and addiction is more a description of the stages some individuals move

through than a prediction of necessary stages

for most individuals, since the majority of substance users do not move on to abuse. Reasonable questions are: What prevents some

individuals from progressing from initial use to

abuse and addiction? Are the obstacles primarily due to the absence of preconditions, such as

biological and pharmacological preconditions

or availability and marketing. Studying those

individuals who do not progress from use to addiction may provide insights and lessons about

how to prevent progression among those who

do progress. Of particular importance are studies of the changing vulnerabilities and resiliencies of individuals in different developmental

stages from childhood through adolescence,

young adulthood, and adulthood.

What is the role of substance use in progression

to abuse and addiction? The initiation of use of

a particular substance may often not be the

most important contributor to the use of a substance higher in the sequence. Other factors directly related to use may play a larger role. For

example, age of onset, quantity, frequency,

techniques, and purposes of the substance use

may be more salient. Longitudinal risk factor

and expectancy studies have begun to look at

the role of these other elements.

Are some individuals more predisposed to use

and abuse substances than others? Individual

biological and psychological factors may also

strongly influence which individuals progress

from use to abuse.

What environmental factors contribute to substance use and abuse? Availability, marketing,

social norms, peer groups, subcultures, and settings that encourage substance use may also be

key in determining which individuals progress.
76 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Despite the need for greater understanding

about the issues above, already completed research into stages in substance use has been

influential in providing the basis for policy and

program recommendations. The gateway hypothesis has encouraged some prevention advocates

and program planners to focus on preventing or

delaying the use of gateway substances (e.g., alcohol, cigarettes, marijuana) as a possibly effective

way to prevent later use of illicit substances. Longitudinal studies have found that the use of cigarettes by youth can be a strong predictor of later

problems with substances (17).

STAGES IN THE CYCLE OF USE,

ABUSE, AND ADDICTION

One approach to the study of stages in substance

use focuses not just on the initiation of use; but

also on the continuation of use, maintenance and

progression of use within a class of substances;

progression across classes; and regression, cessation, and relapse cycles in use and abuse (2).

~ Initiation of Use

Initiation is clearly a key first step in the progression to more serious levels of use. Because substance use is often initiated during adolescence,

most substance use research has focused on initiation of use among adolescents. However, most individuals who initiate substance use do not

progress to harmful use. Also, the factors

associated with such progression may often differ

from the factors associated with initiation. Thus,

the focus on the initiation of use during adolescence is not sufficient for an understanding of the

progression from use to abuse and addiction.

1 Continuation of Use

After trying a substance for the first time, one person may say, “I won’t be trying that again,” while

another may say, “That’s for me.” Although only

limited research has been conducted on risk and

protective factors associated with the transition

from experimentation to continued use, the continuation of use can apparently be influenced by

the pharmacology of the substance (e.g., whether

it produces desired or pleasant experiences), the

biology of the individual (e.g., whether specific

individuals have genetic or acquired biological

predispositions or intolerances to the use of specific substances), the availability and marketing

of the substance (e.g., whether a substance is

widely available, used, and accepted for use), other characteristics of the individual (e.g., at what

developmental stage one is, and whether one has

mental or emotional problems, which may be

ameliorated at least temporarily by substances),

and community contexts (e.g., substance-using

subcultures or settings that strongly encourage

and reinforce a continued use of substances).

1 Maintenance and Progression of Use

Within a Class of Drugs

Maintenance and progression may include conformity with norms of consumption—for example, initial and continued heavy use of alcohol in

a college fraternity. Progression with cocaine

could entail movement from snorting to smoking

or injection. College students in some fraternities

and sororities with drinking traditions may be at

higher risk for heavy substance use, especially of

alcohol. But very little research has been conducted on the risk factors for maintenance of high

levels of use or for progression within classes of

substances to excessive use among this age group.

I Progression in Use Across Classes of

Substances

At this stage, an individual may try different substances for different, and often compensating, effects. For example, the antiemetic properties of

tetrahydracannabinol in cannabis can be used to

facilitate greater use of alcohol, alcohol or marijuana can be used to smooth out the aftermath of

snorting cocaine, and heroin can be used for similar purposes after a binge with crack.

~ Regression, Cessation, and

Relapse Cycles

The transition away from abuse may occur a number of times before an individual succeeds in getting off a substance or, failing that, remains
Chapter 5 Substance Use and Transitions to Abuse and Addiction I 77

In the eighteenth and nineteenth centuries, artists depicted alcoholism as the “drunkards progress.” This example, probably

made around 7850, consists of six printed cotton banners,

dependent. It may also be influenced by the same

factors, or kinds of factors, that contributed to the

substance abuse problem in the first place, including the full range of biological and pharmacological factors, availability and marketing, individual

emotional needs, or contextual factors.

STAGES IN PROBLEM BEHAVIORS

Does substance use itself contribute to conduct

disorders, delinquency, and other problem behaviors? DO these behaviors then, in turn, contribute

to the progression to more use and to abuse and addiction?

Adolescents who use substances, especially

those that are illegal, are more likely than nonusers to exhibit various problem behaviors, including: early sexual experimentation, delinquent

activities, eating problems, and psychological or

psychiatric problems, including suicide and suicidal thoughts ( 10). Less is known, however,

about the sequencing of these behaviors. The interrelations among the factors is likely to vary

widely among individuals, but some sequences

may predominate. Several such sequences have

been proposed. One suggested developmental sequence, for example, includes six stages: oppositional (characterized by disobedience at home);

offensive (including disobedience in school,

fighting, lying); aggressive (physical attacks on

others, theft at home); minor delinquency (shoplifting and status offenses, such as alcohol use,

truancy, running away); major delinquency

(break-in and entry, car theft, substance abuse,

robbery, drug dealing); and violence (assault,

rape, homicide) (15).

One of the few studies of problem behavior sequences looked at the order of initiation of four

different substances, delinquency, and sexual activity, among a sample of black adolescents (3).

For males, it found involvement proceeded gener-
78 I Technologies for Understanding and Preventing Substance Abuse and Addiction

ally from beer use to cigarette use, then to delinquency, sexual activity, marijuana use, and the use

of hard liquor. For females, the progression was

generally from cigarette use, to delinquency, beer

use, sexual activity, marijuana, and hard liquor.

For both sexes, delinquency and youthful sexual

activity tended to precede the use of marijuana and

hard liquor.

While a high correlation among problem behaviors has been frequently found, the sequencing

of those behaviors is less clear. The early use of socalled gateway drugs, such as beer and cigarettes,

may contribute to later problem behaviors, while

the later use of marijuana, hard liquor, and other

illicit substances may be more the result of extended participation in problem behaviors. More

research is needed in this area if these hypotheses

are to be better understood and tested.

KEY ASPECTS OF USE

Some research has focused on characteristics of

substance use that can strongly influence the progression from use to abuse and addiction. In addition to the age of first use, these characteristics

include the frequency, quantity, and type of substance used, and the technologies and purposes

and expectations of use.

1 Age of First Use

Initiation into substance use at a young age is one

of the most striking and often-found predictors of

later problems, including abuse. For example, in

one large community epidemiology study, men

who first used substances before age 15 developed

mental and behavioral problems in 51 percent of

the cases, compared with 16 percent among those

who began at age 18 or later. For women, the comparable figures are 39 and 12 percent, respectively. Other studies have also found problems later on

associated with the earlier introduction to alcohol

or other drug use (19).

This pattern seems to hold specifically for later

substance use and abuse as well. Early use of substances was found to be associated with later problematic use (7,20). Another study estimated that,

of the men who had initiated the use of marijuana

by the age of 14,71 percent would be expected to

initiate the use of other illicit substances by age

25, compared with 9 percent of those who first

started at age 21 (12),

One report asserted that frequency of use was

the mechanism through which early onset probably operates (12). However, another study concludes that preexisting conduct problems are a

better predictor of later substance abuse problems

than is early use (19). It found that, in individuals

with many conduct problems, any use of a substance, no matter how late in youth, was followed

by abuse.

1 Frequency and Quantity of

Substance Used

When addiction occurs, it usually results from a

period of increasing intensity and frequency of use

(5,6). Although frequency has often been

employed as a measure of problematic use, one

study found that quantity of substance used, rather

than frequency of use, was a more powerful predictor of disruptive and problematic use (21).

Quantity and frequency are often related, but they

are not identical. An infrequent user could go on

a binge, where large quantities are consumed, that

could be extremely harmful. By contrast, a frequent user, such as someone who drinks alcohol

every day but in strict moderation, may not encounter substance-related problems (although a

maintenance alcoholic may drink daily with no

apparent intoxication, but with the later development of associated health problems). The quantity

and frequency of substance use can be strongly affected by the availability and marketing of the

substance and by the techniques or technologies

for administering the drug.

1 Type of Substance Used

The type of substance used can also influence the

chances of later substance problems. More addictive substances—those with greater abuse liability—will make restraint from continued and

possibly escalating use more difficult. Cigarettes

provide an example experienced by many individuals: nicotine is extremely addictive, and only a
Chapter 5 Substance Use and Transitions to Abuse and Addiction I 79

minority of those who try cigarettes and continue

to smoke them will be able to control or easily cut

back on their use.

1 Techniques of Use

Techniques of administration can also influence

the progression of substance use. The introduction

of prewrapped, prepackaged cigarettes, together

with wide] y distributed matches, was followed by

the rapid escalation of cigarette use, and presumably addiction to nicotine, in the United States in

the late 1800s and early 1900s. Similarly, the

introduction of smokable free-base and crack cocaine, the administration of which is much more

efficient than the snorting of powdered cocaine,

led to an explosion of cocaine abuse and addiction, The Bahamas, for example, experienced a

hundredfold increase in cocaine-related hospital

emergency room admissions following the

introduction of crack and free-base cocaine in the

1980s (8).

# Expectations and Effects of Use

The expectations and effects of use can also reinforce use and influence progression from use to

abuse and addiction. Research reviews have discussed some examples of the expectations and effects of using illicit substances that can reinforce

their use and may increase the likelihood of progression to abuse and addiction (13,25). These

purposes include:

■

●

The reduction of negative feelings, including

the use of stimulants to alleviate depression and

weakness; psychedelics to combat boredom

and disillusionment; alcohol to assuage feelings of guilt, loneliness, and anxiety; and tranquilizers, amphetamines, and sedatives to

reduce painful feelings.

The reduction of self-rejection. Some researchers have found an association between substance use and indices of insecurity, dissatisfaction with self, desire to change oneself,

defensiveness, low self-esteem, and low self-

-confidence.

■

m

■

●

●

■

The increase in potency. Increases in physical

and sexual potency, daring, and toughness can

be achieved by using specific substances in certain situations. This can be especially appealing to youth, who may be wrestling with

feelings of powerlessness, dissatisfaction, and

frustration.

The expression of anger. Substances can heighten expressions of anger (e.g., in opposition to

mainstream norms) or can medicate away anger and rage. Narcotics and hypnotics may help

reduce rage, shame, jealousy, and impulses toward extreme aggressiveness.

The achievement of peer acceptance. Peers

often play the largest role in endorsing and

encouraging substance use, and in supplying

substances. The initiation, continuation, and

progression of use can be important ways for

individuals to gain acceptance into peer groups.

This can be true in school (e.g., in a fraternity),

at work (e. g., in a sales force that demands that

one be able to “hold one’s liquor”), in substance-using gangs, and among certain groups

of artists (e.g., some contemporary painters and

musicians).

The seeking of euphoria. Many substance users,

especial] y addicts, report favorably on drug-induced euphoria. Indeed, the prospect of euphoria may be the initial attraction of the substance.

It can also encourage continued use, even to the

point of addiction and negative consequences.

The coping with problems. For some users,

substances temporarily y alleviate problems they

have been unable to resolve in other ways.

While the problems may be causing emotional

pain, the use of substances, especially for the

young, can inhibit the development of other

problem-solving skills and may alleviate

symptoms only in the short-run, since the underlying causes of the problems are likely to remain unresolved.

The reduction of overwhelming trauma. Posttraumatic stress (e.g., after a war, or after physical or sexual abuse) can result in the use of

addictive substances, since use may temporari-
80 I Technologies for Understanding and Preventing Substance Abuse and Addiction

ly reduce tears, flashbacks, and other negative

feelings.

The suppression of appetite or hunger. Another

function of using some psychoactive substances is appetite suppression. An extensive

literature exists on the use of nicotine, from cigarette smoking, to control appetite and weight.

This phenomenon often manifests itself in the

negative: for example, current smokers (especially women) are reluctant to stop smoking for

fear they will gain weight (4).

The seeking of stimulus. Individuals who seek

higher levels of external stimulation can also

turn to substances, for a high, for hallucinations, for unpredictable effects.

The regulation of affective and behavioral impairments. Those with mood disorders, such as

depression, and behavioral impairments may

find that some substances alter moods and allow them to modify behaviors.

The above expectations and effects might well

be expected to contribute to more continued and

progressively heavier substance use than would

more casual purposes such as curiosity, experimentation, or recreational use. The more “serious” the expectations, effects, and functions of

substance use, the greater the likelihood of continued use and abuse may be. As noted earlier, the use

of substances, especially by the young, to address

problems or to achieve feelings may impede the

development of skills for managing feelings and

behaviors and for solving problems, and thus may

result in deficiencies in handling problems in life

later on. Indeed, the use of substances at very

young ages may even contribute to permanent

changes in the brain that may contribute to further

use and abuse. More research is needed to clarify

the connections between the expectations and effects of use and the progression to heavier and

more problematic use and abuse.

SUMMARY

Substance use, including the progression to heavier and more harmful use, is a precondition and

contributor to abuse and addiction. Researchers

have focused on stages in the progression of substance use in several ways. They have studied

stages in the initiation of the use of different substances, finding a sequence that moves from the

use of cigarettes and wine or beer, to the use of

marijuana, then hard liquor, and finally other illicit substances. Because many individuals who use

substances do not go on to substance abuse, and

because use at one level does not guarantee use at

a higher level, these stages are descriptive but not

predictive.

In addition to the biologically and pharmacologically reinforcing properties of addictive substances that can lead to tolerance and dependence,

key aspects of substance use that contribute to

abuse and addiction include age of first use, the

frequency, quantity, and type of substance used,

and the techniques and expectations and effects of

use.
Part II:

Individual

Factors

P

art 1 of this report addresses necessary preconditions that

must be present in order for substance abuse and addiction

to be possible. Flowing from the discussion of these preconditions, Part H highlights a selection of demographic,

economic, and psychosocial factors that make some individuals

more or less susceptible to substance abuse. Because of the complex nature of substance abuse and addiction, an inherent risk exists in reviewing individual factors in relative isolation. However,

studies in the field of risk factor research have shown significant

associations, for some individuals, between substance abuse and

certain factors. Conversely, in the field of protective factor research, the lack of certain risk factors and the presence of other

protective factors have been correlated with individual resilience

to substance abuse and addiction.

I 81
Individual

Risk and

Protective

Factors 6

N

o single or generic set of variables explains the misuse of

substances for every individual. Depending on an individual’s biological makeup, developmental stage, and interaction with various environmental forces, individual risk,

vulnerability y, and resilience to substance abuse and addiction will

vary for different factors at different times (3).

Much of the research on substance abuse has focused on identifying factors for drug and alcohol use (see table 6-1 ), specifically

among adolescents and young adults. Risk factors for substance

abuse have been identified as those cognitive, psychological, attitudinal, social, pharmacological, physiological, and developmental characteristics that foster initiation of drug and alcohol

use and abuse by an individual. There is some consensus in the

field of risk factor research that probably two fairly distinct sets of

risk factors affect individuals differently. Social, situational, and

environmental factors are likely to be more influential in initial or

low-level substance use, while individuals who progress from use

to abuse or addiction are influenced to a greater extent by biological, psychological, and psychiatric factors (27). This distinction

between risk factors is more thoroughly discussed in chapter 5.

Protective factors are those characteristics that reduce the risk of

substance abuse and addiction and promote positive development

such as, appropriate role models, involvement in positive peer

groups, and a positive self-image and outlook for the future.

This chapter focuses on a select group of individual factors that

has been combined under the three headings: Demographics,
84 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Bry et al. Newcomb et al. Labouvie et al. Hawkins & Catalano

Catalano (1982) (1986) (1986) (1989) (1992)

Low grade point

average

Lack of religiosity

Early alcohol use

Low self-esteem

Psychopathology

Poor relationship

with parents

Low grade point

average

Lack of religiosity

Early alcohol use

Low self-esteem

Psychopathology

Poor relationship

with parents

Low academic

performance

Low educational

aspirations

Low achievement

orientation

Low self-esteem

Self-derogation

Emotional outbursts

Low parental warmth

Parental hostile

control

Lack of conformity

Sensation seeking Impulsity

Perceived peer

drug use

Perceived adult

drug use

Friends’ deviance

Negative activities

with friends

Low commitment to

school

Cognitive Impairment

Intelligence

Low religious

involvement

Early persistent problem

behaviors

Early onset high-risk

behavior

Poor, inconsistent family

management

practices

Family conflict

Low bonding to family

Alienation/rebelliousness

Attitudes favorable to

drug use

Sensation seeking

Attention defict/

hyperactivity

Low autonomic and

central nervous

system arousal

Hormonal factors

Peer rejection in

elementary school

Association with drug

using peers

Laws/norms

Availability

Extreme economic

deprivation

Neighborhood

disorganization

School organization

factors

Intergenerational

transmission

Low commitment to

school

Cognitive Impairment

intelligence

Academic failure

Low religious

involvement

Early persistent problem

behaviors

Poor, Inconsistent family

management

practices

Family conflict

Low bonding to family

Allenatlon/rebelliousness

Family drug behavior

Attitudes favorable

to drug use

Sensation seeking

Attention defict/

hyperactivity

Low autonomic and

central nervous

system arousal

Hormonal factors

Peer rejection in

elementary school

Association with

drug-using peers

Laws/norms

Availabilty

Extreme economic

deprivation

Neighborhood

disorgamzation

SOURCE Adapted from R Clayton, “Transitions in Drug Use: Risk and Protective Factors, ” in Vulnerability to Drug Abuse, M. Glantz and R. Pickens

(eds ), American Psychological Association, Washington, DC, 1992
Chapter6 Individual Risk and Protective Factors 185

Research on adolescent substance use has documented substantial racial and ethnic differences in

use among high school seniors On average, alcohol, cigarette, and other illicit drug use is highest

among American Indian youth, somewhat lower among white and Hispanic youth, substantially lower

among black youth, and lowest among AsIan youth Additional research explored the hypothesis that

these dlsslmllarlhes could be partially attributed to differences In background (e,g , urban versus rural,

family structure, parental education) and Ilfestyle factors (e g , grades, truancy, evenings out, religlous

commitment)

The flndlngs Indicated that controlling for background factors alone did not account for most racial

and ethnic differences In drug use, but It dld reduce American Indians’ relatively high levels of use,

which suggests that their use may In part be related to disadvantaged socioeconomic status When

both background and Ilfestyle factors were included in the analysis, the racial and ethnic differences

were substantially reduced Educational values and behaviors, relig~ous commitment, and amount of

time spent In peer-oriented actwltles were particularly important explanatory variables

Racial and ethnic differences were also found tn a study on drug-related attitudes and perceptions

Perceived nsk of using drugs, disapproval of drug use, and perceptions of disapproval of drug use by

friends were typically highest among black seniors, at intermediate levels among Hispanic semors, and

lowest among white and American Indian seniors Conversely, perceived peer use of drugs and exposure to persons using various drugs for “kicks” were generally lowest among black and Asian seniors,

at intermediate levels among Hlspamc seniors, and highest among white and American Indian seniors

While these flndlngs are not applicable for those adolescents who drop out of school, researchers

are confident that the results are valld for the majority of adolescents who remain enrolled through the

senior year of high school

SOURCE U S Department of Health and Human Serwces, Publlc Health SewIce National Institutes of Health, Smokmg, Drmkmg,

and /llic/t Drug Use Among Amer/can Secondary School Students, College Students, and Young Adults, 1975-1991, NIH Pub No

93-3480 (Rockwlle MD 1992)

—.

Economics, and Psychosocial/Behavioral. Factors not directly discussed in this chapter are reviewed in either Part I or 111 of the report. These

factors may not appear in every individual with

substance abuse and addiction problems, nor will

all individuals exposed to these factors use or

abuse drugs. In addition, unanimous agreement is

lacking within the field of substance abuse and addiction on the importance, number, order of appearance, or interactive effects of many of these

factors.

Where applicable, each of the factors has been

reviewed in the following manner: historical perspectives; current prevalence; psychosocial and

cultural antecedents; biological and genetic antecedents: relevant prevention programs; and areas

for future research.

DEMOGRAPHICS

1 Age

The preponderance of substance abuse research points to the fact that children who use

drugs and alcohol before the age of 15 have a

greater likelihood of becoming problem alcohol and other drug users, versus those youth

who begin use at a later age (28).

Highlights from the National Household Survey on Drug Abuse (NHSDA) provide a somber

picture of substance use among the Nation’s children (77). Lifetime and past month substance use,

rates for continued substance use, as well as differences in racial and ethnic substance use (see box

6-1 ) are reviewed in this section.
86 I Technologies for Understanding and Preventing Substance Abuse and Addiction

As part of NHSDA, data on lifetime use of alcohol and cigarettes (whose use is illicit for minors) has been collected for youth aged 12 to 17

since 1974; data collection on other illicit drug use

began in 1979 (see figure 6-l). The lifetime use

findings include:

Rates in 1991 for lifetime use of alcohol, cigarettes, or other illicit drugs were the lowest recorded since the survey series began 17 years

ago. The highest rates for any substance use appeared in the late 1970s.

In 1979, 70 percent of youth aged 12 to 17 reported some lifetime use of alcohol compared

to 46 percent in 1991. Since 1979, lifetime cigarette use has dropped from 54 percent to 38

percent.

Since 1979, the use of other illicit substances

(methaqualone, inhalants, heroin, cocaine,

phencyclidine (PCP), crack, tranquilizers,

stimulants, other opiates, barbiturates, nitrites,

lysergic acid diethylamide, hallucinogens, and

marijuana) has followed a similar trend with

rates decreasing from a high of 34 percent to the

1991 rate of 20 percent.

A complementary study of adolescents shows

1991 data for substance use within the past 30

days among a sample of approximately 17,500

eighth graders, 14,800 tenth graders, and 15,000

twelfth graders (75).

Any alcohol use within the past 30 days was reported by 25 percent of the eighth graders, 43

percent of the tenth graders, and 54 percent of

the twelfth graders. Having had more than five

drinks in the last two weeks was reported by 13

percent of the eighth graders, 23 percent of the

tenth graders, and 30 percent of the twelfth

graders.

Fourteen percent of the eighth graders, 21 percent of the tenth graders, and 28 percent of the

twelfth graders reported smoking cigarettes

within the past month. Those who smoked

more than one-half pack per day included 3 percent of the eighth graders, 7 percent of the tenth

graders, and 11 percent of the twelfth graders.

60-

E

a) I

$ 40 - Cigarettes 4

)

n

20- Any other illicit drug 2

h

o~

1974 1976 1977 1979 1982 1985 1988 1990 1991

NOTE The exclusion of inhalants m 1982 E belleved to have resulted

m underestimates In any Illicit use for that year, especially for youth aged

12 to 17

1 Data not avadable for all survey years

Z Use of marliuana or hashish, cocaine (mcludmg crack), Inhalants, hallucinogens (Includlng PCP), heroin, or nonmedlcal use of psychotherapeuhcs at least once

3 Estimates before 1979 for alcohol may not be comparable to those for

later years due to change m methodology

4 For 1979, Includes only people who ever smoked at least fwe ~acks

The other most commonly used substance for

eighth and tenth graders was smokeless tobacco with 7 and 10 percent reported, respectively.

Eighth graders had the highest percentage of

past month inhalant use (4 percent), and of

those individuals, approximately 1 percent reported using inhalants on 3 to 5 occasions within the past month.

For tenth and twelfth graders, the other most

commonly used substance was marijuana and/

or hashish with 9 percent of the tenth graders

and 14 percent of the twelfth graders reporting

past 30-day use. Of those individuals, approximately 2 and 3 percent, respectively, had used

marijuana and/or hashish on three to five occasions.
Chapter 6 Individual Risk and Protective Factors I 87

Another important indicator of potential substance abuse problems among adolescents is the

noncontinuation rate for the use of certain substances. This is an indication of the extent to

which people who try a drug do not continue to use

it, and is based on the number of individuals who

reported ever using a drug divided by the those

who have not used the drug in the past 12 months

(75).

Among a sample of twelfth graders in 1991, the

data show that noncontinuation rates vary widely

among the different drugs, with the highest rates

observed for methaqualone and inhalants (62 percent). As mentioned previously, inhalant use is

higher among younger individuals. The noncontinuation of methaqualone may be due, in part, to

the decrease in its availability. A high noncontinuation rate is also seen for heroin (56 percent),

cocaine (55 percent), PCP (52 percent), and crack

(52 percent). Marijuana has one of the lowest noncontinuation rates (35 percent) in the senior year

of any of the illicit drugs; primarily because a relatively high proportion of seniors continue to use

it at some level over an extended period of time.

Additionally, the noncontinuation rates for alcohol and cigarettes are extremely low. In other

words, 88 percent of the seniors reported some

lifetime use of alcohol, and of those individuals,

78 percent have continued to use it within the past

year, thus only 12 percent of the seniors reported

no alcohol use in the preceding 12 months. Cigarette noncontinuation was defined somewhat differently, as the percentage of those who said they

had ever smoked “regularly” and who also reported not smoking at all during the past month.

Of the regular smokers, only 17 percent stopped

smoking within the past month.

An obvious drawback to these data is the fact

that only those individuals who have not dropped

out of school are included in the survey. It is not

unrealistic to assume that those students with serious drug problems may well have left school before the twelfth grade. More specific discussion of

the factors that influence the risk of adolescent

substance abuse, as well as prevention programs

targeting youth, are thoroughly reviewed in

chapter 8.

While the majority of attention is focused on

adolescent substance use and abuse, young adults

and older adults also show significant levels of

substance use and abuse. The 1991 statistics from

the NHSDA reveal that heavy drinking (defined as

drinking five or more drinks per occasion on 5 or

more days in the past month) was reported by 2

percent of 12 to 17 year olds, 11 percent of 18 to

25 year olds, 7 percent of 26 to 34 year olds, and

4 percent of those 35 and older (77). For those

same age categories, smoking a pack or more of

cigarettes per day was reported by 1, 13, 17, and

17 percent, respectively. The illicit substances reported being used most often in the past month

among all age groups were marijuana and hashish.

Individuals 18 to 25 had the highest percentage

(13 percent) and those 26 to 34 the next highest

percentage (7 percent). The second most commonly reported illicit substance was the nonmedical use of psychotherapeutics, which was again

highest among 18 to 25 year olds (3 percent) followed by those 26 to 34 (2 percent); all other age

groups reported less than 2 percent,

Clearly then, the heavy use of some substances

is not exclusive to adolescents. Young- to middleaged and older adults can also be exposed to

stressful risk factors, such as loss of a job, divorce,

or death of a child, which could contribute to alcohol or drug problems. The adult population presents unique and often overlooked challenges for

the planning and implementation of substance

abuse prevention programs.

1 Gender

Historically, the vast majority of biological and

behavioral substance abuse studies were conducted on male participants, although that has begun to change. A distorted picture emerged, in

which women were assumed to misuse the same

substances, and for the same reasons, as their male

counterparts. It has only been within the past 10 to

20 years that separate research has been conducted

on the causes and consequences of alcohol and

drug problems among women.
88 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Extrapolating percentages garnered from the National Household Survey on Drug Abuse to United States

population figures produced the following approximations:

Women Men

(about 106 million) (about 98 million)

Alcohol use within the past month 46.2 million 56.5 million

440 % 58. 0%

Heavy alcohol use1 within the past month 1,2 million 4.9 million

2.4% 8.6%

Smoking one pack+ of cigarettes per day 35 million 4.9 million

12.9% 17.2%

Nonmedical past month use of psychotherapeutics 1.7 million 1.5 million

1.7% 1 .5%

Past month use of an illicit substance3

54 million 7.3 million

— 5.2940 7.6%

‘ Defined as having five or more drinks on one occasion on five or more days in the past 30 days

— —

2 Sedatives, tranquilizers, stimulants, analgesics

3 Marijuana, inhalants, cocaine, hallucinogens, heroin, nonmedical use of psychotherapeutics.

SOURCE Off Ice of Technology Assessment, 1994, derived from U S Department of Health and Human Services, Public Health Service, Alcohol,

Drug Abuse, and Mental Health Administration, National Household Survey on Drug Abuse Highlights 1991, DHHS Pub No (SMA) 93-1979

(Rockville, MD February 1993)

Women have not been immune to the harmful

effects of alcohol and other drugs. In the late

1800s twice as many women were addicted to narcotics as men. The majority of these women were

white, middle-aged, and of upper-middle class

status. Some had become addicted through the

prescription of narcotics for a host of so-called female problems, while others knowingly misused

opium, heroin, morphine, and cocaine (53).

The number of women drinking alcohol and experiencing alcohol-related problems has risen

steadily since World War II. At least one-third of

the estimated 18 million alcoholics and problem

drinkers in the United States are thought to be

women. These figures, which many consider to be

conservative, would suggest that close to 6 million women are currently dealing with the medical, legal, and social problems of alcohol misuse

(53).

Overall, men report more frequent use of alcohol, cigarettes, and all illicit substances (except

nonmedical use of psychotherapeutics) than

women (79,77). However, this does not mean that

there is not substantial alcohol and drug use

among women (see table 6-2). Additionally, some

gender and ethnic differences may be attributable

to failure to survey hidden populations. The risk

status of women who are not in the workforce, do

not receive prenatal care, and are not visible

through arrest, is less reliably known.

Neither men, nor women, should be considered

homogeneous. For example, alcohol use and its

misuse can vary widely between different racial

and ethnic groups. Among men, Hispanics (60

percent) were slightly more likely to have used alcohol within the past month than whites (59 percent) or blacks (52 percent) (77). In general, white

women drink more frequently than other women.

Large numbers of Native American, Hispanic,

black, and Asian women do not drink at all (70).

Additionally, poor and minority women appear to

come under closer scrutiny for alcohol and drug

abuse than do financially secure or white women

(see box 6-2). These racial and ethnic differences

are more fully discussed in the following section.

Do men and women cite different reasons for

the misuse of alcohol and other drugs? Over the

last several decades within the United States, the

socially defined roles for men and women have

undergone substantial changes. When given a

choice, many women have opted for the traditional role of a stay-at-home mother and homemaker,
Chapter6 Individual Risk and Protective Factors 189

In one county of Florida, anonymous alcohol

and drug tests were conducted on urine samples

obtained from all pregnant women seeking prenatal care from both public health clinics as well

as prwate obstetrical offices White and black

women were discovered to have insignificantly

different prevalence rates for alcohol or Illicit drug

use during pregnancy While black women used

cocaine more frequently than white women (7 5

percent versus 18 percent), white women had

higher rates of marijuana usage (14 4 percent

versus 6 percent) The relatwe stmllarltles between alcohol and drug use also held true for

poor versus middle-class women However, the

study also documented that after delwery, black

women were 10 times more likely to have been

reported to the health authorities for substance

use during pregnancy than were white women

Poor women also had a greater chance of being

reported than middle-class women This study

reflects a discrepancy (n reporting practices

among staff at some public cllnlcs and private

obstetrical ofhces, which appears to be influenced by an indiwdual’s soctal status as well as

race

SOURCE I J Chasnoff H J Landress, and M E Barrett, “The

Prevalence of llllclt-Drug or Alcohol Use During Pregnancy and

Drscrepancles (n Mandatory Reporting In Plnellas County, FIorIda “ The NewEng/andJourna/of Med/c/ne 322(1 7) 1202-1206,

199 0

while other women have pursued career paths that

may or may not include marriage and children,

and still others have attempted to combine the

two. These fairly recent changes have brought

pressures and risks many women had not been

subjected to previously.

Women in the workplace are more likely to encounter drinking opportunities such as business

lunches and office celebrations, where they may

feel encouraged or even pressured to drink (53).

Women have also been recently targeted by the

beer, tobacco, and liquor industries, as well as by

small-scale marketing by nightclubs and bars in

the form of ladies’ nights.

In the early 1970s, researcher Sharon Wilsnack

postulated that some women may abuse alcohol to

submerge those aspects of themselves that did not

conform to the traditional female sex role, thereby

allowing them to feel more acceptably feminine

(53). More recently, several studies on female alcoholics have shown that women, more frequently than men, can pinpoint a specific traumatic life

event that they believe precipitated their problem

drinking. The crises identified most often by

women included a partner’s infidelity, the death of

a family member, a child leaving home, postpartum depression, divorce or separation, infertility,

gynecological problems, and menopause (39,53).

A similar study focused on the impact of various life events on alcoholic men and women. Alcoholic men placed significant importance on

work-related events, marriage issues, sexual difficulties, and arguments with spouses. In addition

to those events cited by the men, alcoholic women

focused on social activities, family troubles, stillbirth and adoption, and death of a close relative

(40).

While much of the substance abuse research

has focused on alcohol issues, various researchers

have examined the differences between men and

women in their use of illicit substances with or

without the presence of alcohol. For men and

women cocaine addicts in treatment, the following significant differences were noted (40,41 ,35):

■

■

m

■

Women had started to use cocaine at a younger

age than men, conversely to what is generally

found among opiate users and alcoholics.

Women had a significantly lower level of social

adjustment than male patients.

Women patients were less likely to be employed, to hold high status jobs, to be self-supporting, and to be financing their own drug use.

Women were more likely than men to cite specific reasons for their drug use: depression,

feeling unsociable, family and job pressures,
90 I Technologies for Understanding and Preventing Substance Abuse and Addiction

8

■

■

■

and health problems; whereas men more often

cited the intoxicating effects of cocaine as a reason for their drug use.

Men reported experiencing more guilt (47 vs.

23 percent), whereas women noted that one of

the desirable effects of cocaine use was a reduction in their feelings of guilt.

Women were more often diagnosed with depression than men, and their depression took

longer to treat, while men were more often

diagnosed with antisocial personality disorder.

Most men and women reported that they used

cocaine to be more sociable.

Women demonstrated a slower recovery than

men, and had more residual problems.

Gender differences among opiate addicts have

also been explored. Researchers have shown that

female addicts are more likely than male addicts

to have first been introduced to heroin by family

members or others close to them, and to have experienced severe family disruption (36). The development of the women’s opiate dependence is

also more likely to be linked to the family’s approval of use or the absence of clear disapproval

of use, in combination with easy access to the drug

(35).

Differences in marijuana smoking may also be

partially attributable to gender. In a recent review,

it was shown that men’s marijuana smoking was

tied more to the availability of the drug, while

women smoking was affected to a greater degree

by social influences, such as weekday versus

weekend smoking, and the smoking of their male

partners. Women have also been shown to increase their marijuana smoking during periods of

anger and other unpleasant dispositions (41 ).

In addition to discovering some sociocultural

dissimilarities, gender differences in biological

and genetic susceptibility to substance abuse have

been examined. The role of heritability and genetics in influencing individual susceptibility is more

thoroughly discussed in chapter 3, thus the discussion in this section will concentrate on biological

differences. Again, a large portion of these studies

has concentrated on alcohol and its effects.

In the late 1970s it was reported that when men

and women of comparable body weight were given equivalent doses of alcohol, women achieved

higher blood alcohol levels. However, these findings have been challenged, as more recent studies

have shown that if the blood alcohol level is based

on total body water rather than weight, the difference in levels between men and women is insignificant (65).

Another avenue that has been explored in explaining the gender difference in blood alcohol

levels has to do with the metabolism of alcohol.

Based on findings from animal research, Mario

Frezza et al. (25) investigated differences in the

“first-pass metabolism” between men and

women. Data from animal studies reveal that a

significant amount of ingested ethanol does not

enter the circulatory system, but rather is neutralized in the stomach by the enzyme alcohol dehy -

drogenase. Using a small study sample (6

alcoholic and 14 nonalcoholic men, 6 alcoholic

and 17 nonalcoholic women) Frezza et al. investigated whether the first-pass metabolism and enzyme activity level varied between men and

women, and alcoholic and nonalcoholic individuals. They discovered that both gender and chronic

alcohol abuse had statistically significant effects

on the first-pass metabolism of alcohol, specifically, the first-pass metabolism was considerably

lower among alcoholic women compared to alcoholic men, which in turn was lower than nonalcoholic men. Similar findings were reported for the

alcohol dehydrogenase activity level; with the

highest activity levels (70 to 80 percent) found in

the nonalcoholic men and women, less activity

among the alcoholic men (37 to 46 percent), and

the smallest activity level among alcoholic

women (1 1 to 20 percent). To summarize, the

women in general had lower rates of first-pass metabolism and lower levels of alcohol dehydrogenase activity, which both lead to an increase in the

amount of ethanol in the circulatory system. The

levels of enzyme activity further decreased among

the alcoholic women and the first-pass metabo-
Chapter 6 Individual Risk and Protective Factors I 91

lism was essentially nonexistent, indicating little

neutralization by the stomach.

Researchers have also been studying the effect

of hormonal changes during the menstrual cycle

on alcohol absorption rates. Alcohol absorption

has been reported to vary during a woman’s

cycle—specifically, the rate of alcohol absorption

increases premenstrually. However, data from

other clinical and animal trials have disputed these

findings (65).

What is clear from this type of biological research is that few firm conclusions can be made

about gender differences in response to alcohol ingestion, and even fewer still about biological responses to drugs other than alcohol.

Nevertheless, the psychosocial differences that

have been identified between the sexes could

assist practitioners in the development of more

gender specific substance abuse prevention programs. For example, because many women can

pinpoint specific events in their lives that they believe contributed to their heavy alcohol or drug

use, it would behoove professionals working with

women to be cognizant of these factors. General

inquires could be made at yearly physical or gynecological exams, which could also serve as informational sessions on the dangers of alcohol and

drug use (39). In addition, special attention should

be paid toward adolescent girls whose first experience with alcohol and drugs is often through a

male family member or boyfriend.

Broadly speaking, there are basic gaps in

knowledge concerning gender differences and

substance use within virtually all the parts identified in this report: Part I-necessary preconditions;

Part II-individual factors; and Part III-activity settings. Until these gaps are addressed, the practice

of transferring data garnered from studies specific

for one gender, to the other gender, is inaccurate

and misleading.

1 Race and Ethnicity

Historically, racial and ethnic minorities have

been linked with, and often blamed for, many of

the drug problems within the United States.

Throughout the late 1800s and early 1900s, the

general public associated the growth in opium addicts with the arrival of Chinese immigrants; although numerous physicians had been freely

prescribing narcotic preparations to their patients,

many of whom were middle- to upper-class

whites. The drug cocaine has long been associated

with blacks. A popular image during this time was

one of cocaine-crazed blacks, although use of cocaine was widespread among whites as well (86).

Throughout this same period, marijuana was

thought to have been brought into the country and

promoted by Mexican immigrants and later

picked up by the subculture of black jazz musicians. Due in part to public paranoia, the Marijuana Tax Act of 1937, which was a direct attempt to

control marijuana use, was born (45).

In the minds of many individuals, this derogatory link between minority populations and rampant drug abuse has continued. Certainly, many

urban areas have high concentrations of minorities, and within these areas the prevalence of alcohol and drug abuse may be high. Often overlooked, however, is the existence of alcohol and

drug problems in suburban and rural areas

throughout the United States, which have varying

percentages of minorities.

Prevalence rates for past month use of an illicit

substance in 1992 (see figure 6-2) are not drastically different between whites, blacks, and Hispanics, although it should be kept in mind that this

statistic does not accurately reflect abuse or addiction. Even though the prevalence of illicit substance use was highest among blacks, over

three-fourths (76 percent) of the past month illicit

substance users were white. In other words, there

were approximately 8.7 million whites, 1.5 million blacks, 885,000 Hispanics, and 315,000 individuals of other racial and ethnic groups who

reported past month use of an illicit substance in

1992 (79).

Also for 1992 among individuals aged 12 and

older, whites reported the highest percentage of alcohol use within the past week (21 percent), followed by blacks (19 percent), and Hispanics (18
92 I Technologies for Understanding and Preventing Substance Abuse and Addiction

8.0

7.0

6.0

5.0

E@

e 4.0

2

3.0

2.0

1.0

0.0

5.5

6.6

5.3

Caucasian Black Hispanic Other

1 Illicit drug use Includes marijuana, cocaine (mcludmg crack), hallucinogens, heroin, and nonmedlcal use of psychotherapeuhcs (stlmuIants, sedatwes, tranqu{llzers, and analgeslc

SOURCE U S. Department of Health and Human Serwces, Publlc

Health Service, Substance Abuse and Mental Health Services Admmlstratlon, “National Household Survey on Drug Abuse Population Estimates 1992, ” DHHS Pub No (SMA) 93-2053 (Rockvdle, MD October

1993)

percent) (79). The rates for heavy drinking were

not statistically different by race or ethnicity (5

percent for whites and blacks, and 6 percent for

Hispanics) (78).

Until fairly recently, much of the analysis of

substance use data has concentrated on the correlations between the use of a substance and one

or two variables such as race and ethnicity and/or

educational level. Often a positive association

was found between minority populations and the

use of certain substances. While statistically correct, these analyses can be simplistic and misleading (see box 6-3). Clearly many risk and

protective factors interact to produce substance

use and abuse. If the majority of these variables

are excluded from the analysis, a skewed picture

may arise as to the importance of certain variables

as risk factors for substance use and abuse. Additionally, to simplify the data collection, racial and

ethnic categories are often broad. The most popular groupings are blacks, white non-Hispanic, Hispanic, and other. Though each of these categories

contains many distinct cultures, gross generalizations are commonly made within each category.

In recent years, there has been a shift toward

analyzing more carefully the complex relationship between cigarette, alcohol and illicit drug

use, and socioeconomic and demographic variables. The previous research had drawn on relatively small databases. However, in 1992, the

National Institute on Drug Abuse (NIDA) critically analyzed the national drug use data collected in

its 1988 and 1990 NHSDA. Predictors of drug and

alcohol use included an extensive array of both individual variables (e.g., age, educational level,

marital status) and aggregate variables based on

the attributes of the census block, community, or

region in which the respondent lived (see table 6-3

for a complete list).

The effect of select variables such as race and

ethnicity were measured, while simultaneously

controlling for all other variables (e.g., age,

educational level, employment status). Individuals of racial and ethnic minorities were found to be

no more likely than whites to use alcohol heavily

(defined as having five or more drinks on five or

more days in the past month) or to use marijuana,

cocaine, or psychotherapeutic drugs (inclusion of

crack or heroin in the analysis was impossible due

to the small number of respondents reporting use).

In fact, when socioeconomic status was controlled

for, both blacks and Hispanics had a substantially

lower likelihood of heavy alcohol use than whites

(76).

A reanalysis of the 1988 NHSDA data was accomplished by an independent group of researchers who clustered the respondent data into

neighborhood risk sets. The original analysis on

the 1988 data revealed that for all ages, blacks and

Hispanics were twice as likely to have ever used

crack cocaine than were whites. Once neighborhood clusters were established, the data revealed

that given similar social and environmental conditions, crack use did not differ significantly for

blacks or Hispanics compared with whites (9).
Chapter6 individual Riskand Protective Factors 193

.

Bwarlate analysis is the process of taking one variable such as employment status and testing Its

correlation and statistical significance to reported alcohol or drug use A major drawback to this type of

analysls IS Its relatlve slmpllcity, It does not control for the potential effects of other variables For example, If a relationship between being unemployed and heavy alcohol use was shown to be statistically

slgnlflcant, one could not be certain of the nature of the relationship Perhaps the individual was unemployed due to hls or her heavy drlnklng Alternately, a person’s unemployment could have caused his

or her heavy drlnklng Furthermore, if more sophisticated analyses using additional variables were completed, the orlglnal association between being unemployed and heavy drinking could disappear altogether

Multlvanate analysls, while having Its own limitations, is a much more comprehensive way in which to

study the relationships between several variables and alcohol and drug consumption The multivarlate

analysls used by the National Institute on Drug Abuse systematically incorporated a variety of individual

variables such as educational level, employment status, race and ethnlcity, and sex, in addition to certain aggregate variables Includlng region (South, Northeast, North Central, West), metropolitan status,

and racial and ethnic composition of census blocks Each one of these variables was then separately

analyzed for Its potential predlctwe value for alcohol and drug use, while the other contributing variables were also taken Into account While multlvarlate analyses fall short of demonstrating causallty,

because additional variables are used to control for plausible alternative explanations, more confidence

can be placed In the significant correlations found

SOURCE Off Ice of Technology Assessment, 19!34

However, the number of reported crack users in

the study was relatively small ( 138), and neighborhoods were identified as crack neighborhoods

with as few as one reported crack user, thus the research findings should not be generalized.

The new research hypothesized that the previous racial differences found in the prevalence of

crack cocaine smoking may have been due to macrosocial environmental risk factors including:

differences in the availability of crack; employment rates; premature death rates; community

contact with the criminal justice system; socially

acceptable mechanisms for coping with life stressors; distribution of wealth; and access to social

resources.

While both studies had specific limitations, the

importance of these types of analyses cannot be

understated. Focus should be placed on the interaction between communities and individuals and

the relative influence on subsequent drug and alcohol use, rather than a person’s race or ethnicity.

Race or ethnicity has not been shown to be either a biological or genetic risk factor for substance use or abuse. To date, the preponderance of

investigative studies has focused on racial and

ethnic differences in response specifically to alcohol. Virtually no study has been completed on differences in racial and ethnic biological responses

to other licit or illicit drugs.

Individual metabolism of alcohol is essentially

controlled by two enzymes, aldehyde dehydrogenase and alcohol dehydrogenase. If the enzyme aldehyde dehydrogenase is inactive for any reason,

ingestion of even a small amount of alcohol can

cause rapid and prominent facial flushing. Continued drinking leads to nausea, dizziness, palpitations, and faintness. This reaction is seen among

many Asians (84,1 6).

A mutant form of alcohol dehydrogenase will

effect the efficiency of alcohol metabolism as

well. Altered forms of the alcohol dehydrogenase

enzyme have also been reported in several Asian

populations.

The two enzymes, aldehyde and alcohol dehy -

drogenase, probably interact in some individuals
94 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Alcohol Marijuana Cocaine

Abstinence Past month Past Any past No past

in past nonheavy monthb month month Any past No past

Predictorsa month use heavy use use use year use year use

individual variables:

Age:

26-34

18-25

35-49

Sex:

Female

Male x

xc x

x

Race/Ethnicity

White

Black

Hispanic

Other

Education

High school

graduate

Less than high

school

Some college

College graduate

Occupation of CWE

White collar

Blue collar

Service

Did not work

Aggregate variables:

Region (South)

Northeast

North Central

West

Metropolitan status (large metro)

x

x

x

x

x

Small metro

Nonmetro x

Percent Black in block (<5%)

5%-50°A

50%

Percent Hispanic in block (<5%)

5%-50%

<50%

Housing occupancy rate (90%-95%)

<90%

<98% x

Median housing value (Middle 60%)

<20th percentile

<80th percentile x

Percent owner-occupied (50%-90%)

<50%

<90%

Marital status

Married x

Divorced/separated x xx xx xx

Never married x x xx xx

Remarried x

Widowed

x

x

x
Chapter 6 Individual Risk and Protective Factors I 95

Alcohol Marijuana Cocaine

Abstinence Past month Past Any past No past

in past nonheavy monthb month month Any past No past

Predictorsa month use heavy use use use year use year use

Employment status

(full-time) x x

Part-time x

Unemployed x x

Homemaker x

Students x

Other

Number of jobs in past 5 years (1 or 2)

None x

3 or more x x x

Number of moves in past 5 years (none) x

1 or 2

3 or more x x x x —-

a Reference categories to which others are compared are shown in parentheses

b Defined as five or more drinks on five or more days in the past 30 days

c Variables which are significant at p< .05 or less

d Highly predictive

SOURCE Off Ice of Technology Assessment, 1994, adapted from tables in National Institute on Drug Abuse, Socioeconomic and Demographic

Correlates of Drug and Alcohol Use, 1992

to amplify the adverse reaction to alcohol consumption (57). Since this reaction discourages

heavy drinking, the observation that it commonly

occurs in some populations where alcoholism is

relatively rare suggests that alcohol and aldehyde

dehydrogenase mutations might be a major determinant of alcohol consumption, abuse, and dependence. This would seem to hold true for

Taiwan and Japan where the reaction occurs in 30

to 50 percent of individuals. Research on these

two enzymes among other racial and ethnic

groups is scanty and inconclusive.

The role genetics plays in the heritability of alcohol and other drug problems has been studied

for the past 30 years. While this topic is more thoroughly addressed in chapter 3, one point is worth

mentioning here. Of the more than 30 family,

twin, and adoption studies that have been completed, the vast majority have used white males as

study subjects. Clearly, among different racial and

ethnic groups the relationship between genetic

heritability and increased susceptibility to alcohol

and other drug problems is an area that deserves

further study.

While race and ethnicity in and of themselves

are not predictive risk factors for future substance

abuse, by reviewing when, how, and why certain

substances became problematic within different

racial and ethnic groups, insight can be gained into

the generational impact drugs have had on these

populations. Four broad racial and ethnic groups

(and one multiracial and ethnic group, see box

6-4) are discussed below in the following manner:

historical perspectives; prevalence statistics; psychosocial and cultural antecedents; and selected

prevention programs. A separate section on areas

for future research is also included.

Native American Indians/Alaska Natives

There are more than 1.5 million Americans Indians and Alaskan Natives throughout the United

States, with vastly different languages and cultural beliefs. Even within the same tribe there maybe

a good deal of cultural diversity, since differences

exist between reservation and rural tribal members, and those residing in urban settings. While

urban dwelling American Indians may constitute
96 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Migrant and seasonal farmworkers (M/SFWs) are individuals “whose principal employment IS in agriculture on a seasonal basis [and who have] been so employed within the last 24 months” (Public Law

100-386), Migratory workers are those “who establish for the purposes of such employment a temporary abode,” while seasonal workers are those who meet the seasonal definition but are not migrant

workers (Public Law 100-386), While seasonal is not explicdly defined m the public law, the Department

of Agriculture defines a seasonal farmworker as one who performs 25 to 149 days of farm wage work in

one year, and does not migrate,

Due to the transitory nature of the job and the employees, obtaining a precise estimate on the number of farmworkers is difficult. State data suggest that upwards of 4 million farmworkers are in the

United States and Puerto Rico, and if ratios from the late 1970s hold true, approximately 30 percent (or

1 2 million) of these are migrants,

The racial and ethnic background of the farmworkers varies with the so-called “stream. ” The East

Coast stream is probably the most diverse with American blacks, Haihans, Jamaicans, Dominicans,

Mexicans, Puerto Ricans, an increasing number of Central American Indians, and a small percentage

of whites In the Midwest and West, the great majority of migrant farmworkers are of Mexican descent,

although increasingly, Asian immigrants are making their way into the stream American Indians make

up a substantial proportion of the farmworker population in the West and Southwest

Farmworkers are most often hired through a middle-person or “crewleader” who is usually In charge

of negohating length of employment, transportation, wages, housing, and meals It IS not uncommon for

migrant farmworkers to move anywhere from two to eleven times m a year Besides the physically taxing

nature of the work, numerous environmental stressors (some unique to this population) increase the likelihood for alcohol and drug abuse, Some of these stressors include physically and socially Isolated

camp locations; unsanitary overcrowded, and unsafe camp conditions, towns which often do not welcome the presence of farmworkers; long periods of separation from family members, feelings of boredom, isolation, and powerlessness, and language and cultural differences

The job’s high mobillty requirements hamper the collection of health data on this population. Anecdotal reformation from health care providers located at Migrant/Community Health Centers (M/CHCs)

and local health departments cite alcohol and drug abuse problems as some of the most significant

health issues faced by M/SFWs, followed by anxiety and depression (McCaw 1991) However, few

quantitative or qualitative studies have documented substance abuse within this population One study

(continued )

more than 50 percent of the total Indian popula- or role model for moderate drinking practices,

tion, little is known concerning their health status

(59).

The American Indians’ introduction to alcohol

dates back to the early 1600s and their initial interactions with European trappers and settlers. Much

of the early trading between the Europeans and

American Indians involved an exchange of alcohol. It was not long before alcohol became a considerable problem for many American Indian

tribes. Some researchers speculate that because

American Indians lacked a prior drinking history,

many tribes adopted a quick and copious style of

drinking, consistently drinking to the point of intoxication. However, in other tribes, it is appears

that being intoxicated was deemed unacceptable,

and over time these tribes developed a “social”

drinking style (35).

Prevalence statistics

Studies among American Indian adolescents have

shown that prevalence rates for licit and illicit

drug use vary insignificantly between tribes (5,4).
Chapter6 Individual Risk and Protective Factors 197

of black and HaltIan farmworkers in upstate New York found that the majority of the heavy drinking on

the migrant camps was done by older, single, black males, and that the drinking patterns of the study

participants who traveled with their families differed Ilttle from Individuals in the general populahon To a

large extent, this was attributed to the social controls family members exerted on one another (Mattera

et al 1983) This IS an important point, as the greater mechanization of farmwork has reduced the need

for manual labor, and many of the farmworkers who previously traveled with their families can no longer

afford to do so Anecdotal evidence suggests that the composition of the migrant workforce has been

shlftlng toward one of single males, rather than families With this shift, a general decrease in social

control among the migrant camps is likely to occur, and a greater number of alcohol and drug problems

may begin to appear

Provldlng substance abuse prevention programs to M/SFWs IS a challenge Few M/CHCs have the

flnanclal or personnel capabilities to implement substance abuse prevention programs Many farmworkers .sImply do not stay m one location long enough Language and cultural differences are vast, not

to menhon the geographical distances somehmes required to reach the camps, which often are located

20 to 30 miles away from the nearest social serwce and/or each other Two organizations (BOCES Geneseo Migrant Center In New York, NY, and Trl-County Community Health Center in Newton Grove, NC)

have successfully Implemented similar types of programs based on the premise of providing weekend

actlvltles as an alternahve to drinking and drug use. Full-day programs are normally held away from the

camps, and include educational, creative, athletlc, and cultural achvltles The activities are free and

transportation IS often provided However, farmworkers can attend only If they have not been drinking or

using drugs

Clearly, greater research KS necessary to adequately document the prevalence of alcohol and drug

use wlthm the migrant streams, as well as the changing composition of the streams, and how this may

affect substance use Little IS known about the differences m substance use between the varying racial

and ethnic groups within the streams, and how the growing number of Immigrants from war-torn countnes WIII affect the health problems seen within the streams

SOURCES U S Congress, Off Ice of Technology Assessment, Health Care /n Rura/Amer/ca, OTA-H-434 (Washington, DC U S Government Prlntmg Off Ice, September 1990) K McCaw, “Migrant Workers, ” C//mea/ Marwa/ of Subsfance Abuse, J Kinney (ed )(St

LouIs, MO Mosby-Year Book, Inc 1991) G Mattera, J Watson, S Kunltz, et al “Alcohol Use Among M{grant Laborers, ” unpublished report for the New York State Health Research Counc[l, Albany, NY, 1983

However, compared to non-Indian youth, Indian In some tribes, up to 30 percent of American Inadolescents consistently begin using alcohol, illicit substances, cigarettes, and inhalants at a

younger age, at higher rates, and in combination

with each other (10,60,69), With regard to alcohol, there is often a great deal of peer pressure to

drink as the Indian thing to do (42). Studies have

shown that Indian youth are three times more likely to be involved in alcohol-related offenses than

their white or Hispanic counterparts. A 1982

study indicated that alcohol was involved in as

many as 58 percent of Indian juvenile arrests (63

percent for males, 37 percent for females).

dian adolescents have used inhalants, most notably, gasoline and glue. The age group with the

highest rate of inhalant use was 11- to 13-yearolds. Contrary to the popular belief that inhalant

abuse occurs primarily among boys, research

among American Indians revealed that eighth

grade girls and boys were equally likely to have

inhaled volatile substances. While the rate for Indian inhalant use decreases substantially among

high school age youth (down to 4 percent), it is

still 2.5 times greater than the rate for non-Indian

youth of that age. Interestingly, while the rate of
98 I Technologies for Understanding and Preventing Substance Abuse and Addiction

inhalant use has remained relatively stable among

Indian youth since 1984, there has been a steady

rise of reported use among non-Indian adolescents

(66).

While there is no substantial difference in alcohol use among various tribal adolescents, rates do

differ between the drinking patterns of tribal

adults. Contrary to the still pervasive drunken Indian stereotype, many tribes have levels of adult

alcohol use below the national average (42). Consistent with the U.S. population as a whole, American Indian males are more likely to drink than

females (42,35). In some tribes it is permissible

for adolescent females to experiment with alcohol, with the understanding that when adulthood

is reached they are expected to abstain or drink

only rarely.

As is true for adolescents, adult Indians encounter an increased rate of legal complications

due to alcohol and drug use. Data on urban American Indians has shown that while under the influence of alcohol and/or other drugs, they are

arrested at four times the rate for blacks and 10

times the rate for whites (44).

Few statistics exist to quantify illicit substance

use among the adult American Indian population.

While alcohol is clearly a major problem for some

tribes, future research efforts should include data

on the use of illicit substances.

Psychosocial/cultural antecedents

The relationship between the majority of American Indians and the early settlers was suffused

with violence, distrust, deceit, and perhaps more

than anything, forcible and abrupt change. The

food American Indians ate, how they dressed,

where and how they lived, what language they

spoke, tribal governing structures, and how they

worshiped were, for the most part, forcibly altered

to conform with the newly dominant society’s cultural and moral views. While these involuntary

changes occurred several generations ago, their

impact on the American Indian culture should not

be underestimated.

In some instances, tribal traditions, languages,

and methods of worship were lost. Thousands of

American Indian children, some as young as 3

years old, were removed from their families and

placed in federally funded and run boarding

schools, where physical, verbal, and sexual abuse

were common. Nuclear and extended families

were dispersed, and with them, a vital social support system. Acculturation issues abounded. Children returned home from boarding schools unable

to speak their native language, or understand the

importance of their cultural traditions. These cultural problems are multigenerational, and current

studies reveal that American Indian children report more emotional problems, mental health

problems, and low self-esteem than non-Indian

children (60). While the relationship between

many of these psychosocial/cultural antecedents

and increased substance abuse levels has yet to be

formally evaluated, clearly the American Indian

people have been, and in some may continue to be,

subjected to cultural disruption.

Prevention programs

For substance abuse prevention programs to be effective within the American Indian population it

is important to realize the diversity that exists between tribes and villages. For example, a specific

program tailored to New Mexico Navajos living

on the Navajo reservation may be culturally unacceptable to Winnebago Indians living in urban

Minneapolis, MN. However, several fairly universal themes permeate American Indian culture:

the importance of tribal identity, which is an individual’s membership or affiliation with specific

tribe(s); a belief that each human is a multidimensional being made up of a body, mind, and spirit,

and that the spirit world coexists and intermingles

with the physical world; the importance of sharing

and generosity, allegiance to one’s family and

community, respect for elders, noninterference,

orientation to present time, and harmony with nature; the importance of an oral tradition as a primary method of teaching values, attitudes, legends,

and stories; an emphasis on observant, reflective,

and integrative skills which lead to communication patterns that give virtue to silence, listening,

nonverbal cues, and learning by example; and the
Chapter 6 Individual Risk and Protective Factors I 99

presence of rituals and symbols that are acknowledged for their underlying significance, which is

expected to emerge as time and experience go on

(72).

One example that assists communities in the

development of culturally sensitive programs is

an instructional publication compiled by The Four

Worlds Development Project in Alberta, Canada.

Information has been collected on health promotion and prevention efforts by various indigenous

people from around the world. The text assists

American Indian communities in tailoring program planning, training, and implementation

techniques with their culture beliefs and specific

needs (24).

Blacks

A great deal of diversity exists within the black

community. One reflection of that diversity is the

use of the terms African American and black.

Some researchers use African American to define

black persons who are direct descendants of men

and women brought to the United States as slaves,

whereas blacks is used to define all people and

cultures of African descent, including black

people from the West Indies, Africa, and the

Americas. At times, the two terms are used interchangeably (72). For this section, both terms will

be utilized where appropriate.

Historically

Many of the first blacks to arrive in the United

States did so as slaves. Plantation owners were responsible for regulating much of their slaves’ alcohol consumption. During holidays, alcohol was

routinely distributed to the slaves in reward for

their loyalty and hard work, and the subsequent

drunken revelries were tolerated. This controlled

permissiveness began to change in the early

1800s, as clandestine groups of black slaves began

their quest for freedom. It was at this point that

blacks were prohibited from owning stills, or even

being in possession of alcoholic beverages. These

laws persisted after the Civil War, when technically, blacks had been granted citizenship (14).

Spanning the late 1800s through the late 1960s,

hundreds of thousands of blacks left the South

and, looking for work, headed for northern cities.

This period was later described as the “Great

Migration,” with a total outmigration estimated at

4.3 million individuals (72,1 4). This outmigration contributed substantially to defining the large

number of blacks currently found in many of the

northern urban areas. Unfortunately, many of

those seeking work did not find it, nor did they

find that they were free from racism, discrimination, and oppression, Slowly, the numbers leaving

the South decreased, and by the 1970s there was

actually some migration back into the southern

states by both northern-born blacks and individuals returning home after unsuccessful moves to

the North.

Prevalence statistics

Differences in adolescent drug use among high

school seniors by race and ethnicity were discussed earlier in this chapter (see box 6-A).

Among this group, alcohol, cigarette, and illicit

drug use was lowest among black and Asian

youth, even after inclusion of background and

lifestyle factors. Obviously, a drawback to this

type of survey is that high school dropouts are not

included in the analyses. The 1991 event dropout

rate (which measures the proportion of individuals who dropped out of school over a specified

time period) for grades 10 to 12, ages 15 to 24, reveal dropout percentages of 3.2 for whites, 6.0 for

blacks, and 7.3 for Hispanics (63). While the event

dropout rate for blacks is double that of white students, low alcohol and drug usage rates have also

been found among black eighth and tenth graders,

so the low rate of substance use among black

twelfth graders cannot be due entirely to dropout

rates (75).

While use of alcohol, cigarettes, and illicit

drugs is relatively low among blacks, data on

heavy or frequent use of such substances differs.

The 1991 NHSDA data for individuals aged 12 to

20 found that 7.3 percent of whites reported heavy

alcohol use (defined as having 5 or more drinks on
100 I Technologies for Understanding and Preventing Substance Abuse and Addiction

one occasion on 5 or more days in the past 30

days), Hispanics reported 3.9 percent, and blacks

reported 2.7 percent. However, for those individuals aged 21 or older, heavy alcohol use did not differ significantly between whites and blacks (5.0

vs. 6.0 percent), but was significantly higher

among Hispanics (6.6 percent) (77). Other studies

on heavy alcohol use, by gender, have shown that

white men aged 18 to 29 report the highest prevalence of heavy drinking, which then declined in

subsequent age groups. Conversely, the abstention rate for black males was highest among those

aged 18 to 29, while subsequent age groups

showed significantly increased levels of heavy

drinking—among whom half report either frequent heavy or frequent high maximum drinking

(70). Similarly, white women in the 18 to 29 age

group were significantly more likely to drink, and

to drink heavily, than were young black women

(67).

Past-month use (which does not necessarily

constitute abuse) of an illicit substance by race and

ethnicity was discussed at the beginning of this

section (see figure 6-2). However, the 1992

NHSDA also contains more specific data for some

of the most commonly used substances such as

marijuana and cocaine. Of the blacks age 12 and

older surveyed, 3.2 reported using marijuana once

a week or more compared to 2.5 percent for whites

and Hispanics. Blacks also had the highest reported weekly use of cocaine (0.5 percent)

compared to Hispanic and white percentages (0.4

and 0.3, respectively) (78).

Persistence of drug use has also been used as

another indicator of substance use severity and is

measured by percent of monthly users divided by

percent of lifetime users. It has been shown that

blacks and Hispanics have a different pattern of

drug persistence from that of whites. Data on cocaine use analyzed from the 1990 NHSDA

showed that the persistence rate for blacks age 18

to 25 was almost three times that of whites (.29

vs.. 09), and among those aged 26 to 34, the rate

for blacks was four times higher than that for

whites (.21 vs. .05). In both age groups, the persistence rates for Hispanics were between those of

blacks and whites. It is important to note that the

differences in persistence did not appear to extend

to alcohol and marijuana (32).

Psychosocial/cultural antecedents

At least initially, many blacks did not arrive in the

United States voluntarily. The legacy of slavery

has shaped much of black culture. Black slaves

struggled with many of the same issues as American Indians: loss of languages, traditions, and

religious beliefs; assimilation and acculturation

issues; and the breakup of nuclear and extended

families. Not allowed to express their original languages, cultures, and beliefs, blacks attempted to

establish new cultural identities amidst oppression, segregation, and racism.

Hypotheses concerning alcoholism among

black males have been proposed by several studies. Some researchers believe that the increase in

the number of heavy drinkers among black males

in their thirties may be due to feelings of frustration and failure concerning career expectations. A

complementary view points to the combination of

high unemployment rates among black males

coupled with the large numbers of liquor stores

found in many urban black neighborhoods, as

having contributed to the alcohol problems faced

by black men ( 14,82).

Prevention programs

With respect to the use of alcohol and other drugs,

common themes link blacks. In general, social

stratification, church and community involvement, and racial identity are thought to be important variables in attitudes toward alcohol and drug

use (72, 14). The level of importance will vary between individuals and groups depending on environmental factors. One program cited as

exemplary by the Center for Substance Abuse Prevention (CSAP) is called Super II, and targets primarily at risk, black inner-city youths 11 to 17 and

their parents. The design and implementation of

the program emphasizes holism and cultural competence, viewing them as crucial in reducing the

strength of risk factors and increasing the strength

of resiliency factors. The program takes place

through already established agencies in the communities (Boys Clubs and Girls Clubs) and incor-
Chapter 6 individual Risk and Protective Factors I 101

porates the childrens’ caregivers, youth and

recreational workers, police officials, local corporations, and a variety of social service agencies.

The first-year evaluation report found reductions

in four of five major categories of alcohol- and

drug- related behavior. These included frequency

of use and amount of use, number of modalities of

use, alcohol- and drug-related behavior problems,

and media influenceability (71).

Another antidrug abuse campaign is being

waged by the Congress of National Black

Churches, Inc. (CNBC), a national nonprofit

religious organization comprised of a variety of

denominations. Through a variety of programs,

the CNBC clergy are mobilizing, creating, and

coordinating groups of individuals interested in

bringing about positive change in their communities. Program strategies are implemented in partnership with the police, criminal justice agencies,

school systems, social service agencies, private

organization and

munity networks

mand for drugs.

Hispanics

Historically

businesses, and informal comto reduce the supply of and deThe term Hispanic was first used by the U.S. Census Bureau in 1980 to designate those individuals

who resided in the United States and whose cultural origins were in Mexico, Puerto Rico, Cuba,

Central America, and other Latin American countries. Not all members of this group accept the

term and prefer to use phrases such as Latino or la

raza (literally, “the race”). Data from the 1990

census reveal an Hispanic population of more than

20 million, and projections indicate that Hispanics will be the largest minority group in the United

States sometime between the years 2000 and

2010. Hispanics of Mexican origin, by far the largest Hispanic group (63 percent), are clustered in

the southwest, particularly California and Texas.

Puerto Ricans, excluding those living on the island of Puerto Rico, are the second largest subgroup (12 percent) and live primarily in the

Northeast, especially in and around New York

City, New York. Cubans (5 percent) live primarily

around their port of entry, Miami, Florida, though

large numbers are found in New Jersey and New

York. Dominicans, who reside primarily in the

Northeastern Atlantic States, are also beginning to

grow in number. In the past 10 years, there has

been a large immigration of Central Americans to

the United States. These individuals have come

primarily from civil war-plagued countries including Guatemala, El Salvador, and Nicaragua. It

is highly possible that many of the problems faced

by newly arrived Hispanic immigrants maybe exacerbated among this population who have left

their countries involuntarily. Refugees escaping

political turmoil or open warfare often show signs

of Post Traumatic Stress Disorder (72).

Prevalence statistics

NIDA data collected from 1975 to 1991 on drug

use among twelfth graders, as well as data from

1991 for eighth and tenth graders, reveal the following for Hispanic students: as a group, Hispanic

youth had the highest lifetime and annual prevalence rates in the senior year for PCP, cocaine,

crack, heroin, ice, and steroids, compared to

whites and blacks, and the rates for crack and steroid use were particularly high; among eighth

graders, Hispanics had higher rates of past month

use for virtually all the drugs surveyed including,

cocaine, heroin, inhalants, alcohol, marijuana,

hallucinogens, and cigarettes. In other words, in

eighth grade, before a considerable number of students has dropped out, Hispanic youth have the

highest prevalence of nearly all drug use, but by

twelfth grade, whites have the highest usage rates.

The researchers suggest two possible explanations, which are not necessarily exclusive. The

first being that the high dropout rate for Hispanics

in later grades (in some areas as high as 40 percent) is causing a shift in the rates, and the second

is that while Hispanic youth begin experimenting

earlier, white youth catch up by the later grades

(75).

National statistics for 1992 of past-month use

of any illicit substance indicated that rates for Hispanics and whites were not significantly different,

and were slightly lower than those for blacks (see
102 I Technologies for Understanding and Preventing Substance Abuse and Addiction

figure 6-2). The same database also revealed that

for the illicit substances measured, Hispanic rates

either fell between black and white rates, or were

the lowest rates reported by an ethnic group. The

only exception would be the heavy alcohol use

data (defined as having 5 or more drinks on one

occasion on 5 or more days within the past 30

days) for 1991 (1992 data not yet available) which

showed that Hispanics aged 21 or older reported

significantly more heavy alcohol use within the

past month as compared to whites and blacks (77).

Psychosocial/cultural antecedents

Dignidad, respeto, confianza--dignity, respect,

and trust—are important elements in the Hispanic

culture. Like many immigrants to the United

States, Hispanics deal with language, cultural, racial, and economic barriers. These barriers and

how they are handled within the Hispanic culture

have a great deal to do with subsequent alcohol

and drug problems. To a large extent, drinking (at

times heavily) among Hispanic males is not only

expected, but encouraged. Much of the research

literature has therefore centered around alcohol

and its misuse. To be able to drink heavily and

maintain “control” is a valued characteristic

among most Hispanic men (38). Personal identities for a vast majority of Hispanic men are intricately entwined with the notion of machismo,

which generally connotes strength, masculinity,

independence, and responsibility (1). The man of

the family is expected to provide for and take care

of his wife and children. For those who may be unable to fulfill this role, due to difficulties learning

English and/or procuring employment, the social

drinking pattern can change from one of low frequency and high quantity, to high frequency and

high quantity (38,1 ). This drinking pattern varies

between Hispanic groups, however. A study completed in 1981 found that drinking levels among

newly arrived Dominicans, Guatemalans, and

Puerto Ricans, when compared to preimmigration

levels, decreased, increased, and remained the

same, respectively (1).

As is relatively true for other cultures, heavy

drinking is not condoned for Hispanic women.

This is not to say that it does not exist. While the

majority of first generation Hispanic women generally abstain or drink very little, changes in drinking patterns among the following generations

have been observed. To the distress of many first

generational Hispanic families, as their daughters

and granddaughters become increasingly acculturated, the drinking patterns and alcohol problems

more closely mirror those found in the general

population (26). Another change observed among

more acculturated Hispanic women is the diminishment of marianismo, which is the female complement to machismo, and encompasses such

behaviors as submissiveness, humility, tolerance,

virtuosity, and devotion to the male (whether father, husband, or first son).

Prevention programs

Important intergroup differences need to be understood for the planning, implementation, and evaluation of substance abuse prevention programs.

For example, while two immigrants, one Mexican

and the other El Salvadorian, may both speak

Spanish and may both be experiencing many of

the same difficulties in adjusting to life in the

United States, they are very likely to have had

vastly different lifetime and cultural experiences

(72).

Funds from CSAP as well as the National Institute on Alcohol Abuse and Alcoholism (NIAAA)

have been distributed to several demonstration

projects throughout the United States and Puerto

Rico that target high-risk Hispanic youth and their

families. Many of these programs are similar to

others previously outlined in this report in their attempt to be as comprehensive as possible through

the coordination of families, schools, law enforcement, and local social services and businesses.

Several of the programs are creating their own audiovisual and written materials in Spanish, others

are utilizing activities such as English courses,

puppet shows, and live theater performances,

while others employ peer group counseling and

mentoring programs (69).
Chapter 6 Individual Risk and Protective Factors I 103

Asian and Pacific Island Americans

Historically

According to the U.S. Census Bureau, Asian and

Pacific Island Americans are the fastest growing

population in the United States. Between 1980

and 1988, the number of Asian and Pacific Island

Americans increased by 76 percent compared

with an increase of 36 percent within the Hispanic

population. Similar to the other racial and ethnic

categories, the term Asian and Pacific Island

American gives one the impression of homogeneity, while in reality, over 60 different racial and

ethnic groups are lumped in this bracket. Some of

the diverse populations included in this group are

Hawaiians, Guamanians, Filipinos, Thais,

Bengalis, and Sri Lankans. Beside the obvious

differences in language, and cultural norms and

beliefs, is the degree to which different subpopulations have acculturated and/or assimilated to the

dominant culture. Many Chinese and Japanese

families have been in the United States for three

generations or more, which is in sharp contrast to

the majority of first-generation Vietnamese, Koreans, Asian Indians, and Filipinos (72,85).

Prevalence statistics

Research on substance use and abuse within the

Asian and Pacific Island American population appears to be sporadic, and often limited to alcohol.

While the three national surveys NHSDA, the National Adolescent School Health Survey, and the

High School Senior Survey, all collect separate

data for Asian and Pacific Island Americans, only

the High School Senior Survey routinely analyzes

the data separately. Due to small sample sizes, the

remaining two surveys included Asian and Pacific

Islanders under the racial and ethnic category of

“other.”

Research on alcohol consumption patterns

among adult Asian and Pacific Island Americans

consistently shows that this population drinks

substantially less than whites and Hispanics, and

slightly less than blacks. Though subgroup variation does exist, as data reveal, native Hawaiians

drink at levels comparable to those of whites,

among mainland Asian Americans, Japanese

Americans drink the most, followed by Koreans

and Chinese Americans. However, Japanese, Korean, and Filipino men all have roughly the same

percentage of heavy drinkers at 28 percent. This

style of heavy drinking is typically associated

with business entertainment and after work socializing (68). Among Asian and Pacific Island American women, four-fifths of Korean and Filipino

women were reported to be abstainers, as were

two-thirds of Chinese women, and one-third of

Japanese women. Among women who drank, the

percentage who did so heavily varied: 12 percent

for Japanese women; less than 4 percent for Filipino women; and virtually none for Chinese and

Korean women (68). A similar statistic for white

women showed 14.5 percent reported drinking

heavily (73). Evidence suggests, however, that the

prevalence of drinking may be on the rise among

both men and women Asian and Pacific Island

Americans, although the exact reasons for this remain unclear. Some researchers have suggested

that paralleling other immigrant populations, the

more acculturated and assimilated generations

will tend to adopt the drinking patterns of the

dominant culture. Yet other researchers point to

the fact that a significant number of second and

third generation Asian and Pacific Island Americans have not adopted a more copious style of

drinking.

For adolescent Asian Americans, the majority

of the studies mirrors the findings for the adults—

this group consistently has the lowest prevalence

of alcohol and other drug use for all racial and ethnic groups with the possible exception of black

youth. Although, a prospective study conducted

in North Carolina found an alarming increase in

reported alcohol and other drug use among Asian

Americans over a three-year period in the late

1980s. The reason for this increase at a time when

prevalence rates for other races and ethnicities was

decreasing remains unknown (72). Another study

on youth in California reported that Chinese

American youth used quaaludes twice as often as

white and Hispanic youth, and five times as often

as black youth (68). Drinking statistics for Asian

American youth are again similar to those re-
104 I Technologies for Understanding and Preventing Substance Abuse and Addiction

ported by the adult population, that is, their overall prevalence rate is one of the lowest, but

statistics for heavy drinking are similar to those

found among white youth (72).

Psychosocial/cultural antecedents

Why does this population have such low overall

rates of alcohol and other drug use? The diversity

present within the Asian and Pacific Island American group makes it impossible to list all the different cultural factors that could influence alcohol

and drug use patterns. However, among many of

the subpopulations, anthropologists and substance abuse experts have found the existence of

the following philosophies: moderation, family

reputation, humility, keeping a low profile, negative community sanctions on excessive drinking

and behavior, and the impact of parental drinking

practices (83). Among Chinese specifically, alcohol is in an important part of many religious and

celebratory ceremonies, yet excessive use is

strongly discouraged.

One study in California uncovered additional

behavioral factors that influenced drinking patterns among some Asian American men. Japanese

respondents were heavily influenced by their

friends’ drinking; among Chinese men, those with

more education were more likely to drink; and Korean men were strongly influenced by their parents’ drinking habits (68).

Few researchers have examined psychosocial

influences on Asian and Pacific Island American

adolescent drinking or other drug use. One factor

which has been mentioned, though, is the pressure

Asian American youth, in particular, are under to

succeed, especially academical y. Thirty-four percent of Asian Americans are college educated,

more than twice that of the United States population as a whole. Those with the least amount of

college education were American Indians (7.7

percent) and Pacific Islanders (9.3 percent). Asian

parents are similar to parents, in general, in their

hopes for their children’s success. However,

among some subpopulations (notably Japanese,

Korean, and Chinese) the feelings for their children are often tied to the child’s academic achievement. When their children perform poorly in

school, some parents respond with strong criticism, disapproval, and shame. This can understandably add a substantial amount of stress to an

adolescent who may already be coping with language and cultural differences (72).

Prevention programs

Mainstream culture in the United States, to a great

degree, emphasizes individuality, competitiveness, and monetary success. Conversely, for many

Asian and Pacific Island Americans the qualities

most stressed are the needs of the family, sharing

and generosity, and a belief in who you are rather

than what you own. Because the extended family

is so important in many of the cultures, it is often

the first group that an individual with problems

will turn to versus an “outsider” or social service

agency. Substance abuse prevention practitioners

need to be aware of the strong resistance within

many Asian and Pacific Island Americans to seek

outside assistance.

One innovative substance abuse program entitled Na Keiki O Ka’Aina (Children of the Land)

is being implemented in Oahu, Hawaii. Children

attending the local Makaha elementary school

work several hours a week on a farm where they

learn to care for the land, their environment, and

themselves as alternatives to lifestyles that rely on

alcohol and other drugs. The program uses the cultural values of native Hawaiians, which emphasize “warm, open friendship and love,” love of the

earth, and other spiritual values. Since the program’s inception, class behavior has noticeably

improved, English scores have increased, and a

survey measuring drug use in the district schools

showed that Makaha school was the only school

that reported a decrease (74).

Areas for Future Research Among Different

Racial and Ethnic Groups

While this section of the report has reiterated the

need to view racial and ethnic groups as heterogeneous, the majority of substance abuse data is not

collected or examined in this way. To date, a variety of distinct cultures are usually grouped under
Chapte 6 Individual Risk and Protective Factors I 105

one classification, and generalizations are made

concerning this group’s drug use. While substance

abuse prevention programs are often better tailored to specific subpopulations and cultures, it is

virtually impossible to adequately evaluate these

programs when little baseline substance abuse

data exists for specific subpopulations. There is

therefore room for improvement in the collection

of prevalence data on alcohol and other drug use

and abuse among distinct racial and ethnic groups.

Furthermore, long-term prospective studies,

which are essential for understanding risk and protective factors specific to different groups, are extremely scarce.

Biomedical research on different racial and ethnic groups has also been inconclusive and scanty

(with the possible exception of alcohol research

and Asians).

ECONOMICS

Economics can be viewed as a factor in individual

substance abuse in two ways. In areas where substance abuse is already well established and viable

employment opportunities are scarce, selling illicit substances can seem very appealing. Several

questions arise from this scenario. Are individuals

lured into the world of illegal drug sales by income potential? And, are drug dealers more 1ikely

to become drug abusers because they are dealers?

Both of these questions have been addressed under the first section.

A parallel issue is that of poverty and the daily

stresses encountered by individuals living in

chronically poor areas. Do individuals living in

these poor areas abuse substances in greater numbers or are fewer social services available in these

areas, and thus the consequences from substance

abuse are more acutely felt and visible?

1 Generated Income

While few studies have attempted to ascertain the

individual incomes of drug dealers, two studies

have concentrated on the street sale of illicit drugs

by urban youth (2 1,52). The research revealed that

individual dealers reported mean gross monthly

incomes of $3,558 to $5,934. Even if these selfreported earnings were exaggerated, this sum of

money is clearly more than many urban youth

could hope to obtain in legitimate jobs at a median

of $7 per hour.

This earning potential may be a serious obstacle to prevention, intervention, and treatment

programs targeted toward urban adolescents. The

staff at an innovative treatment program for drug

dealers in Baltimore, Maryland, has discovered

the difficulties former dealers have in giving up

the fast lifestyles they once led.

Most dealers say they do it because of the

money,” says a staff counselor. “They can’t see

working at McDonald’s for minimum wage

when they’re making $500 to $1,000 per day,”

he adds. Counselors try to help clients think beyond the idea of making fast money to the moral,

social and legal issues associated with drug

dealing. They find, however, that the moral issue is not always clear-cut. In many cases, clients are supporting their families and it is hard

for them to see they are doing something wrong

when they are paying the bills.

Overall, counselors say their clients are addicted to the money. “What we do is help them

see what is all around them, what they’re doing

to themselves and their community by selling

drugs (48).

The potential for monetary gain may be especially true within the crack trade. A young black

male from San Francisco, California, explained

his preference for the immediate rewards of selling crack over the seemingly meaningless rituals

of school:

Forget about school. I’d rather have a life of

selling drugs. . . When you go to school, you do

nothing. You sit around, have books in your

backpack, take ’em home, do your homework,

come back to school, get some grade. When you

sell drugs, see, I had satisfaction of seeing my

work, getting some money for it (22).

It would appear then that for many urban youth,

selling illicit drugs supplies purpose, companionship, and income without compromising dignity.

More money can be gained from the sale of illicit

drugs than through petty crimes, and certainly

more than through minimum wage jobs.
106 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Another issue to be addressed is the dealerturned-client. From the two previously cited studies, dealers were estimated to spend between 59

and 71 percent of their income each month on the

purchase of illicit drugs. For example, out of

$3,558 gross per month, $1,226 was spent purchasing additional drugs for business, $883 was

spent on drugs for personal consumption, and an

additional $533 on expenses associated with drug

dealing.

The Urban Institute has also reviewed the relationship between using and selling drugs. Its

study population was composed of 387 inner-city

adolescent males of ninth- and tenth- grade age.

Of this sample, 79.6 percent reported that they

neither used nor sold drugs within the past year. Of

the remainder, 19.0 percent reported both using

and selling drugs, 44.3 percent reported selling

only, and 36.7 percent reported using only. They

also discovered that the greater the level of involvement in either using or selling, the higher the

likelihood of doing both ( 13).

In summary, the research completed thus far

neither confirms nor negates the possible influence income potential has on luring individuals

into drug dealing. Nor can one conclude that drug

dealers are more likely to become substance abusers than nondealers.

B Poverty

Alcohol and drug problems are present not only

among the poor, but are poor individuals at greater

risk for developing these problems? While a relatively straight forward question, not only is poverty difficult to define, but drawing conclusions

concerning an individual’s potential for future

substance abuse based on one or two variables,

such as family income or educational level, is overly simplistic and deceptive. To adequately review this question, a milieu of both individual and

aggregate measures should be present in any analysis done.

In recent years, great attention has been paid to

the plight of the urban poor, many of whom are

minorities. These inner-city communities are

often riddled with high rates of crime, violence,

unemployment, and inadequate social and medical services. For individuals living in these localities, the consequences of these problems are

serious and far-reaching. Yet according to the 1980

census only 9 percent of all the poor, and 21 percent of all the poor blacks, lived in these types of

areas.

To define the problems of the urban poor as

predominantly “black problems” does a disservice to the two-thirds of African Americans who

are not poor, as well as to the two-thirds of the

poor in our central cities who are not black (8).

Poverty within rural communities, while lacking much of the violence and crime of urban areas,

is no less oppressive. In 1987, compared with the

general population, rural residents were less likely

to be employed and to have completed high

school. They had lower average incomes and

higher poverty rates than did urban residents, and

one out of every six rural families lived in poverty

(compared with one in eight urban families). This

ratio approached one out of two for black rural

families. Areas of chronic poverty were concentrated in the South, where 25 million of the Nation’s 57 million rural residents live (48 percent),

and where four out of every ten rural residents

were poor, elderly, or both (61).

To assess poverty and its relationship to alcohol

and drug abuse problems, one must find appropriate measures. Some researchers have utilized the

Federal guidelines for poverty, while others

employ measures of Socioeconomic Status

(SES), such as educational level and household

income. To date, the largest and most comprehensive analysis of SES variables and substance use

has been accomplished by NIDA (76). Both bivariate and multivariate analyses were completed

on data collected in 1988 and 1990 from NHSDA

(see box 6-C).

The NIDA report has two major limitations.

First, the analysis focused on indicators of drug

and alcohol use, rather than indicators of problem

use or hard-core use. While the report has categories for frequent/heavy use and recent use, it cannot be assumed that individuals who reported such

use had alcohol or drug problems. Secondly, the
.. —.

report lacks data for transient, homeless, or institutionalized individuals, many of whom have serious alcohol and/or drug problems.

Table 6-3 presents the findings from the multivariate analysis of the NHSDA data. The SES

variables pertinent to a possible link between poverty and substance use are educational level, occupation of chief wage earner, employment status,

number of jobs held in past 5 years, median housing value, and percent of housing that is owned.

Neither personal income nor household income

were included in the analysis, as personal income

was most meaningful only for persons who

worked and household income data were not

available in the 1988 survey.

Alcohol consumption within the past month

was measured on three levels: abstinence; nonheavy use; and heavy use. Marijuana use was

measured by any past-month use and cocaine use

was measured by any past-year use (both categories could include frequent as well as casual users). Major findings from the analysis include:

■ SES variables associated with poverty and predictive of past month abstinence from alcohol

were: not having worked in the past 5 years and

having lived in a census block with a high percentage of owner occupancy. For users, versus

abstainers, SES attributes predictive of nonheavy alcohol use included having attended

college (regardless of completion) and living in

census areas with high housing values. Significant for heavy alcohol use was not having

completed high school, holding three or more

jobs in the past 5 years, and living in a census

area with low housing values. No employment

status or occupational categories were found to

be independently predictive of heavy alcohol

use.

■ For any past-month marijuana use the independent SES predictors associated with poverty were being unemployed and having held

three or more jobs in the past 5 years. Individuals who reported no marijuana use in the past

month were more likely to have had some degree of college participation.

Chapter 6 Individual Risk and Protective Factors I 107

Many of the SES predictors for cocaine use in

the past year were similar to those identified

for marijuana use: being unemployed and having worked three or more jobs in the past 5

years. SES characteristics predictive of no reported cocaine use in the past year were being

a college graduate and having a part-time job.

This type of analysis is an exercise in inclusion

and exclusion. A myriad of individual and aggregate characteristics are initially considered in the

equation and, depending on the outcome of interest, whether it be heavy alcohol use or marijuana

use in the past month, different variables will

show themselves to be either predictive or not predictive of the outcome. Because personal income

and household income were not included in the

multivariate analysis, but are often used as SES

measures for poverty, tables 6-4 and 6-5 depict the

bivariate analysis done by NIDA (76). Again, this

analysis reveals associations, not causality.

Personal income (which is highly correlated

with an individual’s age and sex) was examined

only for respondents who reported working full

time during the year prior to the survey. Associations between personal income and drug use were

significant for most drugs. For every drug use

measure (except past-month use of alcohol), plus

heavy use of alcohol, the percentage of users declined as the income level rose. Differences between income levels for frequent use of marijuana

and cocaine, concurrent heavy use of alcohol with

marijuana, and use of psychotherapeutics, hallucinogens, inhalants, and crack were all statistically significant and more than twice as common in

the lowest income group as in the highest. Low income was also associated with higher rates of abstinence from alcohol as well as higher rates of

heavy drinking.

The associations between household income

(which is less affected by age and sex) and drug

and alcohol use were considerably weaker than

those observed for personal income. The only statistically significant associations were for alcohol

use, concurrent heavy alcohol use with marijuana,

and use of hallucinogens. Those with household
108 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Personal income

Drug use category <$9,000 $9,000-$29,999 $30,000+

(Number of respondents) (996) (4,172) (1,564) Significance

Percentage of users and nonusers

Alcohol

No use in past month

Use in past montha

Heavy useb

Marijuana

No use in past month

Use in past montha

Frequent usec

Cocaine

No use in past year

Use in past yeara

Frequent usea

Multiple usee

Alcohol/marijuana

Alcohol/cocaine

Alcohol/psychotherapeutic

Other drugs in past year

Psychotherapeutics

Hallucinogens

Inhalants

Crack (in lifetime)

Heroin (in Iifetime)

43.4

49.0

7.7

90.4

4.9

4.7

93.6

4,4

2,0

38.7 27.9

54.5 66.8

6.8 5.3

93.0 96.3

4.1 2,0

3.0 1.7

94.7 96.6

3.7 2.7

1.6 0.7

Percentage of users

3.4

1.8

2.0

9.1

3.8

3.9

2.0

2,2

2.8 1.1

1.4 1.2

1.0 0.9

5.1 4.8

1.5 0.4

1.1 0.7

2.0 1,0

1.1 0.8

s

s

NS

NS

s

s

s

s

NS

NS = Not significant

S = Significant at p< .05 or less

a Excluding heavy use (alcohol) or frequent use (marijuana and cocaine)

b Defined as having five or more drinks on five or more days in past month

c Defined as using marijuana five or more times in past month

d Defined as using cocaine once in a month or more often in past year

e Heavy use of alcohol in past month and any use of marijuana (past month) or heavy use of alcohol in past month plus cocaine/psychotherapeutics

(past year)

SOURCE National Institute on Drug Abuse, National Household Survey on Drug Abuse, 1988 and 1990

incomes of $40,000 or higher were about twice as among the wealthiest households, but, in general,

likely as those with incomes of less than $12,000 drug use was not strongly related to household into have used any amount of alcohol in the past come.

month. However, the rates of heavy drinking dif- From these types of analyses, a straightforward

fered little across the income levels. Other catego- “yes or no” response to the initial question, which

ries of drug use appear to be slightly less common linked poverty to increased individual risk for
Chapter 6 Individual Risk and Protective Factors I 109

Household income

Drug use category <$12,000 $12,000-$39,999 $40,000+

(Number of respondents) (1,236) (3,454) (2,392) Significance —

Percentage of users and nonusers

Alcohol

No use in past month

Use in past montha

Heavy useb

Marijuana

No use in past month

Use in past montha

Frequent usec

Cocaine

No use in past year

Use in past yeara

Frequent used

Multiple usee

Alcohol/marijuana

Alcohol/cocaine

Alcohol/psychotherapeutic

Other drugs in past year

Psychotherapeutics

Hallucinogens

Inhalants

Crack (in Iifetime)

Heroin (in lifetime)

64.1

30.8

5.1

9 3 3

41

2 6

96.2

25

1.3

2.3

1.0

0.8

3.7

1.0

0.8

1.6

1.0

48.5

45.7

5.8

94.9

3.0

2.1

97.0

2.1

0.9

Percentage of users

2.3

1.0

0.7

4.2

1.3

1.0

1.5

0.8

34.6 s

607

4,7

95.7

2.2

2.1

96.9

2.0

1,1

NS

NS

1.2 S

0.9 NS

0.8 NS

3.7 NS

0.6 s

0.7 NS

1.2 NS

0.8 NS

NS = Not significant

S = Significant at p<-

.05 or less

a Excluding heavy use (alcohol) or frequent use (marijuana and cocaine)

b Defined as having five or more drinks on five or more days in past month

c Defined as using marijuana five or more times in past month

d Defined as using cocaine once in a month or more often in past year

e Heavy use of alcohol in past month and any use of marijuana (past month) or heavy use of alcohol in past month plus cocaine/psychotherapeutics

(past year)

SOURCE National Institute on Drug Abuse, National Household Survey on Drug Abuse, 1990

drug abuse, is clearly impossible. The NIDA anal- were possible alcohol and drug abusers, were exyses demonstrated that the type and quantity of an eluded from the survey.

individual substance use is correlated with a va- As one economist noted, “There is much we

riety of both individual as well as geographic char- still need to learn about poverty. Much of the past

acteristics. Furthermore, while the NIDA report research has focused primarily on economic queswas the largest and most comprehensive to date, tions, reflecting the extensive involvement by

some segments of the population, many of whom economists in this work. Research is much more
110 I Technologies for Understanding and Preventing Substance Abuse and Addiction

limited on topics such as the causes of changing

family structures, the impacts of neighborhoods

and family structure on children’s opportunities in

life, personal and family coping strategies among

the poor, how expectations about future opportunities are formed, and how these expectations influence behavior” (8).

PSYCHOSOCIAI/BEHAVIORAL

1 Aggressiveness

In much of the research literature the term aggression is used almost exclusively when referring to

young children and adolescents between the ages

of 13 and 15. Shortly after this age a divergence

appears within this identified aggressive group.

The vast majority of children “outgrow” their

aggressive behavior, while a smaller percentage

progress into or also exhibit, among other things,

conduct disorders, antisocial behavior, delinquency, and violence. Discussing each of these areas is

beyond the scope of this report. However, it

should be noted that as is true for many individual

risk factors, a number of these behaviors are intricately meshed.

Definitions for the term aggression vary considerably and may include tardiness, breaking

rules, fighting, vandalism, cruelty to animals, and

verbal abuse of other children. Many studies simply fail to define it. Wherever possible, study definitions of aggression will be outlined.

The children in the various studies on aggressiveness and subsequent drug abuse ranged in age

from 5 to 20 years old. Aggressive behavior in the

majority of the studies was exhibited almost exclusively by boys. While girls were included in

the study populations, the number exhibiting

aggressive behavior was very small. However, the

presence of aggressive behavior among some

young girls has not been shown to be predictive of

later adolescent delinquency or substance use

(49). This disparity between the sexes has not

been addressed at any length.

Of the preadolescent boys who exhibited

aggressive behavior, 30 to 40 percent maintained

this behavior into adolescence. This continued aggression has been shown to be a strong predictor

of subsequent alcohol and drug problems (28,33,

51). Interestingly, the combination of shy and

aggressive behavior has also been correlated with

later substance use problems. It has been postulated that aggressive boys may be more likely to

be shunned by conventional peer groups, but accepted by other aggressive children who could encourage drug and alcohol use. Another theory,

while not confirmed, suggests that young children

rejected by conventional peer groups gravitate toward each other and that these groups of former

so-called loners may foster delinquent behavior in

later adolescence (28). Conversely, boys (but not

girls) exhibiting shy behavior have been shown as

less likely to partake in alcohol and drug using activities as they grew older (28,33,51).

Where does this aggressive behavior originate?

Some studies have shown that young children exhibiting sociable, spontaneous, and fearless behavior are at greater risk for future aggressive and

violent conduct. Factors that seem to be protective

include a shy temperament, being first born, having a small and stable family characterized by low

discord (i.e., effective family management), and

having parents who regularly attend religious

services (51 ).

Current psychological perspectives emphasize that aggressive and violent behaviors are

“learned” responses to frustration, that they can

also be learned as instruments for achieving

goals, and that the learning occurs by observing

models of such behavior. Such models may be

observed in the family, among peers, elsewhere

in the neighborhood, and through the mass media (51 ).

This observation could, in part, explain why so

few young girls are identified as aggressive.

While socially defined roles for adults have

changed considerably in the last several decades,

the socialization of children’s behavior to a large

extent has not. Certain behaviors by boys are still

classified by many adults under the “boys-willbe-boys” axiom, while the same behaviors by

girls are often considered inappropriate.

Biological and genetic precursors to aggressiveness have also been explored. Events
Chapter 6 individual Risk and Protective Factors I 111

associated with brain dysfunction that appear to

increase an individual’s potential for aggression

include: brain injuries; in vitro exposure to opiates, cocaine, alcohol, and tobacco; and early

environmental exposure to lead (e.g., air contaminated by leaded fuels, lead-based paint, water

from older plumbing systems) (51).

No genetic studies specific to aggressive behavior have been conducted. Several Scandinavian countries have researched the association

between genetics and violence, obtaining mixed

results. No such studies have been attempted in

the United States (51 ).

By understanding the antecedents of aggressive behavior, prevention programs targeted at reducing such behavior are much more likely to

succeed. It has been asserted that multidimensional programs are more effective than those that focus on one or two components of aggressiveness.

Researcher Karen Dodge submits:

Most intervention approaches are implemented without regard for the type of aggressive

behavior under scrutiny, and that different types

of aggression are likely to respond differently to

different types of intervention. Reactive aggressive children who overly attribute hostility to

others in provocative situations may respond

best to treatment aimed at training them to understand better others’ thoughts and feelings.

Proactively aggressive children may respond

more favorably to consistent punishment of

aggressive behavior and reinforcement of nonaggressive responses; this latter group many

also have a better prognosis than the former

group. Three intervention programs cited as being particularly suitable for differential implementation with these two types of aggressive

children include social problem-solving skills

training, anger-control training, and parent

training (17).

Several unanswered questions point to areas for

future research. Why do boys disproportionately

exhibit aggressive behavior? Are specific aggressive behaviors unique to certain subpopulations?

What are the differences between those individuals who “grow out of’ their aggressive behavior

and those who do not?

Answers to these questions and others will allow for more detailed understanding of aggressive

behavior and its connection to alcohol and drug

abuse, which could in turn provide for an improved structure for the planning of appropriate

prevention programs.

1 Delinquency and Crime

Similar to aggression research, studies define and

collect data on delinquency and crime different y.

Some studies use the two terms interchangeably,

while others define delinquent acts as those less

serious versus acts such as rape, armed robbery,

and manslaughter, which are clearly illegal. Selfreported data are relied on by some studies, while

others utilize only arrest records. These differences must be considered when attempting to generalize delinquent behavior to subsequent misuse

of alcohol and drugs.

As is true for aggressiveness, males are at greater risk for developing delinquent and criminal behavior. Delinquent behavior for most youths

appears to peak between the ages of 15 to 17,

while alcohol and drug use are on the rise. However, only a small percentage (2 to 6 percent) of

these adolescents become young adults who continue to engage in serious criminal activity

coupled with frequent drug use. Statistics reveal

that many arrests for property and violent crimes

can be attributed to this small group of individuals

(29).

Several researchers have linked delinquent and

criminal behavior to alcohol and drug abuse and

have concluded these activities precede the use

and abuse of certain substances (28,29,13,56).

One such study conducted on adolescents examined the relationship between later drug use

and earlier individual delinquent behavior and delinquent peer group bonding (DPGB). Females

were found less likely to engage in individual delinquent behavior before but not after participating in a delinquent peer group. Additionally,

minority students doing well in school had lower

rates of delinquent problems than did nonminority

youth who were also doing well in school. Strong

positive belief systems (beliefs that committing il-
112 I Technologies for Understanding and Preventing Substance Abuse and Addiction

legal or rule-violating acts are morally wrong)

also decreased the potential for future use of alcohol, marijuana, and other drugs. Conversely, those

adolescents who had high DPGB levels had increased rates of alcohol, marijuana, and polydrug

use (20).

A separate study of male and female cocaine

addicts analyzed the psychosocial factors present

among individuals who substantially increased

their cocaine use from adolescence to young

adulthood. Those who progressed to heavier use

displayed a significant lack of law abidance or social conformity (46).

Several points have come to light from studies

on heroin addicts. Studies conducted in the late

1970s found that while delinquency preceded illicit drug use, use of alcohol and first alcohol intoxication took place before delinquency. In fact,

an average of two years lapsed between first alcohol intoxication and first criminal activity for both

males and females who later became heroin addicts (64). A further study on male heroin addicts

that grouped participants into low-crime versus

high-crime categories found that men who had

been placed in the high-crime group admitted significantly more contact with the criminal justice

system before becoming addicted than did those

in the low-crime group. Also, the high-crime

group showed earlier and more frequent use of

substances, as well as use of a wider variety of narcotic and nonnarcotic substances (47).

While a relatively small number of individuals

who exhibit delinquent behavior progress to serious alcohol and drug problems, understanding the

cause(s) of the delinquent behavior may help to

decrease this number further. Psychosocial elements that have been associated with later delinquent behavior include:

low parent-child attachment

family conflict

family social deprivation

school failure

parental and sibling drug use and criminal behavior

poor and inconsistent family management practices (e.g., harsh or lax discipline, lack of supervision)

attitudes and beliefs

lack of neighborhood attachment and community disorganization

family mobility.

Neurophysiological and cognitive dimensions

have also been examined for serious delinquents,

adult criminals, and children with conduct disorders. However, the findings were scanty and inconclusive (29,37).

When discussing prevention programs for

these children, there is the hazard of labeling them

predelinquent. This concern could be applied

equally to most risk factors linked to future alcohol and drug problems. Labeling children as

aggressive, high risk, delinquent, or developmentally slow may be a self-fulfilling prophecy. Some

researchers have suggested that broad, encompassing programs should be implemented in targeted

areas where groups exhibit a number of the risk

factors previously described. This type of approach would not single out individuals but rather

would assist communities, schools, and families

(29).

I Physical and Sexual Abuse

Researchers and clinicians have increasingly addressed the possibility that physical and sexual

abuse, especially in childhood, may be associated

with an increased likelihood of later substance

abuse and addiction. Although there are many

gaps in this literature, and substantive and methodological issues that remain to be addressed,

findings from several studies that have measured

the prevalence of substance abuse strongly suggest that additional research and the evaluation of

targeted clinical interventions are warranted. This

section highlights selected research findings on

the relationship of physical and sexual abuse to

later substance abuse.

One review article on physical abuse found that

children subjected to physical abuse had higher
Chapter 6 Individual Risk and Protective Factors I 113

levels of later substance abuse compared to children not physically victimized. The review also

cited another study which found that 84 percent of

the females in treatment for alcohol or drug addiction reported a history of childhood abuse (1 8).

Childhood sexual abuse appears to be rising.

The National Incidence Study reported in 1988

that approximately 156,000 children had been recognized by public agencies (such as child protective service agencies, mental health agencies, and

the schools) as being sexually abused each year,

for an annual rate of about 0.3 percent (58). This

is an increase in recognized cases of child sexual

abuse of more than 300 percent between 1980 and

1988, and due to the sensitive nature of the topic,

is probably a gross underestimation of the actual

numbers of cases.

Prevalence statistics on childhood sexual assault specific to women range from 6 to 62 percent, depending on the definitions, methodology,

and study populations used (54). One study that

relied on a random sampling method discovered

that of the 391 women who agreed to participate

in the study, almost 34 percent reported being

sexually assaulted by age 18, which provides a

lifetime prevalence rate of one out of every three

women. Of the respondents, over 24 percent reported an experience such as rape, 15 percent had

been victims of molestation, and 10 percent reported some type of noncontact sexual assault

(e.g., voyeurism, verbal threats of sexual assault,

being forced to watch pornography) (54). Other

researchers, measuring childhood molestation

histories among women psychiatric outpatients,

have cited figures of 50 to 70 percent, versus 20

to 30 percent reported by women in nonclinical

populations (12).

While causality has not been established between childhood sexual abuse and later substance

abuse problems, an association between the two

variables has been shown. Several review articles

have summarized the findings from researchers

who consistently report that children exposed to

sexual abuse present with a greater number of

symptoms and problems compared to children

who are not victimized ( 12,34,55). While substance abuse problems are not measured in all the

studies, where it is measured, individuals who

have been sexually abused show a much higher incidence of later substance abuse than their study

counterparts (55). For example, 60 to 80 percent

of individuals in substance abuse treatment programs report having been sexual abused (12), Other researchers have classified common symptoms

by age group, discovering that among adolescents

who had been sexually abused at some time in

their lives, 53 percent reported abusing some substance (34).

Studies on sexually abused women have demonstrated similarly high rates. One study of

women requesting appointments at a crisis counseling unit of a community health center found

that 44 percent of the women walk-in clients reported a history of sexual abuse as children. The

sexually abused women differed from the nonabused women in many ways, but they differed

most in their substance abuse. The abused women

were about 10 times more likely than the nonabused women in this population to report a history of drug abuse (21.1 percent vs. 2.3 percent) and

more than twice as likely to report a history of alcoholism (26.9 percent vs. 10.5 percent) (11 ).

A review of four separate studies on women

seeking treatment for alcoholism shows 34 to 85

percent of the women report a history of sexual

abuse (30); and among recovering chemically dependent women, the topics discussed most often

are sexual child abuse, incest, and rape. Uncovering the memories of these early childhood experiences is thought to be a contributing factor in drug

relapse for some women (31 ). Thus, early experiences of abuse, especially sexual abuse, may require attention in treatment programs, since they

may have been important precursors and contributors to the substance abuse and addiction, and may

be major obstacles to successful treatment and the

prevention of relapse.

Clearly, physical and sexual abuse are not

uncommon phenomena. While this section has

focused on the association between abusive experiences and subsequent substance abuse, there are

many other psychopathologies that also arise from

sexual and physical abuse. The research question

need not be whether physical and sexual abuse
114 I Technologies for Understanding and Preventing Substance Abuse and Addiction

“cause” the later substance abuse and addiction.

Clearly, many factors interact, especially in the

home, school, and peer settings of children as they

grow up. However, the consistent finding of higher levels of physical and sexual abuse among

substance abusers warrants further research to disentangle the many factors that are at work. Unlike

race, ethnicity, and poverty (which are not by

themselves strongly and independently associated

with substance abuse and addiction, but must be

understood in the context of subcultures and the

availability and marketing of drugs in neighborhoods and communities), physical and sexual

abuse may more directly contribute to later behavioral problems, including substance abuse.

Mental Disorders

The sheer number of Americans with mental disorders transforms personal tragedy into a widespread public health problem. Nearly one in three

American adults will experience a mental disorder

during his or her lifetime. Moreover, approximately 1.7 to 2.4 million Americans currently suffer from a persistent and severely disabling mental

disorder, such as schizophrenia or bipolar disorder

(commonly known as manic depression) (62).

There exists a wide array of behaviors classified as symptomatic of mental disorders, ranging

from premenstrual syndrome, hostility toward

others, and other maladaptive personality traits, to

full-blown psychosis (2). It can at times be difficult to delineate where mental health ends and

mental illness begins.

While many alcohol and drug problems may

not be attributable primarily to mental disorders,

they can certainly be exacerbated by these disorders. One comprehensive study found a high prevalence of comorbid (i.e., occurring at the same

time) mental disorders and alcohol or other drug

disorders—including both abuse and dependence

syndromes as defined in the DSM-III-R. Using

data from NIMH’s Epidemiologic Catchment

Area (ECA) survey of 20,291 adults (aged 18 and

older) in communities and in various institutional

settings (prisons, mental hospitals, nursing

homes, and specialized treatment centers), they

assessed the prevalence of comorbid alcohol, other drug, and mental disorders. Schizophrenia,

mood disorders, and anxiety disorders were

among those studied. Specific drugs studied, in

addition to alcohol, included marijuana, cocaine,

opiates, barbiturates, amphetamines, and hallucinogens (50).

Alcohol Disorder as the Primary Diagnosis

An estimated 13.5 percent of all adults in the

United States will have a lifetime diagnosis of

alcohol abuse or dependence (see figure 6-3). For

these individuals, the rate of mental disorder was

almost double that of persons with no history of an

alcohol disorder, and the rate of another drug disorder was almost six times greater. Specific comorbid mental disorders found in people with

alcohol abuse-dependence disorder include anxiety disorders (19.4 percent), mood disorders (13.4

percent), and schizophrenia (3.8 percent).

Drug Disorder (Other than Alcohol) as the

Primary Diagnosis

Some 6.1 percent of the total adult population will

have had a primary diagnosis of drug abuse or dependency at some time in their lives. Over half of

these individuals have also been diagnosed with

a comorbid mental disorder such as anxiety disorder (28.3 percent), mood disorder (26.4 percent),

or schizophrenia (6.8 percent). Compared to those

persons without a drug disorder, these individuals

are at more than four times the risk of having some

type of mental disorder. Additionally, these individuals are also seven times more likely to be addicted to alcohol.

Mental Disorder as the Primary Diagnosis

In contrast, at some time in their lives nearly onequarter of all adults in the United States will have

had a primary diagnosis of mental disorder.

Compared with individuals having no history of

mental disorder, people with a mental disorder

face twice the odds of having alcohol abusedependence and over four times the odds of drug

abuse dependence.
Chapter 6 Individual Risk and Protective Factors I 115

/

22.5Y0

/ Comorbidity \

disorder

\

13.5!40 \ 1.1 %0/ 6.1 yO

/

Ep/dem/olog/cal data suggest that there IS a high degree of

cornorbfddy for menta/ and add/cWe dmorders m the United

States For example, 29 percent of mdwiduais with a mental

disorder wW a/so have an addlctwe disorder

SOURCE D A Regler, M E Farmer, D S Rae, et at , “Comorbldltyof

Mental Disorders With Alcohol and Other Drug Abuse Results From the

EpldemlologlcCalchment Area (ECA) Study Jouma/ of (he American

Medlca/Association 264 2511-2518 1990

Comorbid alcohol and other drug abuse or dependence disorders occur frequently in people

with the specific subtypes of mental disorders included in the study:

m

■

■

Of those who develop schizophrenia and related disorders during their lifetimes (approximately 1.5 percent of the U.S. population),

nearly half will abuse or be dependent on alcohol or other drugs, or both.

Thirty-two percent of people with mood disorders (8.3 percent of the total adult population)

will abuse or become dependent on alcohol,

other drugs, or both.

The anxiety disorders, as a group, occur at

sometime in the lives of 14.6 percent of the

population and are highly likely to be

associated with an alcohol or other drug abuse

or dependence disorder. For example, 35.8 percent of people with panic disorder, and 32.8

percent of people with obsessive-compulsive

disorder will have some form of alcohol or other drug abuse or dependence disorder.

People with both mental disorders and alcohol

or other drug disorders are likely to suffer more

severe psychiatric symptoms, disruptive behaviors, aggression, and criminal behaviors. The importance of early detection for mental disorders is

clear if subsequent alcohol and drug abuse problems are to be avoided. In other cases, an individual drug and/or alcohol problems may precede his

or her mental disorder. In whatever order these

complications are distinguished, it is essential to

remember that millions of men and women suffer

through not one, but two illnesses (62).

n Resiliency

The majority of funding and research has been devoted to understanding and identifying those elements that appear to place individuals at a greater

risk for substance abuse. However, many of these

same factors can, to some degree, be protective.

For example, the vast majority of adolescents who

have used alcohol, cigarettes, and other drugs do

not grow up to become substance abusing adults.

The process of aging and successfully passing

through various developmental stages is in itself

protective. In other cases, the lack of a particular

factor is protective. This is true for many of the

psychosocial factors such as aggressivity, delinquency, mental disorders, and physical and sexual

abuse.

But what about those individuals who live in

stressful and chaotic conditions—who are constant] y exposed to many of these risk factors—yet

who do not develop substance abuse problems.

How do these individuals emerge relatively unscathed, while many of their immediate family

succumb to substance abuse? This section addresses a complimentary set of protective attributes, characteristics identified in individuals who

display resiliency to the effects of various risk factors,

The term resiliency can be described as the ability to recover from or adjust easily to misfortune

or change. A 1991 conference sponsored by the

Children of Alcoholics Foundation released are-
116 I Technologies for Understanding and Preventing Substance Abuse and Addiction

port in which resiliency was conceptualized in the

following manner (15):

m

■

■

●

■

Resiliency is a dynamic process, not a static

condition.

Resiliency is contextual; adaptive behavior in

one context may be maladaptive in another.

Resiliency is the result of inherent personality

characteristics interacting with environmental

factors.

Resiliency is more complex in multiple-risk situations.

Resiliency can be learned.

For the most part, social science research on resiliency in children has not specifically addressed

environmental substance abuse, and where it has,

the research has focused to a large extent on alcoholism within the family. However, in general, resiliency studies have examined high-risk children

from a variety of families and communities, of

which many had substance abuse problems.

One of the largest longitudinal studies spanned

a period of 30 years and was completed by Emmy

Werner on the Hawaiian island of Kauai (80,81).

An entire multiracial cohort of children was followed from the prenatal period to young adulthood, revealing invaluable information on

resiliency in the presence of certain risk factors.

Of the 700 children originally included in the

study, 200 were identified as at-risk for later problems based on perinatal stress, poverty, family

instability, and parents with mental health problems. Through the children’s first decade of life,

approximately 25 percent had at least one parent

with a serious alcohol problem. Of these children,

41 percent later developed serious learning and

behavioral problems by age 18, while the rest did

not. All the children of alcoholic mothers developed problems, with the exception of one. Conversely, children of alcoholic fathers “were

represented in roughly equal proportions among

those who did and those who did not develop serious coping problems by age 18“ (80).

More general findings from the study highlighted the difference between the prevalence of

serious physical, learning, and behavior problems

among girls and boys. Up to age 10, when confronted with a variety of risk factors, boys were

significantly more likely to display a greater number of childhood problems requiring some type of

social service and/or medical intervention. However, this ratio changed markedly by the second

decade (ages 10 to 18). While high-risk boys were

still three times more likely than girls to have records of serious delinquency (77 vs. 26 percent),

by age 18 more than twice as many high-risk girls

reported serious mental health problems. Additionally, of those children in the first decade identified with serious learning and/or behavioral

problems, a greater number of boys than girls had

improved by age 18.

Interestingly, the researchers also showed that

some of the resilience factors identified differed

between the sexes. For example among young

girls, experiences that tended to foster greater maturity and independence, such as absence of a father, responsibility for younger siblings, and

maternal employment outside the home, also appeared to bolster resiliency and competence. On

the other hand, resiliency among young boys was

correlated with the presence of the father, little

family discord or crowding, and the existence of

adequate structure and supervision. However,

overall, a greater number of high-risk girls than

high-risk boys grew into resilient young adults.

Several other studies have also identified factors associated with resiliency in children

(6,19,23). One such factor is described as adaptive distancing whereby the child accomplishes

two things: the child emotionally and psychologically detaches from the chaos of the family and resumes more “customary pursuits” in the outside

world of school and friends, and the child does not

allow the caregiver’s drug or alcohol problem to

be the central focus of his or her world. These behaviors have been observed in children as young

as 3 years old.

A sense of purpose and future have also been

identified with resiliency. Clinicians have observed very young children attempting to make

sense of their situation upon experiencing an array

of hardships such as chronic poverty or familial
Chapter 6 individual Risk and Protective Factors I 117

substance abuse. Resilient children display such

attributes as hopefulness, hardiness, motivation,

and a belief in a bright future even when faced

with challenges and adversity.

Researchers have also found that the ability to

develop competency skills was associated with

resiliency. Competence includes “the qualities of

responsiveness, flexibility, empathy and caring,

communication skills, a sense of humor, and any

other prosocial behavior” (6). Researchers have

consistently documented the presence of these

characteristics among resilient individuals, and

equally important, have noted the lack of these

characteristics among individuals with severe behavioral, criminal, and mental health problems.

Another element that has been associated with

resiliency is the ability to use support systems

effectively. Those children who tapped into

school activities, spoke with counselors, actively

sought an alternative parent figure or role model,

and confided in others were much more likely to

be resilient than those children not involved in

these supportive networks.

Much of a person resiliency depends on a variety of elements including the individual developmental stage, cultural perceptions, and ‘*the

acuteness or chronicity of the adverse circumstances” (19). Nonetheless, many men and

women who have gone on to lead productive and

fulfilling lives, often did so in spite of their circumstances. By understanding how this was

achieved, prevention programs can incorporate

activities to bolster the protective factors in the

lives of all children.

I Spirituality/Religiosity

The terms religiosity and spirituality are neither

mutually exclusive nor inclusive. Both terms encompass an enormous array of fellowships and

individual values, including institutionalized religion, new age religion or quasi-religious groups,

traditional beliefs, and nonreligious persons.

Within the drug and alcohol abuse research

field, studies have focused almost exclusively on

the relationship between institutionalized Christian religions (with the exception of a handful of

studies on Judaism) and its effect on substance use

among adolescents and young adults. Virtually no

data are available on other methods of worship, or

discussion of the effect spiritualism/religiosity

may have on the progression from adolescent alcohol and drug use to problem use and addiction.

A succinct and thorough review of recent literature on religion and substance use was completed

by social psychologist Peter Benson (7). With rare

exceptions, religiousness, in varying degrees, has

been associated with decreased levels of substance use. The substances studied included alcohol, cigarettes, and numerous illicit drugs. This

protective factor held true for men and women

across the four U.S. census regions, and to some

extent among blacks and Hispanics (although

only a few studies analyzed race and ethnicity).

The most widely used measures of religiosity

were church attendance, church affiliation versus

nonaffiliation, and religious importance; yet it

also appeared that such indirect associations as

parents’ religiousness and belief in life after death

were correlated with decreased substance use.

Multivariate analysis was employed to examine

the relative importance of religiousness by controlling for other demographic and social variables. In most instances the protective effect of

religiousness was relatively small, but it did appear to be more predictive than several personal

factors (e.g., self-esteem, purpose in life, locus of

control) and less predictive when compared to social variables such as parental standards, peer

pressure, and social tolerance. Benson puts forth

several explanations for this apparent protective

element, most of which center around the idea that

organized religion fosters and maintains a certain

set of morals and values. Depending on the

religion, deviating from these norms can be somewhat tolerated or, at the other extreme, considered

a profound sin.

For countless individuals, spirituality, while a

more nebulous concept than religion, is intricately

tied to emotional, psychological, and physical

well-being. A practitioner of Zen (Buddhist) meditation and various New Age spiritualities stated:
118 I Technologies for Understanding and Preventing Substance Abuse and Addiction

I think of health at every level: a healthy

mind, a healthy spirit, as well as a healthy body.

So that a person would have to have energy,

alertness, enthusiasm, a love of life, a love of

people, a love of themselves (43).

Many traditional cultures think of illness and

disease as indicators of personal spiritual discord.

For example, the American Indian Navajos strive

for a state of personal wholeness, beauty, and

well-being. The Blessing-way rite, composed of

sacred songs and prayers, is often used to restore

an individual’s harmony with those around him or

her, the environment, and, in a larger sense, the

universe.

By ignoring different racial and ethnic religious

and spiritual beliefs, their importance is minimized and/or trivialized (perhaps inadvertently)

by more dominant religions. From a drug and alcohol prevention point of view, it would seem

both cost-effective and relatively simple to encourage and celebrate religious and spiritual differences among individuals and communities;

and acknowledge the protective benefits these factors provide for many people.

SUMMARY

No single or generic set of variables explains the

harmful use of alcohol and drugs for every individual. While this chapter reviewed a number of

selected individual and protective factors, this information should be viewed in a broader context.

To gain a complete understanding of the complexity of the substance abuse issue, the information

presented before and after this chapter must be incorporated in any argument concerning factors

that in some way effect an individuals potential for

substance use and abuse.

By reviewing the individual risk factors under

the three broad headings of Demographics, Economics, and Psychosocial/Behavioral, certain

gaps in the literature appeared. Within the demographics section, the vast majority of the research

to date has focused on identifying psychological

as well as social characteristics that place preadolescent and adolescent children at greater risk for

the initiation and continuation of drug use. While

the benefits of this type of research are obvious,

the majority of data point to the fact that alcohol,

tobacco, and illicit drug use are highest among

those aged 18 to 25 and 26 to 34. However, few research studies have been devoted to these age

groups. Also, under the demographic section there

was a general paucity of data on risk factors that

may be unique to racial and ethnic minority populations and to some extent women (although this

continues to change).

Within the economics section, while there may

be quotes in the general media of tremendous financial earnings by drug dealers, research substantiating these figures is scanty. There is also

little known about whether those individuals dealing drugs are at an increased risk for becoming

drug abusers.

Many of the psychosocial/behavioral factors

reviewed in the chapter have been extensively studied, and their associations to alcohol and drug

use documented. However, one of the sections

that has fairly recently been scientifically studied

is that of physical and/or sexual abuse. Those

studies that have been rigorously conducted are

beginning to yield data that positively links childhood abuse to later alcohol and drug problems.

Future research in this area is probably warranted.

Also included in the section were select studies on

resiliency and/or protective factors. While research has been conducted in this area for quite

some time, much of the literature is not specific to

alcohol and drug use situations, but rather, encompasses a wide array of variables that place

individuals at a greater risk for behavioral, developmental, and learning problems.
Part III:

Activity

Settings

P

revious chapters in this report addressed necessary preconditions that must be present in order for substance abuse

and addiction to be possible, and some of the risk and protective factors that have been identified as possibly influencing abuse and addiction.

Studying these factors in isolation does not adequately explain

how substance abuse and addiction occur. Drug-seeking and

drug-taking behavior occurs in neighborhoods, among peer

groups. In addition to surveys that attempt to quantify the nation’s

drug problem, research is also being conducted in order to better

explain the environmental contexts in which substance abuse and

addiction occurs. Such research is useful in helping to develop

antidrug programs that are comprehensive in scope and relevant

to different populations.

I 119
Drug n

Studies I

E

thnographic techniques allow researchers to study how

environmental and cultural factors affect values, attitudes, and behaviors of individuals and groups. Historically, ethnography has roots in both anthropology and

sociology (see box 7-1 ).

ETHNOGRAPHIC STUDIES OF ALCOHOL

AND OTHER DRUG USE

Since the 1960s the number of drug ethnographies has grown

steadily. Many of the nation’s social issues were in one way or

another associated with drug use: poverty, urban unrest among

minorities, counter culture, failure of social programs, AIDS

transmission, and urban violence. Research conducted by anthropologists and qualitative sociologists was an important part

of understanding new drug-related social problems and trends.

By the mid- 1970s, “street ethnography” or simply “ethnography”

were the terms commonly used to describe the drug research they

were conducting in the United States (60).

9 Alcohol

Nineteenth century and early twentieth century anthropologists conducted comprehensive community studies in nonindustrial societies in which they recorded ritual and social uses of

alcohol. This extensive but generally unfocused documentation

provided data for later cross-cultural analyses relating alcohol use

patterns to other cultural variables.

The contribution of ethnographic studies conducted outside

the United States was to provide data on the social conditioning of

alcohol effects. The findings from one such study conducted in

1;

“ , /

/

/

I 121
122 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Ethnographic research is descriptive, subjective, analyhcal, and comparative. The focus on context

is central to the ethnographic approach, explaining how a particular behavior, institution, or process is

acted on by larger forces outside of the control of the participants. It describes how events happen and

the social life of the study individuals While qualitative interviewing and other more formal methodologies are usually part of an ethnographic study, participant observation (i.e., informally interacting with

participants and observing events as they naturally occur) is a hallmark of ethnographic research

Studies are subjective in that they focus on the understandings, interpretations, and world views of

the participants Ethnographic accounts describe not only what occurs, but also the multiple levels of

distinctions by which individuals and groups make sense of and purposively act in the world

Ethnographic studies are also analytical The observations, interviews, and documents are raw data,

as forms and responses are raw data for survey statisticians. The ethnographer’s analytic responsibility

is to condense and order these data The analytic work can include the idenhficahon of nonobvious

patterns, associations, and themes, as well as the construction of topologies, process models, or explanatory frameworks.

Finally, ethnographic research is comparative m two senses of the term First, It often explores how

attitudes and behaviors are shaped by social forces m two or more contexts The contexts are at times

spatial (two different cultures or subcultures), at other times temporal (the same culture or subculture at

different times). Ethnographic studies are also conducted within a research tradition, so that each new

project draws on the methods and findings of previous research Over time, a corpus of work develops

regarding a particular cultural community (e g , Samoans, inner-city drug users) or a particular topic

(e g., witchcraft, ethnic boundaries) As new work appears it is scrutinized for fit with the existing corpus Lack of fit may be attributed to differing circumstances, methodologies, theoretical concerns, or

possibly to inferior research or analysis

Bolivia during 1958, alerted the alcohol research

community to the existence of culturally accepted

alcohol use patterns quite different from those

customarily encountered in the United States. For

example, “virtually all of the Camba (of eastern

Bolivia) drink to the point of passing out, at least

twice a month.” Although the beverage they drink

is stronger in alcoholic concentration than that

customarily drunk by other populations, there appeared to be no major health or social problems

associated with their drinking (35).

These data along with findings from research

on four other societies (the Aritama of Colombia,

the Ifaluk of Micronesia, the Takashima of Japan,

and the town of Juxtlahuaca in Oaxaca, Mexico),

support the view that the experiential effect of alcohol is socially conditioned (37). Each of these

societies possessed distinct messages regarding

the use of alcohol, which were clear and consistent. In contrast, individuals in modem societies

are influenced by overlapping, and sometimes

contradictory, social messages based on religious,

ethnic, occupational, generational, regional, and

class differences. Drinking habits and behaviors

within the United States vary enormously.

Since the 1970s, ethnographic research on alcohol use in the United States has concentrated on

specifying and explaining the variations in American drinking patterns. Some ethnographers have

focused on specific subcultures defined by their

problematic alcohol use (53). Other ethnographers have focused on alcohol beliefs and behaviors in ethnically, religiously, and professionally

constituted subcultures-usually exploring the

adaptation of culturally sanctioned drinking patterns, passed on through family and community

modeling, to changing social contexts (5).
Chapter 7 Ethnographic Drug Studies I 123

Cocktail tables, liquor cabinets, and other drinking

accessories were trendy home furnishings following the repeal

of Prohibition The cocktail party became an important social

ritual suited to the homes and apartments many Arnericans

occupied

I Heroin

The majority of ethnography studies conducted in

the 1960s focused on heroin use. Several of these

studies challenged the accepted perception “that

heroin provides an escape for the user from his

psychological problems and from the responsibilities of social and personal relationships—in

short, an escape from life” (47). Researchers documented drug use as a way of life, rather than just

as an escape from life. Two such articles, based on

three years of field work in Oakland, California,

detailed several distinct patterns or styles among

heroin users. Varying levels of prestige were

associated with these different styles, and heroin

users at the top of the hierarchy were observed to

work hard to maintain their lifestyles (54,55).

Another study in New York City, New York, in

the late 1960s, asked why heroin use periodically

mushroomed, in epidemic proportions, in lower

class communities. The data revealed that, regardless of ethnic background, in poor neighborhoods

“there are pressures on adolescent boys to live up

to the ideals of toughness, strength, daring, and

the willingness to challenge the bleak fate of being

poor.” Simply put, “movement into heroin use

was one route to becoming a ‘somebody’ in the

eyes of the important people who comprised the

slum social network” (20). Later articles elaborated on the idea of so-called street status. Based

on 4 years of research, a hierarchy of illicit drugs

was defined by perceived risk components, such

as physical harm, addiction potential, parental

discovery, police, and intragroup dangers. The use

of drugs perceived by the group to be risky, increased a user’s personal status within that group.

The researcher concluded that reliance on legal

sanctions and scare tactics to reduce the use of certain drugs will only make the use of these drugs

appear more daring and hence to some, more attractive (21 ,23).

B Cocaine and Crack

Although ethnographers noted that cocaine use

was on the rise among some middle-class professionals and drug experimenters by the mid 1970s,

it was not until the 1980s that extensive studies on

cocaine users were begun.

While some of these early users, many of

whom were white, progressed from experimental

use of cocaine to heavy use with subsequent biological and behavioral problems, many others did

not (57,58). Several years later, though, middleclass users with cocaine-related problems were

becoming more common, prompting many

would-be experimenters to steer clear of the drug.

During this same time period, cocaine smuggling

escalated, resulting in increased availability, lower prices, and higher quality. Within low-income,

minority communities, cocaine smoking, first as

free-base and then as crack, grew so precipitously

that it was commonly called an epidemic. In New

York City, ethnographers provided complementary perspectives on the rapidly changing crack culture.

In a series of ethno-historical articles, Ansley

Hamid documented the history of cocaine smoking as it evolved in lower income minority neighborhoods in New York City. Among the elements

identified as central to the widespread diffusion of

crack smoking was the interest shown by heroin

injectors with collapsed veins in the concentrated

high of smoked cocaine; the entry of Rastafarian

marijuana distributors into the cocaine trade; the
124 I Technologies for Understanding and Preventing Substance Abuse and Addiction

emergence of young, nonusing street distributors

able to sell unit doses in vials at relatively low

prices; and the rise in crack prices due to increased

demand combined with suppliers who had greater

control over the market. Hamid believes the rise

and fall of cocaine smoking to have followed a developmental cycle similar to that of heroin use between 1964 and 1972 and marijuana use in the

1960s and 1970s (31,32,33,34).

A 1992 study of crack use focused on the children of crack users. It found that the extended family networks in the African American community,

a major source of stability and support, were being

overwhelmed by the drug crisis as the number of

children whose mothers were no longer able to

care for them because of increased drug use. Further, children exposed to drug-taking behavior by

adults may be more likely to display similar behavior. In one family headed by a 60-year-old

woman, an adult son was a crack dealer and a

daughter was a crack-abusing prostitute (1 8).

1 Hallucinogens

Most ethnographic studies of hallucinogens and

mind-altering drugs (e.g., peyote, mescaline,

mushrooms) have focused on tribal societies. Anthropologists have uniformly found that the use of

hallucinogens was socially approved and integrated into the religious and social life of the community. If one defines abuse as use of a drug in

such a way that it interferes with physical, economic, or social functions, then little if any evidence points to drug abuse among tribally

organized peoples (1 ,27,15,42).

Other than scattered studies of hallucinogenic

drug use among hippies (12,1 4,45,46), few ethnographic studies have been completed on use of

hallucinogenic substances in American society.

However, the persistent use of lysergic acid diethylamide (LSD) by some young people, and

concerns that its use may be increasing, have

sparked new interest among ethnographers

(30,38).

I Marijuana

As with hallucinogens, most of the ethnographic

research on marijuana use has been conducted

Poster to advertise the 1937 movie, Marijuana: Weed With

Roots in Hell,

outside the United States. Much of it was initiated

in the 1960s and 1970s, when increasing use of

marijuana among American youth led researchers

to question the social and medical consequences

of marijuana use, especially long-term use. Research was conducted in countries in which marijuana use was long standing and widespread, such

as Brazil, Colombia, Costa Rica, Egypt, Jamaica,

Mexico, Rwanda, and South Africa (1 1,16,17,

51).

In Jamaica, for example, anthropologists Vera

Rubin and Lambros Comitas directed a research

team of 45 social scientists and medical professionals to conduct original ethnographic research

at several field sites, in addition to medical, psychological, and psychiatric testing in hospitals

and clinics. Their controversial findings were that

none of the deleterious social or medical consequences believed by many to be associated with

the drug in the United States could be found

among Jamaican users:
Chapter 7 Ethnographic Drug Studies I 125

. . . There is no evidence of any causal relationship between cannabis use and mental deterioration, insanity, violence or poverty; or that

widespread cannabis use in Jamaica produces an

apathetic, indolent class of people. In fact, the

ganja complex provides an adaptive mechanism

by which many Jamaicans cope with limited life

chances in a harsh environment (52).

Other than a few studies of middle-class users

(10,39) and young African American dealers

(24,25), substantial U.S. ethnographic research on

marijuana use in the United States has been generally lacking, despite the fact that marijuana has

been the most commonly used illicit substance for

decades.

O Phencyclidine (PCP)

An ethnographic study in 1979 of PCP users is frequently cited for its substantive findings and

methodological contribution as the first multisite

ethnographic drug study. Initiating the study when

PCP use was believed to be spreading among

white working-class and middle-class young

people, the National Institute on Drug Abuse

(NIDA) contracted for a four-city ethnographic

study of PCP users not in treatment. After 3

months of working in Miami, Florida, Philadelphia, Pennsylvania, Chicago, Illinois, and Seattle,

Washington, ethnographers documented groups

of users and the underlying social processes. They

found that it was relatively rare for a young person

to use PCP exclusively. Use occurred mainly

within socially distinctive groups of young people

who displayed “a kind of restlessness, an orientation for action, and a sense that life generally was

boring, uninteresting, and lacked recreational activities” (22).

The young people studied were very knowledgeable about drug effects and understood that

the PCP drug experience varied dramatically with

dosage. Low doses of the drug were reported by

different user groups to be mildly euphoric and

hallucinogenic like LSD, or sedating like barbiturates. What concerned regular PCP users was not

the acute adverse effects reported in the media

(e.g., psychotic episodes, assaultive outburst, irreparable harm), but rather “burning out”-a

“spacey” state accompanied by incoherent

thoughts, forgetfulness, and memory loss. As

burnout became apparent, individual users and

groups of users consciously cut back their PCP

use. Within this group, violent episodes were

found to be rare, mainly involving efforts by law

enforcement or hospital treatment staff to restrain

users, thereby seeming to set off panic reactions

and struggle.

The study suggested that a significant gap existed between official agencies responsible for

drug education and prevention and street drug users. When PCP use increased dramatically in the

mid 1970s, there were no official responses because quantitative national data sources, such as

surveys of high school students and hospital emergency reports, failed to include PCP as a separate

drug. When the official agencies recognized the

widespread use of PCP, their prevention efforts

were viewed by users as distorted and were discounted. Ethnographers attribute the eventual decline in PCP use to “the general consensus among

users themselves on the negative features of its

long-term effects rather than the kind of expert

opinion that accompanies legitimate efforts at prevention” (22).

SOCIAL CONTEXT OF DRUG USE

1 Specificity in Drug Abuse Research

As more questions are asked about alcohol and

other drug use, it becomes clear that drug use is not

one phenomenon, but many. There is no generic

pattern of drug use; rather, there is use of specific

drugs in specific situations.

Quantitative researchers frequently use ethnic

categories to increase study specificity. While

studies on different ethnic groups are useful, often

the definitions of ethnicity vary and the concept is

employed uncritically. Moreover, most of the

quantitative researchers using the concept of ethnicity implicitly assume what anthropologists call

a “static” concept of culture, viewing ethnicity as

a trait one is born with, an unchanging characteristic, like hair color or body type. In contrast, most

ethnographers view culture as “a dynamic process

through which individuals and societies learn the
126 I Technologies for Understanding and Preventing Substance Abuse and Addiction

sum total of their society’s behaviors and

associated belief systems, including those encompassing drug use practices and beliefs” (4).

Many recent ethnographic studies focus on socially meaningful units in which members share

social statuses, behaviors, and attitudes. For example, a recent book on drug use among Hispanics included ethnographic accounts of Cuban

so-called streetside drug use in Miami, Florida,

drug use among male and female gang members

from the East Los Angeles, California, barrios,

and drug use and dealing

Puerto Ricans in New York

Chicago, Illinois. (28).

1 Inclusiveness in Drug

One drawback of studying

among low-income

City, New York, and

Abuse Research

increasingly specific

drug-using communities is losing sight of the

larger whole. Ethnographic drug studies at times

fail to link the customs of the specific study communities to customs in other communities or to

place the customs in a larger framework. A way

that both highlights and critiques the contribution

of ethnography in the field of drug research is to

focus on the social relationships around drug use,

specifically, on the pattern of use in relation to

self-identification with a social group. In the ethnographic literature, four basic patterns appear:

■

●

●

■

Individuals who use drugs with others who

share an identification with a lifestyle or subculture in which drug use is the central component.

Individuals who use drugs with others who

share an identification with a lifestyle or subculture in which drug use is customary and

openly accepted, but not the central component.

Individuals who use drugs with friends and acquaintances, but there is no self-identification

with a drug-using lifestyle or subculture.

Individuals who use drugs by themselves while

maintaining self-identification with a group

that stigmatizes drug use (see table 7-1 ).

~ Drug Use Within a Drug Subculture

Numerous studies have documented that, for

pragmatic and social reasons, individuals whose

lives have become oriented to a drug often

associate with others who use the drug in a similar

fashion. Over time a subculture develops with

specialized knowledge, norms, and expectations.

Individuals think of themselves as belonging to

the subculture, and others define them as such.

“Where subcultures exist, social-psychological

barriers separate participants from onlookers”

(13). It has often been noted, for example, that for

many heroin users, use of the drug overrode background characteristics, such as race, class, and

national origin, to become the defining characteristic. As one heroin user related:

I always refer to myself as a junkie, even

when I’m not hooked on anything. And when

you’re introduced to somebody for the first time

the first thing you find out is whether he’s a junkie or not. It’s like belonging to some fantastic

lodge, you know, but the initiation ceremony is a

lot rougher (57).

However, even within a drug-using subculture

variations exist, especially with regard to frequency and amount of use. This difference was emphasized by a 38-year-old regular heroin user from

New York City:

. , . all heroin addicts are not heroin abusers,

okay? And you get the abuser, he’s a dog, right?

He’s the one who sits in the drug house and

shoots all day long. That’s an abuser. I’m a visitor, you never catch me in the drug house. Not

me, no (41).

A similar distinction was made by a female

crack user, who, although her life revolved around

crack, was still attractive, healthy, in a relationship, and the social center of a network of users.

In contrast, for her:

The crack addict is the person who’s lost all

sense of what going on. They are like zombies.

They are out there standing in the pouring rain.

If it’s cold and snowing, they’ll be walking up

and down out there . . . . They are . . . to the
Chapter 7 Ethnographic Drug Studies I 127

Drug use within a Drug use as part of a Drug use with “normal” Drug use in social

drug-focused subculture larger lifestyle/identity partners and peers isolation

Examples Examples:

Heroin use within the Marijuana and LSD use as

subculture of street part of student drug

addicts. subcultures.

Crack use in the subculture Drug use as part of

of “pipers”. artist/musician lifestyle.

Polydrug use in the Drug use as part of criminal

counterculture of the Iifestyle,

1960s

Hallucinogen use among

religious seekers,

SOURCE: Office of Technology Assessment, 1994

point of desperation where they will take off

[rob] people they know. They will set you up. It

comes to the point where they will setup family,

friends, anybody—the point where they don’t

care anymore (61 ).

One ethnographer noted that these types of individuals were attempting “to become ‘visitors’ in

social networks of other users, to establish a degree of contact and membership while remaining

somewhat detached from the network. Their attempts to remain partially marginal to both street

and straight society are a central part of their strategies for controlling their use and their own lives”

(41).

I Drug Use as Part of a Lifestyle

or Identity

Drug use often occurs within a lifestyle or subculture in which drug use is common and accepted,

but is not the defining characteristic. The subculture may be professionally oriented. For example,

some of the earliest drug research was done

among jazz musicians (2,62). Anabolic steroid

use was common among professional and amateur

athletes in certain sports (29). During its peak, cocaine use was rampant among entertainers.

In one study, a waitress at a rock-and-roll bar

called cocaine use an “occupational hazard.” She

and other restaurant workers in the study deExamples:

Social/recreational drug use

with spouses, lovers,

and friends. At home, at

parties, and at social

gatherings.

Inhalant use among

children.

Drug experimentation

among students.

Examples

Physician/nurse use of

nonprescribed

pharmaceutical drugs

Prescription drug abuse.

Medical marijuana use by

glaucoma, cancer, and

AIDS patients.

Functional drug use to

increase performance.

scribed how groups of workers would pool funds

to purchase small amounts of cocaine for use

while working: “For them. . . hard work, constant

activity, and long, late hours seemed instrumental

to their cocaine use” (59).

Recent research has documented that at times

the nuclear or extended family may act as the subcultural unit in which illicit drug use is common

and accepted.

We was with my mother over her girlfriend’s

house when Aunt Jeannie came by and she had

some coke. She cooked it up and told Ma and

Ruth to try it. After that things started goin’ crazier. I had to take care of my oldest sister’s two

sons, my son, and my younger brother. I had to

do everything. Most of the time we didn’t have

nothin’ to eat. We stayed hungry all the time.

When I washed clothes I’d find vials in her

[mother’s] pockets.. . . I ‘member comin’ home

one day and she’d been smokin’ for awhile then,

but the house was full of people smokin’ all over

the place. I went to go to my bedroom and close

the door and it was full too. I said to her, ‘what’s

happenin’? I just turned round and left. I was

tired, the house was dirty with vials on the floor

and the tables and I’d just had my son.. . . I just

wanted to get away., . . At first I had smoked

some crack to kill my appetite, to keep me from

bein’ hungry. . . I just felt like I couldn’t take it

no more so I took my son to my sister and left
128 I Technologies for Understanding and Preventing Substance Abuse and Addiction

A Philadelphia, Pennsylvania, drug house, 1991. Patrons paid

an admission of a dollar or so, inside they would find drugs,

clean bottle caps for smoking heroin, and bleach for

disinfecting needles.

. . . I went on a binge and smoked for three

months. Nobody knew where I was, but I was out

smoking crack and gettin’ money anyway I

could get it (18).

1 Drug Use With Partners and Peers

Drug use can also occur when there is no subcultural support or membership in a group that approves of drug use. In some cases, an orientation

toward, or acceptance of, drug use may have been

acquired earlier in life when the individual was

part of a drug-accepting subculture: former hippies, student drug users, or participants in street

life. Such individuals may continue their drug use

long after ending their other associations with the

subcultures.

Recently reported by ethnographers is the recreational use of MDMA (Ecstasy) by some

middle-class individuals.

Some professionals, particularly those whose

ideas about drugs were formulated during the

1960s, quietly view psychoactive substances as

one of many ways to relax, to relate, to “kick

back.” It is within this context, coupled with the

need to relax fast and relate quickly, that Ecstasy

is used (50).

Drug Use in Social Isolation

Last, some individuals use illicit drugs primarily

by themselves. Often they identify themselves

with a professional subculture or social group that

is opposed to drug use. One well-documented pattern is that of physicians, nurses, and other health

workers who illicitly use psychoactive pharmaceutical drugs, especially narcotics (63,64).

Other patterns of use in social isolation are

known but poorly documented in the ethnographic literature. Unsupervised use of pharmaceutical

drugs is fairly common and often the line between

licitly obtained and illicitly obtained drugs can be

blurred. Emergency room and family physicians,

for example, encounter suspected middle-class

prescription drug abusers. One middle-class

housewife interviewed as part of a study of emergency room drug episodes began her use of prescription pain killers because of a back problem,

and then continued chronic (and essentially unsupervised) use of the drug for years by obtaining

prescriptions from multiple physicians (49).

I Typology as a Whole

The ethnographic method of describing how and,

to some extent, why people use drugs differs from

the purely quantitative method that analyzes the

association of drug use with the social and demographic characteristics of the users.

To date, most of the ethnographic research has

concentrated on drug-focused subcultures or on

crime-related subcultures. There are few studies

on other populations, and many of these are now

dated. For example, there have been no significant

ethnographic studies of student drug use in almost

two decades. The drug problem has been defined

in the public mind and among some funding

sources as a problem of poor minority communities. Some ethnographers acknowledge that, to

some extent, their own attitudes have contributed

to the skewing of the drug research as well. Ethnographic field work with drug-focused and crimi-
Chapter 7 Ethnographic Drug Studies I j129

al subcultures is considered by some to be more

adventurous and professionally rewarding. Also,

in its own way, it may be easier than field work in

the general population, since study participants

can be readily delineated from onlookers and subjects can be relatively easily located on the street

or through their relationship with treatment and

law enforcement agencies.

One consequence of the absence of information

concerning drug use within the general population

is that, like a self-fulfilling prophecy, attention

continues to be paid almost exclusively to minority drug use. Drug use and drug users are defined

as the “other,” different from the rest of society.

Ethnographers have paid relatively little attention

to the relationship between culturally approved

drug use (e.g., caffeine, nicotine, alcohol, psychoactive prescription drugs) and illicit drug use.

Another consequence is that there are few data

available on which to base prevention programs

for individuals who are unlikely to become members of a drug or criminal subculture. Virtually

nothing is known about experimenters, casual

users, controlled users, or chronic users not

associated with a drug subculture.

POVERTY, RACISM, AND

CYCLE OF ABUSE

The preceding section outlined a variety of drug

using contexts in the United States and documented the presence of drug use and abuse among

different social, racial, and ethnic classes. Equally

important, however, is the realization that the

consequences of drug abuse are especially devastating in chronically y poor, often minority, communities. While poverty as an individual risk factor

for substance abuse is described in chapter 6, this

section considers ethnographic observations on

the links between the poverty of the inner-city

communities and substance abuse.

1 The Social Context of Poverty

Drug ethnographers have noted that urban poverty

means more than lacking money. Often it means

living in substandard housing in communities that

lack basic municipal services, and for young

people it usually means attending overcrowded,

underfunded, demoralized schools. Researchers

regard illicit drug use, especially the use of heroin,

cocaine, and crack, as both a result of oppressive

social conditions and a cause of the worsening of

these conditions.

To cope with difficult social circumstances,

ethnographers have documented the effective utilization of extended family networks and kin relationships. However, even with these safeguards,

it is not uncommon for children to encounter alcoholism, other drug use, depression, physical abuse

and neglect, sexual abuse, and other traumatic experiences.

Lack of Opportunity

In ethnographic life histories of men and women

who become deeply involved with illicit drugs,

the characteristic of inner-city life most often

mentioned is the lack of opportunist y for meaningful work. For example, an ethnographer studying

heroin addicts in the early 1970s noted:

Often in interviews with addicts I have

thought that this antiwork attitude was a sourgrapes defense because so few have had meaningful work experiences and many do not

consider good-paying or creative jobs work, but

I think that these attitudes are more than psychological mechanisms. They are, I believe, deeper

in the fabric of our society and arise out of poverty and the reality of poor, uneducated persons

who can only expect the most dull, stultifying,

and meaningless work. Most, I would expect,

held these attitudes before their addiction and

when they became addicted simply added

another good reason not to pursue something

that offered so little (56).

More recently, ethnographers studying the

crack subculture, have related changes in drug use

patterns to structural changes in the world economy. For many inner-city residents the difficult

economic situation of the 1950s and 1960s became impossible in the 1970s and 1980s, as many

of the secure semiskilled and unskilled jobs

shifted overseas. New York City, for example, lost

a half million manufacturing jobs and 100,000

jobs in wholesale and retail trade between 1967
130 I Technologies for Understanding and Preventing Substance Abuse and Addiction

and 1987 (36). For individuals without post secondary degrees, jobs that could support a family

became scarce.

Because of the structural shifts, basic expectations around work have changed dramatically:

The option of a steady, legal job appears so

distant for inner-city high-school dropouts (and

even graduates), that they cease job searches after a few attempts or experiences in low-wage

jobs. Adult household members can rarely provide concrete assistance in finding jobs or help

in accessing networks of employers (19).

1 Racism

Clearly a person need not be a member of a racial

or ethnic minority group to use drugs. Much of the

early ethnographic research was done on white

heroin-using individuals (20,21,48) or with

mixed ethnic and racial backgrounds samples (47,

20,56). Nonetheless, many ethnographers introduce race as an explanatory element. It is not used

in the genetic or biological sense but rather that racial discrimination has shaped the social context

and opportunity structure for many people of color. Ethnographers cite the indirect racism of some

politicians who have been unresponsive to the

worsening social conditions of schools, housing,

and municipal services in many minority communities. Also reported is the active racism encountered by many minority people in daily life (9,8).

Ethnographers describe inner-city minority

residents as having a pervasive sense of not fitting

into white mainstream society. Within most poor

inner-city communities, whites are rarely encountered except as representatives of conventional

institutions such as police, teachers, and social

workers.

Development of an Oppositional Culture

While oppressive social conditions, limited economic opportunities, and racism are identified by

ethnographers as contributing to the high prevalence of drug abuse in the inner city, in and of

themselves they offer little insight into the specific attitudes and behaviors of those involved in illicit drug use. For this, ethnographers have often

relied on the notion of an oppositional culture, one

of resistance or refusal.

Some ethnographers argue that amidst oppression and exclusion, minorities, such as blacks,

Hispanics, and American Indians, develop “a collective identity or sense of peoplehood in opposition to the social identity of white Americans.”

Developed in tandem with this oppositional social

identity is a cultural frame of reference that defines “certain forms of behavior and certain activities or events, symbols, and meanings” as not

appropriate because they are characteristic of

white Americans while “other forms of behaviors

and other events, symbols, and meanings [are defined] as more appropriate because they are not a

part of white Americans way of life. To behave in

the manner defined as falling within a white cultural frame of reference is to ‘act white’ and is negatively sanctioned” (26).

Many ethnographers studying inner-city communities argue that illicit drug use is embedded in

an oppositional culture, formed in response to oppressive social conditions and lack of opportunity.

Ethnographer Terry Williams explains:

. . . to some extent, it is possible to see the violence, crime, and substance abuse that plague

the inner city as manifestations of resistance to a

society perceived as white, racist, and economically exclusive. This could be called a culture of

refusal. The young people in the crackhouses refuse to be part of the system, refuse to obey their

parents, reject school or any adult-controlled

education or training, spurn prevailing social

values and most authority. In the crackhouses,

teenagers and adults refuse to obey the law, refuse to stay sober, refuse to engage in safe sexual

practices--even though this refusal leads them

to behaviors that are manifestly harmful both

physiologically and psychologically (61).

Cycle of Abuse

Attraction of the Drug

Ethnographers have emphasized three factors to

help explain the use of illicit drugs, especially heroin and crack by poor, inner-city, and minority

populations.
Chapter 7 Ethnographic Drug Studies I 131

First, ethnographers report that as the use of a

drug begins to spread through a community, its

use is seen as a status symbol within the street

hierarchy. Many ethnographers attributed the

quick expansion of cocaine smoking that occurred

in the middle 1980s to cocaine’s reputation as a

high-status drug, especially when smoked or free

based (23).

Second, initiation into drug use almost always

occurred through an established friendship or kin

relationship. Virtually every ethnographic study

of drug use quotes users as saying: I was at a party

(or with a friend) and someone offered me some

heroin (cocaine, crack), so I tried it.

The third theme is simply that many people,

when they try heroin or crack cocaine, like it. For

some individuals, at least in the beginning, their

drug experiences are more highly valued than anything else in their lives (6,61).

Several ethnographers have suggested that

once crack became available at relatively low cost

in the late 1980s, the sharp rise in its use was due

primarily to the intensity of the drug experience,

comparable in somatic effect to arterial injection.

The drug’s effects attracted intravenous drug users

with collapsed veins or with concerns about HIV

transmission, as well as many nonintravenous

drug users (23,40,43).

Slide Into Abuse

In explaining the slide of inner-city residents into

drug abuse, addiction, and dependency, ethnographers have highlighted two complementary

themes. One theme explains the function drug dependency serves in simplifying and giving meaning to a drug user’s life. Stated succinctly: “The

euphoria of heroin and the excitement of hustling

serve many addicts in the same way that jobs, sex,

and consumption serve nonaddicts” (56).

A similar conclusion was drawn by another

ethnographer studying crack use patterns:

Substance abuse in general, and crack in particular, offer the equivalent of a millenarian

metamorphosis. Instantaneously users are transformed from being unemployed, depressed high

school drop-outs, despised by the world—and

secretly convinced that their failure is due to

their own inherent stupidity, “racial laziness”

and disorganization—into being a mass of heart

palpitating pleasure, followed only minutes later by a jaw-gnashing crash and wide awake

alertness that provides their life with concrete

purpose: get more crack—fast! (8).

The complementary perspective emphasizes

the lack of a viable lifestyle alternative to drug

use. One researcher contends that due to the unequal distribution of viable nonaddict social roles

in society, some groups will have more difficulty

in recovery than others:

For example, a white, middle-class, highschool-educated, male addict will have more

personal and social resources to draw from when

he decides to give up dregs than will a Chicano

addict living in a barrio. In fact, a relatively uneducated Chicano addict may opt to retain the

junkie-dealer role and identity because it provides him with greater status and financial

rewards than any other social role available to

him (7).

End of the Cycle

Despite little improvement in the social conditions of many inner cities, recent journalistic accounts, ethnographic studies, and reports from

surveillance systems indicate that the prevalence

of crack use maybe decreasing. Ethnographers report that for many individuals, the initial appeal of

crack use has faded. “Youths under 16 have made

a new pastime of ridiculing or beating up crackheads who they say disgrace neighborhoods or are

nuisances or thieves. Five years ago, youngsters

their age had initiated crack use after first becoming distributors, as youngsters had previously

been drawn into heroin use” (34).

Ethnographers present several possible explanations for this downturn. Epidemiologically,

a parallel could be drawn to the decrease seen in

bacteria-based epidemics, where all individuals

most likely to be infected have been. Economically, it could be argued that all possible wealth to be

extracted from the inner city has been. There are

simply fewer resources for drug traffickers, smugglers, and importers.
132 I Technologies for Understanding and Preventing Substance Abuse and Addiction

A complementary explanation is based on concepts put forward 25 years ago (3). It was argued

that the social consequences resulting from a

drug’s use could be related to the historical stage

of the drug’s introduction in society. Most importantly, over time, a subculture of drug users develops “. . . material on how to obtain and ingest the

drug, definitions of the typical effects, the typical

course of the experience, and the permanence of

the effects.. . .“ In the case of marijuana and LSD,

this type of shared information may have accounted for the sharp decrease in reported psychotic reactions even though the actual number of

users was increasing.

This subculture can also define certain drugs or

styles of use as dangerous. For example, ethnographers argue that the downturn in cocaine use in the

late 1980s among middle- and working-class individuals was due to the belief that “cocaine can

mess you up,” and that this subculture of users understood this warning as more than just propaganda of prevention proponents (59).

This same process may be occurring in innercity communities among the subculture of crack

users. Researchers note that the crack epidemic

has followed a predictable developmental cycle,

previously seen with heroin use, “characterized by

periods of onset, incubation, widespread diffusion, peak, and decline. The final stage is stabilization at reduced levels of use” (34).

In exploring the devastation caused by crack

epidemics on inner-city communities, ethnographers have called attention to the process through

which harm-reducing information develops within a subculture of users. For example, among

middle-class, cocaine-using individuals, many

users gained information from conventional

sources (such as books, magazines, and even

scholarly journals) on the progression of cocaine

dependence, long-term negative consequences,

danger signals, and methods to control or end use.

This information then spread through the wider

user community. In contrast, researchers note that

the inner-city subculture of crack users paid little

attention to conventional information sources and

were ideologically predisposed to discount what

information did reach them. While there was no

A 1968 poster commenting on the wide use of marijuana by

U.S. servicemen stationed in Vietnam.

deficit of warnings about the dangers of crack use

in the popular media, ethnographers observed that

little effort was made to translate prevention information into more appropriate media messages

for inner-city communities.

FUTURE RESEARCH

Over the past 30 years, ethnographers have contributed to the understanding of substance abuse

research through their work among different

countries and among different subpopulations in

the United States. However, some additional contributions could be made in the following areas.

I Filling in the Gaps

The earlier sections on the social contexts of drug

use emphasized that drug use in the United States

is much more than heroin and cocaine in the inner

cities and LSD in the suburbs. Research is needed,

for example, on middle-class prescription abusers, substance abusers in rural areas, and hidden

populations (e.g., homeless, runaways, dropouts);
Chapter 7 Ethnographic Drug Studies I 133

since many of these individuals are either excluded from, or under sampled in, the national

drug abuse surveys. To further complete the matrix of substance use and abuse in the United

States, future research could address not only

those individuals whose use is unmanageable, but

individuals and communities who do not use, or

whose use is moderate and controlled.

1 Expanding Research Hypotheses

The documentation that cultural and societal

norms, to a large degree, shape individuals’ and

groups’ behaviors toward drugs use, could be used

to formulate new substance abuse research hypotheses, or expand on existing hypotheses. For

example, understanding the etiology of drug use

through studies of children will help explain initiation of drug use and provide guidance for prevention efforts. Basic studies that document how

children come to perceive drugs are lacking.

“... when it happens, how it happens. How they

conceptualize, for example, what is a drug and

what is a poison, and how that changes when they

begin experimenting with drugs” (44).

1 Planning Prevention Programs

The insight gained by ethnographic research on a

community’s or subculture’s view on substance

use could be incorporated to a greater degree in the

needs assessment, planning, implementation,

monitoring, and evaluation components of substance abuse prevention research. The information gained from ethnographic research could help

assure that the prevention information is culturally appropriate not just in a generic ethnic sense,

but in terms of the specific cognitive framework

and concerns of the target audience. Additionally,

the qualitative tools used in ethnography can assist quantitative researchers in the interpretation

of substance abuse data in varying contexts.

1 Identifying Emergent Trends

Ethnographic research is also useful in its ability

to relatively quickly document changes in existing drug use patterns or identify the use of new

drugs by a particular subculture. This timely information could assist in the planning of appropriate prevention strategies.

SUMMARY

Studies on drug-using subcultures have provided

a wealth of knowledge on why, how, and who uses

and abuses drugs. Experience-based methods of

data collection, such as ethnography, provide the

field of substance abuse research with unique information on drug abuse among individuals,

groups, and communities. Some of the contributions discussed in this chapter have been theoretical, substantive, and programmatic.

Ethnographic studies have documented drug

use patterns worldwide and in so doing have assisted the understanding of societal influences on

drug use. These insights have, for example, been

utilized in the planning, implementation, and to

some extent, evaluation of drug prevention programs in a variety of different social contexts.

Researchers have also utilized ethnographies to

follow constantly changing drug use patterns.

Moreover, ethnographers provide valuable data

on new drug use such as who is using it, how the

drug is being used, and where the probable epicenters of the drug use are.

While not without methodological limitations,

ethnography and other experience-based research

provide new insights into substance abuse, as well

as complimenting more quantitative methods of

data collection.
T

his chapter reviews substance use and abuse-related research on factors and interventions in homes, schools,

workplaces, recreational and other developmental settings, and community-wide settings. These community

activity settings are the major physical and social arenas in communities where individuals interact and learn their values, attitudes, and behaviors, some of which can increase or reduce the

likelihood that individuals will use and abuse substances. The

addition of treatment settings of all types and correctional settings

would provide a fairly comprehensive and systematic overview

of all the major settings in communities. Those settings are not

discussed at length in this report, however, because of its focus

primarily on prevention, even though comprehensive prevention

strategies will almost always want to include treatment and

correctional components as well.

By focusing on any one of these settings, researchers interested

in substance use and abuse can study the interplay of multiple factors in a context, and practitioners can implement programs designed for specific settings. By examining all of these settings

together, policy makers and practitioners interested in substance

abuse and the healthy development of individuals and communities can identify and, within available resources, implement concrete, systematic, and comprehensive preventive interventions

for communities as a whole. The development and strengthening

of community-wide norms against the use of substances may well

be one of the more important ways to protect individuals against

the use of substances. The section on communities discusses

some of the issues and tools for community-wide prevention

planning and coordination,

Community

Activity

Settings 8
136 I Technologies for Understanding and Preventing Substance Abuse and Addiction

There's another tiny nation

that’s worth fighting for.

Partnership for a Drug-Free America
Chapter 8 Community Activity Settings I 137

HOMES AND FAMILIES

Although American society expects families in

their homes to take the lead in dealing with substance abuse and other problem behaviors (69),

families in this country generally receive only

limited outside support in protecting themselves

against substance abuse. This situation may result

in part from the belief that most nuclear families

can raise their children largely independently and

therefore do not need outside support, and in part

from the belief that teens and young adults are

more influenced by their peers. The first belief,

however, is not supported by long-standing practices in most societies, where extended families

and life-long neighbors have traditionally helped

raise children (although in the United States many

parents do not have access to these additional

child-rearing resources because of urbanization,

high technology, and family mobility). And the

second belief is being questioned by growing evidence that certain parenting practices and family

intervention programs can significantly reduce

the risk of substance abuse among adolescents and

young adults.

An extensive and growing body of research

strongly suggests that many families do need, and

can benefit from, support from outside the family,

and can often protect their children from substance abuse, even into adolescence and adulthood. While some of the findings reported here

may appear to be commonsensical, they are presented because they have been addressed by

researchers as part of a growing body of increasingly rigorous research. Some of the studies focus

on risk and protective factors that are known or

thought to be associated with substance use and

abuse, while others focus directly on substance

use and abuse. To reduce redundancy, factors and

programs discussed elsewhere in this report are

for the most part not considered here.

9 Protective Factors

Families can protect against substance use and

abuse by providing close family relationships,

sufficient monitoring, clear messages about substance use and abuse, and attractive alternatives to

substance use and abuse.

Close Family Relationships

Family relationships can help protect against substance use and abuse when they are characterized

by closeness and warmth, effective and positive

discipline, and successful problem solving and

communications. For example, young people

who report feeling close to their families are less

likely to abuse substances than those who report

not feeling close to their families. Parents in such

families are more likely to comfort their children

when they are afraid, have two-way communications, and give children some say in what happens

to them (83,86,152). Because such parents spend

more time with their children, there can be more

conflict, but the time spent together can also lead

to greater mutual understanding and acceptance

(23,59).

Parents can better channel their children away

from substance use and abuse if they have routinely used effective, age-appropriate discipline methods, including clear expectations and rules about

homework, television, curfews, and drugs and alcohol. Such methods are particularly effective

when they are enforced by praise and encouragement, instead of by threatening, nagging, and

blaming (42,47). In contrast, ineffective or provocative family management practices, including

overly harsh or reluctant discipline practices and

inconsistent followthrough, are associated with

early sampling of substances and later abuse

(8,1 15). Unruly behaviors in childhood can lead

children to poor achievement in school, social rejection by more conventional peers, and greater

association with other children with behavior

problems (46).

Skillful handling of problems by families helps

children learn how to distance themselves from

problems and address them with specific problem-solving strategies (77). Such skills can help

children later avoid the use and abuse of substances. By contrast, families where children

eventually abuse substances do not make deci-
138 I Technologies for Understanding and Preventing Substance Abuse and Addiction

sions and solve problems as well as other families

(97). Positive caregiving and discipline can prevent negative outcomes even for highly stressed,

minority, low socioeconomic status (SES), urban

families (177). When the birth parents are not

available, effective parenting by a surrogate, relative, or neighbor can also be protective (173).

Sufficient Monitoring

When parents or parent surrogates know how their

children are spending their time, the risk of substance abuse is low (47). Such monitoring may

prevent abuse by reducing access to substances,

preventing use of substances, or allowing parents

to identify substance use earlier and to apply sanctions. Monitoring may also entail greater involvement by parents in their children’s lives, which

may help render substance use and abuse less

appealing by enhancing feelings of trust, warmth,

and closeness in the family. Such monitoring prevents substance sampling across ages, ethnicities,

and settings.

Single parents and working parents are often

less able to monitor their children thoroughly, because they can be in only one place at a time. However, grandmothers, aunts, after-school personnel,

and other caring and supportive adults can also

monitor children and help reduce deviant behaviors (59,88). Early autonomy and unsupervised

leisure time apparently increase the risk of substance use and abuse by children.

Clear Messages About Effects of

Substances, Including Sanctions

Children are more likely to avoid the use of substances if they know that use will bring negative

outcomes, such as adverse physical and psychological effects, disapproval, and penalties imposed by parents. Many children develop

expectations about the effects of substances as early as the preschool years ( 100), influenced primarily by their parents. Frequent parental use even of

aspirin, cold pills, prescribed psychotropic medications (85), and cough medicine can give children positive expectations about the effects of

substances (61 ).

When parents apply reliable penalties, such as

revoking privileges, and coach their children

about the adverse effects of substances, use is likely to discontinue (6). By contrast, if the possible

adverse effects (e.g., illness and depression) are

not emphasized and few negative sanctions are applied when adolescents first use marijuana, while

the immediate experiences are to feel pleasantly

stoned and potent (87), then continued use and

adult drug problems are more likely (37). Parental

disapproval of children’s alcohol use has been

found to be protective across ethnic groups (33).

Increased appreciation of risks and social disapproval of substance use is credited with the recent downturn in cocaine and marijuana use

nationally (5).

Attractive Alternatives to

Substance Use and Abuse

Participation in religious and other conventional

and challenging activities can protect against substance use and abuse (26,8 1,111, 173). Especially

important are activities about which youth are

passionate.

Parents are more likely to guide their children

away from substance use and abuse if parents have

instilled hope in their children to succeed as adults

(172). By contrast, some children do not look forward to and plan for adulthood, but learn only

short-term thinking (see box 8-1 ) and have been

encouraged by their parents to believe they cannot

succeed.

Parents of inner-city African American children face special difficulties in holding out hope

for their children’s success through traditional opportunities. Unemployment among African

American men is almost 50 percent (24) and the

marriage rate among African American women is

low and still declining (10), with substance use

and abuse among African Americans increasing
—

Chapter8 Community Activity Settings 1139

Eighteen-year-old Lyle IS a senior at an Inner-city high school In four weeks, he WIII receive his high

school diploma In SIX months, he will become a father

Lyle has a significant history of delinquent behav{or, includlng assault, drug deallng, and grand larceny He has recently withdrawn from a gang because “it’s gotten crazy and It’s gotten really out of

hand” and “1 don’t want to dle “ However, he adds, “1 still hang with the fellows and stuff like that “

Because he ‘<feels like working, ” Lyle IS Iooklng forward to getting out of high school He has no

plans for college, which he regards as ‘(too much hassle, to tell you the truth “ HIS plans for the future

are vague-to “work, make money, you know’ ’—but he tries not to think about It much because, ‘(you

know, you might dle “ For Lyle, “the way everything’s happening now, you can’t really think about the

future the way things happen now, you can get shot coming out of your house You can be shot In the

window, you know”

Lyle IS a dally smoker of ten or more cigarettes, a habit he describes as “like a everyday routine—

whenever I can get time to smoke one, I’ll smoke one “ He drinks a couple beers almost daily, and also

smokes marijuana “most Ilkely” every day

But Lyle avoids harder drugs, Ilke cocaine, because “1 don’t want to kill myself “ By way of explanation, he adds “I’d rather kill myself slowly than fast “

SOURCE H Stauber, ‘1 ve Got Plenty of Cells to Waste Perceptions of danger and Invulnerablllty among reckless-behaving

adolescents, Unpublished paper, Harvard Graduate School of Education in progress

as they reach 26 to 34 years of age, instead of decreasing as with other racial and ethnic groups

(1 64).

1 Risk Factors

Families also face risk factors, such as parental neglect and rejection, behavioral problems and

crime, physical and sexual abuse, substance abuse

in the family, failure in school, emotional problems, negative life events, early use of substances,

substance abuse in the neighborhood, and poverty,

unemployment, and hopelessness. Because some

of these factors are discussed elsewhere in this report, this section will focus only on parental neglect and rejection, physical and sexual abuse,

substance abuse in the family, negative life events,

and drug trafficking in the neighborhood.

Parental Neglect and Rejection

Children who are neglected anytime, but especially from earliest childhood, are at greater risk of

substance abuse (17,1 42). When children have

been continually rejected, they become immune

to parental guidance. Such children fail to form

close relationships, get along with others, solve

problems, and regulate impulses.

Physical and Sexual Abuse

Physical or sexual abuse in childhood leads to

greater vulnerability to substance abuse in adolescence and adulthood (38). Rape victims, particularly those with Post Traumatic Stress Disorder

(PTSD) symptoms, are 20 times more likely to

have subsequent substance abuse problems (165).

Substance abuse rehabilitation programs report

that as many as 60 to 70 percent of the female patients and 25 percent of the male patients have

been sexually victimized, while 43 percent have

been beaten (45,99,92). Victims of sexual or

physical abuse often report wishing to avoid unpleasant memories, including flashbacks to the

abuse (126). The use of substances may help some

victims forget for awhile (see box 8-2).

Substance Abuse h? the Fami/y

The biological children of alcoholics have a higher than average chance of abusing alcohol, even if

they are reared away from their alcoholic parents

(40,63). Thus, apart of the vulnerability to alcohol
140 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Janice, a 28-year-old, white, married female, was in outpatient treatment for bulimia nervosa, a

binge-purge pattern of eating that began when she was 18 years old. She also had an intermittent history of alcohol abuse dating from midadolescence Janice appeared to be well-motivated in treatment,

She used the psychoeducational approach taught by her therapist to increase her knowledge of how

her binge-eating and moodiness were related to her restricted daily caloric intake. She made progress

quickly, using cognitive behavioral techniques to challenge her distortions and understand her behavior; she began to eat consistent meals in adequate amounts These changes led to a decrease In her

binge-eating and self-induced vomiting. However, along with this progress she became increasingly

anxious, fearful, and agitated about weight gain (despite the fact that little or none had occurred), At the

same time, she became overwhelmed by the intensity of the feelings she experienced, was having bad

dreams, and withdrew from her support system in ways that angered her friends She once more resorted to inconsistent meal patterns, dieting, poor nutrition, and—inevitably—binge-eating and vomiting Her alcohol use increased,

Janice’s symptomatology shifted once she significantly decreased her bulimlc behavior. Instead of

dealing with everyday feelings, behavior, and thoughts, she began to relive memories from her unresolved traumatic past, These memories started with vague feelings of uneasiness, which grew more

intense as she binged less. She then began to remember her dreams, which, as they came into clearer

focus, caused her to be suspicious of her friends, and particularly of the men around her Janice reported feeling fine one minute and then very frightened the next Whereas she used to be flattered by

any male attention, she now felt fearful when men looked at her She started to remember mulhple sexual assaults in her past, both by persons known to her and by strangers. She felt increasing urges to

suicide, and observed the reality of her internal suffering as being “too awful “ As she said, “If this is

what recovery is all about, I don’t think it’s worth it, I’ll take my chances and struggle with addictions If I

can’t stand that, there’s always suicide, ”

SOURCE M P Root, “Treatment Failures The Role of Sexual Victimlzatlon m Women’s Addlctwe Behavior, ” Anerlcan Jouma/ of

Orthopsych/atry, 59(4), 543, 1989.

abuse, at least for some, may be inherited. Chil- tives outside the family offered them. When their

dren of alcoholics, for example, may experience

more positive effects or fewer negative effects

from the use of alcohol. Either of these responses

could result from individual differences in experienced pharmacological effects of drugs (135) or

differences in temperament that can be modified

by the use of alcohol and other drugs (154).

In addition to friends and acquaintances, relatives are a common source of alcohol and other

drugs for teens. Family members and other relatives can be very persuasive when they offer such

substances to teens. One study, that included both

abstainers and heavy users, found that young

people refused available substances, mainly alcohol, 46 percent of the time when friends offered

them, but only 18 percent of the time when relaown parents offered such substances, the young

people never refused (9). Family members who

use substances can also inadvertently make them

available to teens by leaving family cabinets containing alcohol or pills unlocked (35).

Family members can learn how to use alcohol

and other drugs by watching and listening to abusing family members; they can also adopt the abusing members’ expectations about the effects of

these substances. For example, children of alcoholics are more likely to think that the purpose of

drinking is to get drunk (107). They also have

greater expectations for the use of alcohol (143),

and sometimes believe they can do things better

after a few drinks.
Chapter 8 Community Activity Settings I 141

Families with a substance abusing parent experience significant disruptions in many aspects of

their lives, including child rearing (160). Substance abusing parents and spouses often have difficulties guiding their children, especially away

from substances, because of inconsistent nurturing, monitoring, and disciplinary practices

(36,47). Their abuse of substances can also rob

children of stability in life and of competent adult

role models. Even a nondrinking spouse can become so involved with the drinking spouse and so

depressed and isolated from social support that

children feel neglected (13). Marital quality can

be affected ( 160), and the level of conflict and verbal and physical aggression can be high (151). In

addition, adolescent and adult children of substance abusers are less influenced by their parents

and have lower parental attachment, less involvement with other people, more difficulty getting

along with other people (84), lower self-esteem,

lower academic achievement, higher depression

(1 28), and a greater number of other psychiatric

symptoms ( 1 43).

Major Negative Life Events

Substance use and abuse often increase as children

experience more negative events ( 106, 174) (see

table 8-1 ). Adult alcoholics report a significantly

higher number of severe life events just before

their alcohol dependency begins (65), with seven

out of eight of them reporting disruptions in important personal relationships, such as with

friends, lovers, or spouses. Among the elderly,

late-onset alcoholism is reportedly preceded by

new feelings of loneliness and depression, perhaps also due to recent losses of important relationships (120,1 34).

Such negative 1ife events may heighten vulnerability to substance abuse by increasing depression (174). For instance, one study found that

children who had lost a parent to death had a 7.5

times greater risk of developing a depression than

other children (60). Negative life events may also

occasion perceptions of helplessness and decreased personal control; these too can be offset,

Event Weight a

Death of a parent 91

Divorce of parent 84

Marital separation of parents 78

Child acquired a visible deformity 69

Death of a brother or sister 68

Serious Illness or accident requiring

hospitalization of child 62

Serious Illness or accident requiring

hospitalization of parent 55

Death of child’s close friend 53

Increase in arguments between

parents 51

Change in father’s occupation

requiring increased absence from

home 45

One parent arrested or in serious

difficulty with the law 44

Serious Illness requiring

hospitalization of brother or sister 41

Death of a grandparent 38

Loss of job by parent 38

Brother or sister have serious trouble 36

. .-

a Readjustment weights derived from Coddington, 1972a

SOURCE I Sandier, & M Block, “Life stress and maladaptation of

children, ” American Journal of Community Psychology 7(4),

425-440 1979

Families are likely to have the greatest difficulty

preventing substance abuse if friends abuse substances (86, 109) or if substance use is rampant in

the neighborhood (39,44,5 1, 124). Such conditions encourage substance use and reduce the barriers against use by making drugs continuously

available and socially acceptable (even appeal ing)

and by providing temporary escape from the frequent hassles and tragedies of life among highly

transient and troubled (rather than stable and helpful) neighbors (146).

1 Programs To Enhance

Protective Factors

This section discusses some of the numerous programs that have been developed for families with

infants, school-aged children, and young adults.

at least for awhile, by some drugs (91). Few of these programs specifically target sub-
142 I Technologies for Understanding and Preventing Substance Abuse and Addiction

stance abuse and addiction, but many have

been found to enhance family-based protective

factors and/or reduce risk factors that can be

associated with drug abuse. Unlike some

school-based programs, methodologically rigorous studies correlating the efficacy of these

programs to the level of substance abuse and

addiction have yet to be done.

Families With Infants

Parent education, prenatal and infant care, and social support programs help strengthen involved

and responsive parenting (4), which in turn can

significantly reduce substance abuse risk factors

such as child abuse and neglect and childhood accidents.

Parents who had participated in such programs

attained more education, had fewer other children,

and were less likely to be on welfare by the time

their children were 10 years old, than parents who

had not participated in such programs. Participating parents reported less stress and more confidence in their parenting ( 175). Most importantly,

children were dramatically less likely to experience attendance, behavior, or academic problems

in school (112,138,139),

m

●

■

■

■

These programs can take many forms:

a neighborhood house where parents and their

infants can come during the day for companionship, child care advice, social services, and

health care from a stable professional staff

(139);

twice-a-week home visits by the same nurse,

from pregnancy until the child is 2 years old

(1 12);

home visits, with child development advice,

help in acquiring other services, and time-limited family counseling to lower conflict and increase support from the extended family;

a public school dedicated to pregnant teens and

new mothers and that provides health and child

care education, social services, and intensive

high school education (138); and

parent meetings in the hospital where the baby

was born (175).

Families With School-Age Children

Parent training and support programs can help

parents of school-aged children motivate their

children to more willingly pay attention to and accept parental guidance and to develop skills for

success outside the family. A parent training program called WINNING, provided through a Texas

school system, increased positive and corrective

feedback from parents to children, increased parent-child interactions, and decreased the attention

parents gave to inappropriate child behavior. Concomitantly, the portion of their children’s behavior that was inappropriate decreased (43).

Another parent training and support program,

“How to Help Your Child Succeed in School,”

was offered through Seattle, Washington schools

to increase protective factors and reduce risk factors for substance use and abuse. After the program, parents spent more time reading with their

children and provided more consistent positive

and negative consequences for behavior (70,7 1,

72,73,74).

Involving parents more in schools can further

support parenting and prevent it from being undermined by peers and by school environments. In

the School Development Program in New Haven,

Connecticut, for example, parents serve as members of the School Advisory Council and as employees or volunteers in classrooms. Significant

improvements have been seen in student attendance, language skills, math scores, and social

competence, and virtually all classroom behavior

problems have been eliminated (34,41 ).

A community grassroots effort to provide these

and other resources for parents began 17 years ago

in the Ravendale section of Detroit, Michigan.

The “Joy of Jesus” programs now support families

living in more than 30 contiguous blocks. Every

day after school about 250 youth of all ages participate in scheduled activities such as tutoring, music, dance, gym, writing, teen sex education,

cultural field trips, university tours, and an entrepreneur’s club (for 30 teens who are starting their

own businesses). This program provides several

substance abuse protective factors and prevents

the risk factor of school failure, by monitoring re-
Chapter 8 Community Activity Settings I 143

port cards and enrolling students in an individualized after-school motivational learning program,

if necessary.

In Los Angeles, California, an after-school tutoring and activities program has been developed

in a for profit apartment building. The program,

called EEXCEL, provides a room in the building

and live-in counselors and tutors who offer children a “sanctuary for education [and] ...incentives

for learning.” When report cards come out, good

grades are recognized at parties. Only those families that want this resource for their children are

accepted as tenants in the building ( 108).

Atlanta, Georgia-based Inner-City Families in

Action has been presenting comprehensive information in a series of 2-hour sessions about how

specific drugs, such as alcohol or crack, affect every system in the body, to residents in two Atlanta

housing projects. The curriculum is called “You

Have the Right to Know.” After 2 years of using

the curriculum in many locations, the narcotics arrests in both housing projects are down (52).

Through flyers, personal invitations from

schools, and a 1-hour television special, parents

were recruited to 87 local sites around Seattle,

Washington, for workshops on “Preparing for the

Drug (Free) Years,” led by trained parents. Surveys showed that parents’ attitudes and behaviors

were changed in the direction of providing protective factors. Parents also rated highly the workshops’ content, process, and leaders (71 ).

The Midwestern Prevention Project (Project

STAR) in Kansas City, Missouri, used the local

media to recruit parents to become involved in a

school and parent substance abuse education

course and to repeat the messages for more than

one year. This intensive effort reduced the rate of

increase in initiation of alcohol, tobacco, and marijuana use among seventh and eighth graders who

had participated in the program, as compared to

those who had not participated (11 6).

Families With Young Adults

Job Corps, Peace Corps/VISTA programs, American Conservation and Youth Service Corps, National and Community Service Programs,

universities, and the military all provide young

people sheltered work experiences, educational

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 (48).

I Programs To Reduce Risk Factors

Reducing Drug-Trafficking and

Substance-Using Peers

Operation Clean Sweep, now being run by the

Chicago, Illinois, Housing Authority, is designed

to reduce drug dealing and other crimes in housing

projects. Staff approach one high-rise building at

a time, spending at least a whole day at the building. State and local law enforcement officers and

housing authority security officers search apartment units (if there is reasonable cause) for illegal

weapons and unauthorized residents. Authorized

residents are given photo I.D. cards, while others

are put on the lease, given a 2-week pass, or asked

to leave. The maintenance staff makes repairs,

cleans graffiti, encloses lobbies, and builds a security station for 24-hour-a-day surveillance and review of photo I.D. ’s and passes for admittance.

The program is being replicated in cities across the

nation, with funding and technical assistance from

the U.S. Department of Housing and Urban Development (HUD).

Reducing Physical and Sexual Abuse

Physical and psychological security is important

for the emotional well-being of children (30) and

may well reduce their risk of later substance

abuse. Mandatory arrest and brief incarceration

for physical and sexual abuse of children or mothers has been shown to deter more repeat offenses

than do warnings or counseling alone ( 144), and
144 I Technologies for Understanding and Preventing Substance Abuse and Addiction

court-mandated treatment for convicted offenders

seems to reduce later abuse even further (50).

Since 40 to 87 percent of adult sexual or physical

abusers also report alcohol or drug abuse, individuals treated for family violence should perhaps

also be screened and, if appropriate, treated for

substance abuse (176).

Reducing Substance Abuse in the Family

Substance abuse treatment for the family can reduce substance abuse in the short-term and maintain those reductions in the long-term (27,75,

101,147,149, 153,). Substance abuse treatment for

married adults is more effective when both

spouses are involved (96), and especially with a

behavioral approach to marital problems (1 10).

Clearly, families can help rehabilitate substance

abusers, thereby reducing the risk of substance

abuse for other family members.

Reducing Impact of Negative Life Events

Linking people with modest community supports

during crises or adjustments can reduce risk factors and enhance protective factors. For example,

when widows were contacted individually by

trained, previously widowed persons to discuss

grief and decisions to be made, 61 percent accepted the widow-aide services ( 145) and one

month after bereavement were less depressed and

less preoccupied with the past than widows who

had received no intervention. One year later, the

intervention group was significantly more resocialized in their roles as singles; two years later,

the health of the intervention group members was

significantly better than that of control group

members (168).

Also, a 6-month program for newly separated

or divorced people in Colorado (which included

both one-to-one counseling by trained volunteers

and group meetings about practical problems,

such as career planning and child-rearing) significantly reduced the participants’ problems and

their anxiety, nervousness, and fatigue. It also improved their psychological adjustment (less guilt

and self-blame, more competence), as compared

with a randomly selected control group ( 18). More

indirect approaches have also been tried. For example, socially isolated and lonely individuals,

who were provided a free blood pressure station in

the lobby of their innercity single room occupancy

hotel, were introduced to each other by the nurse

and later formed a “Senior Activities Club.” In

another example, a surplus food distribution service, that required individuals to work together to

get their food, produced new friendships (1 17).

Reducing Parental Neglect

Parents whose children failed to maintain gains

after parent education or family therapy are often

socially isolated and subject to seemingly insurmountable daily problems (49). An experimental

program—with weekly follow-up sessions with

isolated parents, to discuss environmental problems that affected how parents saw their children’s

behavior-reduced maternal criticisms of children, negative responses by children to mothers,

and child problem behaviors (170). When the

weekly discussions stopped, however, the negative interactions resumed.

In a more comprehensive program for low SES

parents believed by Child Protective Services to

be at high risk for child abuse or neglect, Project

12-Ways held meetings with parents in their

homes (95). Treatment goals were developed and,

as needed, behavioral training was provided in

stress reduction, assertiveness, self-control, leisure time planning, marital counseling, and job

finding. Social support groups, alcohol treatment

referral, homemakers, physicians, and mental

health workers were also involved. Parent compliance and involvement in this 5- to 6-month program were high. Twenty months after treatment,

only 2 percent of Project 12-Ways parents abused

or neglected their children, while 10 percent of a

nonprogram comparison group did.

Families on the verge of having children placed

in foster-care, group homes, or psychiatric hospitals can benefit from family preservation programs. Children have fewer behavioral and

academic problems when they are raised by birthparents in safe homes ( 130). Thus, the goal of a

family preservation counselor is to help the family
Chapter8 Communit yActivitySettings 1145

Dara (20) was the natural mother of Christina (9 months) Christina was in danger of placement In

foster care due to the cocaine add[ction of her mother Her father, Matt, was serving time in jail on a

drug charge Christina’s older brother, Jason, was placed In foster care prior to Homebullder involvement Dara’s addlctlon prevented her from properly caring for herself and the children Dara rented the

upstairs apartment In her parent’s home Her 19-year-old boyfriend, Brian, spent a great deal of time

with her and Chrlstlna

I helped Dara find out about drug treatment centers and a schedule for Narcotic Anonymous (N A )

She missed her first drug evaluahon because of having an abortion She and Brian went to one N A

meeting and then missed many days The CPS caseworker met w(th me and Dara and stressed the

Importance of her drug recovery Dara agreed to complete the evaluation as well as attend N A meetings Inltlally I accompanied her to the N A meetings for moral support Sometimes Brian would go and

the rest of the time her mother would accompany her Dara successfully completed her drug evaluation

and attended regular counseling sessions with a drug counselor She volunteered for urinalysis, “just to

keep her honest “ Dara got Involved with other young adults In N A They went to eat together and went

out to dances and movies She began associahng with a new peer group The CPS caseworker authorized maximum day-care to be paid for so she could attend her meetings and counseling Dara’s mother volunteered to baby-sit Chrlstlna If Dara was with her friends from N A

Dara’s husband got out of jail and wanted a dworce He filed for custody of both of their children I

helped Dara arrange for legal ald She said she was more determined than ever to “stay straight so she

would look good In court” over the custody of the children

Dara asked her boyfriend to move out so she could live by herself She and Brian continue to stay in

contact from time to time Dara retained custody of Chrtstlna She and Matt agreed on Joint custody of

their son, Jason, and Dara saw hlm every other weekend. She continued drug counseling and attending N A Her urinalysis always tested negative

SOURCE J Kinney, D Haapala and C Booth, Keeping Fami/(es Together, (pp 22-23) (New York Aldlne De Gruyter, 1991)

out of the crisis and learn how to retain the child

safely at home. The interventions are typically intensive and brief—for example, a counselor is

available for meetings in the home 24 hours a day,

7 days a week, for about 6 weeks. The counselor

deals with any relevant problems, helping the

family clarify values, set goals, and solve problems, and helps connect family members with

community resources (see box 8-3).

Many families, especially those with substance

abuse problems, need more prolonged help. A

family support program that provides such longer

term support is Camden House, in the Ravendale

section of Detroit, Michigan. A rundown house

was purchased, renovated, and made the center of

an outreach and drop-in program for about 1010-

cal families with multiple problems that included

substance abuse, lack of skills, chronic unemploy -

ment, early pregnancy, and crime. After staff had

worked with the families for one tot wo years, taking one problem at a time and actively mentoring

the parents, six out of 10 of the original parents

were out of the Camden House program, drugfree, trained and employed, and safely and responsibly raising their children.

SCHOOLS AND PEERS

Millions of school-age youth in the United States

experiment with alcohol, tobacco, and other drugs

annually, often (especially with alcohol) in ways

that can cause overdose deaths, accidental injuries

or deaths, and permanent impairments. Many

school-age youth continue to use substances and

later develop long-term addictions. To address

these substance abuse problems, schools provide
146 I Technologies for Understanding and Preventing Substance Abuse and Addiction

WHAT

YOUR CHILD

TAKING

IN SCHOOL

THIS

YEAR?

w

Your child isn’t just everyone from learning.

learning about History \

\ Our schools need our help.

and English in school. He’s also learning As a parent, you can do your part.

about amphetamines, barbiturates and Talk with your child. Find out how bad the

marijuana. problem is at his school.

Drugs are rampant in our schools Then talk to other parents. And decide

today. what you as a group can do to get drugs

Kids are taking them before school. out of the classroom.

They’re taking them between classes, Also, contact your local agency on drug

School has even become one of the more abuse. They can provide you with valuable

convenient places to buy drugs. information as well as sound advice.

The sad part is that all this doesn’t just

affect those kids who are taking the

School is your child’s best chance to get

ahead in life. Don’t let drugs take that

drugs. It affects all the kids. Drugs keep chance away.

PARTNERSHIP FOR A DRUG-FREE AMERICA
Chapter 8 Community Activity Settings I 147

the most important settings for reaching young

people with standardized, broadly applied educational and preventive messages.

Because school-age youth are especially likely

to initiate the use of alcohol and other drugs, much

of the research has focused on use, rather than on

abuse and dependency. Such research is nevertheless relevant to an understanding of abuse and

dependency, since use is a precondition and contributor to abuse and dependency and even experimental use can be harmful. For example, nearly

half of all youth who experiment with cigarettes

develop long-term smoking habits, and alcohol

and marijuana use by youth with no chronic problems still contributes to highway deaths, crime,

and violence. This section summarizes results

from an analysis of survey research on the causes

of school-age substance use and discusses schoolbased prevention programming.

1 Analysis of Survey Research on

Causes of School-Age Substance Use

OTA commissioned a review of the survey research literature on school-aged substance use that

compiled, classified, and examined 9,930 statistical analyses from 242 separate studies. This is by

far the most extensive systematic examination of

this body of research conducted so far. Most of the

studies dealt with school-based populations, but

some focused on school-age army recruits, dropouts, children of alcoholics, and individuals involved in clinics. The studies reported statistical

relationships between substance use and its postulated causes. Statistical findings from the study reports were sorted into 11 major categories and 50

subcategories (see table 8-2), and then analyzed to

identify strong, moderate, and weak statistical

relationships, as well as those that had been insufficiently studied.

Characteristics of Database

The studies tended to focus on so-called gateway

substances, with tobacco, alcohol, and marijuana

analyses accounting for 82 percent of the completed analyses (see figure 8-1 ). Cocaine, inhalants, heroin, and prescription drugs, which have

recently received extensive social attention, have

been relatively ignored by quantitative researchers to date; none of these latter categories of substance use accounted for more than 5 percent of

the analyses in the research reports examined.

Gateway drugs are indeed important, since they

may lead some individuals to later abuse. Nevertheless, the literature has gaps. Inhalants, for

instance, may well be one of the most commonly

used and abused substances among some youth,

but they have received almost no attention from

survey researchers.

Although the primary measures were of use,

not abuse, the database included some measures

of alcohol abuse (e.g., drunk driving and impairment from alcohol use). Abuse of cocaine, heroin,

and analgesics was not measured. The percentages of analyses in the database for each of the 11

major types of independent variables is displayed

(see figure 8-2). The types of independent variables most studied were personality, use by others,

and cognitive factors (including attitudes, beliefs,

and values).

Results of Analysis

After being sorted into the 11 major categories and

50 subcategories, the average of all the correlations in each subcategory was calculated. Then,

each subcategory was ranked by its average correlation and the rankings were divided into three

groups, defined by ranges of correlations: primary

(with correlations over .30), secondary (with correlations between about .20 and .30), and tertiary

(with correlations under about .20) (see figure

8-3).

Primary correlates

The four variables that dominate as correlates of

and possible contributors to substance use are: 1 )

prior and concurrent use of substances, 2) substance use by peers and friends, 3) perceived peer

attitudes about substance use, and 4) offers to use

substances, The prominence of prior and concurrent use is consistent with the reinforcing nature

of substance use itself. The prominence of the other three variables emphasizes the importance of
148 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Prior Use

Drug Use by Others

Peer/friend use

Use and deviant behavior by a relative

Sibling use ●

Availability

Parental use

Intentions

Overt and Normative Pressures

Peer/friend attitudes about drug use ■

Offers to use

Others’ attitudes about use

Motivation to comply with pressure

Media influences

Others” attitudes about other issues

Cognitive Factors

Attitudes

■

Beliefs about psychological consequences

Value of achievement

Religious values

General values

Beliefs about health consequences

Demographic Factors

Age/grade

Race ■

Geographic identifiers

Gender

Personality Characteristics

Deviance

Independence

Affect

SOURCE Off Ice of Technology Assessment, 1994

the social environment in contributing to and reinforcing substance use among school-age youth.

Secondary correlates

Of the 15 variables judged to be of secondary

importance, seven are social variables: 1 ) susceptibility to peer pressure, 2) resistance skills,

3) perception of social pressure to use substances, 4) beliefs that such pressure can be effectively handled, 5) beliefs about social consequences of use, 6) bondedness (especially to

school), and 7) peer group characteristics. With

the exception of parent attitudes about substance

use, other parental variables-such as parental supervision, monitoring, and relations—are notably

missing as primary or secondary correlates.

Personality traits

Social personality traits

Self-esteem

Locus of control

Peer Factors

Intimacy

Peer group characteristics

Peer bonding

Peer-parent relations

Competence

Self-efficacy

Stress management skills

School performance

Self-management skills

Intelligence

Institutional Influences

School bonding

Participation in nonstructured activities

Religious affiliation

Moral codes

Church attendance

Participation in structured activities

Academic expectations

Home Factors

Socioeconomic status

Parental relations

Parents’ psychological traits

Parents’ marriage

Parents’ education

Family composition

Tertiary correlates

Of the 38 variables found to have no more than a

minor role in substance use, 10 were included in

at least 100 of the correlational analyses in the

database for this review. They are: 1) substance

use by parents, 2) personality traits, 3) intelligence, 4) social personality traits, 5) parental

relations, 6) affect, 7) participation in structured

activities, 8) bonding with the peer group, 9) beliefs about health consequences of using substances, and 10) self-esteem.

Variables requiring further study

Several of the secondary and tertiary variables in

the studies reviewed here were insufficiently examined to allow general conclusions to be drawn.
Chapter 8 Community Activity Settings I 149

Drunkenness/problems

8.10/0

SOURCE Off Ice of Technology Assessment, 1994

However, they may later prove to be useful to the

field. For example, religious affiliation and the development of substance use-specific values, while

not extensively studied as separate variables, both

address issues related to social norms and influences that have often been found to be

associated with substance use; thus, an association between these two variables and the onset of

substance use might be expected. Also, availability may prove to be important, especial] y if it is defined in future studies more broadly (e.g., as

physical and social availability, as discussed in ch.

5) rather than as potential availability (that is, how

easy it appears to be to get a substance, if motivated), as many current surveys define it,

Preventive Interventions

Schools can seek to prevent substance use and

abuse through curriculum-based drug prevention

programs and through other, more novel approaches, such as school-based clinics, student assistance programs, and holistic environmental

interventions. School-based prevention efforts

have been hampered, however, by a lack of good

evaluation data on the most widely marketed programs and by insufficient information about and

dissemination of the more promising programs.

Numerous studies of the effectiveness of curriculum-based drug prevention programs have

been completed and reviewed (67). Studies of prevention programs focusing on tobacco have been

extensively reviewed (1 6,20,54,58,94,132,1 55)

and alcohol studies have been reviewed several

times (62,64,102). Reviews of school-based prevention curricula that specifically target marijuana or cocaine do not exist. However, several

reviews have examined studies of programs designed to prevent the use of multiple substances

(7,25,102,131 ,156). Even these reviews, however, typically focus primarily on tobacco and alcohol.

Effectiveness of Drug Abuse Resistance

Education Program

Three merchandised curriculum programs have

captured a sizable share of the prevention program

market: DARE (Drug Abuse Resistance Education); Quest: Skills for Living; and Here’s Looking at You 2000. Of these, evaluations only of

DARE have been reported in sufficient numbers

to allow conclusions to be drawn.

The DARE program is delivered in schools by

uniformed police officers who have been trained

in any of five regional training centers. It was designed by the Los Angeles, California, Unified

School District, which borrowed from researchbased programs developed in the early 1980s.

DARE is delivered annually to about 5 million

students in all 50 States, at a total cost of about $50

million (an average annual cost of about $10 per

student) (93). DARE is thus one of the better

funded drug prevention programs in schools.

One research team examined 17 published and

unpublished evaluations of DARE (53). For the 11

studies that met minimal standards of methodological rigor, the average reductions in substance

use were very small. Use among control schools

and DARE schools was roughly equal. The few

studies that were longitudinal found neither shortterm nor long-term reductions.
150 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Cognitive factors 14.6°/0

‘omefac’ors’”’o’o~ Mkcekimo.sl.lO/o

Previous drug use 7.6Y0A“’

h

\

Demographics 4.2?40

IntentIons 0.9?40

Com~etence 8.1°)0 ~

\ Peer factors 4.30/0

Institutional Influences 7.4Y0

SOURCE: Office of Technology Assessment, 1994.

DARE has important strengths, including favorable reactions among students who have participated in DARE programs, widespread

political support, substantial funding, uniformly

reported improvements in school-police relations,

high quality of program implementation, and expert marketing. However, these strengths have not

guaranteed that DARE is always effective as a

drug prevention program. A scientific advisory

group has been established to review research and

evaluation of the DARE program and to consider

changes in the curriculum.

The General Accounting Office (GAO) estimated that about one-fourth of the funds given to

the States and local schools under the Drug-Free

School and Communities Act went toward purchasing and delivering school curricula (163).

However, widely adopted curriculum packages

(such as Quest: Skills for Living; Here’s Looking

at You 2000; Project Adventure; BABES; Project

CHARLIE; and Children Are People) have presented no adequate evaluation results that allow

program effectiveness to be judged. Evaluations

conducted to date have been primarily short-term

—

reviews for dissertations and theses, and they lack

interpretable behavioral end-points. Given the

widespread dissemination of these curricula,

quality evaluation studies would be important.

Conclusions About Curriculum-Based

Prevention in Schools

Curriculum-based drug prevention efforts to date

can be characterized as showing promise

(67,156), but critics point out that the effectiveness of these programs, especially those that are

being commercially marketed, has not yet been

proven and that significant difficulties remain

(102). Some of these are methodological difficulties intrinsic to all field trial research, while others

relate to the possibly intrinsic limitations of curriculum approaches when used alone. Individual

studies suggest that curriculum-based prevention

programs in the schools may ultimately be proven

to be effective for preventing substance use

among some youth, especially when used as components in more comprehensive substance use

prevention efforts. However, school-based pre-
Chapter 8 Community Activity Settings I 151

0.40 I

Secondary

0.35 +

5

0.30 Primary

‘AA

4A

0.10

0.05

1 5 9 13 17 21 25 29 33 37 41 45 49

Variable rank order

SOURCE: Office of Technology Assessment, 1994.

vention technologies currently in use have not

been refined and tested enough to demonstrate

their effectiveness for reducing substance use for

students in general, and especially not for multiproblem youth, who are at higher risk of substance

abuse. Clearly, for DARE and for the other major

school-based curriculum prevention programs,

resources must be set aside to properly evaluate

program results.

Noncurricular Approaches to

School-Based Prevention

Curriculum-based efforts have dominated the

field, largely because they are relatively simple to

understand, implement, and replicate, and because methods to evaluate them have become

standardized. However, curriculum-based prevention programs have not been demonstrated to

be effective, and several noncurricular approaches

have recently emerged, including student assistance programs, school-based clinics, and more

holistic school-community collaborations and alterations of psychosocial environments in

schools. These approaches have been evaluated

only rarely, but interest in them has been growing.

For example, although student assistance programs remain largely unevaluated, they accounted

for about half of the spending, under the DrugFree Schools and Communities Act, in six recently evaluated urban school districts (163).

Student assistance programs try to identify substance-using students early on and then provide

social support, build skills for dealing with life

problems, or refer to treatment, as appropriate.

Peers often help as crisis managers, small group

facilitators, and referral agents, while adults often

act as program facilitators and counselors. Programs typically counsel students who are children

of alcoholics, who use alcohol or drugs abusively,

and who are performing poorly at school. Programs can also help parents address their children’s needs.

Only three evaluations of student assistance

programs were found by OTA for this review. Two

focused on process issues only (89,1 18), while

one addressed program outcomes (90). The outcome study focused on interventions for students

in six residential facilities, including a locked
152 I Technologies for Understanding and Preventing Substance Abuse and Addiction

correctional facility. Although the sites are atypical for student assistance programs, the program

otherwise resembled student assistance programs

in schools.

The outcome study found that marijuana and

tobacco use declined among program participants

in five of the six facilities. Alcohol use declined

in half of the sites, while alcohol use in two sites

remained unchanged and in one site rose slightly.

The declines in use were observed at about nine

and 15 months after participation in the program.

Although these results are promising, one study

(especially a study conducted in nonschool settings) cannot support general conclusions about

the effectiveness of student assistance programs in

schools.

Many schools, either directly or through community agencies, are bringing services into

schools to help deal with social and health problems that are often interrelated, such as depression, violence, substance use, and sexually

transmitted diseases. School-based clinics and

youth service centers are being set up to provide

comprehensive and integrated health and social

services. This new wave of programming has been

supported by State governments, local school districts, and private foundations.

School-based clinics have been developing in

response to growing poverty, widespread lack of

insurance, and increases in health and social problems among youth. One study indicates that the

percent of adolescents defined as living in poverty

increased from 15 percent in 1979 to 19 percent in

1986 (22). Not all youth living in poverty are covered by Medicaid or other health insurance, and

millions of other youth (e.g., in near-poor or recently unemployed families) also lack health insurance. Violence, teen pregnancy, and substance

use and abuse remain high or are increasing in

many communities, and these problems often require direct one-on-one medical or social interventions, if they are to have a chance of being

resolved.

Self-referral and other data suggest that schoolbased clinics are providing health care and social

support. For example, a survey of 306 such clinics

in 33 States and Puerto Rico (22) found that about

half the visits were for medical problems, such as

injuries and illnesses, with 40 percent of the visits

for counseling and 10 percent for birth control

supplies or counseling about reproductive issues

more generally. No evaluations seem yet to have

focused on the effectiveness of school-based clinics for assisting with the treatment and prevention

of substance use and abuse. School-based clinics

perhaps should not focus primarily on these problems, but as clinics expand in numbers questions

will naturally and more frequently arise about

their role in addressing substance use and related

problems.

Several notable collaborations between

schools and other community agencies and resources have been supported and, at least in part,

studied. For example, the Community Partnership

Program, administered by the Center for Substance Abuse Prevention, has supported more

than 250 local partnerships for the prevention of

substance use and abuse, with over 60 percent actively involving schools as coalition members.

Each site must have a local evaluator that will

monitor primarily program activities, and a national evaluation to monitor program activities

and outcomes has begun. The local evaluations

are expected to vary widely, in part because uniform, accepted standards for community-wide

program evaluation have yet to be developed.

Outcome findings are expected by 1997.

The Midwest Prevention Project (1 16) provides and studies school-based interventions in

the greater Kansas City, Missouri, metropolitan

area and in Marion County (Indianapolis), Indiana. Due to constraints in the study design, the

evaluation results to date speak directly only to the

impact of the school-based curricular interventions; the impact of community organization, parental, and media components cannot be

evaluated. Nonetheless, this approach suggests

the potential for communities to support schoolbased prevention efforts.

Cities-in-Schools is a national nonprofit organization devoted to preventing students from

dropping out, through partnerships among

schools, local governments, and businesses.

Cities-in-Schools operates in 122 communities in
21 states with 384 schools participating in the program. The national organization strives to bring

health, social, and employment services into

schools across the nation, to help youth find jobs,

tutors, and counseling and to motivate them to

stay in school. A national staff assists local

boards. A prominent person in business presides

over each local program, directs fund-raising, and

organizes a team of professionals to help potential

dropouts. In most programs, a case manager is assigned to each high-risk child. Beyond these basics, programs vary greatly, focusing on a

diversity of prevention and intervention strategies. Several Cities-in-Schools sites have

achieved national attention. Although little concrete evaluation data are available about the effects of these programs in general or on substance

use, the model appears promising and warrants

further study.

Changing the social or physical climate in

schools may also help reduce substance use and

abuse. Future research and evaluation studies

could focus on the impacts on substance use and

abuse of this and other holistic models, such as

open versus closed campuses, alternative schools,

and after-school care programs. These models

may be especially promising for high risk youth

suffering from multiple risk factors and limited

protective factors, many of which are rooted in

problematic (often substance using and abusing)

homes, neighborhoods, peer groups, and other

subcultures, which cannot easily be influenced by

more 1imited school-based prevention approaches

alone.

WORKPLACES

Workplaces can also contribute to and protect

against alcohol and drug abuse. This section reviews literature on factors and interventions

associated with substance abuse in the workplace,

with a special focus on the role of workplace settings themselves. Researchers have investigated

the causes of substance abuse among workers for

nearly four decades, and U.S. management and labor have been concerned about workplace substance abuse for over a century ( 150,158, 159).

Chapter 8 Community Activity Settings I 153

Alcohol has been the drug most studied in workplaces and appears to be the drug most commonly

used.

1 Magnitude of Problem

The prevalence of substance abuse among the

employed remains inadequately documented,

based on a small number of flawed studies. For

American workers more information exists on the

extent of alcohol use and dependence (although

gaps remain) than on the use and abuse of illegal

substances (57, 68, 114).

The 1988 National Health Interview Survey

found that about 13 percent of employed men and

6 percent of employed women were alcohol dependent (68). This nationwide household survey

of almost 27,000 individuals found that, for both

men and women, the percentage of white-collar

workers who drank was greater than the percentage of blue-collar workers who drank. However,

among those who drank, blue-collar workers

drank more than white-collar workers. Consistent

with an earlier survey in Detroit, Michigan, alcohol-related disorders were also found to be greater

among blue-collar workers, with the rates highest

for men who were craftsmen, laborers, and service

workers, and for women who were machine operators, laborers, and service workers (11 4). Another investigator has reported that the rate o f

on-the-job substance use among young men in the

6 months prior to the study was about 28 percent

(105).

Substance abuse contributes to workplace

problems, such as accidents, injuries, absenteeism, turnover, lost productivity, compensation

claims, and insurance costs (11 ). The total cost to

the American economy related to substance abuse

has been estimated to be more than $144 billion a

year, with about 60 percent due to alcohol abuse

and 40 percent due to the abuse of other drugs

(121 ). Costs to the economy include costs due to

medical care, prevention, law enforcement, and

lost productivity, The 1985 National Household

Survey on Drug Abuse found that substance-using

employees were 3.6 times more likely to have accidents than nonusing employees. They had 2.5
154 I Technologies for Understanding and Preventing Substance Abuse and Addiction
Chapter 8 Community Activity Settings I 155

times more absences of 8 days or more. They were

three times more likely to be tardy than nonusing

employees and were 2.2 times more likely to ask

for early dismissal. They requested sick leave

three times as much as non using employees. They

were five times as likely to file for worker compensation. The total cost of lost productivity due

to alcohol and other drug abuse has been estimated

at more than $33 billion in 1985 and a little more

than $43 billion in 1988 (1 22).

1 Factors Affecting Individuals

in Workplaces

Substance abuse in workplaces can be affected by

nonworkplace factors and workplace factors.

Nonworkplace Factors

Early research attributed drinking and other drug

problems on the job to factors outside the workplace. Substance abuse was seen as a problem

brought to the workplace but not caused by the

workplace, and some believed that substance

abusers selected workplaces where they could

conceal their problems. This view assumed that

substance abusers had the knowledge and freedom

to choose jobs on this basis, an assumption unlike1 y to apply to all, given the 1imits of education and

work experience among many substance abusers,

especially blue-collar workers (11 3). In any case,

family and community experiences interact with

workplace experiences (2), and workers from

families and other subgroups that drink may find

that drinking influences their work lives as well.

As noted earlier, drinking problems are more

common among those with lower SES, although

drinking occurs more frequently among higher

SES individuals (31). Workplaces that employ

more lower SES employees may therefore be expected to have more alcohol abusers (157).

The acceptance of alcohol and other drugs in

the larger society outside the workplace can also

influence substance use and abuse in the workplace. This can be seen in the new attitudes in

American society toward smoking. Consumers

used to be assailed constantly by advertisements

presenting smoking in a positive light, but are now

more informed about its negative effects on

health. As a result, smoking has been banned from

many airplane flights, restaurants, stores, and

public and private workplaces.

The availability of alcohol in the local community from which a work organization derives its

employees can also influence workplace drinking

(157). Higher rates of drinking problems exist in

communities where alcohol is cheaply and widely

available and alcohol outlets remain open for long

hours.

Workplace Environment Factors

Several decades ago, researchers distinguished

four categories of workplace factors that place employees at risk for excessive drinking ( 127). They

are:

■ lack of work visibility,

■ absence of job structure,

■ lack of social controls that discourage alcohol

use, and

■ job stress.

A more recent review ( 157) of risk factors internal

to workplace environments identified the following elements:

■ alienation and powerlessness,

■ work stress,

■ structural features of the workplace,

■ influence of administrative subcultures,

■ poorly implemented intervention programs,

and

■ union-management conflict.

It has also been suggested that individual factors and perceived work situations may be more

important for alcohol use than objective work situations (136). Those with boring and routine jobs,

or jobs over which they have little control, may be

more likely to drink (3,76). For example, a study

of auto factory assembly line workers found that

40 percent drank alcohol at work (129), Other research found a consistent relationship between

powerlessness and alcohol use, and no evidence

that work experience or social support moderated

alcohol use (137).
156 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Workplace subcultures, whether administrative or occupational, may also encourage drinking

or the use of other drugs at work. Administrative

support for heavy drinking can exist throughout

the work organization or can be limited to specific

sites or occasions. Subcultures that can support

the heavy use of alcohol, but strongly discourage

the use of illicit drugs, are found in the military

(28, 119). Anecdotal reports suggest that other occupational settings have encouraged the use of cocaine (e.g., entertainment industry). Although

available research does not support the conclusion

that workplace subcultures are the primary cause

of substance abuse, there is evidence that at least

alcohol problems vary widely according to occupation (148).

Workplaces can offer protective factors as well.

For some, the fact of being employed, with the income and stability and status that employment can

convey, may offer protection against substance

use and abuse. If unemployment and underemployment are viewed as risk factors, then employment by itself, at a decent wage in a decent job,

may offer protection. In addition, the specific

characteristics of a workplace can be protective.

For example, the risk factors listed above could be

viewed as the extremes on a continuum, the other

end of which could be expected to offer

protection. Thus, work visibility, job structure,

manageable stress, worker involvement and empowerment, supportive administrators, well implemented treatment and prevention programs,

and union-management harmony could be expected to be protective factors.

1 Interventions

Two primary ways of dealing with employee substance abuse and health have emerged: traditional

employee assistance programs (EAPs), which

seek to help employees with identified problems,

and health promotion programs, which seek to

prevent illness and promote health (56).

Employee Assistance Programs

EAPs help employees with personal problems at

the employer’s expense, by providing services directly (through the work organization) or indirectly (through a provider in the community) (1 40). In

some workplaces, for example, EAPs are located

in medical departments, which generally provide

emergency medical care and may also provide

preventive or rehabilitative care. Medical departments, however, appear to be declining as sites for

EAPs (141).

EAPs rely on a strategy of constructive confrontation, which assumes that supervisors or coworkers of substance abusers will help refer them

to the EAPs. In addition, workers are encouraged

to refer themselves to EAPs for assistance.

A review of what works in fighting substance

abuse in the workplace stresses that an employee

assistance program is a key to a good workplace

program (167). It also recommends a written

drug-free workplace policy, management and supervisory training, drug testing in workplaces

where appropriate (one example of which is when

substance abuse may be dangerous to self or others), and employee education programs focused

on substance abuse. Testing may well prevent substance use and abuse in workplaces.

Some studies suggest that EAPs can be cost-effective for business. The Department of Labor has

reported that employers generally find that for every dollar invested in an EAP, savings of from $5

to $16 are achieved (167). Other reviews of the

limited evaluations of the economic and other

benefits of EAPs have found that health care costs

and absenteeism, for example, decline after employees have been served by EAPs ( 178).

However, EAPs have also been criticized in

some cases, for their inability to reach those at

greatest risk, their incomplete coverage of lower

status employees, their failures to identify problem drinkers early enough, their inadequate handling of situation-dependent drinking problems,
Chapter 8 Community Activity Settings I 157

and their uncertain effectiveness in rehabilitating

problem drinkers (140). The relative lack of EAPs

in medium and small workplaces is an important

constraint on the ability of EAPs to offer more

widespread protection to the employed.

Health Promotion Programs

Health promotion programs seek to prevent illness and promote wellness through behavior

change. For example, they provide information

and support activities to help individuals increase

exercise, quit smoking, change diets, and manage

stress and hypertension. There are several advantages to using such general workplace health

promotion programs to prevent substance abuse in

the context of promoting positive life-style

changes for all employees. These include:

■ 1ittle or no stigma;

■ the use of positive, optimistic approaches;

= ease in selling to employees and generating enthusiasm; and,

■ generous corporate financing of health promotion programs ( 1 03).

The use of health promotion programs to prevent substance abuse can also present problems,

however. For example, prevention historically has

been one of the lowest priorities for Federal funding (104). When implemented by businesses,

health promotion programs may inadequately

deal with the needs of a particular work organization’s employees, since the programs often come

from outside and have not been tailored to fit the

needs of a particular group of employees. Decision makers within a workplace may decide on the

basis of intuition, whim, or trendiness to buy a

health promotion program from the increasing

number of purveyors of programs (140). Furthermore, many of the proponents of marketed health

promotion programs have failed to adequately

evaluate their programs. Unfortunately, this has

been particularly true of activities intended to prevent substance abuse.

Environment-Oriented Approaches to

Substance Abuse Prevention

A third approach, often associated with Scandinavia, focuses less on changing employee behaviors

and more on altering workplace factors that influence worker health. The Swedish Work Environment Fund, established in 1972, supports

research, workplace innovations, information dissemination, and training to achieve better working

environments. Grants that support occupational

health centers and research programs in Sweden

are financed through a combination of employer

fees, payroll taxes, and government financial assistance.

By contrast, the goal of alcohol policy in the

workplace in the United States has for centuries

been to change individual drinking behavior (1).

Researchers have recently begun to focus on how

the workplace environment influences problem

drinking. The Harvard School of Public Health,

jointly funded by the National Institute on Alcohol Abuse and Alcoholism and the Robert Wood

Johnson Foundation, is surveying thousands of

managers and work groups in up to 10 large multinational corporations (17 1). The study will determine corporate and work site patterns of

drinking, levels of work site drinking problems as

they relate to attitudes and practices of management, how corporate culture affects managerial

behavior and drinking problems in the workplace,

and what role the work group plays in promoting

or preventing problem drinking.

RECREATIONAL SETTlNGS

Recreational and other developmental activities

and settings may also contribute to the prevention

of substance use and abuse, or by their absence increase the risk. Examples of such recreational and

other developmental activities and settings include Boys and Girls Clubs, Boy and Girl Scouts,

organized sports, cultural activities, and local park

and recreation department programs.
158 I Technologies for Understanding and Preventing Substance Abuse and Addiction

HIGH ON THE CORPORATE LADDER

1’ m Coping with the pressure of corporate life

turning to illegal drugs. Just

Ie wear white collars doesn’t

at they’re immune to the lure

of the likes of heroin or cocaine.

Whether they’re high on the

corporate ladder or somewhere

near the bottom, drug abusers

need your help now, before

it’s too late. Look. Listen,

Drug abuse is everywhere,

Partnership for a Drug-Free America
1 Organized Activities and Drug Abuse

Research on the impact of organized youth activities on substance use and abuse is limited, and

only a few studies have addressed the issue directly, while others have addressed it more indirectly.

One study (which relied extensively on reports

from employees of Boys and Girls Clubs) found

that public housing developments served by

Clubs had 22 percent less drug activity than developments not served by Clubs. The presence of

crack in particular was 25 percent lower, and even

lower in developments served by new Clubs with

SMART Moves, a substance abuse prevention

program (1 33).

A more extensive investigation has been conducted by the Search Institute, which has surveyed

180,000 6th through 12th grade youth in 430

school districts since 1988. Analysis of the data

found that as developmental assets increased (including involvement in music, school team

sports, nonsport school-based cocurricular activities, nonschool clubs or organizations, and

churches) at-risk behaviors decreased, including

the use of alcohol, tobacco, and illicit drugs (12).

Specifically, the correlations:

■ tend to be small;

● are strongest for tobacco use and weakest for alcohol use; and,

■ are slightly higher for church involvement than

for other activities.

Involvement in youth programs and activities

has been found to be associated with fewer at-risk

behaviors among youth. One study found that

higher levels of four youth assets (perceived positive school climate, family support, involvement

in structured youth activities, and involvement in

church or synagogue) were associated with lower

levels of 20 at-risk indicators, contained mainly in

eight at-risk domains (alcohol, tobacco, illicit

drugs, sexuality, depression/suicide, antisocial

behavior, school, and vehicle safety) (12). High

school students who listed no assets, for example,

reported an average of 5.6 at-risk indicators, while

Chapter 8 Community Activity Settings I 159

students listing all 4 assets reported only 1.7 atrisk indicators.

A study of different communities found that 55

percent of the youth in the healthier communities

(defined by fewer at-risk behaviors among youth)

were involved in structured activities, whereas

only 39 percent of the youth in the least healthy

communities were involved in such activities

(19).

Qualitative assessments across prevention disciplines support these findings. For example, although a review and analysis of delinquency,

adolescent pregnancy, substance abuse, and

school failure and dropout prevention programs

did not directly investigate connections between

youth development programs and substance

abuse prevention, its authors concluded that the

elements in youth development organizations can

play a critical role in preventing each of these

problem behaviors (48).

The Carnegie Council on Adolescent Development has identified several successful prevention

efforts launched by national youth-serving organizations, including the adolescent pregnancy efforts of the Association of Junior Leagues and of

Girls, Inc., and found that participation in such

programs was associated with fewer at-risk behaviors (32). The Carnegie Council’s Task Force

on Youth Development and Community Programs concluded that, taken together, current social science theory and field evaluations provide

a solid rationale for strengthening and expanding

the role of community-based programs in promoting healthy adolescent development, since unsupervised after-school hours represent a period of

significant risk, with young adolescents standing

a greater chance of engaging in substance abuse.

Another study tested whether inactivity or

boredom was associated with substance abuse. It

compared adolescents who had been clinically

diagnosed as substance abusers with a comparison

group of nonsubstance abusers, and found that the

substance abusers experienced their leisure activities as more boring, even though they had partici-
160 I Technologies for Understanding and Preventing Substance Abuse and Addiction

pated in more leisure activities (including such

activities as going to concerts and going for a

drive). Available leisure activities may, for some

youth, fail to satisfy “their need for optimal arousal,” leaving them more vulnerable to the appeal of

drugs (78).

Thus, being active does not by itself protect

against substance abuse. Some activities, such as

those that are unstructured and unsupervised, may

even increase the risks of substance use and abuse

through association with a wider range of peers,

some of whom are using substances. In addition,

activities perceived as boring may not protect

against substance use and abuse. More research is

needed, to clarify the aspects of recreational and

other leisure activities that may protect against

substance use and abuse. Research might profitably focus on whether activities that are supervised, structured, drug-free, empowering,

skills-building, self-esteem-promoting, active,

shared, and nonboring (or some combination of

those) are associated with lower levels of substance use and abuse.

1 Elements of Notable Programs

Several of the most important elements of notable

substance abuse prevention programs are provided by youth development programs as well.

These include:

● Promoting social and life skills. Programs that

rely exclusively on transmitting information

about the health, legal, and social risks of substance use and abuse are generally ineffective

(79). If, as the author of a recent longitudinal

study contends, substance use is a symptom

rather than a cause of personal and social maladjustment, promoting social and psychological well-being may help prevent substance

abuse (66). Many alcohol and other drug prevention programs focus on the development of

social and life skills, as a way to help youth understand their emotions, control their anger,

curb aggressiveness, and presumably reduce

their inclination to turn to substances (66,166).

fl Strengthening families. Increasingly, alcohol

and other drug prevention programs are recognizing and addressing family factors. Youth development organizations afford opportunities

for involving parents in recreational and other

nonschool, nonfamily activities.

■ Promoting healthy peer interactions. Several

studies have shown the value of using peers as

role models in prevention programs. One study

conducted a meta-analysis of 143 adolescent

drug prevention programs and collapsed prevention programs into 5 strategies or types:

knowledge only, affective (i.e., addressing feelings) only, peer programs, knowledge plus affective, and alternatives. Peer programs that

highlight peer influences and emphasize skill

building were found to be the most successful

(156). Peers are often the best positioned to

help others build resistance skills and bring

about significant results in reducing substance

use, as compared to teachers or other adults.

Peer counseling and student assistance programs, for example, offer unique opportunities

for youth to cope with difficult issues and develop skills to resist peer pressure (33).

■ Indirect and participatory approaches to

substance use. Substance prevention programs are more likely to be effective if they develop creative ways to reach and connect with

their participants. Many programs incorporate

lessons concerning substance use into activities

such as games, theatrical performances, creative arts, and sports. Some programs avoid

stating in their names that they are focusing on

substance use prevention, and in this way often

attract more youth and preclude them from

feeling stigmatized (161). Because youth

spend so much time in school, where didactic,

lecturing approaches so often predominate,

these approaches may well be less effective in

nonschool activities. GAO has recommended

that programs engage youth in activities that

are more motivational and participatory, such

as support groups, dramatic productions, leadership training, and role-playing (161 ).

● Alternative activities. Communities are beginning to create healthy, substance-free alternative activities, such as teen centers or

drug-free parties, for youth who may feel there
Chapter 8 Community Activity Settings I 161

is nothing else to do. This alternatives approach

grows from the idea that youth who turn to substances to meet certain social and psychological needs can meet those needs in more positive

and healthy ways without chemicals. In its

guide book, Prevention Plus III, CSAP stresses

the importance of incentives for youth to participate in such alternative activities. At a minimum, activities should reflect the interests and

preferences of the youth involved. A IO-year

study with over 500 subjects found that the

largest percentage (67 percent) of assuredly recovered substance abusers, defined as those

who have been clean for five years, used alternative activities to cope with or improve their

moods (169). However, although it remains a

promising strategy, many agree that more substantial research is needed.

The elements of notable programs suggest that

youth development organizations may be able to

play a greater role in the prevention of substance

abuse. First, they can provide specific information

about substances and training in refusal skills.

Second, they can address life skills development,

emotional issues, and academic remediation. Further, they can involve both youth and their families, as well as peers, in settings for collaborative,

substance-free interactions. Research has shown

the importance of building supportive communities through such networks of social support that

can diminish substance use and abuse and promote healthy youth development (1 4,19,133).

PLANNING, IMPLEMENTING, AND

EVALUATING COMMUNITY-WIDE

PROGRAMS

If substance abuse and addiction problems in a

particular community affect individuals via multiple risk and protective factors interacting in multiple settings, then efforts to prevent these problems

may require multipronged efforts involving

schools, parents, media messages, and other community resources (116). While it is possible that

an assessment of problems may be carried out by

relatively few individuals, it is extremely unlikely

that the planning, implementation, and evaluation

of community-wide efforts can be achieved without participation of residents and leaders throughout the community. Widespread coordination and

cooperation are intrinsic to community-wide efforts. To help achieve such community-wide coordination and cooperation, several different types

of community coalitions have been created.

The CSAP has studied the ability of 7 pilot test

communities, under Community Partnership

grants, to gather information on 15 communitywide indicators of alcohol and other drug abuse

(see table 8-3). Some of these indicators are directly related to and measure the extent of substance

abuse and addiction among subpopulations in a

community (e. g., number of drug positive urine

samples from pregnant women at time of delivery), Some of the indicators measure the extent of

behaviors or outcomes that maybe directly related

to substance abuse (e.g., number of single vehicle

nighttime accidents and number of deaths due to

alcohol and other drugs). Some of the CSAP indicators relate to community activity settings, such

as workplaces and schools.

CSAP has recently supported, through the

Community Partnership program and the HighRisk Youth program, the use of nonquantitative

techniques to gain insights into substance abuse

and addiction and related problems in communities. This information can be garnered by ethnographers and citizen informants, who can report on

the values, attitudes, purposes, behaviors, and experiences of individuals in the subcultures of communities.

The Robert Wood Johnson Foundation has

funded 13 community coalitions in its ‘*Fighting

Back” program to reduce substance abuse and addiction. About 600 coalitions now belong to a national organization, Community Anti-Drug

Coalitions of America (CADCA). Some coalitions have been formed to address other health and

social issues, including the ASSIST and COMMIT community tobacco control programs,

funded by the National Institutes of Health, and

the Planned Approach to Community Health

(PATCH) program, funded by the Centers for Dis-
162 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Public Safety

1. Number of single vehicle nighttime accidents,

2. Number of drug positive from urine samples of

arrestees (e g , based on Drug Use Forecasting

(DUF) System),

3. Number of arrests for drug possession,

4. Cost and purity of Illegal street drugs.

Physical and Mental Health

5.

6.

7.

8.

9.

10.

11.

12.

Number of drug positives from urine samples of

pregnant women at time of delivery.

Number of alcohol -and-other-drug-related

emergency room episodes (e. g., based on Drug

Abuse Warning Network (DAWN)).

Number of alcohol- and other drug-related

deaths (e.g., based on DAWN),

Number of individuals on waiting lists for and

admissions to inpatient and outpatient alcohol

and other drug program services,

Number of referrals and admissions to mental

health centers for alcohol and other drug

problems.

Incidence of alcohol- and other drug-related

outcomes (e g , fetal alcohol syndrome, positive

drug toxicology).

Incidence of drug-related sexually transmitted

diseases, including HIV transmission of AIDS

cases.

Number of alcohol- and other drug-related

medical conditions (e. g., cirrhosis of the Iiver,

hepatitis),

Workplace

13. Number of drug positives from urine samples of

job applicants and employees

Consumption

14. Aggregate per capita consumption of alcohol,

based on alcohol tax revenue data,

Education

15. Existing school surveys of alcohol and other

drug use and attitudes.

SOURCE: Community Partnership Prevention Program National

Evaluation, Community-Wide Indicators of Alcohol and Other Drug

Abuse Pilot Test Report (Draft), Center for Substance Abuse Prevention, 1992

ease Control and Prevention to encourage local

coalitions for community health planning and implementation (29). HUD now has funds to support

Community Coalitions Against Crime, which

also address substance abuse and addiction. And

CSAP has supported numerous activities conducted by approximately 250 coalitions through

its Community Partnership program (see table

8-4).

A recent review of some of the Community

Partnerships revealed the wide range of activities

they have so far implemented, including general

prevention programs, public education, alternative activities, community organizing and empowerment, advocacy for policy change, and

other community activities.

Although coalitions have not been extensively

evaluated as yet, and although the evaluations that

are now in process will not produce outcome results for several years, there is reason to believe

that community coalitions offer promise for community-wide efforts to prevent substance abuse

and addiction. First, as documented by this report,

the factors contributing to substance abuse and addiction are multiple and interactive. Second, these

factors interact in subcultures and community activity settings that can encourage or inhibit substance abuse and addiction and are widely

dispersed. Thus, especially in communities severely impacted by these problems, multiple efforts addressing multiple factors in multiple

settings may be required. A recent report from the

General Accounting Office concluded that “preliminary research results indicated that a community-based approach may hold promise in

preventing drug use,” and went on to emphasize

the need for comprehensive evaluations of such

efforts (162).

Community coalitions could make use of the

framework in this report to develop plans for preventive interventions addressing targeted populations in selected community activity settings.

Building on a systematic quantitative and nonquantitative assessment of needs, a coalition

could identify optional preventive interventions

that address selected populations and settings, and

then phase them in as resources permit. However,

some community coalitions may need additional

support and technical assistance to help them resolve conflicts, form consensus on goals and

plans, and sustain cooperative, coordinated efforts
Chapter 8 Community Activity Settings I 163

Prevention Programs

Program for at-risk youth of single parents

Parent courses

Youth retreat

Employee assistance programs for local businesses

School-based prevention program

Street-based prevention program

Public Education

Radio talk show

Prevention library

Newspaper articles

Anti-drug media campaigns

Presentations to businesses

Information booth at car show

Prevention program guide

Brochures

Education for health care professionals

Public awareness days

Television forum

Computerized database of prevention materials

Resource center

Newsletter

Metrobus poster campaign

Alternative Activities

Family oriented sports

Alcohol-free fiesta

Youth centers

Basketball program

Drug-free dance

Drug-free cultural activities

Boxing and karate lessons

Drug-free concerts

Drug-free clubs for youth

Drug-free graduation night for youth

Drug-free New Year’s Eve party for youth

Community Organizing and Empowerment

Community center fund-raising

Community conferences

Blueprint for community action

Technical assistance to develop community

association

Neighborhood cleanups

Empowering senior citizens to work with community

Community days

Youth council

Town meeting

Pot luck dinner for community

Advocacy for Policy change

Working with other Partnerships to lobby State

legislature

Briefings to politicians on substance abuse issues and

programs

Position paper opposing drug Iegalization

Other Community Activities

Workshop on farm issues and stress

Program to employ unemployed unskilled adults

Inmate treatment program

Youth mediation training for nonviolence in schools

HIV training in school

Rites of Passage Program for black youth

Master Program to employ seniors

Workshop for pregnant women and teens

Youth mentor program

SOURCE National Evaluation of the Community Partnership Demonstration Program, Second Annual Report, Center for Substance Abuse Prevention, 1992

that are subject to more rigorous evaluations and

midcourse corrections. Each community coalition

needs to take a critical look at what works and

what does not work, and needs to be flexible

enough to try promising and proven analytical and

programmatic technologies, even if they are

somewhat new to the coalition.

SUMMARY

This chapter has reviewed research on factors and

interventions relevant to the onset and prevention

of substance use, abuse, and addiction in the four

principal community activity settings—homes

and families, schools and peers, workplaces, and

recreational and other community settings.

Research indicates that families may influence

whether family members, especially (but not limited to) the young, initiate substance use and progress to abuse and dependency, and can be the target

of a wide range of increasingly tested preventive

interventions that can help family members resist

the use of substances. Similarly, schools, especial-
164 I Technologies for Understanding and Preventing Substance Abuse and Addiction

ly through peer group norms and behaviors related

to substance use, can also be important locations

for the onset of substance use (including alcohol

use) and for preventive interventions, especially

those that focus on social influences, including

peers. Factors in workplaces, although less studied, can also contribute to and protect against

substance use and abuse, and workplace interventions that focus on individuals and environments

provide opportunities for prevention. Finally, an

emerging literature on the role of recreational settings and activities, especially for youth, suggests

that the availability of attractive and compelling

substance-free activities can play a role in dissuading youth from becoming heavily involved in

the use and abuse of substances.
Options 9

I

ssues related to substance abuse and addiction have long occupied the attention of the American public. Congress has:

authorized a multitude of federal programs aimed at reducing or preventing the supply and demand of illicit drugs and

to regulate the availability of illicit substances, appropriated billions of dollars each year to federal agencies, provided oversight

of federal programs, and passed broad-based legislation to coordinate programs as part of the war on drugs.

Congress faces several fundamental difficulties in addressing the causes of substance abuse and addiction:

●

m

■

No scientific consensus exists as to what is the driving cause

of substance abuse and addiction. A range of risk and protective factors have been associated with drug use, abuse, and addiction.

Federal antidrug efforts, though coordinated by the White

House Office of National Drug Control Policy (ONDCP),

are spread among many federal agencies, whose authorization and appropriations are the subject of action by numerous congressional committees and subcommittees.

ONDCP efforts in drug demand reduction efforts alone involved the efforts of federal agencies across at least 11 Cabinetlevel departments. This makes coordinated legislative action

difficult to achieve.

The federal budget deficit is an obstacle to the creation of

new domestic programs that target known risk and protective factors in individuals and communities. The framework

and literature reviews presented in this report make clear that

r 1

A,.

I 165
166 I Technologies for Understanding and Preventing Substance Abuse and Addiction

m

multiple factors in individuals, groups, and

substance abuse and addiction can arise and be

influenced by communities. Thus, effective intervention requires prevention practitioners to

select from a variety of options, so they can target the specific factors that are especially important for the particular populations and

communities they are addressing. This does not

mean that everything must be done at once nor

that everything be known in advance of taking

action. To the contrary, policy makers and practitioners can take small steps at a time, and then,

as resources and new knowledge permit, take

additional steps that address a fuller range of

factors and contexts in greater depth.

Current drug prevention programs lack

scientifically accepted standards for determining their success or failure. While federal

supply-side efforts yield hard data (e.g.,

amount of illicit drugs confiscated, number of

persons incarcerated), it is much more difficult

to demonstrate and quantify the impact of a domestic program designed, in part or in whole,

to prevent drug abuse. Whatever methods are

developed, tested, and incorporated into prevention programs, a critical component of success is careful, rigorous evaluation. Answering

“what works?” is essential in making advances

in preventing substance abuse.

This chapter addresses some of the policy issues brought to the Office of Technology Assessment (OTA’s) attention during the course of this

assessment, and possible options for congressional action. The issues and options are broken

into four broad categories: federal focus and

prevention program structure, research needs,

community activity settings, and availability.

Given the broad nature of federal antidrug efforts,

many important issues relating to federal antidrug

efforts remain beyond the scope of this report.

Such topics include drug treatment, interdiction

and enforcement, and drug legalization.

The order in which the issues and options are

presented does not imply priority. Moreover, the

options presented under each policy question are

intended as a short menu from which Congress

can choose one or more options for consideration

and implementation, and they are not necessarily

mutually exclusive.

FEDERAL FOCUS AND PREVENTION

PROGRAM STRUCTURE

1 Supply vs. Demand Reduction

The federal substance abuse control policy has

as its primary focus the eradication of the supply of drugs. The federal government currently

spends over $12 billion annually on antidrug

efforts, with approximately two-thirds of this

amount supporting drug interdiction and law

enforcement activities, and the remainder supporting demand-side activities, such as drug

treatment, research, and prevention programs.

While ONDCP’S most recent National Drug Control Strategy argued for a slightly increased percentage of funds for demand-side reduction, the

larger percentage of funds remain devoted to supply-side efforts. Congress could decide that existing levels of effort and program approaches in

interdiction may need to be continued for a longer

period of time before they can succeed in reducing

the production, distribution, and local availability

of illicit substances. Congress could direct that interdiction efforts, and the balance between supply

and demand efforts, continue on the same track.

If Congress decided to increase federal efforts

in demand reduction efforts, it could adopt any of

three methods: 1 ) increase appropriations for

treatment and prevention programs; 2) redirect

some of the interdiction funds to increase support

for treatment and prevention programs; or 3) require that assets forfeited in drug seizures be

increasingly used to support treatment and prevention programs. If Congress chose to simply increase appropriations for additional treatment and

prevention programs, this option would require

raising the current level of federal spending for

drug control efforts at a time when the federal deficit is a key concern. Since costly interdiction and

incarceration programs have not eliminated either

the supply of illicit substances or the demand for

and use of such substances, Congress could decide

to increase appropriations for treatment and pre-
Chapter 9 Policy Options I 167

vention programs by reallocating funds currently

spent in drug interdiction and law enforcement

activities; this would mean a drop in supply-side

efforts such as drug interdiction and law enforcement activities. The reallocation of assets forfeited in drug seizures to treatment and prevention

programs, if done together with closer coordination of local antidrug efforts among law enforcement and treatment and prevention practitioners,

may be an attractive small step. Congress could

direct that ONDCP monitor the reallocation of

such assets, to ensure the flow of funds to programs that directly focus on substance abuse and

addiction and, programs that do not directly address substance abuse and addiction but that target

risk and protective factors known to be associated

with abuse and addiction.

Many stakeholders agree that the federal antidrug effort should be more focused on treatment

and prevention. Widespread disagreement exists,

however, as to whether such additional treatment

and prevention efforts should be created at the expense of, or in addition to, current supply-side efforts.

1 Structure of ONDCP

Since its creation in 1988, ONDCP has served as

the most visible federal entity in the war on drugs.

The Director, the so-called drug czar, has the opportunity to galvanize public attention on federal

ant i drug efforts, and to propose and advocate policies within the White House. ONDCP’S effectiveness is limited, however, both in its statute and

through its operation as a White House office.

Congress could choose to reauthorize ONDCP,

and in so doing maintain or alter its mission and

authority; or allow ONDCP to expire.

If Congress chooses to reauthorize ONDCP, a

number of options exist for altering its mission.

Congress could:

■ Direct ONDCP to address the full range of

the most harmful abusable substances, including alcohol, tobacco, and inhalants. Although federally funded prevention programs

address the range of abusable substances, the

statute creating ONDCP emphasized illicit

substances. As a result, ONDCP has historically provided limited attention on abusable substances that have been associated with higher

levels of death and injury than illicit drugs.

More recently, ONDCP increased the focus in

its National Drug Control Strategy on the illicit

use of alcohol and tobacco by minors because

of the extensive damage to the health and safety

of minors, resulting from the use and abuse of

these substances. This approach could be enhanced through congressional authorization.

■ Alter ONDCP’S leadership structure.

ONDCP by statute has a Deputy Director of

Supply Reduction and a Deputy Director for

Demand Reduction. This structure has, in part,

resulted in an ongoing public policy debate regarding the overall federal focus on antidrug efforts, with supply-side and demand-side

reduction efforts seen by some as philosophically incompatible (see discussion on supply

versus demand reduction earlier in this chapter). By creating an alternative structure,

ONDCP maybe encouraged to adopt programs

that more closely link various elements of the

antidrug strategy (e.g., a focus on drug availability could link current supply-side elements

that target physical availability of a drug with

current demand-side efforts that focus on economic and social availability, as discussed in

chapter 4). Despite the advantages that may result from a new organizational structure, the

simplicity of the current structure makes it easier to provide a sharper focus on supply and demand elements of the National Drug Control

Strategy.

■ Give ONDCP increased authority over federal agency antidrug programs. Although

ONDCP is charged with leading a war on

drugs, its authority is limited to a coordinating

function. Congress could provide the Director

of ONDCP with specific authority over certain

elements of various federal programs, or with

additional authority over federal agency budget

proposals. Such actions would give the drug

czar more substantive authority to direct the

war on drugs, but would likely be viewed by
168 I Technologies for Understanding and Preventing Substance Abuse and Addiction

●

some federal agencies as an unwarranted intrusion in agency matters.

Mandate the size of ONDCP. Because it is part

of the Executive Office of the President,

ONDCP is subject to increased political manipulation by each administration. Recently, for

example, ONDCP took the largest personnel

cut of any White House office to meet President

Clinton’s pledge of a 25 percent reduction in

overall size of White House staff. While mandating a specific size for ONDCP might lead to

increased effectiveness for the office, it would

hamper White House efforts to control staff

size.

Alternatively, Congress could allow the authorization for ONDCP to expire. While

ONDCP has produced National Drug Control

Strategies that summarize and set policy for federal efforts, the office lacks the authority to shape

the antidrug policies of the federal agencies. Coordination of antidrug efforts is difficult at best

when the number of relevant agencies is so large;

since antidrug policy involves many federal agencies, it might make sense to disband ONDCP and

rely on efforts by diverse federal agencies to continue to address the many aspects of the drug problem. Recent reductions in the size of the ONDCP

staff, as a part of the down-sizing of the White

House staff, could make this an opportune time to

eliminate the office altogether. Terminating

ONDCP would, however, be viewed by many as

federal abdication of the war on drugs.

1 Structure of Federal Substance Abuse

Prevention Programs

Federal efforts supporting substance abuse prevention programs are housed at a number of agencies. Congress recently reorganized the Alcohol,

Drug Abuse, and Mental Health Administration

(ADAMHA), splitting service-based components

into the Substance Abuse and Mental Health Services Administration (SAMHSA) and researchbased components—the National Institute on

Alcohol Abuse and Alcoholism (NIAAA), the

National Institute on Drug Abuse (NIDA), and the

National Institute on Mental Health (NIMH)—

into the National Institutes of Health (NIH). More

recently, the Centers for Disease Control (CDC)

has been renamed the Centers for Disease Control

and Prevention (CDCP), which has already expanded its title and mission to include prevention.

Congress could maintain the current structure

if it determines that substance abuse is a problem that has many aspects and deserves to be

addressed by many agencies and in many settings.

If Congress decided to create a more centralized structure, it could enact legislation designating a single federal entity as the chief agency for

prevention efforts, or merge the components of

various agencies under one federal roof. Possibilities include:

■ Merging NIDA and NIAAA into a single National Institute on Substance Abuse and Addiction. The use of multiple substances

(including alcohol, tobacco, marijuana, cocaine, and heroin) is increasingly reported by

researchers and practitioners. Indeed, the gateway theory or hypothesis focuses on the progression in the use of substances, beginning

with alcohol and tobacco (which are illegal for

youth, but legal for adults) and moving to marijuana, cocaine, and heroin. Since clinicians and

researchers have increasingly commented on

the progression in substance use and on the cooccurrence of the use of multiple substances,

the separation of the major federal research

agencies into an alcohol agency (NIAAA) and

a drug agency (NIDA) is more and more inconsistent with the shape of the problem. The Center for Substance Abuse Prevention (CSAP) is

an integrated substance abuse agency that explicitly focuses on alcohol, tobacco, and other

drugs, and all state alcohol and drug abuse

agencies are now integrated or located in the

same place. To facilitate more integrated and

coherent research on the range of abusable substances, NIDA and NIAAA could be combined

into a national institute on substance abuse and

addiction. Such a merger would further integrate the federal research efforts in substance
Chapter 9 Policy Options I 169

abuse, but might be seen by some as downplaying the emphasis given to illicit substances.

~ Place CSAP in CDCP or in the Health Resources and Services Administration

(HRSA). CDCP could give the substance

abuse prevention field a solid base in the health

and medical sciences, especially in the tracking

and prevention of diseases. HRSA could give

CSAP a broader health care environment to

work within, which includes Community

Health Centers and the National Health Service

Corps. One disadvantage to the merging of

CSAP into either of these other health agencies

is that it would emphasize the medical aspects

and interventions of drug prevention and

downplay the many nonmedical factors and interventions that are important in the onset of

substance use and abuse. Merger would also

present problems of moving people—CSAP is

headquartered in Rockville, Maryland, while

CDCP is headquartered in Atlanta, Georgia—

and threaten the loss of identity that some proponents of CSAP say is found in an agency that

solely addresses substance abuse and prevention. However, the fragmentation of the federal

effort on substance abuse prevention has been

viewed by some as extreme and counterproductive, and the efforts of ONDCP have not

succeeded in achieving coordination across departments.

= Merge federal substance abuse prevention

efforts into a single agency, such as CSAP.

CSAP has been working collaboratively with

the staff in many other federal agencies, and

would be seen as a natural leader for this effort.

In addition, its recent efforts to begin to develop standards of practice for substance abuse

and addiction prevention programs could be

continued and more effectively infused into the

components of programs currently in other

agencies and departments.

1 Evaluation of Prevention Programs

Current drug prevention programs lack scientifically y accepted standards for determining their success or failure. Most evaluations focus on the

processes used in formulating and implementing a

prevention program (e.g., who was involved,

what type of program was used) and outcome

evaluation (e.g., how man y people were p art of the

program, how the program was replicated). Congress could allow the current level of process

and outcome evaluation related to substance

abuse prevention programs to continue.

If it chose to improve the quality of program

evaluation, Congress could direct NIDA and

NIAAA, or CSAP to design, lead, and support

a multiyear national process (involving representatives of other federal agencies and of

outside organizations) to forge consensus on

standardized definitions and outcome measures, using technical reviews, consensus-forming techniques, and technical assistance monographs. These definitions and measures could include substance use, heavy drinking, substance

abuse, substance addiction or dependency. and related behavioral problems such as school truancy,

unemployment, delinquent and criminal behaviors, and the like. CSAP, NIDA, NIAAA, the Department of Education (DOE), and other federal

agencies could be required to increase funding and

technical assistance for process and outcome evaluations through grants and contracts. CSAP could

focus on process evaluations that may assist program managers throughout the course of a program. NIDA and NIAA could focus on outcome

evaluations that are more rigorously designed and

conducted by individuals who are independent of

the programs being evaluated. DoE could require

both process and outcome evaluations by states

and by schools, using Drug-Free School monies.

NIDA, NIAAA, or CSAP could be directed to

provide incentives for researchers and programs

to participate in a national program database, using consistent definitions and including data from

multiple evaluations. The creation of such a database would allow researchers to extend their own

analyses by tapping into data from other program

sites and populations that have used consistent

definitions and measures.

States could be required by legislation to use

a portion of their 20 percent prevention set-
170 I Technologies for Understanding and Preventing Substance Abuse and Addiction

asides under the Alcohol and Drug Abuse

Block Grant program and a portion of their

Drug-Free Schools funds for evaluation of substance abuse prevention programs. Since evaluations of prevention programs can be expensive,

Congress could consider increasing block grant

funding levels to allow increases in evaluation

studies without requiring decreases in programs.

If such an option were enacted, Congress could

mandate that evaluations be conducted by independent bodies, such as university-based researchers, rather than by state government

agencies that have vested interests in demonstrating program effectiveness.

RESEARCH NEEDS

B Data Collection

The National Household Survey and the National

Survey of High School Seniors have developed

credibility over the years for their regular reporting of substance use in households and high

schools. These surveys could be allowed to continue, with no substantial changes in the cost,

frequency of data collection, focus on target

groups, analysis, and sharing of the database.

Because of the methodology employed, national surveys miss or underreport various populations. Much of the data now collected focuses on

substance use (e.g., any use within the past 30

days or anytime in a lifetime), rather than on more

intense substance abuse and addiction. In addition, questions are substance-specific, and less

oriented to the use and abuse of multiple substances. Such polydrug users and abusers are increasingly being identified by researchers and

clinicians. While substance use is a key precondition to later abuse and addiction, most individuals

who use illicit substances do not go on to addiction. Thus, an important question for the development of prevention policies and programs is:

What are the characteristics of individuals who

abuse and become addicted to substances, and

how do they make the transition from use to abuse

and addiction?

If Congress felt that current data do not provide

adequate information, it could direct that the

Household and High School Surveys be conducted less intensely or less frequently. The expense of these surveys, especially the National

Household Survey, is high. In 1992, the High

School Survey cost about $3 million, and the

Household Survey cost over $12 million. Spending could be reduced if the survey data were compiled less intensely (e.g., with fewer questions or

from a smaller sample) or less frequently. Alternatively, Congress could direct NIDA to develop

and support survey methodology that reaches

populations missed by current surveys (notably

the homeless, school dropouts, and residents of

some inner-city and rural areas), or through legislation, create a mechanism, comparable to the

release of economic indicators, for the regular

and nonpolitical release of survey data. Data

could then be released through a well-defined

process that includes careful and timely technical

reviews for compliance with high standards of

data collection and analysis, rather than being subjected to bureaucratic or political reviews that may

delay the release of or bias the data.

1 Individual Risk and Protective Factors

A substantial body of research has been developed

regarding potential risk and protective factors for

children and adolescents. A variety of theories has

been developed concerning how many and which

risk factors increase the chances for a child or adolescent to first use alcohol or other drugs. Historically, one of the flaws with much of the risk and

protective factor research has been that studies

analyzed one factor in isolation from all others. Increasingly though, researchers are examining a

wider variety of factors among different populations, as well as using more complex data analysis

procedures. Even so, sophisticated multifactor research studies are still in the minority.

While a substantial amount of risk and protective factor research has focused on children and

adolescents, not as much is known about factors

among other populations. Recent research has led

to interest in the possibility of further analyses in

selected populations and/or selected risk or protective factors. Some examples:
Chapter 9 Policy Options I 171

■ Adults. Additional research in this area could

result in learning more about factors associated

with long-term drug abuse and addiction as

well as the importance of factors more often

found in adult populations (e.g., effects of aging, death of a spouse or child, divorce). Data

from a recent National Household Survey on

Drug Abuse show that individuals aged 18 to

25, and 26 to 34, respectively, have the two

highest reported rates for heavy drinking and

smoking, past month use of cocaine, crack,

marijuana and hashish, or psychotherapeutic

drugs. Additionally, gender, racial, and ethnic

substance use differences appear within the

adult population. Some research has indicated

that women who drink heavily do so several

years later than men, although the reasons for

this remain unclear. Researchers also indicate

that black men who drink heavily, do so in their

late twenties and early thirties, in contrast to

white men whose drinking peaks at age 15 to

early twenties. Increased research on the adult

population could be useful in developing appropriate substance abuse prevention and treatment programs for adults.

● Race and Ethnicity. The biological and genetic substance abuse studies completed on different racial and ethnic groups have been few in

number, mostly limited to alcohol, and inconclusive. While race and ethnicity have not been

shown to be biological or genetic predictors for

substance use, abuse, or addiction, certain risk

factors appear to be unique for specific cultures. To date, however, the racial and ethnic

categories used in many large-scale studies are

so broad that many researchers consider them

useless. Increased federal funding for studies of

specific subpopulations living in geographically different areas (e.g., urban versus rural, reservation versus nonreservation) will provide

much needed baseline data on which to plan,

implement, and evaluate appropriate substance

abuse services.

■ Poverty. Disagreement exists on the appropriate definition of poverty and its exact relationship to substance abuse. While few researchers

deny that the daily stresses associated with living in chronic poverty probably contribute to

substance abuse, poverty is certainly not the

only factor, or perhaps even the most important. There are after all, more individuals living

in poverty who do not abuse substances than

who do. However, the consequences of substance abuse appear to be worse in chronically

poor areas. Additional research to study the

complex relationship between poverty and substance abuse could provide substance abuse

practitioners with a framework from which to

build programs most suitable for (he special

needs of chronically poor areas.

Congress can, through its reauthorization and

oversight powers, monitor the amount and

scope of risk and protective factor research

that is being conducted, and redirect federal efforts toward more extensive multifactor research and analysis, as appropriate. Such focus

could include factors other than substance usc that

may contribute to later abuse and addiction, such

as other problem behaviors, availability, marketing, psychological factors, social norms in communities, and subcultures. The increased use of

ethnographers as part of a multidisciplinary drug

abuse prevention research teams could also be encouraged.

1 Biomedical Research

Biomedical research on substance abuse helps explain the acute and chronic biological effects of

substances on the brain and other organs, and also

points to appropriate short- and long-term medical

treatments for substance abuse. This in turn helps

treatment providers understand treatment outcomes and relapse rates for long-term abusers.

Most federally supported biomedical research is

administered by the 17 institutes that comprise the

NIH. With the passage of the Alcohol, Drug

Abuse, and Mental Health Administration Reorganization Act of 1992 (Public Law 102-321),

NIDA and the NIAAA were moved to NIH. Research targeting substance use, abuse, and addiction is supported primarily by these two institutes,

whose combined appropriation level ($580.7 mil-
172 I Technologies for Understanding and Preventing Substance Abuse and Addiction

lion in fiscal year 1994) is approximately 5 percent of the NIH total.

Congress has historically increased annual

appropriations for biomedical research at

NIH; if Congress continues this trend, both

NIDA and NIAAA annual appropriations will

rise, although not at the dramatic levels many

scientists would like. If Congress were to decide

that substance abuse and addiction should command more of the nation’s biomedical research

budget, it could substantially raise appropriation

levels for NIDA and NIAAA. Such an action

would allow increased levels of research in a number of areas including: genetics; drug development; identification of biological factors related to

transitions from casual drug use to abuse, addiction, and dependence; the pharmacology of multiple drug use; environmental factors and their

effect on individual biological susceptibility; and

the biological effects of drug use and abuse on the

development of children and adolescents. Given

budget realities, however, an increase in the funding levels available for basic biomedical research

could mean a decrease somewhere else.

A number of budgetary pressures have recently

slowed robust NIH budget growth, including the

need to fund disease-specific research (e.g., acquired immunodeficiency syndrome), indirect

costs of research, and the increasing pressure to

limit discretionary spending. Some scientists

identify stable budget growth—as opposed to

sporadic increases targeted at particular topics—

as most important for continued progress in research. In fiscal year 1994, both NIDA and

NIAAA received a 5.2 percent increase in appropriations, following an Administration request

that would have raised NIDA’s appropriation by

less than 1 percent, and decreased NIAAA’s appropriation by 1.6 percent. Fluctuations in appropriation levels could impede the development

of scientific advances that are necessary to the creation of new medications and therapies.

The Congressional Budget Office (CBO), in its

March 1994 report to Congress, Reducing the Deficit: Spending and Revenue Options, identified a

reduction in funding for NIH research as one of

nearly 200 policy options. As noted by CBO, areduction in NIH funding could have adverse effects

on biomedical research and might cause some researchers to leave the field. NIH cannot currently

fund the majority of grants it approves; in addition, funding is insufficient to support some important areas of research. According to a 1992

General Accounting Office report on Drug Abuse

Research: Federal Funding and Future Needs,

antidrug research appears now to have a very modest role, with only about 4 percent of total drug

strategy spending devoted to research and development.

COMMUNITY ACTIVITY SETTINGS

Substance abuse and addiction occur in communities around our Nation. Those who believe that

drug abuse and addiction are closely related to social and economic problems argue that antidrug

programs should more directly address the risk

and protective factors that have been identified by

researchers. Many prevention program providers

also argue that the most successful programs are

those that are more comprehensive in scope (i.e.,

tailored to address the many community settings

in which drug abuse can occur) rather than addressing one or two risk factors in isolation.

In conducting this assessment, OTA surveyed

literatures addressing substance abuse and addiction in various community settings—families and

homes, schools and peers, workplaces, and recreational settings (see ch. 8). The literature reviews

presented in this report make clear that substance

abuse and addiction can arise and be influenced by

multiple factors in individuals, groups, and communities. Thus, effective intervention ideally

should be comprehensive, employing multiple

services and addressing the many factors that

cause drug abuse and addiction; and communitybased, sensitive to and directed at the needs of the

local population.

Still, three problems arise in assessing policy

options related to community settings:

1. There is the inherent difficulty in drawing a link

between many social services and their effect

on drug abuse and addiction.
Chapter 9 Policy Options I 173

2. Since broad-based social services are provided

through the work of many federal agencies, further analysis (e.g., by ONDCP or a congressionally enacted national commission) could

identify which federal agencies are best suited

to implement the variety of options that Congress may wish to employ.

3. The federal budget deficit is an obstacle to the

creation of new domestic programs that target

known risk and protective factors in individuals and communities.

I Schools and Peers

The primary focus of federal efforts at community-based drug prevention is programs aimed at our

nation’s schoolchildren. In fiscal year 1993, Congress appropriated $598 million to DOE under the

Drug-Free Schools and Communities Act of

1986. The federal government could continue to

fund school-based prevention programs, with

a continued emphasis on prevention curricula

and evaluations that are limited to substance

use prevention. The likely limited effects on preventing abuse among high-risk youth would continue. Other school-based prevention programs

would continue to be implemented sporadically,

without significant evaluation and with few or unknown effects.

If Congress decided that more rigorous evaluation of school-based programs was called for, it

could mandate DOE to spend a set percent of its

Drug Free Schools monies on research and

evaluation of prevention curricula and the dissemination of findings. A special initiative could

be launched to test prevention curricula for highrisk youth and for different racial and ethnic

groups, since most of the research and evaluation

to date has been based on samples of schools with

middle income white youth. Special expertise

would need to be brought in, on staff and as advisers, to assure the research and evaluation meet

high standards of methodological rigor. This

could be achieved by hiring staff with research and

evaluation expertise, detailing staff from the

NIDA, setting up an interdepartmental advisory

group that guides and oversees a research and

evaluation program, or appropriating funds directly to NIDA (e.g., as a set-aside from the DrugFree Schools appropriation) to support such a

research and evaluation program. Also, easier access to information about the many drug prevention curricula that exist could help school

personnel select curricula that fit their needs.

DOE could be directed to prepare and disseminate more widely information about the purposes, design, methods, resources required,

and evaluations (if any) of drug prevention

curricula currently available, and to inform

school personnel of the limitations of schoolbased curriculum approaches and the growing

availability of supplementary and alternative

approaches. If Congress decided that Drug-Free

Schools funds should be used more widely to target risk and protective factors found in schoolaged populations, it could require DOE to set

aside a certain percentage of Drug-Free

Schools funds for a variety of activities that target high-risk youths and to work individually

with them and their families. Such targeting

could enhance activities already carried out under

the Drug-Free Schools Act (e.g., Drug Abuse Resistance Education, replication of successful programs, local programs for high-risk youth, school

personnel training). However, congressional

mandates could reduce state and local flexibility

in tailoring programs best suited to local needs,

and could increase administrative costs associated

with implementing the Drug-Free Schools Act.

In addition to Drug-Free Schools programs,

comprehensive primary health, mental health, and

social services can be provided in many schoolbased clinics. School-based clinics can be supported by a variety of federal funding sources,

including Medicaid, the Maternal and Child

Health Block Grant, Drug-Free Schools, and

Special Education funds. DOE and the Department of Health and Human Services could be

encouraged or directed to collaborate on the

support of such services in schools.

Since researchers have found that peers and

other social influences strongly affect substance

use, programs that strengthen total school envi-
174 I Technologies for Understanding and Preventing Substance Abuse and Addiction

ronments may be potent in preventing substance

use and abuse. Models that involve school restructuring, parent involvement, mental health components, and elevated expectations for achievement

have been developed and are being tested. The hypothesis is that engaging high-risk youth in positive educational environments and experiences

can profoundly influence their behaviors for the

better. Congress could expand research on the

effects of restructuring of school environments

on substance abuse by appropriating funds for

extensive large-scale longitudinal research

that could be supported by DOE, NIDA, the

Centers for Disease Control and Prevention

(CDCP), and other federal agencies that conduct and support research on youth outcomes.

I Homes and Families

Congress appropriates funds for federal programs addressing substance abuse and addiction in homes and families, which are

supported by the HUD and HHS’ Administration on Children, Youth, and Families (ACYF)

and CSAP. Also relevant to the health and welfare of families are health funding programs

(e.g., Medicaid and Medicare) and welfare programs (e.g., Aid to Families with Dependent

Children). Through its oversight, authorization,

and appropriations of these programs, and others

that impact on the quality of family life, Congress

can support a number of preventive interventions

that are both comprehensive and intensive. Programs can be initiated by almost any local service

or support setting, such as health care, school,

family preservation, juvenile justice, and housing

authority, with coordination with other services

and settings. Such interventions can include

health care, counseling, intensive in-home services, neighborhood patrols, clean sweeps of public housing, and family and parent education for

all family members.

Because substance abuse and other related

problems can be influenced by so many family

factors and programs, a long-term effort to identify family needs maybe desired. Congress could

enact legislation to create a Presidential commission or task force to formulate a national

family policy and create a blueprint for longterm national efforts to shore up the many families, rich and poor, that would benefit from

more guidance, skills, and support. Such a national policy could be framed in the near-term,

based on the many studies and program interventions that have been documented so far. Alternatively, it could be formulated later, after additional

research and program interventions have been

supported and major gaps in knowledge have been

filled.

1 Workplaces

Congress could allow current activities that focus

on providing workplace employees with information, development of drug-free workplace policies, drug testing, and employee assistance

programs to continue. These programs are scattered among many federal agencies, with some

leadership by the Department of Labor (DOL),

CSAP, and the Office of Management and Budget.

If Congress chose to increase efforts in workplace antidrug prevention, it could mandate that

federal agencies increase the information that

is made available to workplaces about drugfree workplace programs and policies. For example, DOL is implementing an electronic

database, with information about workplace substance abuse treatment, prevention, and other control programs and research. Such a database, if

properly supported, publicized, and accessed by

businesses and unions, could help workplaces

identify and implement approaches that can meet

their needs in affordable ways.

1 Recreational and Community Settings

Congress currently funds community partnership demonstration programs administered by

CSAP. These partnerships foster public/private

sector partnerships that create and preserve comprehensive strategies for addressing substance

abuse prevention within communities. A major

advantage of these partnerships is the ability to

create programs that address substance abuse prevention within individual communities. As with
Chapter 9 Policy Options I 175

other drug prevention programs, however, evaluation has generally been limited. Congress could,

through appropriations and authorization, direct

CSAP to expand the provision of technical assistance and expand the national process and

outcome evaluation of partnerships. More site

visits would be possible, with additional resources for national and regional workshops, conferences, and training.

Other federal activities in this area remain limited and largely uncoordinated. Major current programs are administered by the Department of

Agriculture’s Cooperative Extension Service

(with its 4-H program, which is refocusing its efforts on high-risk youth) and CSAP (through

some of its High Risk Youth Demonstration

Grants). The President Council on Physical Fitness addresses one aspect of recreational and leisure activities--that is, physical fitness. If

Congress decided to provide more information

and support more research on recreational, leisure,

and other youth development programs, an information clearinghouse could be established

to share information about federal and nonfederal recreational, leisure, and youth development activities. The purpose would be to help

communities and program developers identify

and develop such programs especiall y for youth at

risk of drug use and abuse. The clearinghouse

could be managed in-house or under contract, and

could be located in the Cooperative Extension

Service (which is now attempting to redirect 4-H

programs to address high-risk youth): ACYF; or

CSAP (perhaps in the existing National Center for

Alcohol and Drug Information, a federally sponsored clearinghouse ),

The dearth of recreational places, especially in

highly developed urban areas. can be remedied by

an enhanced national effort to acquire land and

facilities for park and recreation purposes.

Such an effort could focus especially. but not exclusively, on rural and inner city areas where low

property values make the acquisition of such

properties financially attractive as long-term investments in the future development and enrichment of communities. Such a national effort could

be comparable in scope and long-term commitment to the development of the national park system, but could contribute to a broader national

system of parks owned and managed by the federal, state, and local governments specifically for

more intense human uses. Such a system could focus on the developmental needs of youth, especially in urban areas, where usable open spaces are

often in short supply. Congress could designate a

lead federal agency for such an effort (e.g., Department of Interior or HUD), and could acquire

properties outright or by encouraging and subsidizing the acquisition of properties by nonprofit

groups and by state and local governments. The

latter approach would require less federal funding

and administration. Possible sources of land and

facilities include: closed military bases, holdings

of the Resolution Trust Corporation, assets forfeited through drug seizures, individual gifts and

bequests, and corporate and philanthropic gifts.

AVAILABILITY

The primary current focus of federal antidrug efforts is stemming the physical supply of illicit

drugs. A multitude of policy issues arise in addressing drug availability, most of which are beyond the scope of this report. The discussion in

chapter 4, however, touches on two availability issues currently on the congressional agenda.

1 Taxes

The federal government currently levies excise

taxes on alcoholic beverages and tobacco products. Excise taxes on all types of alcoholic beverages were raised in 1990 to their current levels.

Currently, for example, beer (six pack, 12-ounce

cans) carries a 33 cent federal excise tax, a 750 ml

bottle of wine carries a 21 cent federal excise tax.

A pack of cigarettes carries a federal excise tax of

24 cents. If Congress takes no action, current federal levies will remain in effect.

Congress could enact legislation raising the

federal excise tax on a variety of tobacco and

alcohol products if it sought to decrease consumption of such products, to recover estimated societal costs (i.e., health costs, injury,
176 I Technologies for Understanding and Preventing Substance Abuse and Addiction

death) resulting from consumption of such

products, or to raise revenue for federal spending programs. Such tax hikes could be targeted at

all tobacco and alcohol products, or at selected

products in these industries. Advocates of increased excise taxes have argued that abuse of and

addiction to tobacco and alcohol products cost the

United States more than any illicit substance; that

increased taxes would make such products less

economically affordable and hence less used and

abused; that increased taxes could be used to pay

for financial damages arising from the use of such

products; and that such excise taxes, which have

increased less rapidly than the general rate of

inflation, should be adjusted upward to reflect

inflation. Opponents of taxation have argued that

excise taxes are regressive in that they target primarily low- and middle- income taxpayers, that

increased taxes would result in significant losses

to major companies that are important players in

the American economy, and that targeting socalled sin taxes unfairly singles out millions of

Americans who use tobacco and alcohol products.

1 Alcohol Labeling

Federal law currently requires that each alcoholic

beverage container bear a specific warning

statement that is conspicuously and prominently located (27 USC 215). This requirement

was enacted by Congress in 1980. Both Congress

and States have authority regulating alcohol advertising. At least 35 states regulate alcohol advertising, and self-policing by segments of industry

places some limits on advertising (e.g., the distilled spirits industry code prohibits the advertising of liquor on radio or television).

Congress has considered legislation that would

require warnings on all alcohol beverage advertising, both print and electronic media.

Congress could amend current alcohol labeling

law to require stricter labeling (e.g., multiple labels, rotating labels, specific messages). Opponents of such action argue that no significant

relationship has been found between exposure of

individuals to alcoholic beverage advertising and/

or labeling and drinking behaviors.
Appendix A:

Drug Control Policy

T

in the United States:

Historical

Perspectives A

he United States has always been a drug-using country. In

colonial days, people drank more alcohol than they do

today, with estimates ranging from three to as many as

seven times more alcohol per year (13) While public

drunkenness was a criminal offense, it was generally considered a

personal indiscretion. ( 1). The temperance movement began in

earnest after the Revolution, when heavy drinking was revealed

to be a problem, and religious figures became committed to temperance. (1). Since then, the American experience with both licit

and illicit drugs can be viewed as a series of reactions to the public’s shifting tolerance toward their use (9).

THE EARLY 1900s: NARCOTICS AND COCAINE

In the late 19th century it was possible to buy, in a store or

through mail order, many pseudomedical preparations, containing morphine, cocaine, and even heroin (9). The ubiquitous soft

drink Coca-Cola used to contain cocaine until 1903, when it was

replaced with caffeine (9). Pharmacies sold cocaine in pure form,

as well as a number of opium-derived drugs, such as morphine

and heroin, the latter of which became well-known when it was

marketed by the Bayer Co. beginning in 1898 ( 10). Physician prescriptions of these drugs increased from 1 percent of all prescriptions in 1874 to between 20 to 25 percent in 1902; they were not

only available but they were wide] y used, without major concerns

about negative health consequences (14).

Cocaine and narcotic preparations were taken off the market

for various reasons. Increasing awareness of the hazards of drug

use and adulterated food led to such regulations as the Pure Food

and Drug Act of 1906 that required that fraudulent claims be re- I 177 moved from patent medicines, as well as disclosure of habit-
178 I Technologies for Understanding and Preventing Substance Abuse and Addiction

forming substances. The passage of several antinarcotic and pharmaceutical labeling laws was

spurred on by these health concerns, a growing

temperance movement, the development of safe

pain relievers (such as aspirin), a broader range of

medical treatments, and the growing immigrant

population thought to be associated with specific

drug-using practices. However, these laws did not

make patent remedies, cocaine, and opium illegal.

Some individual states imposed tighter restrictions on their availability, but there was no uniformity among state laws. It was United States

involvement with international narcotics concern

that led there (9,10.1 4).

In 1909, the International Opium Commission

called by the United States, met in Shanghai, to

begin an international discussion concerning the

problems of narcotics and the narcotics trade.

Twelve nations. in addition to the United States,

were present to discuss problems relating to opium. At that time the perception in the United

States was that Chinese immigrants were to blame

for the opium smoking problems. This angered

the Chinese, who had instituted strict campaigns

against the sale and use of opium within their own

country. The Chinese were seeking U.S. assurances for help in ending Western opium trafficking into China. The State Department not only

wanted to support China drug control efforts, but

thought that international drug control measures

would help stanch the flow of drugs into the

United States, and thus the nonmedical consumption of these drugs. It would not be until two years

later, in the Hague. that a treaty would be signed

stating that all the signatories would enact domestic legislation controlling narcotics trade, specifically limiting the use of narcotics for medicinal

purposes (9,10).

Hamilton Wright, the State Department’s opium commissioner, attempted to draft legislation

but met opposition from the States, the medical

profession, pharmacists and pharmaceutical companies. After nearly three years of debate, Congress passed the Harrison Act in December 1914

(named for Representative Francis Burton Harrison, who introduced the initial form of the bill for

the Administration). The bill provided for strict

control of opium and coca and their derivatives:

both their entry into the country and their dispersion to patients. Maintenance of addicts by physicians was allowed until 1919. Opposition to the

Harrison Act came mainly from pharmaceutical

companies and pharmacists, who objected to what

they called the Act’s confusing and complex record keeping requirements (9).

Passage of the Harrison Act reflected, in part,

growing public sentiment that opium and cocaine

were medicines to be taken only in times of illness

(and then only when prescribed by a physician)

and that these substances could cause insanity and

crime, particularly in foreigners and minorities.

Smoking opium was associated with Chinese immigrants; popular belief also held that cocaine

would affect blacks more forcefully than whites

and incite them to violence. Marijuana was believed to have been brought into the country and

promoted by Mexican immigrants and then

picked up by black jazz musicians. These beliefs

played a part in the 1937 Marijuana Tax Act,

which attempted to control the drug’s use (9). As

early as 1910, many people argued against any

nonmedical use of narcotics.

PROHIBITION AND BEYOND

I Focus on Alcohol

Ratification in 1919 of the 18th amendment prohibited the manufacture, sale, transportation, importation, and exportation of alcohol and shifted

the Nation focus for more than a decade from the

dangers of narcotics to the Nation’s alcohol problems. Prohibition had its roots in the Temperance

Movement, which began shortly after the Revolution. In 1784, Benjamin Rush, a physician and

signer of the Declaration of Independence, published a pamphlet entitled, “An Inquiry Into the

Effects of Ardent Spirits on the Mind and Body,”

which was widely disseminated among Temperance leaders. In it he described a “disease model”

of excessive drinking, which characterized drunkenness and alcohol addiction as a “disease of the

will,” in addition to causing many physical diseases. By the mid-19th century, the American

middle class had become more aware of the dan-
Appendix A Drug Control Policy in the United States: Historical Perspectives I 179

gers of alcohol to the family, the nation, and the

factory (1). By the late 19th century and early 20th

century, the Temperance Movement came to be

associated almost exclusively with American

Protestantism as a political mechanism to control

the growing numbers of non-Protestant immigrants. This political and social strength helped, in

1919, to ratify the 18th amendment which forbade

the sale of alcoholic beverages, and to implement

it by means of the Volstead Act in 1920 (1).

The shifting tolerance of Americans toward

substance use is evidenced by the successes and

failures of the Prohibition era. In 1919, many were

optimistic that the prohibition of alcohol would

solve many of the country’s social problems. If alcohol contributed to the crime and unemployment

associated with the cities, then removing it from

the market might help solve those problems.

However, despite evidence that consumption declined (based on declining rates of death due to

cirrhosis and of alcoholic psychosis in State mental hospitals), there is also evidence that widespread dishonesty existed in the enforcement of

dry laws. Jobs to enforce Prohibition were doled

out as political favors, which may have contributed to graft, corruption, and the surge in underworld crime (9, 17). In addition to the perceived

rise in corruption, the passage of progressively

stricter laws regarding violations of the Volstead

Act also contributed to waning public support of

prohibition (17). The 1933 repeal of Prohibition

signaled that public sentiment had once again become favorable toward alcohol, and alcohol and

its related problems returned to private, rather

than public, arenas.

The scientific literature of the 1930s and early

1940s concentrated mainly on captive alcoholic

populations in jails, mental hospitals, and skid

row, allowing many Americans to distance themselves from alcoholism (1). During this same period, Alcoholics Anonymous (AA) was founded,

but lacked mainstream recognition until the 1950s

and 1960s when the scientists lent support to the

disease model of alcoholism, which has always

been the central tenet of AA (1, 11).

I Focus on Narcotics

While alcohol experienced a transition period in

respect to public tolerance, negative attitudes toward narcotics and other drugs remained constant,

or became even more severe. During the 1920s,

the Federal government expanded its antidrug efforts through new Treasury Department regulations (8). In 1930, President Hoover created the

Federal Bureau of Narcotics and appointed Harry

Anslinger as the Commissioner of Narcotics. a

position Anslinger held from 1930 to 1962, a precursor, perhaps, to the modern day drug czar. For

more than three decades, Anslinger oversaw all

aspects of drug control, from interdiction to domestic supply, to public relations. He effectively

used religious and other antidrug groups to maintain a high antidrug sentiment in the country. He

also controlled the flow of legal drug supplies, by

keeping watch over doctors who might prescribe

unusually large amounts of narcotics. Anslinger

was opposed to the medical treatment of addiction, and addicts, like alcoholics, were seen as deviants (9, 15).

Prior to the mid-1960s, marijuana use in the

United States was mostly confined to various subgroups such as Mexican laborers, jazz musicians,

and beatniks. Although portrayed as a killer weed

and a menace by anti marijuana reformers, there is

little evidence that it was either at this time. In

1937, the Marihuana Tax Act (the Federal government then spelled marijuana with an “h”), became

law, making the use and sale of marijuana without

a tax stamp Federal offenses. Some companies

were permitted to apply for a license to use cannabis products (e.g., for birdseed, paint and rope),

and doctors could still prescribe marijuana in limited circumstances. However, starting in 1937,

recreational use was punished with greater severity (15). Some speculated that the passage of the

Marihuana Tax Act resulted from strong antiMexican sentiment in the Southwest and the political power of Anslinger (5).

Intolerance toward drug use was very strong in

the 1930s and 40s. Federal laws concerning the
180 I Technologies for Understanding and Preventing Substance Abuse and Addiction

sale and use of drugs got progressively stricter,

culminating in the introduction of the death penalty for the sale of heroin to anyone under 18 years

old by anyone older than 18 (10). Illicit drug use

during these decades was low in the mainstream

population. This marginalization of narcotics (or

at least, of the people who used them) may have

played apart in the resurfacing of these drugs after

the 1930s. There was a concern during World War

II that American soldiers in Asia would succumb

to drug supplies available in those countries and

return home with drug habits. The Bureau of Narcotics received no budget increases, since Congress apparently believed it was well equipped to

deal with the current drug levels (9).

In the 1950s, however, heroin was brought into

the country in larger quantities than at any time

since it was outlawed. Dealers learned that poor

quality heroin could be sold at inflated prices, and

this higher cost pushed users into criminal lifestyles heretofore not seen on such a wide scale

(12). A nationwide scare that drug use would

spread from the urban poor (mostly minorities) to

the rest of the country erupted. The fact that young

people appeared to be the biggest users of heroin

was particularly alarming. This fear was reflected

in the passage of the Narcotic Control Act of 1956,

which increased penalties for the sale and possession of marijuana and heroin (15).

The reaction to this rise in drug use was not entirely fearful, however. Scientific and technological advances offered altemative answers to coping

with the drug problem a switch from the past tactics of law enforcement. Even though the stereotypical heroin user was still a poor minority, new

ideas for treating and helping these people

emerged as part of increasing acceptance of the

medical model of addiction. In the 1960s, methadone maintenance pilot programs were launched.

By using the long-acting opioid methadone for

treatment of addiction to the short-acting opiate

heroin, these programs offer a way for heroin addicts to control their addiction (6).

1960s-PRESENT

In the 1960s, white middle-class youths, who

were more visible than their minority counterparts, began experimenting with drugs, including

marijuana and heroin, causing wide public concern and demand for more treatment approaches

and additional law enforcement (17). Some of this

new interest in drug use may be attributed to the

intolerance toward it in the preceding decades.

Marijuana had never been widely used, and after

the 1930s its use was not a widespread concern. It

was rediscovered by young people in the 1960s,

who had grown up with parents who used alcohol.

Some of the drug consumption may also be linked

to an increase in consumption generally during the

late 1960s and early 1970s, the Vietnam War protest movement, and the rapid changes in American

society that occurred in those years (9,10,17).

Despite the image of the sixties as a time of

widespread experimentation, the increase of drug

use activated many who had been quiet on the issue. Marijuana, the drug of choice among many

young people, was seen by some researchers as the

gateway to more dangerous drug use. Richard

Nixon was elected President in 1968 on a law and

order platform, and it is said that no other President has campaigned as hard against drug abuse

(9). As during World War II, concern rose that soldiers serving in Southeast Asia would develop

drug habits while there. In this case, the fears were

well-founded, as many servicemen did avail

themselves of cheap supplies of heroin and marijuana. However, even among those who became

addicted, many stopped their drug use upon returning to the United States. During the 1960s, the

old linkages between corruption, Asians, and opium surfaced once again in public opinion, leading

to more stringent measures to stop the flow of

drugs into the United States from both Asia and

Latin America (8).

Public support of law enforcement against

drugs was high during the late 1960s and early

1970s, and President Nixon spoke of mounting “a

frontal assault on our number one public enemy

[drugs],” but long mandatory minimum sentences

for possession of small amounts of marijuana dis-
Appendix A Drug Control Policy in the United States: Historical Perspectives I 181

turbed many Americans, even those who did not

approve of marijuana use. The Comprehensive

Drug Abuse Prevention and Control Act of 1970

lessened penalties for possession of marijuana. It

also established a system for classifying drugs

into five schedules, which is still used today.

Drugs are placed in each schedule based on their

potential for abuse, their known harmfulness, and

medical value. Marijuana and heroin are listed in

schedule 1-drugs with high potential for addiction and no recognized medical value. There have

been, however, limited experimental programs

approved by the DEA and FDA for the use of marijuana in treatment of nausea due to chemotherapy

and of ocular pressure due to glaucoma. Cocaine

is listed in schedule 2-drugs with potential for

addiction for acceptable for some medical applications. Subsequent to the establishment of this

system, drug policies and laws for individual

drugs have been based on the drug’s schedule

(3,16).

In 1972, the President’s National Commission

on Marijuana and Drug Abuse recommended that

the laws against the use of rnarijuana be relaxed,

since the enforcement of these laws was becoming

too burdensome to police in some areas. and was

considered intrusive on individual privacy in others. The drug was incresingly thought to be innocuous in its effects, both by scientists and others

(4). Several States passed decriminalization laws,

which allowed possession or use of small amounts

of marijuana and imposed fines instead of prison

sentences for transgressions of minor possession

laws ( 10). The Commission remained strict on cocaine, which was also seeing a surge in use, but

few experts thought it was physically addictive or

should be classified in the same category as other

narcotics.

Despite President Nixon’s emphasis on “law

and order” responses to drug use, his drug budget

favored prevention, education, and treatment. The

National Institute on Drug Abuse (NIDA) was

created as the lead agency for demand reduction,

directing Federal prevention and treatment services and research. The Drug Enforcement Administration was created as the lead agency for

supply reduction, and single state agencies were

created to guide Federal funds into state and local

antidrug programs (3),

From the mid-sixties to the late seventies, the

composition of drug users changed substantially.

While drug use was still associated primarily with

minorities and the lower classes. drug use by

middle-class whites became a widespread and

more accepted phenomenon. As in the late nineteenth and early twentieth centuries. when middle

class whites haphazardly used narcotic preparations, this new group of drug users down-played

or ignored the dangerous effects of drugs, and extolled their virtues as agents of nonconformity and

mind-expansion. Cocaine was an expensive and

high-status drug, used mainly for recreation by

upper- and middle-class whites.

From the drug experiences of this cohort,

which were by no means entirely positive, the

public of the late seventies was better educated

about the effects of drugs, and public disapproval

of drug use began once again to increase. Drug

use, however, particularly of cocaine and marijuana remained high. The Ford Administration

( 1974- 1977) focused on the drugs it thought posed

the greatest danger—heroin, amphetamines, and

barbiturates. Some even thought that drugs such

as cocaine and marijuana should be legalized, “so

as to end the enormous government expenditures

of money and time on a problem that only seemed

to bring profits to drug dealers and elicit contempt

for the law from an ever-growing body of drug users” (9).

During the Carter Administration (1977-

198 1), Peter Bourne, a special assistant for health

issues, argued for Federal decriminalization of

possession of small amounts of marijuana, while

focusing interdiction efforts on heroin. But

Bourne resigned over a scandal involving criticisms over his prescribing practices. His resignation forced President Carter to take a harder

position on drugs, and Federal decriminalization

never occurred. There were still States in which

marijuana was decriminalized, but these decreased in numbers through 1990, when the last

State—Alaska—to have decriminalization repealed those laws.
182 I Technologies for Understanding and Preventing Substance Abuse and Addiction

The departure of Bourne coincided with the

emergence of several parents’ groups concerned

about drug use by their preteen children. One

group in particular. in Atlanta, Georgia, became

enraged when they found that in addition to drug

use at parties, their children were able to buy drug

paraphernalia and prodrug literature in local

stores. The group formed the Parent Resources

Institute on Drug Education, National Families in

Action, and the National Federation of Parents.

These groups were instrumental in prodding

NIDA to publicize more widely the dangers of

marijuana and other drugs once thought of as

harmless.

The Administration of Ronald Reagan

(198 1- 1989) favored a strict approach to drug use

and increased law enforcement. First Lady Nancy

Reagan actively campaigned against drug use,

urging school children to “Just Say No.” At the

same time, funding for research and treatment decreased, while the availability of cocaine, heroin,

and marijuana remained the same (9). The budget

for antidrug related activities rose from $1.5 billion in 1981 (split nearly equally between supply

reduction (domestic law enforcement and international/border law enforcement) and demand reduction (research, prevention and treatment) to

$4.2 billion by the end of President Reagan’s second term. Two-thirds of the funds were now allocated for law enforcement activities, with the

remaining third allocated for demand reduction

(2). In 1984, the Crime Control Act increased dramatically Federal mandatory minimum sentencing provisions for drug-related crime, including

the manufacture, distribution, or possession of

controlled substances. It also expanded the criminal and civil asset forfeiture laws to penalize drug

traffickers and increased Federal criminal penalties for drug-related offenses (3). This trend continued through the remainder of the Reagan

administration as well as that of President Bush.

The 1980s saw significant shifts in patterns of

cocaine use. The negative effects of cocaine use,

especially long-term use, had previously been

masked, but middle-class users with drug-related

problems suddenly were more common. Concurrently, cocaine smuggling escalated, resulting in

increased availability, lower prices, and higher

quality. Low-income, minority communities began experiencing major drug problems, first with

powdered cocaine, then in the mid-eighties especially with the new form of cocaine-crack. Commonly called an epidemic, the spread of this

smokable cocaine inspired both President Reagan

and antidrug groups to heightened drug intervention efforts. Crack appeared to be highly addictive, as well as affordable, and fear of its

consequences forced many lawmakers into action. The Anti-Drug Abuse Act of 1986 authorized more funds than ever before for the war on

drugs, most of which was designated for international interdiction activities (9), and the establishment of the Office of Substance Abuse Prevention

(OSAP). The AIDS epidemic has also affected

patterns of drug use, since some intravenous (IV)

drug users may have switched to smoking crack in

order to avoid exposure to the AIDS virus. Other

IV drug users, however, have continued to inject,

and comprise a large percentage of the AIDS-infected population.

While the main focus of drug control policy in

the 1980s was interdiction of illicit drugs, significant policy initiatives concerning alcohol were

also implemented. For example, the goal of the

national minimum drinking age of 21 was stated

in 1984 and achieved by 1988. Warning labels

were required on all retail containers of alcoholic

beverages beginning in 1989 (7).

When George Bush was elected President in

1988 the climate within the country was highly intolerant to the use of illicit drugs. President Bush

echoed President Nixon when he declared that the

drug epidemic was “public enemy number one”

(16). The Anti-Drug Abuse Act of 1988 mandated

the creation of the Office of National Drug Control Policy (ONDCP), to be headed by a director,

sometimes called the drug czar, who would coordinate U.S. drug control and abuse policy, resources, and operations (Public Law 100-690).

The first director was William Bennett, former

Secretary for Education under President Reagan.

He was followed by Robert Martinez, former

Governor of Florida. The director, in conjunction

with the President and Cabinet Secretaries, sets
Appendix A Drug Control Policy in the United States: Historical Perspectives I 183

Administration policy on drug control. However,

ONCDP lacks budgetary authority, and under

President Bush the director of ONDCP was not a

Cabinet position. During the Bush Administration, additional funds were authorized for the war

on drugs, including increased funds for treatment

and prevention. However, most of the funds were

designated for law enforcement activities. Spending for antidrug-related activities rose from the

high of $4.2 billion under President Reagan, to a

proposed $12.7 billion in the last year of President

Bush’s term. Again, the monetary split was rough1 y two-thirds for law enforcement and international interdiction activities and one-third for demand

reduction (2).

While “The War on Drugs” has remained part

of the political lexicon, President Clinton, after

taking office in 1993, cut the Office of National

Drug Control Policy from 146 positions to 25. He

elevated the director of ONDCP to cabinet status,

and Lee P. Brown, former Police Commissioner

of New York City was appointed to this position.

During his campaign for the presidency, Clinton

advocated drug treatment on demand, and the

addition of 100,000 new police officers to the

streets.
Appendix B:

Federal Programs:

Prevention and

B Causation

receive

A

total of 12 executive branch departments, four independent agencies, one multiagency program (Weed and

Seed), one White House office (the Office of National

Drug Control Policy—ONDCP), and the Judiciary, all

federal funding as part of national drug control strategy.

These efforts include interdiction, treatment, and prevention programs. In order to compile information on federal substance

abuse prevention initiatives and to discuss factors related to substance use, abuse, and addiction, the Office of Technology Assessment (OTA) and the General Accounting Office (GAO)

convened a two-day workshop. Representatives from federal

agencies that were members of ONDCP’S Demand Reduction

Working Group were invited (for list of workshop participants,

see appendix E).

During the workshop, federal agency representatives were

asked to make a short presentation covering the following three

issues:

1.

2.

3.

The agency’s substance abuse prevention program(s). What

are its goals and objectives (primary or secondary prevention,

research)? What are its target populations?

Risk and/or protective factors related to substance abuse that

the agency has identified. To what extent is the agency able to

address specific factors in the implementation of prevention

programs?

Methods the agency uses for assessing whether prevention

programs are effective? What requirements (if any) does the

agency impose on grantees for reporting program effectiveness

and evaluation outcomes?

184 I
Appendix B Federal Programs: Prevention and Causation I 185

This appendix summarizes presentations made

at the workshop, and focuses on federal agencies

with external programs (e.g., outreach, technical

assistance, grants). In addition to these programs,

each federal agency, pursuant to the federal Employee Substance Abuse and Treatment Act of

1986 (Public Law 99-570), maintains an employee assistance program (EAP) to provide appropriate prevention, treatment, and rehabilitation

programs for drug- and alcohol-related problems

among civilian employees. The total federal government cost for EAPs in fiscal year 1991 was

$30.5 million, covering administrative and counseling services for employees seeking to overcome drug, alcohol, emotional, and other

personnel problems (4).

ACTION

ACTION’s mission is to foster and expand voluntary citizen service in communities throughout the

Nation in activities designed to help the poor, the

disadvantaged, the vulnerable, and the elderly.

Needs assessment and programs that address

needs are designed and implemented at the local

level. (In April, 1994, ACTION was merged into

the Corporation for National Service.)

The agency spends over $10 million annually

to support volunteer programs addressing drug

abuse prevention. The Drug Alliance Program

awards about $1 million each year to communitybased volunteer efforts designed to assist in the

delivery of illicit drug use prevention information.

Under Volunteers in Service to America (VISTA),

full-time stipended volunteers are assigned to local sponsoring organizations to perform activities

determined and defined by the sponsoring organization and the low-income communities in which

they serve. The needs being addressed are numerous. and include the need to reduce the spread and

use of illicit drugs in low-income communities.

Over 450 full-time volunteers are currently engaged in drug reduction projects. Drug abuse prevention activities can be found in other ACTION

programs, including student community service

programs (small grants 1 inking student volunteers

with their communities), the retired senior volunteer program (intergenerational drug abuse prevention activities), and a foster grandparent

program (person-to-person services between senior citizens and children who are mental] y, emotionally, or physically disabled) that frequently

includes children born to mothers who used drugs

during pregnancy.

DEPARTMENT OF DEFENSE

The Department of Defense (DOD) consolidated

all drug interdiction and counter-drug activities

into a single appropriations line in fiscal year

1990. The demand reduction component accounts

for approximately 10 percent (about $10 million)

of DOD drug-related spending; by far the largest

percentage of dollars is spent on support to law enforcement and the National Guard.

The linchpin of DOD’s prevention efforts is

mandatory urinalysis drug testing (28,000 tests

were conducted during fiscal year 199 1). DOD

policy for military personnel is zero tolerance. In

most cases—the exception being lower ranking

enlisted personnel caught for the first time—an

officer or noncommissioned officer caught using

illicit drugs will be processed for separation from

the service. Substance abuse education for military personnel begins upon reporting to duty.

There are mandatory briefings each year for military personnel, as well as during transfers between

commands. DOD dependent school programs on

military installations throughout the world have

adopted the Drug Abuse Resistance Education

(DARE) program.

Congress recently expanded DOD's legal authority to conduct community-based awareness

programs, providing authority to the National

Guard and to the active and reserve military to go

out beyond military installations, particularly into

innercity schools, to present antidrug programs.

Congress provided 5 years authority for this program.

DEPARTMENT OF EDUCATION

The Department of Education (DOE), pursuant to

the Drug-Free Schools and Communities Act

(DFSCA) of 1986 (Public Law 99-570) and sub-
186 I Technologies for Understanding and Preventing Substance Abuse and Addiction

sequent amendments, implements the largest federal program addressing drug abuse prevention. In

fiscal year 1993, Congress appropriated $598 million for DFSCA.

The majority of DFSCA funds is allocated as a

formula grant program to States. Each State is required to allocate at least 90 percent of the funds

it receives to local educational agencies (LEAs) to

improve antidrug abuse education, prevention,

early intervention, and rehabilitation referral programs. Remaining State funds are allocated to the

governor of each State. The governor provides financial support for antidrug abuse efforts to parent

groups, community based organizations, or other

public or private nonprofit entities. At least 42.5

percent of the Governor’s funds must be used for

programs for high-risk youth.

At the national level, DOE operates the following grant programs:

= Emergency. This program provides funds to

LEAs that demonstrate a significant need for

additional assistance in combating drug and alcohol abuse. LEAs compete for funding to support a comprehensive range of services,

including educational programs, counseling

programs, enhancement of school security,

after-school programs, programs for parents

and other community outreach efforts, and

alternative programs for students with a history

of drug abuse or others who are difficult to

reach in the regular school setting. Appropriation in fiscal year 1993: ($24.5 million).

- Institutes of Higher Education. The Fund for

the Improvement of Postsecondary Education

in the Office of Postsecondary Education has

awarded more than 800 grants since fiscal year

1987 to institutions of higher learning to

develop, implement, operate, and improve

drug education and prevention programs for

students enrolled in institutions of higher

education. Three discretionary grant competitions are involved: institution-wide programs

for comprehensive, campus-based programs; a

specific approaches program; and the National

College Student Organizational Network

Program to support student organizations prevention efforts. In addition, the Office of Elementary and Secondary Education awards

grants to institutes of higher education to support demonstration programs in drug and alcohol abuse in elementary and secondary schools.

Appropriation in fiscal year 1993: ($19.3 million).

● Regional Centers. DFSCA authorizes the Department to support five regional centers to: 1 )

train school teams to assess and combat drug

and alcohol abuse problems, 2) assist State

educational agencies in coordinating and

strengthening prevention programs, 3) assist

local educational agencies in developing training programs for educational personnel, and 4)

evaluate and disseminate information on effective substance abuse education and prevention

programs and strategies. Five cooperative

agreements were awarded during fiscal year

1990 for 4-year terms. Appropriation in fiscal

year 1993: ($16. 1 million).

■ School Personnel. This program provides financial assistance to State and local educational agencies and institutions of higher learning

to establish, expand, or enhance programs and

activities for the training of elementary and secondary school teachers and administrators, and

other personnel in the areas of drug and alcohol

abuse education and prevention. Appropriation

in fiscal year 1 993: ($1 O million).

● Indian Youth. This program is administered

under a memorandum of understanding between the Departments of Education and Interior. Drug and alcohol abuse education and

prevention services are provided to Indian children attending elementary and secondary

schools operated by the Bureau of Indian Affairs. Appropriation in fiscal year 1993: ($5.6

million).

■ Counselor Training. This program provides

financial assistance to State and local educational agencies, institutions of higher learning,

and private nonprofit agencies to establish, expand, or enhance programs and activities for

the training of counselors, social workers,

psychologists, or nurses who are providing or
Appendix B Federal Programs: Prevention and Causation I 187

will provide drug abuse prevention, counseling, or referral services in elementary and secondary schools. Appropriation in fiscal year

1993: ($3.6 million).

Native Hawaiians. This program provides

funding for drug prevention and education for

Hawaiian natives. The Governor of Hawaii

designates organizations eligible to receive

funding under this program. Appropriation in

fiscal year 1993: ($1, 1 million).

In addition to these grant programs, the Department supports a number of activities, including

the development of curriculum and production of

drug prevention newsletters, videotapes, and other materials in conjunction with the Department of

Health and Human Services (HHS) and the National Clearinghouse for Alcohol and Drug Information. In conjunction with the Department of

Justice, the Department of Education is supporting activities at the National School Safety Center

on prevention of drug-related violence in schools.

A Department-commissioned study (1 ) estimates that DFSCA has been very successful in

providing schools and localities with resources

to expand their programs. An estimated 11,000

local educational agencies (78 percent of the total)

comprising approximately 94 percent of all

schoolchildren receive DFSCA services. While

coverage is extensive, evaluation efforts need to

be strengthened in order to improve school-based

prevention programs. Currently, 25 States conduct surveys in drug attitudes and use, but only 15

State education agencies had performed outcome

studies.

DEPARTMENT OF HEALTH AND

HUMAN SERVICES

I Center for Substance Abuse Prevention

The Center for Substance Abuse Prevention

(CSAP), created in 1986 by Congress as the Office of Substance Abuse Prevention, provides national leadership for alcohol and drug abuse

prevention and intervention efforts, with special

emphasis on programs for youth and high-risk

populations.

To accomplish its mission, CSAP carries out

demonstration projects targeted to specific highrisk groups; assists communities in developing

long-term, comprehensive prevention programs

that involve all sectors of the community; operates

a national clearinghouse of publications and other

materials and services; develops and carries out

media campaigns and other knowledge-transfer

programs; provides training in the prevention of

addictive disorders for health care and allied professionals, parents, youth, multicultural groups,

and others; and provides technical assistance and

other services to help communities, organizations, and others develop and implement prevention efforts.

These projects address a number of risk and

protective factors that fall within five major

groupings: individual-based factors, familybased factors, school-based factors, peer-based

factors, and community-based factors.

CSAP demonstration grants address different

points on the spectrum of risk and protective factors. Primary evaluation is process-oriented, in order to assure that projects are targeting multiple

systems (e.g., youth, family, schools, community

organizations) seen as being crucial to effective

drug prevention efforts.

~ Indian Health Service

The Indian Health Service (IHS) contracts with

tribal groups for a variety of health care services.

The fiscal year 1993 budget for alcohol and drug

abuse prevention services was $82.3 million. Unlike other federal grants for such services, IHS

provides funds for sovereign Indian nations on a

contract basis. Thus, there is no mandate for demonstration programs, research protocols, or the

like. IHS has a target population of 1.1 million

people.

I National Institute on Alcohol Abuse

and Alcoholism

The National Institute on Alcohol Abuse and Alcoholism (NIAAA), part of the National Institutes

of Health (NIH), is the primary federal research

agency on alcohol-related programs including
188 I Technologies for Understanding and Preventing Substance Abuse and Addiction

epidemiology, genetics, neuroscience, medical

consequences of alcohol and alcoholism, alcohol

use and pregnancy, adverse social consequences

of alcohol use and dependence, diagnostic criteria

and screening instruments, prevention, intervention, and treatment.

NIAAA supports two types of prevention research. Basic prevention research explores factors

that influence the risk of developing alcohol use

problems. These factors include individual characteristics that may place a person at risk (e.g.,

age, gender, and family history) and factors within

the environment that may affect risk (e.g. family

interaction, workplace factors, characteristics of

drinking establishments, and alcoholic beverage

prices). Applied prevention research evaluates the

effectiveness of purposeful actions taken to reduce problems related to alcohol use. Such actions

include measures to modify the drinking environment (e.g., legislation establishing minimum

drinking age, laws regarding drinking and driving, and server training programs) and measures

designed to change individual behavior (e.g.,

educational programs).

Epidemiologic research has examined a variety

of individual characteristics—”including age, gender, and race and ethnicity—related to alcohol

consumption and risk for alcohol problems. For

example, NIAAA has found that both alcohol

abuse and alcohol dependence are more likely to

occur among men than among women; young,

single men are more likely to be frequent heavy

drinkers and to report alcohol dependence and

alcohol-related problems. Black men and white

men have similar drinking patterns overall,

although black men had somewhat higher abstention rates than white men (29 percent verses 23

percent, respectively,), and white men were somewhat more likely to be heavier drinkers. However,

black men appear to experience some types of

alcohol-related problems at lower levels of consumption. research has also focused on early behavioral characteristics of children that predict use

of alcohol and other drugs, as well as individual

risk factors associated with fetal alcohol syndrome (2).

1 National Institute on Drug Abuse

Programs and Target Populations

The National Institute on Drug Abuse (NIDA) is

the lead federal agency for research to increase

knowledge about the causes and treatment of drug

abuse and addiction, to identify the means of preventing and controlling drug abuse, and ultimately, to eliminate the demand for illicit drugs. NIDA

was created by Congress in 1974 as one of the

three institutes in the Alcohol, Drug Abuse, and

Mental Health Administration (ADAMHA). In

1992, with the reorganization of ADAMHA by

Congress, NIDA was moved to NIH.

NIDA consists of three major components:

staff offices, which assist the agency’s Director

with leadership and management functions; program divisions, which oversee research grants and

contracts; and the Addiction Research Center

(based in Baltimore, Maryland), NIDA’s intramural arm.

The Division of Epidemiology and Prevention

Research, one of six NIDA divisions, is primarily

responsible for prevention and causation/correlation research. A broad-based epidemiology grant

program examines the natural history, incidence,

and prevalence of drug abuse in the population as

a whole and among several subpopulations, such

as children and adolescents and pregnant women

and their offspring. Research efforts also focus on

the etiology, or causes, of drug abuse, which encompasses the identification and study of risk factors, high-risk populations, and the crime-drug

nexus. The fundamental information obtained

from these studies guides NIDA in determining its

research priorities.

By supporting researchers across the country

and conducting its own field research, the Division seeks to answer questions such as what drugs

are being abused, to what extent, and by whom.

Major ongoing research efforts include the National Household Survey, the High School Senior

Survey, and the Drug Abuse Warning Network,

which monitor use trends among households,

high school seniors, and emergency room populations, respectively.
Appendix B Federal Programs: Prevention and Causation I 189

Other areas of research interest include the consequences of drug abuse; the efficacy of various

prevention strategies; and the economic, demographic, and psychosocial factors that place individuals at higher risk for becoming drug abusers.

Drug abuse among children of child-bearing age,

maternal drug use, and pregnancy outcomes are

also areas of particular concern.

The Division works with State, federal, and international governmental agencies and private

organizations to encourage the sharing of information. This is accomplished by developing

community- and State-based epidemiologic surveillance networks and by providing technical assistance and other consultation to researchers

interested in developing studies or surveys in

areas such as prevention research.

In fiscal year 1992, the Prevention Branch had

a research budget of $14 million and supported 40

grants. The Epidemiological Research Branch,

which conducts etiology research, had a budget of

$28 million and supported between 60 and 70 individual projects.

Factors Addressed

NIDA has sponsored etiologic research for 20

years. Its studies indicate that correlates to drug

use and abuse can be clustered into four groups of

risk and protective factors: individual, family,

peer group, and community. As a result, NIDA

encourages research that is theory-based, has multiple components in the intervention, is comprehensive to include multiple stages and

environments.

DEPARTMENT OF HOUSING AND

URBAN DEVELOPMENT

The Department of Housing and Urban Development (HUD) does not undertake research programs, but through its Public Housing Drug

Elimination Program, targets a population identified as being at risk for drug abuse and addiction:

residents of public housing.

The Public Housing Drug Elimination Program, funded at a level of$165 million in fiscal

year 1992, has resulted in a total of more than

1,300 grants being awarded to public housing

agencies for such activities as innovative drug

education and treatment programs, counseling;

support of tenant patrols acting in cooperation

with local law enforcement agencies: physical improvements designed to enhance security; and

employment of security personnel and investigators.

In addition, HUD sponsors a Youth Sports Program, designed to foster recreational activities in

public housing, and technical assistance and training program that helps housing authorities and

resident organizations assess the nature of local

drug problems and develop a strategy for addressing problems.

DEPARTMENT OF INTERIOR

The National Park Service has implemented the

DARE program in public schools adjacent to certain national parks and Indian reservations. The

DARE program, taught by uniformed law enforcement officers, is designed to teach elementary and high school students how to resist peer

pressure to use drugs. Over 70 park service personnel have been trained as DARE instructors;

these instructors have made presentations to more

than 8,000 students in 70 schools.

The Bureau of Indian Affairs (B IA) has been

involved in the DARE program since 1988; 47

BIA personnel have presented the DARE program

to 3,300 students. BIA has two substance abuse

training programs—a counselor training program, to train school personnel, and a drug-free

schools program, where BIA schools receive

1 percent of federal drug-free school funding (see

description under Department of Education). BIA

and HHS’ Indian Health Service have an interdepartmental memorandum of agreement that results in the coordination of data collection,

resources, and programs of both agencies to assist

American Indian tribes and Alaska natives to

achieve their goals in the provision of prevention,

intervention, and treatment services for those affected by substance abuse.
190 I Technologies for Understanding and Preventing Substance Abuse and Addiction

DEPARTMENT OF JUSTICE

The Department of Justice is primarily responsible for interdiction efforts to stem the sale, possession, and use of drugs. While law enforcement

officials have a primary focus on supply-side issues, a number of programs are targeted toward

demand reduction. These efforts, spread across

several DoJ entities, do not focus on root causes or

risk factors per se, but rather at broad-based

awareness building efforts.

1 Drug Enforcement Administration

The Drug Enforcement Administration (DEA)

employs 20 agents (out of a total force of approximately 3,000 agents) in a demand-reduction program. Each of 19 geographic divisions has a

demand-reduction agent, with the exception of the

Atlanta office, which has 2 such agents. Total

DEA spending for its demand reduction program

is $700,000, with half those funds being obligated

by DEA national headquarters, and the 19 field offices receiving funds ranging from $12,000 to

$30,000 a year.

Because of the small budget and limited personnel for demand-reduction efforts, DEA attempts to work with intermediaries who develop

drug prevention programs, in an attempt to maximize the effect of its efforts. DEA has identified

five national priorities for its demand-reduction

efforts: minority and high-risk youth, sports drug

awareness programs, user accountability programs, training for law enforcement personnel,

and development of community-based coalitions

and alliances.

Activities include school visit programs, conducting about 100 drugs in the workplace seminars annually, and working with communities to

adopt programs that are seen as being effective.

1 Federal Bureau of Investigation

The Federal Bureau of Investigation (FBI) established a Drug Demand Reduction Program

(DDRP) in 1988 to augment the enforcement efforts of the FBI as a long-term solution to the drug

abuse problem. DDRP seeks to reduce the demand

for drugs in diverse communities through flexible

strategies designed to focus primarily on the youth

and to respond to community requests and needs.

A staff of 5 persons at FBI headquarters supports 60 special agents ( 14 of whom are full-time)

across the United States. Agents go into communities to do drug prevention work, usually educational presentations that are a component of a

larger, ongoing, comprehensive program. Field

office programs report to the Office of Public and

Congressional Affairs at FBI headquarters in

Washington.

The FBI budget for this activity is approximately $300,000. The average field office receives about $800, although larger field offices,

such as New York and Los Angeles, receive close

to $8,000 for this program. The FBI has developed

some materials on its own, and relies heavily on

CSAP and the Department of Education for materials as well. Youths are the target population for

most FBI-related programs.

1 Office of Justice Programs

The Office of Justice Programs (OJP) collects statistical data and conducts analyses of emerging

criminal justice issues through five component

units. Of these five components, two-the Bureau

of Justice Assistance (BJA) and the Office of Juvenile Justice and Delinquency Prevention

(OJJDP)—have a particular emphasis in substance abuse prevention issues.

Programs and Target Populations

BJA provides funding, training, and technical assistance to State and local governments to combat

violent crime, gang activity, and drug trafficking.

BJA’s primary effort is the National Citizens

Crime Prevention Program, a coalition of more

than 110 federal, national, and State organizations. The national “Take a Bite Out of Crime”

program featuring McGruff the dog, is perhaps the

best-known part of this campaign. An offshoot of

this effort is BJA’s community drug abuse prevention initiative, designed to assist programs and encourage active participation by communities in

working with law enforcement officials to enhance the quality of life by reducing crime, violence and drug abuse. BJA also sponsors national
Appendix B Federal Programs: Prevention and Causation I 191

night-out campaigns (e.g., front-porch vigils and

community patrols), the Southern Christian Leadership Conference’s program targeting AfricanAmerican neighborhoods, expansion of boys and

girls clubs in public housing projects, efforts to

train instructors in working with parents to help

their children remain drug-free, and the DARE

program. As of July 1992, almost 14,000 police

officers had received DARE training through

BJA’s regional training centers.

OJJDP awards funds to state and local governments and sponsors research to prevent and control juvenile crime.

Factors Addressed

OJJDP has identified a number of risk factors as

predictors for delinquency and drug use: 1 ) early

variety and frequency of antisocial behavior in

elementary schools; 2) having parents or siblings

engage in crime or drug use; 3) family situations

lacking supervision, excessively severe or inconsistent disciplinary practices, or low communication and involvement between parents and

children; 4) family situations where high levels of

conflict exist; 5) social isolation and multiple entrapment of parents in extreme poverty, poor

living conditions, and low status occupations;

6) school failure; 7) association with drug-using

peers; and 8) transitions, such as the change from

elementary to junior high school, and junior to senior high school.

Evacuation Methods

Each project funded by BJA contains an evaluation plan. Although evaluation activities vary

from bureau to bureau, four types of evaluations

are generally conducted:

Program assessments, where a program’s

strengths and weaknesses are described in order to evaluate progress made in solving the

problem addressed by the program.

Impact evaluations, describing how a program

has an impact on the problem addressed, explaining the processes critical to the success of

the program, with a focus on outcomes.

Intensive impact evaluations, which explain

why a program is effective as well as whether

the program has had significant impact. They

examine how a program produced results and

depict the special processes to which the outcomes may be attributed.

Evaluation reviews, which examine topics

where a number of evaluations are already

complete but have never been synthesized for

use by the criminal justice system.

United States Attorneys

The U.S. Attorneys are the chief federal prosecutors in 94 district offices across the country. Within each of the 94 offices is a Law Enforcement

Coordinating Committee (LECC) to improve

cooperation between State, local, and federal law

enforcement agencies within each district.

The primary role of U.S. Attorneys offices is on

supply-side issues, including criminal prosecution and enforcement of asset forfeiture laws.

Since the mid- 1980s, LECCS have become more

involved in demand-reduction efforts in their districts, by playing a role in activities such as training seminars for law enforcement officials on drug

use prevention; drug education subcommittees;

task forces to assess the needs and resources of local communities; involvement in school assemblies; and coordination of antidrug rallies.

LECCS tailor their programs to local needs, and

have resulted in variety of activities. In Delaware,

for example, the United States Attorney and police chiefs throughout the state created a police

rock band that goes into local schools with a local

antidrug message. In Florida, the U.S. Attorney

organized a law enforcement summit on drug

abuse prevention. In the Northern District of New

York, the LECC coordinator helped prepare a

1 -hour television and radio program that was simulcast on major networks in the Syracuse area.

In the Northern District of Georgia, the LECC

coordinator is involved in turning a former nightclub that was seized and forfeited into a law enforcement center that will also be used by young

people as a drug-free recreational center.
192 I Technologies for Understanding and Preventing Substance Abuse and Addiction

DEPARTMENT OF LABOR

Section 4303 of the Anti-Drug Abuse Act of 1986

(Public Law 99-570 mandated the Secretary of the

Department of Labor (DOL) to” . . . collect such

information as is available on the incidence of

drug abuse in the workplace and efforts to assist

workers including counseling, rehabilitation, and

employee assistance programs.” The statute also

authorized the Secretary to “conduct such additional research as is necessary to assess the impact

and extent of drug abuse and remediation efforts.”

While DOL lacks a direct mandate in substance

abuse prevention, and therefore, deals indirectly

with identification of root causes or risk factors,

the Department is concerned because substance

abuse and addiction directly affects several of its

major mandates, including employee training,

worker safety, occupational health, productivity,

and competitiveness. Approximately 66 percent

of illicit drug users are employed either full- or

part-time, and it is assumed that alcohol abusers

(1 in every 10 people in this country) are represented in the work force at about the same proportion that they are in the general population.

The Employment Training and Education Administration provides job training and education

to address unemployment, which is a risk factor

often associated with substance abuse. Through

the Job Training Partnership Act, money is distributed through block grants to the States. Recipients of such monies are encouraged to provide

drug education and awareness to participants.

The Job Corps program provides residential

training programs for youth aged 16 to 21. They

conduct drug screening, education, and orientation at all 105 Job Corps training sites, and all sites

do some drug intervention.

The Mine Safety and Health Administration

formed a substance abuse committee in 1985, consisting of representatives of labor, management in

union and nonunion mines, and federal government agencies that have a role in reducing substance abuse. The committee has developed a

manual and two videos on substance abuse prevention for distribution through 800 mines nationwide.

The primary effort undertaken by DOL has

been a survey by the Bureau of Labor Statistics to

collect information about drug testing programs

in workplaces. This survey found that drug testing

was more prevalent in larger establishments than

in smaller ones, current employees were most

often tested for reasonable suspicion, testing programs were more likely to target job applicants

than current employees, and applicants were more

likely than current employees to test positive for

drugs.

The Department, in conjunction with the Small

Business Administration (SBA) and the Office of

National Drug Control Policy, has sponsored a national conference on substance abuse in small

business, and is in the process of developing a substance abuse data base, drawing in large part on information available through other government

agencies. Through the Occupational Safety and

Health Administration, administers an employee

assistance grant program to employers and employer groups to enable the development of employee drug and alcohol abuse programs. Under

this grant program, $1.5 mill ion has been awarded

to 23 groups.

OFFICE OF NATIONAL DRUG

CONTROL POLICY

ONDCP was created by Congress as part of the

Anti-Drug Abuse Act of 1988 (Public Law

100-690). The Director of ONDCP, the so-called

drug czar, is responsible for coordinating U.S.

drug control policy, resources, and operations.

ONDCP has no authority over federal agencies,

nor does it issue grants or conduct research. As a

policymaking agency, ONDCP created a national

drug control strategy, which contained four elements for preventing drug use: mobilizing communities against drugs, educating young people

that drug use is harmful and wrong, encouraging

businesses to establish drug-free workplace programs, and promoting antidrug programs through

the media.

Following his election in 1992, President Clinton cut the size of ONDCP staff and announced his

intention to elevate the drug czar to Cabinet status.
Appendix B Federal Programs: Prevention and Causation I 193

SMALL BUSINESS ADMINISTRATION

SBA’S Office of Workplace Substance Abuse Prevention was established in 1992 to coordinate the

Agency’s efforts to help small businesses meet the

challenges imposed by substance abuse in the

workplace. In each of SBA’S 110 field offices

throughout the country, an individual serves as a

substance abuse coordinator, to provide direct assistance to the small business community.

The most tangible SBA effort to date is the development of a self-help drug kit to provide assistance and guidance to small business owners

wishing to establish and implement a workplace

substance abuse program. The kit, “Drug-Free:

It’s Good for Business,” is a step-by-step system

with instructions, training aids, forms, and informational material to assist business owners in

adopting formal antidrug policies, provide supervisory and employee training, organize an employee assistance program, and (if desired)

establish drug testing procedures.

SBA is developing a STOP DRUGS initiative

(Small Businesses Together and Organized to Prevent Drugs), a coalition of small businesses willing to share information with other small business

operators. SBA is working with NIDA and DOL

to undertake research that specifically examines

the effect of employee substance abuse on small

businesses. SBA is also working with the DoJ’s

Weed and Seed program. SBA views its role as

part of the ‘*seeding” component by offering financial and business development resources to

targeted communities.

DEPARTMENT OF TRANSPORTATION

The National Highway Traffic Safety Administration (NHTSA), part of the Department of Transportation, regulates automobile safety and

administers traffic safety programs. Because alcohol is the single largest factor involved in highway

auto deaths and injuries, NHTSA has targeted as

its primary risk group young people aged 15 to 20

(the age group with the highest ratio of accidents

attributed to alcohol).

NHTSA’S programs fall under two categories-deterrence programs and prevention programs. Deterrence programs include advocating

for the passage of State laws in a number of areas,

including: immediate suspension of licenses for

driving under the influence of alcohol, lowering

the blood alcohol level at which it is illegal to

drive to .08 (all States except five currently have

a standard of O. 10), prohibiting open containers of

alcohol in cars, prohibiting consumption of alcohol in automobiles, sobriety check points, provisional licensing (e.g., laws creating restrictions on

new drivers such as daylight-only driving), zero

tolerance (e.g., laws making it illegal for a minor

to have any level of alcohol in his/her blood), and

improved enforcement of laws already in effect

(e.g., minimum age alcohol purchase laws). Prevention programs include public information and

education programs aimed at schools, employers,

and programs aimed at responsible use of alcohol.

NHTSA created the Techniques for Effective Alcohol Management (TEAM) program, and has

worked with the Ad Council in creating public

service announcements on drinking and driving.

NHTSA has also collaborated with other federal

agencies to identify communication strategies to

reach young persons at high risk for health-related

problems (with HHS’ Office for Disease Prevention and Health Promotion), and to develop workshops for school-based programs (with the

Department of Education and HHS’ CSAP.
Appendix C:

Perspectives

on Defining

Substance

c Abuse

F

our broad arenas that encounter substance abuse-related issues include, mass communications, criminal justice,

medicine, and public health. These entities often operate

independently of one another and use substantially different terms when describing the use of illicit substances or the illegal use of licit substances.

MASS COMMUNICATIONS

The traditional realm of mass communications includes television, radio, and popular journals and newspapers. Within these

media, the term substance abuse has become a catch-all phrase,

with no clear boundaries. Much of the general public has become

familiar with the term substance abuse within this ambiguous

context.

1 CRIMINAL JUSTICE

I While it is well-known that many crimes are committed by persons with substance use disorders and that these disorders can be

major contributors to their crimes, there is no systematic policy

within the criminal justice system for the evaluation of these disorders. In many jurisdictions, whether federal, state, or local, the

prevailing sentiment is that any use of an illicit substance and/or

use of a licit substance in an illegal manner, is considered criminal

abuse. A limited set of quantitative analyses including blood,

urine, and breath tests can be performed to detect illegal levels of

alcohol and/or the presence of illicit substances. The Blood Alcohol Concentration (BAC) is 0.10 grams/deciliter for all States excluding Oregon, California, Utah, Vermont, and Maine, where

194 I the level is 0.08 grams/deciliter. As of December 1992, 15 states

-- I

had lower BAC levels for youthful offenders charged with driv-
Appendix C Perspectives on Defining Substance Abuse I 195

ing while intoxicated. These levels range from

0.00-0.02 grams/deciliter, which is considered

“zero tolerance,” up to 0.04 grams/deciliter (6).

The alcohol breath test, while a different procedure from the BAC, converts the results into BAC

units. Thus, the levels of intoxication for BAC and

breath test are identical.

However, there are limitations to these analyses. In some jurisdictions, these tests can be performed only with the written consent of the

person. In others, the urine test measures the presence of only one or two drugs rather than looking

for the entire range of abusable substances.

Besides the limited amount of testing and evaluation, there is little use of psychological screening examinations or structured interviews to

determine the level and severity of use, abuse, or

dependence.

PUBLIC HEALTH

The traditional public health model incorporates

the host-agent-environment relationship. Each of

these factors has an individual, as well as an interrelated role in the potential use and/or harmful use

of a substance.

Host factors may include possible genetic, psychological, and biological susceptibility. Agent

factors incorporate the substance’s abuse liability

capacity, as well as how the substance is marketed.

Last] y, environmental factors encompass not only

the availability of the substance, but the social,

cultural, political, and economic climate as well

(3,4).

Over the past 20 years, professionals within the

field of public health have attempted to reemphasize the strict medical concept of substance abuse.

Attention had previously focused almost exclusively on individual drug use patterns, rather than

featuring the diverse problems of drug, alcohol,

and tobacco use as being intimately tied into communities and society as a whole.

Even the term “substance abuse” has come under scrutiny. While the word “substance” may at

first appear quite generic, in many fields, this term

has come to incorrectly infer illicit drug use—reinforcing the misperception of many individuals

that alcohol and tobacco are not drugs. “Abuse”

generally denotes the more severe forms of addiction. In reality, there is a continuum that begins

with initial drug use and may progress to harmful

use and addiction, with various problems present

along the spectrum. In lieu of the term ‘*abuse,”

public health professionals prefer terms such as

“alcohol and drug problems” or the ● *harmful/hazardous use” of a drug.

The focus of the public health perspective is to

understand the importance social norms, environment, and availability play in the shaping of alcohol- and drug-related problems both on an

individual and societal level.

MEDICAL

Within the fields of medicine, the two most frequently cited texts for the definitions of substance

abuse and dependence are the Diagnostic and Statistical Manual of Mental Disorders (DSM) issued by the American Psychiatric Association and

the International Classification of Diseases

(ICD) published by the World Health Organization (WHO). Each successive version of the DSM

and ICD has been given a number signifying its

order in the overall sequence of manuals; DSM

uses Roman numerals and ICD uses ordinary

numbers. The newest version of ICD, ICD-10,

was published in 1992. The current version of

DSM is the Third Edition-Revised (DSM-III-R),

which will shortly be superseded by DSM-IV.

I ICD

While the current ICD and DSM definitions of

substance dependence are nearly identical, the

two manuals differ sharply on the concepts of

abuse, which ICD classifies as harmful use.

The ICD manual is intended to be used on an

international basis, and the socially defined

“American” criteria present in the DSM manual

for substance abuse cannot be adequately transferred to a wide range of cultures. The current

ICD-10 category of harmful use, while applicable

cross-culturally, is limited to: “A pattern of psychoactive substance use that is causing damage to

health. The damage may be physical (as in cases
196 I Understanding Substance Abuse and Addiction

of hepatitis from the self-administration of injected drugs) or mental (e.g., episodes of depressive disorder secondary to heavy consumption of

alcohol ).”

1 DSM

In the early 1950s the first DSM manual grouped

alcohol and drug use disorders under the broad

category of ‘*Sociopathic Personality Disturbances.” At that time, a substance use disorder

was considered a moral weakness or the manifestation of a “deeper” psychological problem,

rather than a disorder in-and-of itself with social,

psychological, and perhaps even genetic determinants.

Throughout the 1970s and 1980s clinical research identified the need for separate categories

for substance use disorders. The DSM-III manual,

in 1980, was the first manual in this series to clearly identify substance abuse and dependence as

pathological conditions different from substance

use alone. DSM-III also alluded to the fact that social and cultural factors are contributors to the onset and continuation of abuse and dependence.

The DSM-III definition of dependence emphasized tolerance (needing to take much higher

doses of the substance to obtain the same effect)

and withdrawal (having a distinct pattern of physiological arousal upon abrupt discontinuation or

reduction in dosage), and required the presence of

one or both of these phenomena to make a dependence diagnosis. Substance abuse was defined as

problematic use with social or occupational impairment, but with the absence of significant tolerance and/or withdrawal. In both disorders,

impairment in social and occupational function

was a prominent aspect of the definitions, creating

a significant overlap between the criteria for substance abuse and dependence. In 1987, DSM-III

was revised (DSM-III-R) to give the behavioral

aspects of substance use disorders equal weight to

the physiological components.

This shift away from the physiological to the

behavioral elements of dependence was strongly

influenced by the work of researchers Edwards

and Gross, who had extensively studied persons

with alcohol problems. These researchers conceptualized alcohol dependence as a syndrome of

graded severity that involved an interconnected

complex of behavioral, psychological, and physiological elements associated with loss of control

over alcohol consumption.

Contributing to the emphasis on behavioral aspects of dependence was work by Brady, Thompson, and others who had shown that animals can

be taught to self-administer substances of abuse.

Once taught, it was observed that most animals

will expend tremendous amounts of energy to obtain additional doses and that this “drug-seeking

behavior” is very difficult to extinguish. Efforts to

repeat drug self-administration were especially

prominent if the experimental drug was one with

a high abuse liability such as morphine, methamphetamine, or (especially) cocaine and was difficult to extinguish.

This body of work was among the first in a line

of investigation studying the behavioral aspects of

drugs. This field of research became known as

“behavioral pharmacology” and was strengthened

by additional studies by Olds and others.

Thus, both the work of Edwards and Gross, that

of behavioral pharmacologists, and of basic scientists pointed toward the presence of a definable

and independent syndrome that can result after an

organism has learned to self-administer abusable

substances. This syndrome was not dependent on

the ability of the drug to produce tolerance and

withdrawal, but rather on its positive reinforcing

effects. These effects were evident by observing

the behavior of the organism, and could be measured by quantifying the work that the organism

would produce to obtain the substance.

The development of the substance use disorders section for DSM-IV began in 1988 and involved the most extensive process yet undertaken

for such a task. The major change in DSM-IV is

in the definition of substance abuse. Unlike DSM111 and DSM-III-R, DSM -IV clearly separates the

criteria for dependence from those of abuse. Dependence in DSM-IV is a syndrome involving

compulsive use, with or without tolerance and

withdrawal; abuse is problematic use without
Appendix C Perspectives on Defining Substance Abuse I 197

compulsive use, significant tolerance, or withdrawal. Preliminary data from the DSM-IV field

trials indicate that this change will probably increase the number of persons diagnosed as having

substance abuse, especially for those using hallucinogens, inhalants, sedatives, and amphetamines.

Substance Use and the Transition to

Abuse/Harmful Use or Dependence

One problem in developing criteria for this second, nondependent category, whether called

abuse or harmful use, is that though dependence

has been well-studied, the progression from use to

abuse has not been adequately researched (except

in the case of alcohol); and depending on the perspective, may not always be linear. For example,

using the DSM-IV classifications, it is possible

that substances such as opiates may follow a path

that begins with use and progresses to dependence

before abuse-related problems are identified.

Within the field of alcohol research, the consensus

of studies is that consuming three to four standardized drinks/day by males (equal to 40 or more

grams of alcohol at 12 grams/drink) is associated

with an increased probability for the development

of problems. As females tend to absorb alcohol

more quickly, studies have shown that problems

typically begin at about two to three drinks/day

(1 ,2,5).

Little work has been done on other substances.

All persons who end up with abuse, harmful use,

or dependence begin with use. Use of a substance,

whether licit or illicit, does not constitute a substance use disorder even though it may be unwise

and strongly disapproved of by family, friends,

employers, religious groups, or society at large.

Use by itself is not considered a medical disorder.

For a disorder to be present, use must become

something else such as: occur more frequently;

occur at higher doses; or result in a magnitude of

problems. Though there have been some conceptual models developed for how one might approach a better understanding of this transition,

there are few data available to clearly point out

where the border lies.

DSM-IV AND ICD-10 DEFINITIONS

1 DSM-IV Diagnostic Criteria:

Abuse

A.

B.

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the

following occurring over the same 12-month

period:

1.

2.

3-.

4.

Recurrent substance use resulting in a failure to fulfill major role obligations at work,

school, or home (e.g., repeated absences or

poor work performance related to substance use; substance-related absences,

suspensions, or expulsions from school;

neglect of children or household).

Recurrent substance use in situations in

which it is physically hazardous (e.g., driving an automobile or operating a machine

when impaired by substance use).

Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct).

Continued substance use despite having

persistent or recurrent social or interpersonal problems caused or exacerbated by

the effects of the substance (e.g., arguments

with spouse about consequences of intoxication, physical fights).

Has never met the criteria for Substance Dependence for this substance.

Dependence:

A maladaptive pattern of substance use, leading to

clinically significant impairment or distress, as

manifested by three or more of the following occurring in the same 12-month period:

1. Tolerance, as defined by either of the following:

a. need for markedly increased amounts of the

substance to achieve intoxication or desired

effect

b. markedly diminished effect with continued

use of the same amount of the substance
198 I Understanding Substance Abuse and Addiction

2.

3.

4.

5.

6.

7.

m

Withdrawal, as manifested by either of the following:

a. the characteristic withdrawal syndrome for

the substance

b. the same (or closely related) substance is

taken to relieve or avoid withdrawal symptoms

The substance is often taken in larger amounts

or over a longer period than was intended

Any unsuccessful effort or a persistent desire

to cut down or control substance use

A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use of

the substance (e.g., chain-smoking), or recover

from its effects

Important social, occupational, or recreational

activities given up or reduced because of substance use

Continued substance use despite knowledge of

having had a persistent or recurrent physical or

psychological problem that is likely to be

caused or exacerbated by the substance (e.g.,

current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made

worse by alcohol consumption)

Specify if:

●

m

with physiological dependence: Evidence

of tolerance or withdrawal (i.e., either items

(1) or (2) are present).

without physiological dependence: No evidence of tolerance or withdrawal i.e., neither items (1) nor (2) are present).

ICD-10 Diagnostic Criteria for Clinical

Use:

Harmful Use:

A pattern of psychoactive substance use that is

causing damage to health. The damage may be

physical (as in cases of hepatitis from the self-administration of injected drugs) or mental (e.g., episodes of depressive disorder secondary to heavy

consumption of alcohol).

The diagnosis requires that actual damage

should have been caused to the mental or physical

health of the user. Harmful patterns of use are

often criticized by others and frequently associated with adverse social consequences of various kinds. The fact that a pattern of use 01

particular substance is disapproved of by another

person or by the culture, or may have led to socially negative consequences such as arrest or marital

arguments is not in itself evidence of harmful use.

Acute intoxication or “hangover” is not in itself

sufficient evidence of the damage to health required for coding harmful use. Harmful use

should not be diagnosed if dependence syndrome,

a psychotic disorder, or another specific form of

drug- or alcohol-related disorder is present.

Dependence Syndrome

A definite diagnosis of dependence should usually

be made only if three or more of the following

have been experienced or exhibited at some time

during the previous year:

1.

2.

3.

4.

5.

A strong desire or sense of compulsion to take

the substance.

Difficulties in controlling substance-taking behavior in terms of its onset, termination, or levels of use

A physiological withdrawal state when substance use has ceased or been reduced, as evidenced by: the characteristic withdrawal

syndrome for the substance; or use of the same

(or closely related) substance with the intention

of relieving or avoiding withdrawal symptoms.

Evidence of tolerance such that increased doses

of the psychoactive substance are required in

order to achieve effects originally produced by

lower doses (clear examples of this are found in

alcohol- and opiate-dependent individuals who

may take daily doses sufficient to incapacitate

or kill nontolerant users)

Progressive neglect of alternative pleasures or

interests because of psychoactive substance

use, increased amounts of time necessary to obtain or take the substance or recover from its

effects.
Appendix C Perspectives on Defining Substance Abuse I 199

6. Persisting with substance use despite clear evidence of overtly harmful consequences, such as

harm to the liver through excessive drinking,

depressive mood states consequent to periods

of heavy substance use, or drug-related impairment of cognitive functioning; efforts should

be made to determine that the user was actually,

or could be expected to be, aware of the nature

and extent of harm.

Narrowing of the personal repertoire of patterns of psychoactive substance use has also been

described as a characteristic feature (e.g., a tendency to drink alcoholic drinks in the same way on

weekdays and weekends, regardless of social

constraints that determine appropriate drinking

behavior).

It is an essential characteristic of the dependence syndrome that either psychoactive substance taking or a desire to take a particular

substance should be present; the subjective awareness of compulsion to use drugs is most commonly seen during attempts to stop or control

substance use. This diagnostic requirement would

exclude, for instance, surgical patients given opioid drugs for the relief of pain, who may show

signs of an opioid withdrawal state when drugs are

not given but who have no desire to continue taking drugs.

The dependence syndrome may be present for

a specific substance (e.g., tobacco or diazepam).

for a class of substances (e.g., opioid drugs), or for

a wider ranger of different substances (as for those

individuals who feel a sense of compulsion regularly to use whatever drugs are available and who

show distress, agitation, and/or physical signs of

a withdrawal state upon abstinence).

The diagnosis of the dependence syndrome

may be further specified by the following (the following roughly correspond to the course modifiers and relapse section of DSM-IV):

●

■

■

■

m

■

■

Currently abstinent.

Currently abstinent, but in a protected environment (e. g., in hospital, in a therapeutic community, in prison, etc.).

Currently on a clinically supervised maintenance or replacement regime (controlled dependence, e.g., with methadone; nicotine gum

or nicotine patch).

Currently abstinent, but receiving treatment

with aversive or blocking drugs (e. g., naltrexone or disulfiram).

Currently using the substance (active dependence).

Continuous use.

Episodic use.
Appendix D:

List of

Contracts

For this assessment, OTA commissioned reports on various topics relevant to substance abuse and

addiction. The manuscripts of 10 of these contractors are available from the National Technical Information Service, 5285 Port Royal Road, Springfield, VA 22161; (703) 487-4650.

●

●

■

■

●

●

■

“Substance Abuse and Addiction: Genetic Components,” Stephen H. Dinwiddie and Theodore Reich, Jewish Hospital of St. Louis, St. Louis, MO; William J. McBride, Indiana University School of Medicine, Indianapolis, IN, (PB94-1 75694).

“Drug Abuse in Schools: Contributing Factors and Preventive Interventions,” William B.

Hansen, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, NC

(PB94-175635).

“The Contribution of Drug Availability to Drug Use and Abuse,” National Center for Juvenile

Justice, Pittsburgh, PA (PB94-175676).

“Assessment of Dependence Liability of Psychotropic Substances: Nature of the Problem and

the Role of the College on Problems of Drug Dependence,” Theodore J. Cicero, Washington

University School of Medicine, St. Louis, MO (PB94-175643).

“Defining Substance Abuse,” George E. Woody, Philadelphia Veterans Administration Medical Center and University of Pennsylvania, Philadelphia, PA (PB94-175650).

“Factors Contributing to Drug Abuse in Workplaces,” Frank Baker, Baltimore, MD (PB94-

175627).

“Research on the Family Setting’s Role in Substance Abuse,” Brenna H. Bry, Rutgers University, Piscataway, NJ (PB94-175692).

200 I
Appendix D List of Contracts I 201

■ 

bThe Role of Ethnography in Understanding and Preventing Drug Abuse,” Mitchell S. Ratner,

TIGER Research, Takoma Park, MD (PB94-175668).

■ “The Role of Poverty in Drug Abuse, “ The Urban Institute, Washington, DC (PB94-174000).

■ “The Role of Recreational, Cultural, and Other Community Activities and Settings in Preventing Drug Abuse Among Youth,” Center for Youth Development and Policy Research,

Washington, DC (PB94-175619).
Appendix E:

List of

Workshops

and

E Participants

Walter W. Barbee

Office of Justice Programs

Washington, DC

Jane Boorman

Small Business Administration

Washington, DC

William Bukowski

National Institute on Drug Abuse

Rockville, MD

Tom Burns

Indian Health Service

Albuquerque, NM

Judy Cherrington

Department of Education

Washington DC

Judith DeJong

Center for Substance Abuse Prevention

Rockville, MD

Robin Dinerman

Federal Bureau of Investigation

Washington, DC

Karen Dodge

Department of Health and Human Services

Washington, DC

Jan Howard

National Institute on Alcohol Abuse and Alcoholism

Rockville, MD

James Howell

Office of Juvenile Justice and Delinquency

Prevention

Washington, DC

Gary Johnson

Department of Interior

Washington, DC

Ingrid A.C. Kolb

Office of National Drug Control Policy

Washington, DC

Harri J. Kramer

Department of Justice

Washington, DC

G. Gary Kowalczyk

ACTION

Washington, DC

202 I
Appendix E List of Workshops and Participants I 203

Ella Lankford

Bureau of Indian Affairs

Washington, DC

Bernard McColgin

Center for Substance Abuse Prevention

Rockville, MD

William Modzeleski

Department of Education

Washington, DC

Judith Peterson

Department of Labor

Washington, DC

Robyn Prichard

Department of Housing and Urban Development

Washington, DC

John Rogers

Office of Personnel Management

Washington. DC

Bob Simpson

Department of Energy

Washington, DC

Tom Stewart

Drug Enforcement Administration

Washington, DC

Richard Suchinsky

Department of Veterans Affairs

Washington, DC

Maria Vegega

Department of Transportation

Washington, DC

Megan Walline

U.S. Attorney’s Office

Washington, DC

Michael A. Wermuth

Department of Defense

Washington, DC

James Wilcox

United States Information Agency

Washington, DC

Antonia Abbey

Wayne State University

Detroit, MI

Murray Durst

National Council of Juvenile and Family Court

Judges.

Reno, NV

Richard Gable

National Center for Juvenile Justice

Pittsburgh, PA

Leigh Henderson

T. Head and Co., Inc.

Rockvillc, MD

Hunter Hurst, IV

National Center for Juvenile Justice.

Pittsburgh, PA

Joe Maffia

Austin McCormick Center

Brooktondale, NY

Dorothy Ross

Santa Clara County Juvenile Probation

San Jose, CA

Douglas Thomas

National Center for Juvenile Justice

Pittsburgh, PA
204 I Understanding Substance Abuse and Addiction

Philip Benson

Center for Social and Community Development

Piscataway, NJ

Dale Blyth

Search Institute

Minneapolis, MN

Marcia Chaiken

LINC

Lincoln, MA

Judith DeJong

Center for Substance Abuse Prevention

Rockville, MD

Eric Goplerud

Substance Abuse and Mental Health Services

Administration

Rockville, MD

Robbie Hayes

North Central Regional

Educational Laboratory

Oak Brook, IL

Mary Kimball

Center for Youth Development and Policy Research

Washington, DC

Julie Knight

Fairfax County Department of Extension and

Continuing Education

Fairfax, VA

Patricia Nelson

University of Delaware Cooperative Extension

Newark, DE

Raymond O’Brien

Center for Youth Development and Policy Research

Washington, DC

Karen Pittman

Center for Youth Development and Policy Research

Washington, DC

Mitchell Ratner

Consultant

Takoma Park, MD

Stephen Small

Child and Family Studies

University of Wisconsin

Madison, WI

Barry Tindall

National Recreation and Park Association

Arlington, VA

Joan Wynn

The Chapin Hall Center for Children

Chicago, IL

Shep Zeldin

Center for Youth Development and Policy Research

Washington, DC
Appendix E List of Workshops and Participants I 205

Karst Besteman

Institute for Behavior Resources

Substance Abuse Center

Washington, DC

Jackie Butler

CPC/Alcohol and Substance Abuse, Inc.

Cincinnati, OH

Phil Diaz

Miami, FL

Charlene Doria-Ortiz

Center for Health Policy Development, Inc.

San Antonio, TX

Mary and Eddie Edwards

Joy of Jesus

Camden House

Detroit, MI

Marjorie Gutman

Robert Wood Johnson Foundation

Princeton, NJ

Felice Kirby

Citizens Committee for New York City

New York, NY

Ron LaDue

Blackfeet Community College

Browning, MT

Gloria Martin-Payne

Pennsylvania Department of Health

Harrisburg, PA

June Milam

Developing Resources for Education in Mississippi

(DREAM)

Jackson, MI

Jim Neal

South Carolina Department of Alcohol and Other

Drug Abuse Service

Columbia, SC

Sue Rusche

National Families in Action

Atlanta, GA

Leon West

The Congress of National Black Churches, Inc.

Washington, DC

Ford Kuramoto

Asian American Network

National Asian Pacific American Families Against

Substance Abuse

Los Angeles, CA
F

Appendix F:

Acknowledgments

OTA thanks the members of the advisory panel, conference and workshop participants, contractors, and

the many individuals and organizations that supplied information for this report. In addition, OTA

acknowledges the following individuals for their comments on drafts of this report.

Sally J. Andrade

University of Texas at El Paso

El Paso, TX

Kent Auguston

Substance Abuse and Mental Health Services

Administration

Rockville, MD

Fred Beauvais

Colorado State University

Fort Collins, CO

Philip Benson

Center for Social and Community Development

Piscataway, NJ

Dale Blyth

Search Institute

Minneapolis, MN

Jane Boorman

Small Business Administration

Washington, DC

John Boren

National Institute on Drug Abuse

Rockville, MD

Brenna Bry

Rutgers University

Piscataway, NJ

Tom Burns

Indian Health Service

Albuquerque, NM

Carmen Carrillo

Department of Public Health

San Francisco, CA

Marcia Chaiken

LINC

Lincoln, MA

John E. Collingwood

Federal Bureau of Investigation

Washington, DC

206 I
Appendix F Acknowledgments I 207

Robert Cook-Deegan

Institute of Medicine

Washington, DC

David R. Cundiff

Jefferson County Health Department

Louisville. KY

Judith DeJong

Center for Substance Abuse Prevention

Rockvillc, MD

Philip Diaz

Miami, FL

Ted Dielman

The University of Michigan

Ann Arbor, MI

Karen Dodge

Department of Health and Human Services

Washington, DC

Joy Dryfoos

Hastings-on-Huston, NY

Marty Duckenfield

Clemson University

Clemson, SC

Patricia Durana

Office of Technology Assessment

Washington, DC

Harvey Feldman

Oakland, CA

Susan Galbraith

Legal Action Center

Washington, DC

Carol Giannini-Small

Metropolitan Washington Council of Governments

Washington, DC

Meyer Glantz

National Institute on Drug Abuse

Rockville, MD

Mark Gold

University of Florida

Gainesville, FL

Enoch Gordis

National Institute on Alcohol Abuse and Alcoholism

Rockville, MD

Chris Hansen

Washington Department of Social and Health

Services

Olympia, WA

Adele Harrell

The Urban Institute

Washington. D.C.

Dwight Heath

Brown University

Providence, RI

Leigh Henderson

T. Head and Co., Inc.

Rockville, MD

Stephen Higgins

University of Vermont

Burlington, VT

Gary A. Hill

Conwall, Inc.

Falls Church. VA

Jan Howard

National Institute on Alcohol Abuse and Alcoholism

Rockville, MD

Gail Johnson

General Accounting Office

Washington, DC

Peter Johnson

Office of Technology Assessment

Washington, DC

Steven Jonas

State University of New York at Stony Brook

Stony Brook, NY
208 I Technologies for Understanding and Preventing Substance Abuse and Addiction

Glenn Kamber

Department of Health and Human Services

Washington, DC

Denise Kandel

Columbia University

New York. NY

Linda Kaplan

National Association of Alcoholism and Drug

Abuse Counselors

Arlington, VA

Maureen Kerrigan

Employee Assistance Professionals Association

Washington, DC

Ella Lankford

Bureau of Indian Affairs

Washington, DC

Geoffrey Laredo

Substance Abuse and Mental Health Services

Administration

Rockville, MD

Barbara W. Lex

Harvard University

Cambridge, MA

Stephen Long

National Institute on Alcohol Abuse and Alcoholism

Rockville, MD

Scott Lukas

McLean Hospital

Belmont. MA

William J. McBride

Institute of Psychiatric Research

Indianapolis, IN

Richard A. Millstein

National Institute on Drug Abuse

Rockville, MD

James F. Mosher

The Marin Institute

San Rafael, CA

Thomas H. Murray

Center for Biomedical Ethics

Cleveland, OH

Patricia Tanner Nelson

University of Delaware Cooperative Extension

Newark, DE

Nora Noel

University of North Carolina

Wilmington, NC

E.R. Oetting

Colorado State University

Fort Conings, CO

Patrick O’Malley

Institute of Social Research

Ann Arbor, MI

Constance Pechura

Institute of Medicine

Washington, DC

Judith Peterson

Department of Labor

Washington, DC

Roy W. Pickens

Baltimore, MD

Harold A. Pincus

American Psychiatric Association

Washington, DC

Joel Marus

General Accounting Office

Washington, DC
Appendix F Acknowledgments I 209

Sylvia L. Quinton

Center for Substance Abuse Prevention

Rockville. MD

Mitchell Ratner

Takoma Park. MD

Marilyn Roberts

National Center for State Courts

Arlington, VA

Dorothy Ross

County of Santa Clara Probation Department

San Jose, CA

Sally Satel

Yale University School of Medicine

New Haven, CT

Marguerite Saunders

New York State Division of Alcoholism and

Substance Abuse Services

Albany, NY

Brian E. Sheridan

Department of Defense

Washington, DC

Earle Simpson, Jr.

Office of Substance Abuse

Augusta, ME

Margaret Slinski

University of Massachusetts

Amherst, MA

Sharman Stephens

Department of Health and Human Services

Washington, DC

Susan Stern

Boston University School of Social Work

Boston, MA

Richard Suchinsky

Department of Veterans Affairs

Washington, DC

Doug Thomas

National Center on Juvenile Justice

Pittsburg, PA

Patricia Tice

Strong Museum

Rochester, NY

Rafael Varela

Pinal Hispanic Council

Eloy, AZ

Frank Vocci

National Institute on Drug Abuse

Rockville, MD

Megan Walline

Law Enforcement Coordinating Committee

Washington, DC

James Wilcox

United States Information Agency

Washington, DC

George E. Woody

Philadelphia, PA

Joan Wynn

University of Chicago

Chicago, IL

Washington, DC
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1. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 3d ed. rev. (Washington, DC: APA,

1987).

2. Curie, E., Reckoning: Drugs, the Cities, and

the American Future (New York, NY: Hill

and Wang, 1993).

3. Dumas, K., “War on Drugs Is a Standoff in

the Partisan Trenches,” Congressional

Quarterly, Apr. 6, 1991, p. 58.

4, Institute of Medicine, Treating Drug Problems: Volume 1 (Washington, DC: National

Academy Press, 1990).

5. Retak, R. M., The Mind (Totonto, ON: Bantam Books, 1988).

6. U.S. Bureau of the Census, Poverty in the

United States: 1991, Current Population Reports, Series P-60, No. 181 (Washington,

DC: U.S. Government Printing OffIce,

1992).

7. U.S. Congress, OffIce of Technology Assessment, Adolescent Health-Volume 11:

Background and the Electiveness of Selected Prevention and Treatment Services,

OTA- H-466 (Washington, DC: U.S. Government Printing OffIce, November 1991).

8. U.S. Congress, OffIce of Technology Assessment, Alter-native Coca Reduction StratI 210

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(Washington, DC: U.S. Government Printing Office, July 1993).

9. U.S. Congress, Office of Technology Assessment, Biological Components of Substance Abuse and Addiction, OTA-BPBBS-1 17 (Washington, DC: U.S. Government Printing Office, September 1993).

10. U.S. Congress, Office of Technology Assessment, Border War on Drugs, OTA-O-366

(Washington, DC: U.S. Government Printing Office, March 1987).

11. U.S. Congress, Office of Technology Assessment, The Effectiveness of Drug Abuse

Treatment: Implications for Controlling

AIDS/171V Infection, Aids-Related Issues

Background Paper 6 (Washington, DC: U.S.

Government Printing OffIce, September

1990).

12. U.S. Department of Justice, Office of Justice

Programs, National Institute of Justice, Research in Action, DUF: 1988 Drug Use

Forecasting Annual Report (Washington,

DC: 1990).

13. U.S. Office of National Drug Control Policy,

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tional Drug Control Policy White Paper

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CHAPTER 3: BIOLOGY AND

PHARMACOLOGY

1.

2.

. ? .

4.

-.5

6.

7.

8.

9

1

1

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Blum, K., Noble, E. P., Sheridan, P.J. et al.

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Blum, K., Noble, E.P, Sheridan, P.J. et al.,

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Bohman, M., bbSome Genetic Aspects of Alcoholism and Criminality: A Population of

Adoptees,” Archives of General Psychiatry

35;269-276, 1978.

Bohman, M., Sigvardsson, S., and Cloninger, C. R., “Maternal Inheritance of Alcohol

Abuse. Cross-Fostering Analysis of

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Bolos, A. M., Dean, M., Lucas-Derse, S. et

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Cadoret, R., Troughton, E., and Widmer, R.,

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1981.

Cloninger, C. R., Christiansen, K. O., Reich,

T. et al., “Implications of Sex Differences in

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Cloninger, C. R., Sigvardsson, S., Gilligan,

S.B. et al., “Genetic Heterogeneity and the

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Collins, A. C., and Marks, M. J., “Genetic

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Alcoholism: Clinical and Experimental Research 16:806-809, 1992.

19. De Jong, J. A., and Roy, A., “Paternal Lineage and Cohort Effects,” Addiction

88:623-629, 1993.

20. Di Chiara, G., and North, R. A., “Neurobiology of Opiate Abuse,” Trends in Pharmacological Sciences 13: 185-193, 1992.

22. Frances, R. J., Bucky, S., and Alexopoulos,

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23. Goodwin, D.W., “Alcoholism and Heredity.

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General Psychiatry 36:57-61, 19’79.

24. Griffiths, R. R., and Sannerund, C. A.,

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25. Gurling, H. M.D., Oppenheim, B. E., and

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Acta Genetics Medica 33:333-339, 1984.

26. Guze, S. B., Cloninger, C. R., Martin, R. et

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Comprehensive Psychiatry 27:501 -510,

1986.

27. Harris, R. A., Brodie, M. S., and Dunwiddie,

T. V., “Possible Substrates of Ethanol Reinforcement: GABA and Dopamine,” P.W.

Kalivas and H.H. Samson (eds.), The Neurobiology of Drug and Alcohol Addiction, Annals of the American Academy of Sciences

654:61-69, 1992.

28. Heath, A. C., and Martin, N. G., “Teenage Alcohol Use in the Australian Twin Register:

Genetic and Social Determinants of Starting

to Drink,” Alcohol and Clinical Experimental Research 12:735-741, 1988.

29. Hill, S. Y., Cloninger, C. R., and Ayre, F. R.,

● ’Independent Familial Transmission of Alcoholism and Opiate Abuse,” Alcoholism:

Clinical and Experimental Research 1:335-

342, 1977.

30. Hill, S. Y., “Absence of Paternal Sociopathy

in the Etiology of Severe Alcoholism: Is

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the Study of Alcohol 53(2): 161-169, 1992.

31. Holtzman, S. G., “Caffeine as a Model of

Drug Abuse,” Trends in Pharmacological

Science 11:355-356, 1990.

32. Hwang, B. H., Lumeng, L., Wu, J.-Y. et al.,

“Increased Number of GABAergic Terminals in the Nucleus Accumbens Is Associated With Alcohol Preference in Rats,”

Alcoholism 14:503-507, 1990.

33. Jaffe, J. H., ● *Drug Addiction and Drug

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34. Johanson, C., Woolverton, W. L., and Schuster, C. R., “Evaluating Laboratory Models of

Drug Dependence,” Psychopharmacology:

The Third Generation of Progress, H. Meltzer (cd.) (New York, NY: Raven Press,

1987).

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University of Lund, Department of Psychiatry, 1960 (Cited in D.W. Goodwin, “Genetic

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36. Kaij, L., and Dock, J., “Grandsons of Alcoholics: A Test of Sex-Linked Transmission

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37. Kalant, H., “Behavioral Criteria for Tolerance and Dependence,” The Bases of Addic-

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38. Kalant, H., “The Nature of Addiction: An

Analysis of the Problem,” Molecular and

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40. Kendler, K. S., Heath, A. C., Neale, M.C. et

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41. Koob, G. F., and Bloom, F. E., ‘bCellular and

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42. Koob, G. F., “Drugs of Abuse: Anatomy,

Pharmacology, and Function of Reward

Pathway s,” Trends in Pharmacological Sciences 13: 177-184, 1992a.

43. Koob, G. F., “Neural Mechanisms of Drug

Reinforcement,” P.W. Kalivas and H.H.

Samson (eds.), The Neurobiology of Drug

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1992b.

44. Kreek, M. J., “Medical Safety and Side Effects of Methadone in Tolerant Individuals,”

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46. Lewis, C. E., Rice, J. P., Andreason, N. et al.,

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1 :379-383, 1987.

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49. Luthar, S. S., Anton, S. F., Merikangas, K.R.

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50. Luthar, S. S., Anton, S. F., Merikangas, K.R.

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54. Merikangas, K. R., “The Genetic Epidemiology of Alcohol ism,” Psychology and Medicine 20: 11-22, 1990.

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56. Morgan, W. W., “Abuse Liability of Barbiturates and Other Sedative-Hypnotics,” Ad-

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57. Murphy, J. M., McBride, W. J., Luming, L. et

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58. Noble, E.P. Blum, K., Ritchie, T. et al., “bAllelic Association of the D2 Dopamine

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NY: Plenum, 1985).

Beschner, G., and Bovelle, E., “Life with

Heroin: Voices of Experience,” Life With

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Biernacki, P., Path~’ays From Heroin Addiction: Recovery Without Treatment (Philadelphia, PA: Temple University Press, 1986).

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Bourgois, P., ‘“In Search of Horatio Alger:

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10. Carey, J.T., The College Drug Scene (Englewood Cliffs, NJ: Prentice-Hall, 1968).

11. Carter, W. E., (cd.), Cannabis in Costa Rica:

A Study of Chronic Marijuana Use (Philadelphia, PA: Institute for the Study of Human Issues, 1980).

12. Caven, S., Hippies of the Haight (St. Louis,

MO: New Critics Press, 1972).

13. Cleckner, P.J., “Blowing Some Lines: Intracultural Variations Among Miami Cocaine

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37-42, 1976.

14. Davis, F., “Heads and Freaks: Patterns and

Meanings of Drug Use Among Hippies,”

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15. Dobkin de Rios, M., Hallucinogens: CrossCultural Perspectives (Albuquerque, NM:

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Dunlap, E., “Impact of Drugs on Family Life

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1973.

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23. Feldman, H. W., Muhammad, A., Calica, H.,

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and Improvement of Practice, U.S. Department of Education (Washington, DC, forthcoming).

24. Fields, A. B., “Slinging Weed: The Social

Organization of Street-Corner Marijuana

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25. Fields, A. B., “Weedslingers: Young Black

Marijuana Dealers,” Teen Drug Use,

G. Beschner and A.S. Friedman (eds.) (Lexington, MA: Lexington Books, 1986).

26. Fordham, S., and Ogbu, J., “Black Students’

School Success: Coping With the Burden of

‘Acting White ’,” Urban Review’ 18(2): 177-

205, 1986.

27. Furst, P.T., Hallucinogens and Culture (San

Francisco, CA: Chandler and Sharp, 1976).

28. Glick, R., and Moore, J. (eds.), Drugs in Hispanic Communities (New Brunswick, NJ:

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29. Goldstein, P., ‘* Anabolic Steroids: An Ethnographic Approach,” mimeo (New York, NY:

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30. Grob, C., and Dobkin de Rios, M., b’Adolescent Drug Use in Cross-Cultural Perspective,” Journal of Drug Issues 22(1]:

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31. Hamid, A., “The Political Economy of

Crack-Related Violence,” Contemporary

Drug Problems 17(1 ):3 1-78, 1990.

32. Hamid, A., “From Ganja to Crack: Caribbean Participation in the Underground

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Drugs, Crime, and Social Isolation: Barriers to Urban Opportunity, A. Harrell and G.

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36. Kasarda, J. D., “The Severely Distressed in

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All These Years (New York: Lexington

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40. Mieczkowski, T., ‘bCrack Distribution in Detroit,” Contemporary Drug Problems 17( 1):

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41. Morris, R. W., “Not the Cause, Nor the Cure:

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42. Myerhoff. B. G., Peyote Hunt: The Sacred

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43. Page, J. B., and Smith, P. C., “Venous Envy:

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CHAPTER 8: COMMUNITY

ACTIVITY SElllNGS

1.

2.

3.

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———

4. Andresen, P. A., and Telleen, S. L., “The Relationship Between Social Support and Maternal Behaviors and Attitudes: A MetaAnalytic Review,” American Journal of

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5. Bachman, J. G., Johnston, L. D., O’Malley,

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6. Bailey, S. L., Flewelling, R. L., and Rachal,

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7. Bangert-Drowns, R. L., “The Effects of

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8. Baumrind, D., ‘

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10. Bennett, N. G., Bloom, D. E., and Craig, P. H.,

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15. Berrueta-Clement, J. R., Schweinhart, L. J.,

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19. Blyth, D., Healthy Communities, Healthy

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20. Botvin, G. J., and Wills, T. S., “Personal and

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21. Brannon, B. R., Dent, C. W., Flay, B. R., et al.,

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22. Brindis, C., Morales, S. S., McCarter, V., et

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23. Brook, J. S., Whiteman, M., Gordon, A. S., et

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24. Brunswick, A. F., Messeri, P. A., and Titus,

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27. Bry, B. H., Conboy, C., and Bisgay, K., “Decreasing Adolescent Drug Use and School

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29. Butterfoss, F. D., Goodman, R. M., Wandersman, A., “Community Coalitions for Prevention and Health Promotion,” Health

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30. Buzawa, E. S., and Buzawa, C.G. (eds.), Domestic VioZence (Westport, CT: Auburn

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31. Cahalan, D., Understanding America’s

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32. Carnegie Council on Adolescent Development, A Matter of Time: Risk and Opportunity in the Non-School Hours (New York,

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33. Catalano, R. F., Morrison, D. M., Wells, E. A.,

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34. Cauce, A. M., Comer, J. P., and Schwartz, D.,

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35. Chambers, C. D., Sheridan, B. K., and Willis,

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36. Chassin, L., Pillow, D., Curran, P., et al.,

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37. Christiansen, B. A., Goldman, M. S., and

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38. Clayton, R. R., “Transitions in Drug Use:

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40. Cloninger, C., Bohman, M., and Sigvardsson, S., “Inheritance of Alcohol Abuse:

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. ——

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43. Dangel, R. F., and Polster, R. A., “Winning!

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44. Dembo, R., Blount, W. R., Schmeidler, J., et

al., “Perceived Environmental Drug Use

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45. Dembo, R., Dertke, M., La Voie, L., et al.,

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46. Dishion, T. J., Patterson, G. R., Stoo]miller,

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47. Dishion, T. J., Reid, J. B., and Patterson,

G. R., ‘b

Empirical Guidelines for a Family

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48. Dry foos, J, G., Adolescents at Risk (New

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49. Dumas, J. E., and Wahler, R. G., “Predictors

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50. Dutton, D. G., “The Outcome of Court-Mandated Treatment for Wife Assault: A QuasiExperimental Evaluation,” Violence and

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51. Elliott, D., Huizinga, D., and Ageton, S., E.rplaining Delinquency and Drug Use (Beverly Hills, CA: Sage, 1985).

52. EMSTAR Research, Inc., Inner-City Families in Action Cumulative Evaluation Report. Unpublished research report, Atlanta,

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53. Ennett, S. T., Ringwalt, C. and Flewelling,

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55. Evans, R. I., Rozelle, R. M., Mittelmark,

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Physiological Effects and Coping with Peer

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56. Fielding, J., “Health Promotion at the Workplace,” Work, Health, and Productivity,

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57. Fillmore, K., and Caetano, R., “Epidemiology of Alcohol Abuse and Alcoholism in Occupations,” Occupational Alcoholism: A

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58. Flay, B. R., “Psychosocial Approaches to

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59. Galambos, N. L., “Parent-Adolescent Relations,” Current Directions in Psychological

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60. Gersten, J. C., Beals, J., and Kallgren, C. A.,

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62. Goodstadt, M. S., “Drug education: A Turn

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63. Goodwin, D. W., Van Dusen, K.T., and Mednick, S.A. (eds.), Longitudinal Research in

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64. Gordon, N.P. and McAlister, A. L., Adolescent Drinking: Issues and Research, (New

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65. German, D. M., and Peters, T. J., “Types of

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66. Griffin, T., Svendsen, R., & Benson, P.,

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67. Hansen, W. B., “School-Based Substance

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the Art in Curriculum, 1980- 1990,” Health

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68. Harford, T. C., Parker, D. A., Grant, B. F., et

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69. Harris, L. and Associates, A Catalyst for Action: A National Survey to Mobilize Leadership and Resources for the Prevention of

Alcohol and Other Drug Problems Among

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70. Hawkins, J. D., Catalano, R. F., Jones, G., et

al., ‘*Delinquency Prevention Through Parent Training: Results and Issues From Work

in Progress,” From Children to Citizens:

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York, NY: Springer-Verlag, 1987).

71. Hawkins, J. D., Catalano, R. F., and Kent,

L. A., “Combining Broadcast Media and

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72. Hawkins, J. D., Catalano, R., & Miller, J.,

**Risk and Protective Factors for Alcohol

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73. Hawkins, J. D., Catalano, R. F., Morrison,

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74. Hawkins, J. D., Von Cleve, E., and Catalano,

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75. Higgins, S. T., Budney, A. J., Bickel, W. K., et

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76. Hingson, R., and Mangione, T., “Job Characteristics and Drinking Practice in the Boston Metropolitan Area,” JournaZ of Studies

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78. Iso-Aloha, S. and Crowley, E., “Adolescent

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1993.

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82. Johnson, D. L., and Breckenridge, J. N., “The

Houston Parent-Child Development Center

and the Primary Prevention of Behavior

Problems in Young Children,” American

Journal of Community Psychology 10(3):

1982.

83. Johnson, V., and Pandina, R.J., “Effects of

the Family Environment on Adolescent

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84. Johnson, V., and Pandina, R. J., “Familial

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85. Kandel, D. B., and Davies, M., “Progression

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86. Kandel, D. B., Kessler, R. C., and Margulies,

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Appendix G: References I 231

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123. Rickel, A. U., Smith, R. L., and Sharp, K. C.,

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124. Robins, L. N., and McEvoy, L., “Conduct

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125. Rohrbach, L. A., Hansen, W. B., and Pentz,

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126. Rohsenow, D., Corbett, R., and Devine, D.,

‘bMolested as Children: A Hidden Contribution to Substance Abuse?,” Journal of Substance Abuse Treatment, 5: 13-18, 1988.

127. Roman, P. M., and Trice, H. M., “The Development of Deviant Drinking Behavior:

Occupational Risk Factors,” Archive of En-

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128. Roosa, M. W., Sandier, I. N., Beals, J., et al.,

“Risk Status of Adolescent Children of

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Journal of Communiv Psychology 16(2):

225-239, 1988.

129. Runcie, J. F., ‘*By Day I Make the Cars,” Harvard Business Reviel~’ 58( May/June):

106-115, 1980.

130. Rutter, M., “Maternal Deprivation: New

Findings, New Concepts, New Approaches,” Child Development 50:283-304,

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131. Schaps, E., DiBartolo, R., Moskowitz, J., et

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132. Schinke, S. P., Gilchrist, L. D., and Snow,

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133. Schinke, S., Orkmdi, M. & Cole, K., “Boys

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134. Schonfeld, L., and Dupree, L. W., “Antecedents of Drinking for Early- and Late-Onset

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136. Seaman, F. J,, “The Etiology of Problem

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137. Seeman, M., Seeman, A.Z. , and Budros, A.,

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138. Seitz, V., Apfel, N. H., and Rosenbaum,

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232 I Technologies for Understanding and Preventing Substance Abuse and Addiction

139. Seitz, V., Rosenbaum, L. K., and Apfel,

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140. Shain, M., “Work Site Community Processes and the Prevention of Alcohol Abuse:

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141. Shain, M., and Groeneveld, J., Employee Assistance Programs: Philosophy, Theory, and

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142. Shedler, J., and Block, J., “Adolescent Drug

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143. Sher, K.J., Walitzer, K. S., Wood, P. K., et al.,

“Characteristics of Children of Alcoholics:

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144. Sherman, L. W., and Berk, R. A., “The Specific Deterent Effects of Arrest for Domestic

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145. Silverman, P. R., “Widowhood and Preventive Intervention,” Family Coordinator

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146. Simcha-Fagan, O., and Schwartz, J. E.,

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147. Sisson, R. W., and Azrin, N. H., “FamilyMember Involvement to Initiate and Promote Treatment of Problem Drinkers,”

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148. Slattery, M., Alderson, M. R., and Bryant,

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149. Stanton, M. D., Todd, T. C., The Family Therapy of Drug Abuse and Addiction, (New

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150. Steele, P. D., “Substance Abuse and the

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151. Straus, M. A., and Sweet, S., ● ’Verbal/Symbolic Aggression in Couples: Incidence

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152. Streit, F., and Oliver, H. G., Jr., “The Child’s

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153. Szapocznik, J., Foote, F. H., Perez-Vidal, A.,

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154. Tarter, R. E., Alterman, A. I., and Edwards,

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A Behavior-Genetic Perspective,” Journal

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155. Thompson, E. L., “Smoking Education Programs, 1960- 1976,” American Journal of

Public Health, 1978.

156. Tobler, N. S., “Meta-analysis of 143 Adolescent Drug Prevention Programs: Quantitative Outcome Results of Program

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16:537-567, 1986.

157. Trice, H. M., “Work-Related Risk Factors

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Health & Research World 16(2): 106-111,

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158. Trice, H. M., and Schonbrunn, M., “A History of Job-Based Alcoholism Programs:

1900- 1955,” Journal ofDrug Issues 11(1 2):

171-198, 1981.
Appendix G: References I 233

159. Trice, H. M., and Sonnenstuhl, W. J., “Drinking Behavior and Risk Factors Related to the

Work Place: Implications for Research and

Prevention,” Journal of Applied Behavioral

Science 24:327-346, 1988.

160. Tubman, J. G., “A Pilot Study of Family Life

Among School Age Children of Problem

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161. U.S. Congess, General Accounting Office,

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162. U.S. Congress, General Accounting Office,

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163. U.S. Congess, General Accounting Office,

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164. U.S. Department of Health and Human Services, National Institute on Drug Abuse, National Household Survey on Drug Abuse,

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165. U..S. Department of Health and Human Services, National Institute on Drug Abuse,

“Female Crime Victims with Stress Disorder More Likely to Abuse Drugs,” NIDA

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166. U.S. Department of Health and Human Services, OffIce of Substance Abuse Prevention, Signs of E~ectiveness: The High-Risk

Youth Demonstration Grants, (Rockville,

MD: OSAP, 1992).

167. U.S. Department of Labor What Works:

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1991.

168. Vachon, M. L. S., Lyall, W. A. L., Rogers, J., et

al., “A Controlled Study of Self-Help Intervention for Widows,” American Journal of

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169. Valliant, G. E., The Natural History of Alcoholism (Cambridge, MA: Harvard University Press, 1983).

170. Wahler, R. G., and Dumas, J. E., “Stimulus

Class Determinants of Mother-Child Coercive Interchanges in Multidistressed

Families: Assessment and Intervention,”

Prevention of Delinquent Behavior, J.D.

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171. Walsh, D. C., Hingson, R. W., Merrigan,

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325(1 1):775-782, 1991.

172. Way, N., Stauber, H. Y., Nakkula, M. J., and

London, P., Social Class Differences in the

Relationship Betw~een Hopelessness, Depression, and Substance Use, paper presented at the biennial meeting of the Society

for Research in Child Development, Seattle,

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173. Werner, E. E., “Vulnerability and Resiliency

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174. Wills, T. A., Vaccaro, D., and McNamara, G.,

“The Role of Life Events, Family Support,

and Competence in Adolescent Substance

Use: A Test of Vulnerability and Protective

Factors,” American Journal of Community

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175. Wolfson, A., Lacks, P., and Futterman, A.,

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234 I

176.

177.

178.

179.

Technologies for Understanding and Preventing Substance Abuse and Addiction

Wright, J. M., Chemical Dependency and

Violence: Working With Dually A@ected

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Wyman, P. A., Cowen, E. L., Work, W. C., et

al., “Developmental and Family Milieu Correlates of Resilience in Urban Children Who

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American Journal of Community Psychology 19(3):405-426, 1991.

Yandrick, R. M., “Taking Inventory,” EAPA

Exchange, 22-29, .July 1992.

Zigler, E., and Muenchow, S., Head Start,

(New York, NY: BasicBooks, 1992).

APPENDIX A: DRUG CONTROL POLICY

IN THE UNITED STATES: HISTORICAL

PERSPECTIVES

1.

2.

3.

4.

5.

6.

7.

8.

9.

Bennett, L., and Ames, G. M., (eds.), The

American Experience with Alcohol: Contrasting Cultural Perspectives (New York,

NY: Plenum Press, 1985).

Executive Office of the President, Office of

National Drug Control Policy, NationaZ

Drug Control Strategy, (Washington, D. C.,

January, 1992).

Harrell, A., The Evolution of the War on

Drugs (Urban Institute, draft, 1993).

Heath, D., personal communication, 1993.

Himmelstein, J., The Strange Career of

Marihuana: Politics and Ideology of Drug

Control in America (Westport: Greenwood

Press, 1983).

Kreek, M.J., “Epilogue: Medical Maintenance Treatment for Heroin Add iction, from

a Retrospective and Prospective Viewpoint,” State Methadone Maintenance

Treatment Guidelines (Office for Treatment

Improvement, Division for State Assistance, November, 1992, pp.255-272).

Long, S. W., personal communication, 1993.

Morgan, H. W., Drugs in America: A Social

History, 1800-1980 (Syracuse, NY: Syracuse University Press, 1981 ).

Musto, D. F., The American Disease: Origins

of Narcotic Control (Expanded Edition)

10.

11.

12.

13.

14.

15.

16.

17.

(New York, NY: Oxford University Press,

1987).

Musto, D. F., “Opium, Cocaine and Marijuana in American History,” Scientific American, 285: 40-47, 1991.

Peele, S., Diseasing of America: Addictior.

Treatment Out of Control (Boston, MA:

Houghton Mifflin Co., 1989).

Preble, E., and Casey, J. J., “Taking Care of

Business: The Heroin User’s Life on the

Street,” International Journal of Addictions

4 (March): 1-24, 1969.

Rorabaugh, W. J., The Alcoholic Republic:

An American Tradition (New York, NY: Oxford University Press, 1979).

Starr, P., The Social Tran~formation of

American Medicine (New York, NY: Basic

Books, Inc., 1982).

Strong Museum, Altered States: Alcohol and

Other Drugs in America (Rochester, NY:

1993).

Wells, T., and Triplett, W., Drug Wars: An

Oral History From the Trenches (New York,

NY: William Morrow and Co., Inc., 1992).

Zimring, F. E., and Hawkins, G., The Search

for Rational Drug Control (Cambridge, UK:

Cambridge University Press, 1992).

APPENDIX B: FEDERAL PROGRAMS:

PREVENTION AND CAUSATION

1.

2.

U.S. Department of Education, A Study of

the Drug-Free Schools and Communities

Act, Report on State and Local Programs:

Executive Summary, prepared under contract

by Research Triangle Institute, contract No.

LC88028001 (Research Triangle Park, NC:

January 1992).

U.S. Department of Health and Human Services, Public Health Service, Alcohol Drug

Abuse, and Mental Health Administration,

National Institute on Alcohol Abuse and Alcoholism, Alcohol and HeaZth, Seventh Special Report to the U.S. Congress (Rockville,

MD: January 1990).

3. U.S. Office of Personnel Management, Sixth

Annual Report to Congress on lltle VI of
Appendix G: References I 235

Public Law 99-570, Federal Employee Substance Abuse Act of 1986, Fiscal Year 1991,

OPM Document OLRQP-2 (Washington,

DC) October 1992.

APPENDIX C: PERSPECTIVES ON

DEFINING SUBSTANCE ABUSE

1.

2.

Babor, T. F., Kranzler, H. F., Lauerman, R. J.,

“Social Drinking as a Health and Psychosocial Risk Factor: Anstie’s Limit Revisited,”

Recent Developments in Alcoholism, M. Galanter (cd.) (New York, NY: Plenum Press,

1987).

Kranzler, H. R., Babor, T. F., Lauerman, R. J.,

“Problems Associated with Average Alcohol Consumption and Frequency of Intoxication in a Medical Population,” A/-

-.3

40

5.

6.

coholism: Clinical and Experimental Research, 14: 119-126, 1990.

Mosher, J. F., Jernigan, D. H., “New Directions in Alcohol Policy,” Annual Review

Public Health 10:245-79, 1989.

Room, R., ‘*Alcohol Control and Public

Health,” Annual Re\ie\i Public Health

5:293-317, 1984.

Sanchez-Craig, M., Israel, Y., “Pattern of Alcohol Use Associated with Self-Identified

Problem Drinking,” Public Health Reports,

75: 178-180, 1985.

Vegega, M., Program Manager, Office of Alcohol and State Programs, U.S. Department

of Transportation, National Highway Traffic

Safety Administration, Washington, DC,

personal communication, Feb. 19, 1993.
I ndex

A

AA (Alcoholics Anonymous), 179

AAMCO Transmissions, 73

Abt Associates, 38

abuse liability

determination of, 48

abuse liability assessment

federal role, 49

manufacturer’s role, 49

ACTION, 185

addiction

prevention, treatment, 24

root causes, 25

addictive substances, reinforcing properties, 80

Administration on Children, Youth, and Families

(ACYF)

policy options for Congress, 174

adolescent substance abuse

behavioral problems, 77-78

role of family, 1 37–139

adoption studies

alcoholism, 2, 52

antisocial personality disorder (ASDP), 53

Denmark, 52-53

distinguishing between biological/cultural transmission, 52

Africa, 99

African American

drug use among, 138-139

see also blacks

Aid to Families With Dependent Children, policy

options for Congress, 174

AIDS, 1,39, 121, 127, 162, 182

Alaska, 181

Alaska Natives, 95

alcohol

advertising, 68

availability, 2,7–9, 58

classification, 30

development of physical dependence on, 50

development of tolerance to, 47,50,73

DSM classifications, 197-198

ethnographic studies, 121–123, 129

gateway hypothesis, 74

genetic factors related to use of, 2,7,50

initiation of use, 74

marketing strategies, 8, 66

minimum drinking age, 182

ONDCP, 166

OTA survey on availability, 62--63

physiological effects, 3,73

policy options for Congress, 168

reinforcing actions of, 50

stepping stone hypothesis, 74

subjective availability, 62

taxation, 60,68-69, 175–176

testing for presence of, 194

warning labels, 176, 182

alcohol and drug abuse block grant, policy options

for Congress, 168-170

alcohol dehydrogenase, 90,92

Alcohol, Drug Abuse, and Mental Health

Administration (ADAMHA)

policy options for Congress, 168

reorganization, 188

alcohol use

Asians, 99

blacks, 91,99

delinquency and crime, 111-112

depressive disorder caused by, 34

economics, 107

expectations and effects of, 79

Hispanics, 91

men, 87–91

mental disorders, 114

Native American Indians, 95-98

NHSDA statistics, 35-36,87

OTA review of school-age use, 147-149

physical and sexual abuse, 112

poverty, 107

public health model, 195

racial and ethnic differences in, 93

seventh and eighth graders, 143

stages in cycle of use, abuse, and addiction, 76

U.S. history of, 177-183

whites, 91

withdrawal syndrome associated with, 47

YOUth, 86-87

236 I
Index I 237

alcohol use disorders

Diagnostic and Statistical Manual of Mental I)iSorders (DSM), 1 !&l 97

alcoholic beverages, federal excise taxes on, 60-61

Alcoholics Anonymous (AA), 179

alcoholism

adoption studies, 43, 52–54

Denmark, 52-53

familial tendency of, 51

genetic component of, 50

twin studies, 52

type 1, 53

type 2, 53

type 3, 53

aldehyde dehydrogenase, 92

American Conservation Corps, 143

American drinking patterns, 122

American Protestantisrn, 179

American Psychiatric Association (APA), 34, 195

arnobarbital, 3

amphetamines

development of tolerance to, 46

DSM abuse criteria, 196

expectations and effects of, 79

Ford Administration, 181

mental disorders, 114

OTA survey on availability, 63

stimulants, 4, 31

withdrawal syndrome associated with, 47

Amytal, 3

anabol ic steroid, 127

analgesics, 32

animal genetic models

substance and alcohol abuse, 54

animal models,

evaluation of drug abuse potential using, 49

evaluation of physical dependence and tolerance

using, 50

heredity of substance abuse, 54

study of alcoholism using, 5&51

Anslingcr, Harry, 179

Antidrug Abuse Act, 18, 24, 182, 192

antisocial personality disorder (ASPD)

alcohol ism, 53

opiate use, 51

anxiolytics, 3, 30

Arkansas, 58

Asian Americans

alcohol USC, 103

definition of tcml, 103

Makaha elementary school (prevention program),

104

Na Keiki Oka Aina (Children of the Land), 104

prevention programs, 104

psycho/cultural antecedents, 104

quaalude USC, 103

substance use, 11

Asian Indians, 103

Asians, alcohol dchydrogenase, 93

aspirin, 138, 178

Association of Junior Leagues and of Girls, Inc.,

159

attention deficit hyperactivity disorder, 54

autism, 54

availability

as precondition to drug abuse and dependence,

7-8,57

definition, 57

economic, 57

effects on frequency and quantity of substance

use, 78

environmental factors, 195

policy options for Congress, 175-176

research 1 imitations, 75

social, 57

subjective, 57

Bahamas, 79

B

barbiturates

development of tolerance to, 47

Ford Administration, 181

mental disorders, 114

OTA survey on availability, 63

sedative, 3, 30

use among youth, 86

“Baseball”, 66

Bayer Company, 67, 180

beer

a case history, 75

alcoholic beverage, 3

case of availability, 75

problem behaviors, 77-78

progression of use, 8, 80

taxes, 175

behavioral pharmacology, definition, 196

behavioral problems, stages in, 77-78

Bengalis, 103

Bennett, William J., 19, 28, 182

Benson, Peter, 117

benzodiazepincs, withdrawal syndrome associated

with, 47

biological factors contributing to substance use,

abuse, and addiction, 43

biological preconditions, need for further research,

75

biological susceptibility to drugs, 50,55

“black poison”, 66

blacks
238 I Technologies for Understanding and Preventing Substance Abuse and Addiction

adolescent drug use, 99

alcohol use, 99–100

cigarette use, 99

cocaine use, 100

discrimination, 13–15

diversity among, 99

drug use by, 91,92

historical perspective, 99

marijuana use, 100

prevention programs aimed at, 100

psychosocial/cultural antecedents, 100

see also African Americans

blood alcohol concentration (BAC), 194-195

blood analysis, 194

Bolivia, 122

Bonsack, James A., 59

Boume, Peter, 181-182

Boy Scouts, 159

BOyS Clubs, 157, 100

Brady, 196

brain

how drugs affect the, 43-44,55

physiological effects of addictive substance:

the, 73

site of drug action, 55

brain reward system

cocaine-seeking behavior, 54

explanation of, 46

heredity of neurons that control, 54

role in substance abuse, 2

stimulation of, 45,56,73

Brazil, 124

breath tests, alcohol, 194-195

Brown, Lee P., 182

“Brown Wrapper”, 66

bulimia nervosa, 140

Bureau of Indian Affairs (BIA), 186, 189

Bureau of Justice Assistance (BJA) 190-191

Bureau of Labor Statistics, B–9

Bureau of Narcotics,

Bush, President George

drug policy, 19,24, 182

c

Cabinet Secretaries, U. S., 182

caffeine

ethnographic studies, 129

in coca-cola, 177

withdrawal syndrome associated with, 47

California, 58, 101, 103, 104, 194

California

East Los Angeles, 126

Los Angeles, 143, 149, 190

Oakland, 1231

San Francisco, 105

Camden House, 145

Canada, Alberta, 99

cancer, 127

cannabis

progression in use across substance classes, 76

withdrawal syndrome associated with, 47

THc, 3,30

Carnegie Council on Adolescent Development, 159

Carnegie Council’s Task Force on Youth

Development and Community Programs, 159

Carter Administration, 181

Carter, President, 181

Centers for Disease Control, see Centers for Disease

Control and Prevention (CDCP)

Centers for Disease Control and Prevention (CDCP)

community substance abuse prevention program

161-162

policy options for Congress, 174

Center for Substance Abuse Prevention (CSAP)

black substance abuse prevention programs, 100

description of, 1871

s on DOT collaboration, 190

FBI collaboration, 190

Hispanic prevention programs, 102

policy options for Congress, 168, 174-175

prevention programs, 161–163

Central America, 101

chewing tobacco, 3, 30

child protective services, 144

Chiidren of Alcoholics Foundation, 115

China, 178

Chinese immigrants, 13,91, 103–104

chlordiazepoxide hydrochloride, 3

cigarette broadcast advertising ban, 68

cigarette use

blacks, 99

escalation in the United States, 79

influence on later substance problems, 78–79

men, 88

Native American Indians, 97

NHSDA 1991 statistics, 87

problem behaviors, 77–78

women, 88

youth age 12 to 17,86-87

cigarettes

ease of availability, 75

economic availability, 60

gateway hypothesis, 74

nicotine, 3, 30

per capita consumption, 61

progression of use, 8,80

taxes, 175

Cities–in-Schools, 152–153
Index I 239

Civil War, 99

Clinton, President

drug policy, 168, 183, 192

Cloninger, C. R., 53

Coca-Cola, 177

cocaine

availability, 182

development of tolerance, 46

ethnographic studies, 123–1 24

Ford Administration, 181

free–base, 79

initiation of use, 74

major events in combatting use, 24

marketing strategies, 66

NHSDA 1988 and 1990 data, 92

OTA survey on availability, 61

policy options for Congress, 168

President’s National Commission on Marijuana

and Drug Abuse, 181

progression in use across substance classes, 76

pseudomedical preparations, 177

psychoactive substances, 4,26,30-33

Reagan Administration, 182

reinforcing effects, 53

schedule–2 drugs, 181

self–administration in animals, 196

social availability, 61

techniques of use, 79

withdrawal syndrome associated with, 47

cocaine-seeking behavior

dopamine-containing neurons and receptors in

the brain, 54

cocaine use

blacks, 91

entertainers, 127

family studies, 52

high school seniors, 61

in the sixties and seventies, 181

in the 1980s, 182

men, 88–9 1

mental disorders, 114

middle– and working-class individuals, 132

poor, 129

racial and ethnic minorities, 91

socioeconomic status, 107

survey findings, 34

whites, 91

women, 88–91

youth, 86-87

cold pills, 138

College on Problems of Drug Dependence (CPDD),

abuse liability testing, 89

college students, substance use among, 76

Colombia, 124

Colombia, the Aritama of, 122

Colorado, 144

combatting drug abuse, historical perspective of

federal role, 24

Comitas, Lambros, 124

community activity settings

policy options for Congress, 172-175

substance use and prevention of use, 12

Community Anti–Drug Coalitions of America

(CADCA), 161

Community Coalitions Against Crime, 162

Community Health Centers (CHCS), policy options

for Congress, 168

Community Partnership Program, 152, 161-162

Comprehensive Drug Abuse Prevention and Control

Act, 18,24,48, 181

“Conan”, 66

concordance rate, as a genetic component indicator,

<?

conditioned withdrawal, 55

conditioning

drug-seeking, –using behavior, 55

drug withdrawal, 55

Congress, U.S.

broadcast advertising ban for cigarettes, 68

cigarette and alcoholic beverage labeling, 69

historical role in drug policy, 24

Member of, 37

national drug policy, 23

Office of Technology Assessment, 23,25

policy options for, 19-22, 165–176

Harrison Act, 178

see also specific committees

Congress of National Black Churches (CNBC), 101

Congressional Budget Office (CBO), research

funding cuts, 172

Connecticut

New Haven, 142

Waterbury, 58

Constitution, U.S.

18th Amendment, 19, 178

21st Amendment, 19, 178

continuation of substance use, 76

Cooperative Extension Service, 175

Costa Rica, 124

costs, spending

ACTION, 185

biomedical research, 171-172

data collection, 170

DOD, 185

DOE, 185-187

DOJ, 190-191

DOL, 192

Drug-Free Schools and Communities Act, 1731

employee assistance programs (EAPs), 185

federal antidrug spending, 166
240 I Technologies for Understanding and Preventing Substance Abuse and Addiction

HHS, 187-189

to society, 1,23, 175–176

cough medicine, 138

crack cocaine

appearance in the eighties, 182

cocaine alkaloid, 4

intravenous drug users, 131

marketing strategies, 66

NHSDA 1988 and 1990 data, 92

OTA survey of availability, 63

progression in use across substance classes, 76

racial differences in use, 93

socioeconomic status, 107

subculture, 129–1 30

techniques of use, 79

use among subcultures, 126-127

use by blacks, 92

use by Hispanics, 92

use by whites, 92

use by youth, 86-87

use by the poor, 129–130

crack houses, 74, 130

crack use patterns, 131

Crime Control Act, 182

criminal behavior as a risk factor, 11 1–112

criminal justice, definition of substance abuse, 194

criminal justice mode], 34

Cuba, 101

Cubans, 101

cycles of use, abuse, and addiction

regression, 76-77

cessation, 76-77

relapse, 76-77

Cylert, 4

cystic fibrosis, 50

D

Declaration of Independence, 178

Delaware, 191

delinquent peer group bonding (DPGB), 111-112

demand reduction

ONDCP, 167

policy options for Congress, 166

Reagan Administration, 182

demographic variables, 92

Denmark

alcoholism research, 52–53

adoption studies, 52–53

Department of Agriculture

policy options for Congress, 175

Department of Defense, 185

Department of Education (DOE)

DOT collaboration, 193

drug abuse prevention efforts, 185-187

FBI collaboration, 190

policy options for Congress, 168, 173

Department of Health and Human Services (HHS)

DOE collaboration, 187

DOT collaboration, 193

role in abuse liability determination, 48

Department of Housing and Urban Development

(HUD)

community substance abuse prevention, 162

drug abuse programs, 189

policy options for Congress, 174-175

risk reduction programs, 143

Department of Interior, 175, 186, 189

Department of Justice, 36

interdiction efforts, 190

SBA collaboration. 193

Department of Labor ‘

drug abuse programs, 192

EAPs, 156-157

policy options for Congress, 174

SBA collaboration, 193

Department of State, 178

Department of Transportation (DOT)

deterrence and prevention programs, 193

Department of Treasury, 179

dependence

definition, 47

drug, 25

DSM criteria, 197

physiological factors, 73

psychological factors, 73

Depression, the, 19

Dexedrine, 4

dextroamphetamine, 4

Diagnostic and Statistical Manual of Mental

Disorders (DSM), 34,38, 195-198

diazepam, 3

dispositional tolerance, 48

Dodge, Karen, 111

Dominicans, 101, 102

dopamine

brain reward system. 45

inherited differences’ in dopamine system, 54

neurotransmitters, 44

dopamine receptor, genetic regulation, 54

dopamine response, acute tolerance to, 47

drug abuse research

ethnicity, 125

specificity in, 125

drug abuse

biological components of, 43

drug consumption, 25

prevention, 165-166

risk and protective factors, 25–27
Index I 241

Drug Abuse Resistance Education (DARE)

Department of Defense, 185

Department of Interior, 189

Department of Justice, 190

effectiveness of, 1 49–151

policy options for Congress, 173

Drug Abuse Warning Network (DAWN), 36-38,

162, 188

Drug Alliance Program, 185

drug classification, Comprehensive Drug Abuse

Prevention and Control Act of 1970, 181

drug consumption, three levels of, 25

drug CZar

creation of, 8, 24

ONDCP, 182, 192

policy options for Congress, 167

drug dealers, generated income, 105-106

Drug Demand Reduction Program (DDRP), 190

Drug Evaluation Committee (DEC), abuse liability

testing, 49

Drug Enforcement Administration (DEA)

creation of, 19, 24, 181

drug classification, 181

role in substance regulation and policy, 48

spending, 190

drug-free schools, policy options for Congress,

169-170, 173-174

Drug-Free Schools and Communities Act of 1986,

151, 185-187

drug markets

flagrant, 60, 67–68

open–air, 67–68

private, 60,67-68

drug paraphernalia, 64-65,66

drug screening and testing to determine abuse

liability, 48, 49

drug use

experimental, 28

in social isolation, 128

public health model, 195

with partners and peers, 128

drug use disorders, DSM, 196-197

Drug Use Forecasting System (DUF), 36-38, 162

drugs

abuse potential of, 43

OTA survey on availability, 62-63

E

early substance use, 75

economic availability of substances

effect of federal, state, and local taxes, 60-61

prices, 57

economics

as a risk factor, 105

drug dealers, 105-106

educational level, 107

employment status, 107

generated income, 105

household income, 107

housing, 107

poverty, 106

socioeconomic, status, 10G107

ecstacy (MSDA), 128

Edwards, 196

Egypt, 124

El Salvador, 101

El Salvadorian 102

emphysema, 69

employee assistance programs (EAPs), 156-157,

185

Employee Substance Abuse and Treatment Act of

1986, 185

Employment Training and Education

Administration, 187

environmental factors

effects on values, attitudes, and behavior, 121

research limitations, 75

role in substance abuse, 2

environmental stimuli leading to drug use, 55–56

ethanol, 90

ethnic background, 123

ethnic differences in substance use, 9–12, 91–105

ethnic groups, social context of drug use, 125–126

ethnic minorities, link with drug use, 91

ethnicity

as a risk factor, 9–12

quantitative research, 125-126

ethnographic techniques, 16, 121

ethnographic studies

alcohol, 12 1–123

cocaine and crack, 123–1 24

future research, 132-113

hallucinogens, 124

heroin, 123

inclusiveness in, 126

marijuana, 124

phencyclidine (PCP), 125

ethnography

definition, 121-122

European trappers and settlers, 96

excise taxes

alcoholic beverages, 60

motor fuels, 60

tobacco, 60

F

families

prevention of substance abuse, 15-16, 137-145
242 I Technologies for Understanding and Preventing Substance Abuse and Addiction

role in substance abuse, 15–16, 137–145

family studies

alcohol use, 2, 7, 50-51

cocaine use, 52

opiate use, 5 1–52

sedative–hypnotic use, 52

Federal Bureau of Narcotics, 179, 190

federal legislation

prohibiting sale of paraphernalia, 65

see also specific legislation

federal regulation of substances, 48

fetal alcohol syndrome, 162

Filipinos, 103

first usc of substances, age of, 78

Florida, 191

Florida

Governor of, 182

Miami, 101, 125–126

Food and Drug Administration (FDA)

drug classification, 181

role in substance regulation and policy, 48

Ford Administration, 181

4-H program, policy options for Congress, 175

France, 74-75

Frezza, Mario, 90

Fund for the Improvement of Postsecondary

Education, 186

G

gamma amino butyric acid (GABA)

brain reward system, 45

inherited differences in, 54

neurotransmitters, 44

gangs

Arkansas, 58

California, 58

Canton, MS, 58

Chicago, IL, 59

Davenport, IA, 59

East Los Angeles, CA, 126

ethnographic studies, 126

Memphis, TN, 58

Paducah, KY, 58

Philadelphia, PA, 59

role in marketing and trafficking, 58-60

Waterbury, CT, 58

gasoline, 32,35,97

gateway hypothesis, 74

gateway drugs, 147

gender differences in substance use, 87-91

General Accounting Office, US

community–based substance abuse prevention,

162

drug abuse research, 19,

Drug-Free Schools and Communities Act spending, 150

organized youth activities, 160-161

teenage smoking and excise taxes, 69

workshop on federal drug strategies, 184

genetic factors of drug abuse, 2,7,50-56,95

genetic linkage analysis

drug dependency, 54

Georgia

Atlanta, 143, 168, 182

Northern District of, 191

German immigrants, 14

gin, 3

Girl Scouts, 157

Girls Clubs, 100, 157

glaucoma, 127

glue, 32,35,97

glutamate, 44

‘*Gofer”, 66

“grass”, 3

Gross, 196

Guamanians, 103

Guatemala, 101

Guatemalans, 102

H

Hague, the, 178

hallucinogens

classification, 31

DSM abuse criteria, 197

ethnographic studies, 124

marketing, 58

mental disorders,

social context of use, 127

socioeconomic status, 107

use among youth, 86

Hamid, Ansley, 123

hard liquor

alcoholic beverages, 3

problem behaviors, 78

progression of use, 8,80

Harrison, Representative Francis Burton, 178

Harrison Narcotics Act, 19,24, 178

Harvard School of Public Health, 157

hashish

cannabis, 3

NHSDA 1991 statistics, 87

oil, 3

use among youth, 86

Hawaii

Governor of, 187

Kauai, 116

Oahu, 104

Hawaiians, 103
Index I 243

head shops, 64-65

Health Resources and Services Administration, 168

heart disease, 69

hepatitis, 34, 162

heroin

availability, 182

Carter Administration, 181

death penalty, 180

ethnographic studies, 123, 131

Ford Administration, 181

illegality of, 26

marketing, 66

Narcotics Control Act of 1956, 180

opiate 180

OTA survey on availability, 63

policy options for Congress, 168

progression in use across classes of substances,

76

pseudomedical preparations, 177

Reagan Administration, 182

heroin use

drug houses, 128

men, 88

NHSDA 1988 and 1990 data, 92

poor, 129-130

social context, 127

subcultures, 126

women, 88

youth, 86-87

high-risk youth demonstration grants, 175

“Hinkley”, 66

Hispanics, substance use, 11,91,92, 100-102

HIV transmission, 131, 162

Hoover, President, 179

“horse”, 3

House Committee on Government Operations, 25,

28

Household Survey (see National Household Survey

on Drug Abuse)

Huntington’s disease, 50

hypnotics

classification, 30

expectations and effects of, 79

I

illegal drug use

survey findings, 34-37

illicit drug use

among blacks, 99

among Native American Indians, 97

among youth, 96

Illinois

Chicago, 59, 125-126, 143

Hillsboro, 65

Jacksonville, 65

Indian Health Service (IHS), 187, 189

Indiana

Brownstown, 65

Indianapolis, 152

Marion County, 152

South Bend, 65

inhalants

classification, 32

DSM abuse criteria, 197

legality of, 26,28

Native American Indians, 97-98

ONDCP, 167

OTA survey on availability, 63

psychoactive substances, 5

socioeconomic status, 107

use of, 35

youth, 86-87

inhalation of drugs, 45

initiation of substance use, 76

initiation of use of addictive substances, 74

inner-city communities

crack use, 132

substance abuse, 129–1 30, 13 1–132

International Classification of Diseases (ICD), 34,

196-197

International Opium Commission, 178

intravenous administration of drugs, 44-45

intravenous (IV) drug users, 131, 182

Iowa, Davenport, 59

Irish immigrants, 13

Israel, 74

J

Jamaica, 124-125

Japan, 95

Japan, the Takashima of, 122

Japanese, 103

Job corps, 143, 192

Job Training Partnerships Act, 192

Joy of Jesus, 142

judicial penalties, in response to dmg availability,

63

“Just Say No,” 182

K

Kentucky

Barbourville, 64

Frankfort, 64

Nicholasville, 65

Paducah, 58

“Keys to St. E.’s”, 66

Koreans, 103-104
244 I Technologies for Understanding and Preventing Substance Abuse and Addiction

L

la raza, 101

labeling

alcohol products, 69

antinarcotic and pharmaceutical, 178

tobacco products, 69

Latin America, 101, 180

Latino, 101

law enforcement to curb availability, 63

Law Enforcement Coordinating Committee,

(LECC), 191

learning

conditioning, 55

drug craving, 55

during drug-taking activities, 55

legalization, drug, 20, 166

Librium, 3

local educational agencies (LEAs), 186

LSD (see lysergic acid diethylamide)

lung cancer, 69

lysergic acid diethylamide (LSD), 31

ethnographic studies, 124-125, 132

social context of use, 127

withdrawal syndrome associated with, 47

M

Maine, 194

marijuana, 26, 30

availability, 182

cannabis, 3

Carter Administration, 181

chemotherapy, 181

Comprehensive Drug Abuse Prevention and Control Act of 1970, 181

criminalization of, 74

decriminalization, 181

ethnographic studies, 124, 132

Ford Administration, 181

gateway hypothesis, 74

glaucoma, 181

Narcotics Control Act 1956, 180

OTA survey on availability, 63

policy options for Congress, 168

President National Commission on Marijuana

and Drug Abuse, 181

problem behaviors, 77-78

Reagan Administration, 182

social availability, 61

stepping stone hypothesis, 74

Marijuana Tax Act, 14, 19,24,91, 178, 179

marijuana use

adolescents, 77

age of initiation, 78

black jazz musicians, 91

during the 1960s and 1970s, 180

high school seniors, 61

history of use in the United States, 178

mental disorders, 114

Mexican immigrants, 91

National Household Survey on Drug Abuse, 87,

92

poverty, 107

problem behaviors, 77

progression of, 80

social context of, 127

YOUth, 8687

marketing of drugs, 7–8, 57,63-64,75,78, 196

marketing strategies

place, 66,67-68

pIiCf3, 6667

product, 66

promotion, 65-66

Martinez, Robert, 182

Maryland

Baltimore, 105

Rockville, 168

mass communications definition of substance abuse,

194

Maternal and Child Health Block Grant, policy

options for Congress, 173

MDMA (ecstacy), 4, 128

Medicaid

policy options for Congress, 173-174

school–age children substance use, 152

medical model, 34, 180

Medicare, 174

men, substance use among, 87–91

mescaline

ethnographic studies, 124

hallucinogen, 4

mesocorticolimbic pathway (MCLP)

brain reward system, 46

diagram of, 46

methadone, 180

Methadrine, 4

methamphetamine, 4, 196

methaqualone

hypnotics, 3

use among youth, 86-87

methylphenidate hydrochloride, 4

Mexican marijuana use, 14, 178-179

Mexico, 124

Mexico, Oaxaca, Juxtlahuaca, 122

Michigan, 18,24

Michigan

Barboo, 65

Detroit, 142, 145, 153

University of, 36
Index I 245

Micronesia, the Ifaluk of, 122

Midwest Prevention Project, 143, 152

military, 143

Mine Safety and Health Administration, 192

Minnesota, Minneapolis, 98

Mississippi, Canton, 58

Missouri, Kansas City, 143, 152

morphine, 177, 196

Mothers Against Drunk Driving (MADD), 73

“Mr. T“, 66

Mushrooms

ethnographic studies, 124

hallucinogen, 4

N

naloxone, 47

narcotics

expectations and effects of, 79

OTA survey on availability, 63

use in social isolation, 128

Narcotics Anonymous (NA) 145

Narcotics Control Act of 1956, 180

narcotics trade, 178

nasal route of administration, 44

National Adolescent School Health Survey, 103

National and Community Service Programs, 143

National Center for Alcohol and Dmg Information,

175

National Center for Juvenile Justice (NCJJ)

data base of probation administrators, 62

OTA contract to study dmg availability, 57-58

National Citizens Crime Prevention Program, 190

National Clearinghouse for Alcohol and Drug

Information, 187

National College Student Organizational Network

Program, 186

National Dmg Control Strategy, 166-167

National Families in Action, 182

National Federation of Parents, 182

National Health Interview Survey, 1988, 153

National Health Service Corps, policy options for

Congress, 168

National Highway Traffic Safety Administration

(NHTSA), 193

National Household Survey (see National

Household Survey on Drug Abuse)

National Household Survey on Drug Abuse

(NHSDA, National Household Survey)

and the workplace, 153, 155

Asian Americans/Pacific Island Americans, 103

drug monitoring, 36-38

drug use among children, 85-87

National Institute on Drug Abuse, 188

policy options for Congress, 170-171

1988 data, 92, 106-107

1990 data, 92, 100, 106

1991 data, 99

1992 data, 36-38

National Incidence Study, childhood sexual abuse,

113-114

National Institutes of Health (NIH)

policy options for Congress, 168, 171-172

research programs, 187–1 88

tobacco control programs, 187–1 88

National Institute on Alcohol Abuse and Alcoholism

(NIAAA)

Hispanic prevention programs, 102

policy options for Congress, 168-169, 171-172

research program, 187–1 88

National Institute on Dmg Abuse (NIDA)

creation of, 181

ethnographic drug studies, 125

Hispanic drug use, 101

NHSDA, 92

policy options for Congress, 168-169, 173-174

research program, 188–1 89

role in substance control policy, 48–49

Small Business Administration, 193

socioeconomic status variable analysis, 12,

106–1 10

National Institute on Justice, 35–36

National Institute on Mental Health, comorbid

mental disorders and alcohol, dmg disorders, 114

National Institute on Substance Abuse and

Addiction, policy options for Congress, 168

National School Safety Center, 187

National Survey of High School Seniors (National

High School Seniors Survey, Seniors Survey)

Asian/Pacific Island Americans, 103

drug monitoring, 36-38

National Institute on Drug Abuse, 188

policy options for Congress, 170

Native American Indians (American Indians)

cultural diversity, 95, 98

drug use among adolescents, IO- I 1,96-98

introduction to alcohol, 96

Navajos, 118

prevention programs, 98-99

Nembutal, 3

neuroadaptive changes, brain reward system, 56

neurons, 44

neurotransrn itter

definition, 44

role in brain reward system, 45

New Hampshire, Conway, 65

New Jersey, 101

New Jersey, Mount Holly, 65

New Mexico Navajos, 98
246 I Technologies for Understanding and Preventing Substance Abuse and Addiction

New York, 101, 126, 190

New York

New York City, 101, 123, 126, 129

Northern District of, 191

Rochester, 66

Syracuse, 191

New York City Police Commissioner, 183

Nicaragua, 101

nicotine

ethnographic studies, 129

expectations and effects of, 79

techniques of use, 78

tobacco, 3, 30

withdrawal syndrome associated with, 47

nitrites, 32, 86

Nixon, President Richard M.

antidrug abuse campaign, 180, 182

prevention, education, and treatment, 181

War on Drugs, 19,24

nonuse of substances, 75

norepinephrine, 44

Noriega, Gen. Manuel Antonio, 19,24

North Carolina 103

0

Occupational Safety and Health Administration, 192

“007”, 66

Office for Disease Prevention and Health

Promotion, 193

Office of Elementary and Secondary Education, 186

Office of Justice Program (OJP), 190

Office of Juvenile Justice and Delinquency

Prevention (OJJDP), 190--191

OffIce of Management and Budget, policy options

for Congress, 174

Office of National Drug Control Policy (ONDCP)

creation of, 18, 24, 182–183

Department of Labor, 192

description of, 192

federal drug control efforts, 184

policy options for Congress, 19-21, 167-168,

173

Office of Postsecondary Education, 186

Office of Substance Abuse Prevention, 182

Office of Technology Assessment (OTA)

policy issues, 166

related reports by, 39, 44

report on Biological Components of Substance

Abuse and Addiction, 39

scope of report, 1–2, 38

survey of availability, 62-63

survey of community settings, 172

survey of juvenile probation administrators,

62-63

survey of school-age substance use, 147

workshop on federal drug strategies, 20, 184

OffIce of Workplace Substance Abuse Prevention,

193

Oklahoma, Muskogee, 65

Olds, 196

Operation Clean Sweep, 143

opiates

antisocial personality disorder associated with, 51

conditioned withdrawal, 55

development of tolerance, 47

family studies, 52

mental disorders, 114

narcotics, 32

use among youth, 86

opioids

as neurotransmitter, 44-45

methadone, 180

opium, 24, 91, 178

oral ingestion of drugs 44

Oregon, 194

Oregon, Prineville, 65

P

Pacific Island Americans

alcohol use, 103

definition of term, 103

see also Asian Americans

pain killers, use in social isolation, 128

Panama, 19,24

Parents Resources Institute on Drug Education, 182

Pavlov, conditioning experiments, 55

Peace Corps, 143

Pemoline, 4

Pennsylvania

Harrisburg, 64

Philadelphia, 59, 125, 128

pentobarbital sodium, 3

peyote

ethnographic studies, 123

hallucinogen, 4

PCP (see phencyclidine)

pharmaceutical drugs, 127

pharmacodynamic tolerance, 48

pharmacokinetic tolerance, 48

pharmacological equivalence and drug

discrimination, 50

pharmacological precondition, need for further

research, 75

phencyclidine (PCP)

description, 32

ethnographic studies, 125

marketing, 66

NHSDA data, 35
Index I 247

psychoactive substances, 5

use among youth, 8&87

phenmetrazine hydrochloride, 4

physical abuse as a risk factor, 113, 139

physical availability of substances, 57-58

physiological effects of addictive substances, 73

Planned Approach to Community Health (PATCH)

161-162

Post Traumatic Stress Disorder, 139

“pot”, 3

poverty

alcohol use, 107

as a risk factor for substance abuse, 105–1 06, 129

as an indicator of drug use, 37

association with drug use, 121

cocaine use, 107

marijuana use, 107

substance use among those living in, 129

preconditions, need for further research, 75

pregnancy, 69

Preludin, 4

prescription drugs

abuse, 127–1 28

marketing restrictions, 8

nonmedical use, 35

President’s Council on Physical Education, 175

President’s National Commission on Marijuana and

Drug Abuse, 181

prevention

early intervention efforts, 63

of drug use, continuing use, or progression,

72-73

research, 133

prevention programs

blacks, 101

Hispanics, 102

lack of data for basis, 129, 133

Native American Indians, 98

school–based 149–1 51

prohibition

18th Amendment, 19, 24

21st Amendment, 19,24

repeal of, 179

Temperance Movement, 178-179

Project Star, 143

Project 12-Ways, 144

protective factors

definition, 83

of substance abuse and prevention, 26

resiliency, 11 5–117

spirituality, religiosity, 11 7–118

psilocybin, 4

psychedelics, OTA survey on availability, 63

psychoactive compounds

development and testing of, 49

use in treatment of brain disorders, 49

psychoactive pharmaceuticals, use in social

isolation, 128

psychoactive prescription drugs, 129

psychoactive substances, 30-33

psychological effects

of addictive substances, 73

of alcohol, 73

psychotherapeutics, 87,88,92, 107

psychotropic medication, 138

Psychotropic Substances Act of 1978,48

Public Health Cigarette Smoking Act of 1969,68

public health model, 28-29

Public Housing Drug Elimination Program, 189

Puerto Ricans, 102

Puerto Rico, 101, 152

Pure Food and Drug Act, 19,24, 177

Q

quaaludes, 3

quantitative analyses to detect presence of

substances

blood tests, 34

breath tests, 34

urinalysis, 34

R

racism, 99, 130

racial differences in substance use, 9–12, 9 1–105

Rastafarian marijuana distributors, 123

Reagan, First Lady Nancy, 182

Reagan, President Ronald

antidrug spending, 182

war on drugs, 19, 23–24

recreational settings

impact on substance use and abuse, 17, 19,

157-161

policy options for Congress, 174-175

organized youth activities, 157–1 59

recreational use of substances, 80

religious activities as protective factors, 117–1 18,

159

research

areas needing further, 75–76, 104-105

limitations, 75-76

on expectations and effects of substances, 79

policy options for Congress, 166, 170-172

Resolution Trust Corporation, policy options for

Congress, 175

Revolution, American, 178

risk factors

age, 9

biological, psychological, psychiatric, 83

community context, 12, 1 5–17, 1–19
248 I Technologies for Understanding and Preventing Substance Abuse and Addiction

drug dealer, 105-106

economics, 12, 105

gender, 9

individual, 9–1 2, 83

of substance abuse and addiction, 26-27

poverty, 106

social, situational, environmental, 83

risk marker

definition, 54

heredity of alcohol and substance abuse, 54

Ritalin, 4

Robert Wood Johnson Foundation, 157, 161

root causes of substance abuse and addiction, 1–2,

25,28,41

routes of administration of drugs, 44-45

and effects of drugs, 55–56

Rubin, Vera, 124

Rush, Benjamin, 178

Rwanda, 124

Scandinavia, 157

s

school–age children

substance use among, 145–1 53

school–based clinics, 152

schools

community setting for drug abuse, 16-17, 173

policy options for Congress, 173-174

Search Institute, 159

secobarbital sodium, 3

Seconal, 3

sedatives

description, 30

DSM abuse criteria, 197

expectations and effects of, 79

sedative–hypnotics and family studies, 52

self–adm inistration

addiction producing properties, 49

of drugs to stimulate the brain reward system, 45

of injected drugs, 34

self–reporting of drug use, 37

Senate Committee on Governmental Affairs, 25

Senate Committee on Labor and Human Resources,

25

Seniors Survey (see National Survey of High School

Seniors)

sensitization, 46-47, 56

serotonin 44-45

inherited difference, 54

sexual abuse as a risk factor, 113, 139

Shanghai, 178

“smack”, 3

Small Business Administration (SBA), 192-193

SMART Moves, 159

smokeless tobacco, 3, 30, 86

“Smurf”, 66

snuff, 3

social availability of substances, 61

social drinking and tolerance, dependence, 73

socimdtural effects of addictive substances, 74

socioeconomic status (SES), 106-107

socioeconomic variables, 92

sociopathic personality disturbances, 196

South Africa, 124

South Dakota, Sioux Falls, 64

Southeast Asia, 180

Southern Christian Leadership, 191

spending

Antidrug Abuse Act of 1986, 182

Bush Administration, 183

Reagan Administration, 182

see also costs

spirituality as a protective factor, 11 7–118

Sri Lankans, 103

stepping stone hypothesis, 74

stimulants, 31, 86

subcultures

crack, 129

criminal, 128–1 29

ethnographic studies of, 122, 12&l 29

substance–using, 74-76, 121

subjective availability of substances

alcohol, 62

definition, 61

substance

definition, 195

substance abuse

definition, 71

substance abuse and addiction

definitions, 25-26,28

Substance Abuse and Mental Health Services Administration (S AMSA), policy options for Congress, 168

substance use

among minorities, 130

as a precondition to abuse and addiction, 72

early and frequent, 74

expectations and effects of, 79

frequency of, 78

quantity of, 78

substance use disorders

DSM, 19&197

ICD, 198-199

supply reduction

ONDCP, 167

policy options for Congress, 166

Reagan Administration spending, 182

Supreme Court, U. S., 19,24
Index I 249

Surgeon General, U.S.

1984 report on smoking, 68

warnings, 69

susceptibility to drug abuse, 43, 195

Sweden, 157

Swedish Work Environment Fund, 157

sympathomimetics, 32

synapse, diagram of, 45

Taiwan, 95

T

taxes

excise, 60

policy options for Congress, 175-176

tobacco, 68

Techniques for Effective Alcohol Management

(TEAM), 193

techniques of drug administration, 78–79

Temperance Movement, 177-179

tetracetyl morphia, 67

tetrahydrocannabinol, 3, 76

Texas, 101

Texas

Fort Worth, 64

school system, 142

Thais, 103

The Four Worlds Development Project, 99

Thompson, 196

tobacco

advertising, 68

availability, 2–4, 58, 59

control programs, ASSIST, COMMIT, 161–162

economic availability, 60

federal excise taxes on, 60-61

initiation of use, 74

labeling, 69

marketing strategies, 66

ONDCP, 167

policy options for Congress, 168

stepping stone hypothesis, 74

taxation, 68

use by Americans, 35

use by school–age children, 147

tolerance

development of, 46,56

drug, 25

physiological, 73

psychological factors, 73

Tourette’s syndrome, 54

tranquilizers

expectations and effects of, 79

OTA survey on availability, 63

sedatives, 3

use among youth, 86

treatment

in response to drug availability, 63

scope of report, 39

twin studies

alcoholism, 52, 56

distinguishing between biological and cultural

transmission, 52

smoking, 52

u

United States

cigarette use in, 79

drug flow from Asia into the, 180

ethnographic studies of drug abuse, 121–1 22,

124-125, 132-133

FBI agents, 190

history of drug use, 177-183

role of family in substance abuse, 137

studies on initiation of drug use, 74

Urban Institute, 106

urinalysis tests, 34, 145, 162, 194-195

U.S. Attorneys, 191

U.S. Census Bureau, 103

Utah, 194

Valium, 3

v

Vermont, 194

Vietnam, 132

Vietnam War, 180

Vietnamese, 103

Volstead Act, 179

Volunteers in Service to America (VISTA), 143, 185

War on Drugs, 19, 23-24

w

Washington, DC

crack cocaine marketing, 66

heroin marketing, 66

PCP marketing, 66

Washington, Seattle, 125, 143,

welfare programs

policy options for Congress, 174

Webb et al. v. United States, 19

Weed and Seed program, 18, 184, 193

Werner, Emmy, 116

West Indies, 99

whiskey

alcoholic beverage, 3

economic availability, 60

White House, 19, 184

whites

alcohol use, 100

cocaine use, 100

t!? us. GOVER1l’llENT PRDTIITIJG OFFICE: 1994 - 301-804 - 814/27406
250 I Technologies for Understanding and Preventing Substance Abuse and Addiction

drug use ,91-92

marijuana use, 100

Wilsnack, Sharon, 89

wine

alcoholic beverage, 3

ease of availability, 75

progression of use, 8,80

taxes, 175

Winnebago Indians, 98

withdrawal symptoms, 25

withdrawal syndrome, 4&47

women, substance use among, 87–91

workplace

contributions to substance abuse, 18, 155–156

policy options for Congress, 174

World Health Organization, 34, 195

World War II, 88, 180

Wright, Hamilton, 178

Y

Youth Service Corps, 143

Youth Sports Program, 189

z

zero tolerance, 72, 193, 195

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