4 The Influence of Public Understanding and Attitudes on Drug Education and Prevention
Peter Goldberg and Erik J. Meyers
The Historical Context of Modern Drug Education and Prevention Programs
DURING THE LATE 1960s the American public became alarmed by increasing reports of illicit drug use. The use of widely known illicit drugs seemed to have spread beyond the confines of the inner cities and become more evident in all areas of the country, particularly among the young. In addition, a new wave of chemical compounds with sometimes frightening and unintelligible names appeared.
The immediate public reaction was almost universally negative: These illicit drugs, new or old, were inherently "bad," and all use ought to be prevented by every available means. The use of an illicit substance was automatically considered harmful. This societal reaction, however, seems to have been based more on subjective, emotionally held conceptions of what is socially and morally acceptable than on scientific knowledge. An overwhelming majority of adults associated any use of illicit drugs with a general disrespect for law, order, and societal mores.' One national survey taken in 1969 revealed that 42 percent of American parents would report their own children to the police if discovered using prohibited drugs.2 Yet many youths, as part of a commitment to social, political, and economic change in American society, adopted illicit drug use as a concrete symbol of disaffection with generally prevailing national values.
Because of the increase in illicit drug use in the 1960s, government at all levels began to design and implement an increasing variety of programs calculated to keep people from using prohibited substances. The terms "drug education" and "prevention" were coined, becoming euphemisms for a campaign which sought to dissuade the young from using illegal drugs. Despite a lack of trained teachers and adequate educational materials, state legislatures passed laws mandating "drug education" courses in the schools; these drug education programs rapidly became a part of the standard public school curriculum.
When looking at the more recent progeny of early drug education programs, one must remember the turbulent social context in which they first appeared. It is this setting which has largely influenced the present goals, accomplishments, and problems of drug education and prevention.
This chapter is primarily devoted to examining the influence of public attitudes and understanding on drug education and prevention programs. That influence has been the critical factor in past and current program content and policy direction, and is likely to determine their future course as well. The first section of this chapter examines briefly the programs now in place and their recent historical development. The latter sections address what the authors perceive as critical topics in any discussion of drug education and prevention: first, the nature and extent of public knowledge and understanding of illicit drug use and misuse, and second, the real differences between drug use and misuse.
We have not set out to evaluate in any comprehensive fashion existing prevention efforts. Such evaluations already exist or are being prepared, generally with government funding.3 Our discussion instead focuses on the assumptions underlying present efforts, examining the true determinants of our drug education and prevention policies—public attitudes and understanding.
School-Based Drug Education and Prevention
In the late 1960s and early 1970s it was common to refer to drug education and prevention as "drug abuse education" or "drug abuse prevention." Only in retrospect has it become apparent that the term "drug abuse" is an ambiguous and pejorative one. It is a term which has contributed to the underlying confusion within the drug field, among educators, and (even more broadly) among the general public as to when drug use becomes drug misuse. "Drug abuse" came to stand for any use of an illicit drug. It was a term not often used—in fact, it was generally avoided—in describing the misuse of licit drugs, such as prescription drugs, alcohol, or nicotine. The inability to define "drug abuse" in terms other than such polarities as licit versus illicit, medical versus nonmedical, or socially approved versus nonapproved suggests the value-laden nature of the term. It has also created difficult public-policy problems, particularly as regards the appropriate goal for drug education and prevention programs.
The basic confusion over the meaning of the term "drug abuse" is reflected in the lack of a widely accepted definition of "prevention." In their 1977 report on prevention, the Cabinet Committee on Drug Abuse Prevention, Treatment, and Rehabilitation acknowledged the ambivalence of the term and their difficulty in obtaining widespread agreement on what precisely one is seeking to prevent.' The term "prevention" is generally applied to activities seeking to persuade those likely to use potentially harmful psychoactive drugs to either abstain or moderate their use, depending upon the substance in question. However, prevention programs vary considerably in content: Some provide information on drugs, others on responsible decision making and values-clarification; other programs offer alternatives to drug use, such as organized sports, theater, and social work. However, by failing to differentiate the goal of preventing any drug use at all from that of preventing the harmful aspects of misuse, we are left with a confusing and ambiguous concept of prevention. Predictably, it has become difficult to separate the good programs from those that do not work.
Drug Education: The Development of Approaches.
The keystone of American drug prevention efforts has been school-based drug education. As with prevention generally, drug education programs are hard to characterize. Early education efforts tried to either frighten potential youthful drug users into abstinence by elaborating upon illicit drugs' potential for harm or produce abstinent behavior by providing information about various drugs in the belief that the "true facts" would deter use. These efforts were supplanted later by programs attempting to educate students regarding the process of making decisions about their values in areas of personal and social significance (including drug use). These ostensibly different programs were and often are still grouped together under the rubric of "drug education." However, as yet there is little agreement either among educators or the general public as to what topics or information ought to be taught and for what purposes.
As stated above, the underlying assumptions guiding early "educational" efforts were straightforward: Illegal drugs were by definition "bad" and dangerous and young people were ignorant of the dangers. It was also believed that an intensive educational campaign could significantly reduce the number of people who might otherwise use illicit drugs. Accordingly, the single criterion originally used to measure the success of drug education was the elimination of illicit use.
Among the earliest approaches to drug education were programs geared toward frightening potential and actual users from illicit drug use with often exaggerated reports on the harmful aspects. One critic of drug education describes a typical format for this kind of program in the following terms:
The most prevalent but least effective theme in the drug education program is to "scare the hell out of them." Too often the program consists of one or more meetings at which a local physician, a law enforcement officer, and perhaps a former addict will endlessly catalogue the horrible outcome of drug usage. The physician will exaggerate the degree to which drugs can produce bodily damage. The law enforcement officer will gravely talk about the increasing flow of drugs into the community and will throw in a few anecdotes about young people he has seen mined by drugs. Sometimes to show to his presumably horrified audience, the former addict, who is usually the star performer, will recount his sordid experiences as a drug user and will glowingly report the salutary effects of his reformation.5
This "horrors of addiction" approach to drug education failed. Reporting on the status of drug education efforts in Dealing with Drug Abuse, Wald and Abrams wrote of these early programs, "Virtually all experts now agree that such tactics have not proved effective. Indeed, in many cases, they have been counterproductive, causing disrespect, skepticism, and resistance to all advice on drugs."6 Instead of frightening youth away from drugs, these early efforts made skeptics of many and often served to increase curiosity about illicit psychoactive substances. However, these observed negative results have not completely eliminated attempts to scare potential users.
A second prevalent form of early drug education programs was based on the simplistic premise that given the "facts" about illicit drugs a youthful audience would see their dangers and abstain from consumption. This factual approach to drug education assumed, first, that the facts about various drugs and drug-taking behaviors were undisputed; second, that such facts comported with society's goal of illicit drug abstinence; and, third, that, standing by themselves, they would be convincing and could be objectively provided. Although the more dramatic elements of the "horrors of addiction" approach were abandoned, abstinence was still considered the only acceptable program result and the emphasis was on teaching about the dangerous nature of illicit drugs.
Trouble cropped up almost immediately with this factual approach, as drug educators tried to fashion scientific arguments to prove that marijuana—the drug whose use increased most rapidly during the late 1960s and early 1970s—was a dangerous drug. Their inability to make a convincing case to students put school-based drug education in an embarrassing position. The dilemma of the factual approach was summarized in one report as follows:
Most drug education programs are ambivalent. They profess an honest desire to tell the truth—but only up to a point. When known facts run out or become controversial, as they almost certainly do when the subject [of marijuana] comes up, the approach reverts to imposed value judgments, half-truths, or presumptions that the law is right—devices easily seen through by the skeptical young.'
In short, conveying information on illicit drugs suffered from the predetermination that the drugs in themselves were "bad." Despite the hopes of educators and parents of school-age children, it proved to be difficult if not impossible to promote the desired abstinence from illicit drugs through the provision of varnished or even unvarnished scientific drug "facts."
The difficulty of providing information on drugs in an atmosphere free of social moral judgments was only one problem. More serious was that of the accuracy of the information conveyed; the demand for educational materials on drugs had developed so rapidly that one observer called the situation a "state of enthusiastic confusion," adding further, "The growth of drug education materials as a lucrative commercial market, nourished on community anxiety, had resulted in claim and counterclaim of effectiveness without any thought to testing or evaluation of efforts."8 Essentially, no one was judging the accuracy of the information being produced.
The extent of the accuracy problems in drug education materials began to become apparent in 1972 when the National Coordinating Council on Drug Education (NCCDE) began a systematic review of drug education films. Of the 220 drug education films reviewed by NCCDE, one-third were rated so inaccurate or distorted as to be totally unacceptable and an additional 50 percent were judged to be unsuited for general audiences:without a skilled instructor. Only 16 percent were rated both scientifically and conceptually acceptable by NCCDE.° More disturbing than the inaccuracies revealed was the realization of how much inaccurate information had been approved by the "experts" for student audiences and the general public.
The Refinement of Drug Education Approaches.
In the 1960s, when drug education was based on the belief that the "awful but true" facts would keep young people from using drugs, one could readily test students on their retention of drug information. Educational researchers were at first enthusiastic about conducting evaluations; their search was expected to show those methods leading to the greatest reduction in drug use. However, the results were not encouraging. As early as 1969, educators had become aware of the inadequacies of drug education programs. This was the most common reason given by school districts for not agreeing to participate in one large California study of drug education programs.10 In the few evaluations that showed measurable gains in abstinent behavior as a result of drug education courses, the research methodology was eventually questioned and the positive results cast into doubt."
These early drug education evaluations were of limited scientific quality. It was, however, consistently found that drug education programs did not substantially reduce either present or prospective drug use. In fact, even uninformed observers could readily see that illicit drug use was steadily increasing, with greater numbers of young people trying illicit substances. (Little attention, however, was given to their per capita consumption.) The early assurance with which drug education had been pursued began to weaken.
In March 1973, the National Commission on Marihuana and Drug Abuse recommended a comprehensive review and evaluation of the entire drug education effort.12 First, the commission called for a moratorium on the production and distribution of new drug information materials until standards for accuracy could be developed and existing materials analyzed. The commission report declared, "No information at all is preferable to inaccurate, dogmatic information which destroys the credibility of the source."13 The commission also recommended a moratorium on all drug education programs in the schools, "at least until programs already in operation have been evaluated and a coherent approach with realistic objectives has been developed."14 Further, it recommended that the states repeal those laws mandating drug education courses in the public schools. Recognizing that the issues of drug education went far deeper than the provision of factual information, the commission saw the proposed moratorium as a breathing space during which goals, techniques, and program results could be assessed and revised.
A moratorium on the production of drug education and information materials was subsequently imposed by the federal government, but it was limited to federal agencies, recipients of grants, and contractors. After ten months of study and review, the moratorium was lifted and new federal guidelines were issued. In apparent recognition of the shortcomings of earlier drug education efforts, these guidelines sought to exclude messages that relied on a "fear element," inadvertently demonstrated how to use illegal drugs, or relied on stereotypes of authority figures to say "Don't use drugs."15 Instead, the guidelines called for "messages that stress the complexity of the problem, the inconsistency of society regarding use of the range of psychoactive substances, the interaction of different variables on drug effects, and alternatives and positive role models for young people."18 Essentially the guidelines continued to emphasize the development of materials which would reinforce and encourage drug-free behavior, albeit in a more reasonable and moderate fashion. The guidelines failed, however, to resolve the essential ambiguity involved in not differentiating any use of a drug from usage which can cause harm.
In the past several years since the issuance of the report of the National Commission on Marihuana and Drug Abuse, drug education has begun to focus less on abstinence from illicit drugs and more on the reasons why people choose to use them. Thus, emphasizing concepts seeking to enrich personal development and social growth, such as responsible decision making, values-clarification, "affective" education, and alternative activities has become popular. Although the goal of total student drug abstinence is now generally acknowledged to be unachieveable, it remains the impossible dream underlying these newer efforts. The reasoning behind this change in educational strategy may reflect a belief that, since abstinence was not achieved by providing the "facts" on illicit drugs, there must be something wrong with how the young arrive at their decisions.
However, a more moderate outlook on drug prevention has recently received greater official support. The 1977 prevention report of the Cabinet Committee on Drug Abuse Prevention, Treatment, and Rehabilitation openly acknowledged that many adolescents will continue to experiment with psychoactive drugs as part of the typical contemporary maturation process. In contrast to earlier, more dire, assessments, the report's authors characterized this fact as "not particularly distressing."17 The emphasis on abstinence has also been changed; one of the report's recommendations was that education and prevention efforts be "primarily focused on moderating the effects of drug taking."18
In addition, the new federal prevention strategy report recommends that drug education and prevention efforts be broadened to apply to alcohol and tobacco products, since they are the first two psychoactive substances used by many people. For credible approaches to develop, the report contends, drug education and prevention programs cannot maintain the fiction that alcohol and tobacco, though legal, are not akin to other psychoactive substances. However, even with the inclusion of licit drugs in education and prevention efforts, it is generally difficult to think of them as attempting to provide information that will help people avoid the harmful consequences of any psychoactive substance. Given the current public climate, it is generally impossible to explicitly set the prevention of harm—rather than the prevention of use—as the primary goal of drug education.
Nevertheless, more complex and sophisticated concepts are beginning to influence the development of federal drug prevention policies.19 These include such issues as the relative health dangers of different illicit substances, the relative health dangers between illicit substances and licit drugs such as alcohol and tobacco; and the relative health dangers associated with different levels of use of any drug, licit or illicit. Essentially these new concepts seek to move away from arbitrary distinctions among licit and illicit drugs and toward a more flexible response which would address, among other things, how a drug is used, how often, and in what kind of setting. In effect, the new goal—without ever being explicitly stated as such—is to educate to prevent harmful use. Assuming that these concepts become more widely adopted as guidelines at the program level, they can have a profound influence on future education efforts.
The Influence of Federal Policies on Local School Practices.
The role of the federal government with respect to drug prevention has been generally limited to declarations of policy principles, support of research and demonstration programs, and provision of some training and technical assistance.20 The actual practice of school-based drug education has remained under local control; the influence of recent federal pronouncements on local program efforts is uncertain.
In fact, it is possible to find indications of a wide gap between local school practice and federal policy pronouncements in the popular press.21 For example, recent newspaper stories recorded the suspension and reprimand of a Maryland high school teacher for advising her students to avoid paraquat-contaminated marijuana if they smoked the drug. Another recent news article reported on Virginia school officials' encouragement of undercover police surveillance in the school to prevent student marijuana use. While such examples may not be typical, they nonetheless suggest some distance between new federal prevention policies and those local school districts where traditional views and public antidrug influences are strongest. Such examples also suggest that most public school educators remain trapped in the dilemma of having to choose between supporting the dominant public view demanding abstinence or being accused of undermining it by promoting "drug abuse" through free inquiry and decision making.
Another unresolved issue concerns how closely the educational system should relate to drug law enforcement efforts. Educators have traditionally been given the task of shaping human behavior to conform to the dominant moral view. But when normal educational techniques fail in this respect, how authoritarian should the school systems become?
The furthest extension of the enforcement approach in the schools probably came with the mandatory student urinalysis program tried in one New York City school and proposed in Montgomery County, Pennsylvania. (The Pennsylvania proposal was rejected as unlawful by court action.E2) Similarly, police surveillance and searches on school property demonstrate the questionable roles the school system can assume when the demands on them to produce adolescent drug abstention become excessive.
Official school policy on student use or possession of illicit drugs has tended to reflect a strict approach. A 1972 survey found a large number of school systems that would suspend or dismiss a student for possession of marijuana, frequent failure in official school policy to distinguish between marijuana- and heroin-related offenses, and public schools with relative frequency referring students in drug possession cases to the police rather than to treatment programs.23 The authors of the study concluded,
The credibility of a school to educate students in any manner about the nonmedical use and misuse of drugs will be quickly challenged as hypocritical by a student body that itself often knows the difference between marijuana and heroin better than the school administrators seemingly do. In particular, the disruption of a student's education for the possession of marijuana is a punitive measure, not a rehabilitative or educational one. We question whether such a function is a proper one for the public school systems to assume.24
Evaluation of Drug Education Programs.
Despite the widespread support of prevention and education as means of limiting "drug abuse," evaluations of various drug education programs have not shown promising results. One reason may be simply that good drug education evaluations are not easily achieved; it is exceedingly difficult to isolate changes produced by a program from those caused by unrelated factors. This problem is compounded in any longitudinal study; yet such studies are particularly needed, because the purpose of drug education has been to affect the drug-using behavior of young people over an extended period of time. Nevertheless, among those evaluations which would generally be considered to meet scientific standards there is little empirical support for the pervasive notion that education can produce substantial changes in drug-using behavior.
The stated goal of traditional drug education is to discourage new or continued use of certain drugs, in particular those classified as illegal. There are, however, two intermediate purposes to these educational efforts: to increase knowledge about drugs and their effects and to improve attitudes toward drug use, the individual, and society. It was—and to some extent still is—expected that accomplishment of these intermediate goals would lead directly to the realization of the primary goal, reduced drug use. But the results of drug education evaluations which have attempted to measure both intermediate changes and desired ends fail to corroborate these expectations.
Still, increased knowledge—the traditional object of education—can be achieved. Adolescents and preadolescents frequently express interest in knowing more about drugs and their effects. While this interest is not too surprising in light of the widespread use of illicit drugs among American youth, it is somewhat surprising considering the long history of misinformation and "scare tactics" in formal drug education programs. In one national survey of high school students conducted during 1973-74, nearly 40 percent reported that their drug education courses did not teach them anything they did not already know, and nearly one-third of the students thought the information was used to "scare you. "25 Nevertheless, despite such criticisms there appears to be genuine interest in drug information both among youth and adults and thus a potentially valuable role for the school system to fill.
Some evaluations of drug education courses have shown significant knowledge gains for the students.26 However, increased knowledge about drugs may result in an increase in actual or intended use rather than the desired decrease.27 Most students know from observation and experience that drugs—licit and illicit—can be pleasurable, but also powerful and potentially harmful. Many of the young have a healthy respect for drug troubles and, short of abstinence, want to know how to prevent them. Students may want the educational system to do the job in the drug field that it is willing to do in others; that is, without condoning use at least offer information to help avoid the hazards of drug misuse. Accurate information not only increases an individual's knowledge, but by reducing the fear of the unknown enables him or her to discriminate lower-risk choices from the higher-risk ones. Thus, the result of knowledge development may be an acutal increase in less harmful types of illicit drug use coupled with a decrease in more harmful drug misuse.
Self-reported use and intentions to use must serve as the indicators of drug use and potential usage, since actual use is nearly impossible to determine. Two major experimental drug education programs showed only minimal reduction in drug use at best.28 Other smaller research studies have shown similar results. The findings noted in a study of the Coronado school district program in California, one of the best evaluations of a highly regarded drug education program, provide perhaps the clearest indicators of the potential of drug education programs for reducing drug use. That evaluation concluded that the Coronado program effected only a tendency toward less drug use.29 Furthermore, one of the few follow-up studies on the effects of any drug education program concluded, "In spite of a strengthening not to take or reducing of intentions to accept most drugs immediately after the lessons, there is relatively little change in most pupil's intentions to take any drugs in the longer term."30
Although it is impossible to prove that drug education cannot work, there is little empirical evidence to support the view that significant changes in drug-using behavior can be induced by it. The evidence on hand makes a reasonable case that drug education efforts are not likely to have a substantial impact on the frequency or variety of psychoactive substances used. Summarizing the research done on the effectiveness of drug education one comprehensive review stated, "There is an almost total lack of evidence indicating beneficial effects of drug education. "31
In the final analysis, public satisfaction or dissatisfaction with the content and results of school-based drug education depends upon the public's understanding—or, as is too often the case, its lack of understanding—of the issues.
Public Knowledge and Attitudes
The Advance of Scientific Knowledge Versus Lack of Public Understanding. A notable result of the American government's concern with the drug field during the 1970s has been a greater knowledge and understanding of drugs and drug policies. Appreciably more is known now about illicit drugs than at the beginning of the decade. More is also known about who uses drugs and about the effectiveness of various treatment, prevention, and enforcement programs Marijuana is a prime example of a drug that has received considerable research attention; even where questions remain—as with some possible health consequences of marijuana use—recent research studies have been invaluable in sorting out myths from realities. Yet another illustration of this increase in knowledge comes from the recent evaluation of the New York State "get tough" drug law, which provided important insights into the effects of criminal law on drug-using behavior. Such research reports and program experiences have advanced knowledge in nearly every aspect of drug use and misuse.
There is also, however, a growing realization of how much more there is to be learned. In many instances, what was thought to be known has turned out to be uncertain. Increasingly, among those who have been active in the drug field, the answers of earlier eras are being replaced with questions. Earlier generalizations about illicit drugs and their users are giving way to more complex theories.
Although research and evaluation have contributed to more informed discussion within the drug field, effective communication of these new, emerging concepts to the general public has been slow to develop. This failure to create widespread public understanding limits the benefits of any drug education or information program. It is not exaggerating to say that the future course of national drug policies will be determined by the ability of the drug field to convey the experiences, understanding, and knowledge developed in recent years.
Underlying the problem of effectively communicating a new set of concepts about illicit drugs and their users is the tenacity of traditional views. Public attitudes toward such drugs as marijuana, cocaine, and heroin evolved early and have remained fixed for many years; they have been reinforced by nearly every public and private institution. In 1973 the National Commission on Marihuana and Drug Abuse observed, "Society tended to view the problem exactly as the law defined it.... "32 There was little room for alternative points of view. Those who voiced reservations about the effectiveness or desirability of strict antidrug laws were generally dismissed as loose-thinking "liberals". Those who openly used the prohibited substances were made into social outcasts.
The public's reaction to the threat of illicit drugs has exceeded factual, scientific bases of support. Yet concepts introduced in recent years which contradict the prevailing popular beliefs are at a competitive disadvantage. The newer ideas must, it seems, do more than make sense. Even overwhelmingly convincing evidence runs a difficult road in dislodging the familiar older assumptions. The experience of recent years suggests that the facts by themselves may not be sufficient to alter public perceptions and thus drug policy. Old drug myths apparently die remarkably hard.
Understandably, it is often difficult to separate myth from reality. In addition, many existing popular conceptions about illicit drugs, because simplistic, are more easily comprehended than more complex facts and theories. The complexity of the new concepts, coupled with the substantial disagreements within the field itself, creates a significant obstacle in the path of greater public understanding. Departing from the uniformity of the past, many differing views can find some support in research findings; sometimes the same research is used to "prove" opposite positions. Instead of black-and-white answers, the public is given several sets of facts and interpretations from which it is expected to select the best constructed line of reasoning.
The Current State of Public Knowledge
It is hard to generalize about the current state of public knowledge about illicit drugs. The preponderance of national polling data concerns attitudes rather than knowledge. Nevertheless, what information is available suggests that a large segment of the American population harbors mistaken beliefs about drugs and their effects.
For example, a 1972 poll by the National Commission on Marihuana and Drug Abuse assessed the knowledge and attitudes of American adults on drug use and users. Similar surveys were conducted in 1974 and again in 1976.33 The responses to these surveys give some indication of the extent of the misconceptions about drugs. They also show how slowly public beliefs change: For example, in 1972 44 percent, in 1974 46 percent, and in 1976 48 percent of those surveyed agreed that "you can try marijuana once or twice with no bad effects"34; only 26 percent in 1972, 24 percent in 1974, and 25 percent in 1976 believed that "you can use marijuana without ever becoming addicted to it"35; 65 percent in 1972, 62 percent in 1974, and 60 percent in 1976 believed that marijuana makes people want to try stronger drugs, such as heroin.36 These beliefs reinforce the idea that the use of any illicit drug will eventually lead to the use of heroin, the "worst" drug of all to most Americans.
Even the simplest pharmacological facts seem to be unknown to the public. For instance, 68 percent of the adults in the 1974 survey believed that marijuana is addictive, while only 62 percent believed methadone to be addicitve. This response changed only slightly in the 1976 survey. Such attitudes are reflected in the fact that about one-third of the American public believes that mandatory treatment is the best response to a first conviction for marijuana possession.37
Other studies and measures of public knowledge replicate this lack of public understanding. A 1974 television show, modeled after the National Drivers Test, asked fourteen factual questions of a Washington, D.C. viewing audience about heroin and heroin addiction treatment. According to the Bureau of Social Science Research, which analyzed the test results, the average viewer was able to answer eight of the fourteen questions correctly. Only 4 percent of the viewing audience was able to correctly answer twelve or more of the questions.38 A similar television show on marijuana, aired in March 1976, presented thirteen questions to a Washington, D.C. viewing audience of which more than half answered six incorrectly.°9
Improving public knowledge and changing public attitudes about drugs and their effects is, as already noted, a difficult task. The general public's first-hand experience with illicit drugs is limited inasmuch as use and possession of them are illegal. Therefore, the influence of trusted professionals who can speak authoritatively on the issues becomes stronger. Those whom the public generally regards as experts about drugs include physicians, lawyers, judges, and law enforcement authorities. In addition, the nation's news media, in conveying information from those directly involved in the drug field to the general public, strongly influence public attitudes and understanding about drugs. To find an explanation for the public's lack of appreciation of the complexities of drug issues, one must look to those on whom it depends for its information: the medical, legal, law enforcement, and communications fields.
The Medical Profession.
One source to whom the public should normally be expected to turn for information and advice about illicit drugs is the medical profession. The drug field is intricately and intimately involved with health issues, medical problems, and physician responsibilities. Yet in spite of this relationship the active involvement of the medical profession in formulating drug policies and developing treatment programs has been generally minimal.
In part, the detachment of the medical profession from illicit drug issues may be traced to the federal government's efforts, beginning with the District of Columbia Pharmacy Act of 1906, to limit the authority of the profession to employ and prescribe particular drugs in the course of medical practice.40 Throughout much of the twentieth century the federal government's response to illicit drug use has been dominated by enforcement approaches. This perspective has enjoyed wide popular support. Treatment came to be perceived as a rather "soft-hearted" approach to an enforcement problem, and few physicians became involved in the "drug abuse" field in any active way.
Historically, the number of doctors who have treated those misusing illicit drugs has been small, basically because the facilities were so few.41 For more than thirty years there were only two federally supported opiate treatment programs in this country—one at Lexington, Kentucky and the other in Fort Worth, Texas. These two institutions trained physicians in the complexities of opiate addiction, but the number of participating doctors was small; they developed no wide constituency within the medical community.
In recent years, with the development of methadone treatment methods and the large-scale expansion of federal support for drug treatment programs, the medical profession has gained a new foothold in the public dialogue about illicit drugs. Even so, the number of doctors involved represents only a small fraction of the three hundred thousand physicians in the country.42 The number of medical doctors with more than a casual understanding of the pharmacological properties and effects of psychoactive drugs is still limited.4s
For the most part, the medical profession has stuck to a rather strict definition of drug abuse.44 Nearly all medical definitions of drug abuse use the term to apply to the use of any drug not prescribed by a physician. In effect, the acceptance of this definition would establish a medical prerogative to determine who can use which drugs and under what circumstances, and drug consumption would be limited to medical need. Any and all use of illicit drugs would constitute drug abuse.
Not all doctors have specialized knowledge about drugs. Their exposure to the latest findings about those drugs currently classified as having no legitimate medical use (such as marijuana, heroin, and cocaine) is very limited, and their formal education and training often provides only a cursory view of drug misuse problems. Moreover, since more than half of the present number of practicing physicians in this country went through medical school before the profusion of new psychoactive drugs, licit and illicit, developed, their exposure to research on these substances has been limited.45 However, many physicians can and do take training courses periodically to update their knowledge and understanding of new developments in the drug field.
Even now only a minority of medical schools in the country offer courses in psychopharmacology, which is the basic science of how drugs affect the mind.49 Virtually all medical schools offer courses in pharmacology—the basic science of how drugs work on the body—but these courses are a relatively small part of the physician's education. Even when they are offered, a recent survey shows they cover only the most serious and destructive symptoms resulting from the use of intoxicants.47 Peter Dews, MD., a professor of psychiatry and psychobiology at the Harvard Medical School, has concluded that the training physicians receive regarding drugs and their actions on the human mind and body is "an overwhelming failure."48 Other medical educators echo his sentiments.49
The consequences of this failure to provide physicians with an adequate understanding of drug misuse problems are many, affecting both licit and illicit drugs. For example, there is some evidence that physicians have unwittingly contributed to the widespread misuse of licit prescription drugs and thus to an improper understanding of other drugs. Approximately 275 million prescriptions for psychoactive drugs are written annually, a figure which many contend is far in excess of the actual need."
Moreover, several recent studies suggest a relationship between the use of licit and illicit drugs. Blum in California, Smart in Canada, and Louria in New Jersey have shown that the use of legitimate psychoactive drugs by parents greatly increases the chances of their children using illicit drugs.51 From his study Dr. Smart believes that "the conclusion is inescapable that the parents who are users of tranquilizers, barbiturates and stimulants are likely to have children who are users of drugs, such as marijuana, LSD, speed, as well as prescription drugs and alcohol and tobacco. "52
The potential contribution the medical profession can make to the development of informed public attitudes about drugs is great. However, it would seem to be unwarranted at this time to hold the attitudes and opinions of the medical profession in any special status simply because of their professional background.5" Many doctors, rather than being experts about drugs, often share the same misconceptions and biases of the public at large.
The Legal Profession.
Among the many legal doctrines that guide today's lawyers is the doctrine of stare decisis, the practice of standing by past legal rulings in deciding current disputes. The fact that the legal profession embraces this conservative doctrine may be a partial explanation for its continued reliance on outmoded concepts in the drug field. Although individual attorneys may be at the leading edge of drug law reform efforts, the majority of the profession echoes the more traditional views on the subject.
While it is lawyers who generally change the law through either the statute books or courtroom argument, they also uphold it through the same processes. It is difficult, therefore, to characterize the field as holding only to one view. For example, a leading textbook for trial attorneys on handling cases related to illicit drugs states,
The addict, exposed to and in fear of withdrawal, will be driven irresistibly to any lengths to obtain a supply, and in desperation may even resort to suicide as a way out.54
In contrast to this traditional view of heroin overpowering the will of the user and making him uncontrollable are the views of other legal scholars, such as Professor Nicholas Kittrie at the Institute for Studies in Justice and Social Behavior at the American University and advisor to the National Commission on Marihuana and Drug Abuse. Professor Kittrie contends that illicit drugs have not been shown to be connected in any causal way with the subsequent commission of crimes. In fact, notes Kittrie, "it is the high cost of the drugs and their unavailability which often produce the reported criminal behavior."55
For the most part, however, drug law reform efforts sponsored by the organized bar and other traditional elements of the legal profession tend to be years behind the current state of knowledge. A good example of this time-lag process can be seen in the relatively recent boost of support for pretrial drug diversion programs: Increasingly judges, prosecutors, and defense attorneys concur that referral to treatment is the preferable course of action where the defendant has tested positive for drug use, even when the arrest had nothing to do with drugs of any kind.56 The support for such diversion is derived from a belief in the overpowering, "irresistible" nature of certain drugs (particularly heroin), an attribute which is often viewed as inevitably involving the user in criminal activities.57 Other traditional views figure in this formula as well: The heroin user is almost invariably seen as an addict and as unable to financially support continued use of the drug except through criminal activities. Recent information on the existence of large numbers of heroin "chippers" and other nonaddicted users and the continued failure to prove a direct heroin-crime relationship remain largely unrecognized by the legal profession.
Lawyers frequently see themselves as the executors of the law rather than its creators. Reluctant to mount frontal assaults on long-standing precedent, the legal profession favors a more gradual process of erosion, based on case-by-case factual distinctions, until the original rule collapses from an accumulation of legal undercutting. This process of change is underway in altering legal attitudes towards illicit drugs and drug users. For example, the Association of the Bar of the City of New York undertook a three-year project to analyze the effects of the 1973 "get tough" drug law in New York State. The final report issued by the Bar Association's study group challenged the efficacy of increasing drug law penalties and issued a markedly cogent series of general observations.
First, the use of heroin and other opiates is but one element of a larger problem. The misuse of all dangerous drugs—alcohol, cocaine, opiates, and other mood-changing drugs, some prescribed and some sold over the counter—all together constitutes "the drug problem." Problems with so many components do not yield to one-dimensional solutions. As no single drug treatment method is suitable for all users, so there is not likely to be a single legal approach that is suitable for all offenders.
Second, whether or not illicit drug use is for the most part a medical concern as some contend, it is incontrovertibly deeply rooted in broader social maladies. Narcotics use in particular is intimately associated with, and a part of, a wider complex of problems that includes family break-up, unemployment, poor income and education, feeble institutional structures, and loss of hope.
The final observation is a corollary of the second: it is implausible that social problems as basic as these can be effectively solved by the criminal law.58
Bar associations and law schools are becoming more involved in sponsoring seminars to present and analyze recent research in the drug field. The Minnesota State Bar Association recently persuaded the state of Minnesota to sponsor a judicial education series providing judges, prosecutors, and defense attorneys with the latest information on the use and misuse of licit and illicit psychoactive substances as well as on the development of drug controls.59 These educational activities by the organized bar are promising attempts to increase the profession's understanding of illicit drug issues. The influx of many younger lawyers into the bar may also have an impact on attitudes. One recent study of student attitudes in a southern law school showed a significant percentage supported liberalizing the laws relating to marijuana.80 The personal drug experiences of so many recent law school graduates may have a profound effect on the profession's attitudes in the future.
One promising sign of the legal profession's growing awareness of the complexities of drug issues is the increasing tendency to differentiate between levels of drug use. For years, the legal approach was simply to define any use of an illicit drug as abuse, subject to penalty structures which failed to distinguish between use, misuse, or abuse. More recently, particularly with marijuana decriminalization laws, there appear to have been more concerted attempts made to separate possibly destructive drug use patterns from those which, although involving nonapproved substances, pose little apparent societal danger.
In summary, legal attitudes seem to be evolving to accommodate new knowledge and information about drug issues and problems. Nonetheless, this change is occurring very slowly, and legal precedent still supports traditional concepts even in some reform efforts. While the organized bar may play a role in educating its members, the growing number of young attorneys who have themselves had contact with illicit drugs like marijuana may have a more profound impact on the profession's attitudes in the future.
Law Enforcement Views.
Law enforcement agencies and personnel, charged with the practical administration of the law, generally view the enforcement of drug laws as an ordinary part of their overall job. However, for some the enforcement of the drug laws is of particular concern because of widely held beliefs about the close relationship between illicit drug use and criminality.81 In addition, police and other law enforcement professionals tend to view the use of certain drugs in moral terms and see their role as protecting minimum societal standards of morality. Public pronouncements by law enforcement officials about illicit drugs often reflect rigidly moralistic stances.
In part, the views of law enforcement officials are based upon traditional understandings of the effects of drugs upon the human body. There seems to be little recognition of variance of effect from drug to drug and user to user. The tendency appears to be to assume that the "worst" case example is not only the typical but also the inevitable result of illicit drug use. For example, a leading criminology textbook makes the following statement:
The officer sees the many ugly aspects of drug abuse such as the crime, violence, death and disorientation it causes. Sometimes he sees the more pleasant side too; for example, when he meets an individual who is no longer involved with drugs.82
Compounding the problem are laws that the police are charged to enforce, laws which, for example, frequently describe both marijuana and cocaine as "narcotics" when it is widely known in the scientific community that these drugs have entirely different characteristics. This misunderstanding of the basics of pharmacology helps produce the view that the use of one drug may as well be the use of another; they are all equal in the eyes of the law and thus in the eyes of the law enforcement officer.
In contrast to the more traditional enforcement views are those which, looking more pragmatically at a broad range of criminal law enforcement problems, see the enforcement of drug laws as an unwelcome burden and occasionally as counterproductive. The Knapp Commission, which investigated police corruption in New York City, found widespread problems within that police department concerning the administration of antidrug laws. The fact that most drug arrests are "spontaneous" (i.e., involving no prior investigation) suggests the haphazard way in which current laws are enforced. Maurice Cullinane, who recently retired as police chief in Washington, D.C., stated his view on marijuana law enforcement: "When you look at how you're going to utilize your manpower, going out and looking for individuals who are using marijuana just for themselves is very, very low on my priority list. "e3 These kinds of observations led a Mississippi sheriffs' association to support and help pass a marijuana decriminalization bill.e4
However, it is accurate to say that the majority of law enforcement opinion continues to be on the side of stringent antidrug laws along current lines. Drugs continue to be blamed by enforcement officials for a broad cross-section of society's ills. Writing in a professional journal, Edward Davis, then president of the International Association of Chiefs of Police, made the following-statement:
Lower penalties and decriminalization became popular political promises and narcotic use increased. Some states began issuing traffic-like citations for possessing "small amounts" of narcotics and the drug business boomed. The crime rate also increased and so did the toll of human wreckage."
News Coverage of Drug Issues.
Traditionally, American newspapers have been an important, influential source of information to the public. The role and responsibilities which the free press serves are indispensable to the functioning of a democratic society. The American public has come to expect and depend upon the press to provide reliable, accurate, and unbiased news coverage; they expect the press to aggressively scrutinize government programs and policies and not just reprint press releases from official sources.
In an area such as illicit drug use where the general public lacks first-hand experience and knowledge, careful news coverage is essential. News coverage about drug use provides more than just information; since direct sources of information are so limited, the news coverage of this issue has even more influence than usual on public attitudes toward drugs.
Historical analyses of drug issues and the responses to them have not systematically examined the press's role, the sources of their reports, or their overall accuracy. The available anecdotal accounts suggest that the press has usually reflected the prohibitionary policies of the federal government without question and shared the punitive law enforcement orientation which has dominated government response.88 However, until the current decade there have been few alternative positions for the press to report, inasmuch as nearly all established private-sector organizations have tended to reaffirm the basic philosophy of the government. On the other hand, press coverage given to some of the more sensational aspects attributed to illicit drug use may have helped to give undue credibility to the myths and exaggerations which still surround certain illicit drugs. One newspaper reporter who has written extensively about drug issues in the 1970s has observed,
I think we in the media are to blame for compounding the drug stereotypes that have been foisted off on the public since the 1930s. We've accepted every police and law enforcement statement about drugs without question. We've failed to explore the culture of the drug user fairly, and we've failed to dispassionately explore the entire phenomenon of drug use.B7
Just as there seemed to be little debate about drug policies within the government bureaucracy and in public forums, there also seemed to be few press challenges to the conventional wisdom about drugs.
Newspaper and television news coverage of the so-called drug abuse "crisis" of the past decade was extensive.88 This coverage reflected the widespread public concern about "drug abuse." And although it is not possible to measure the actual impact of the news coverage given drug issues, it is reasonable to assume that it has had a strong influence on public attitudes and opinions. In at least one instance the way in which a drug story was presented in newspaper, radio, and television reports directly influenced the development of federal drug policies and programs.e9
It was not until 1972-73 that any study of newspaper reporters was undertaken to find out how much they knew about the drug issues they were covering. Robert Bomboy, himself a journalist, interviewed nearly forty reporters, columnists, and editors from thirty newspapers and two national wire services. His observations and conclusions paint a bleak picture.70 Among them are the following:
1. A great deal of drug reporting in major newspapers reflects ignorance, fear and false preconceptions.
2. Newspapers continue to be most strongly interested in the sensational or dramatic aspects of the drug abuse story. This has often precluded serious analysis or discussion of the problem.
3. Acting out of a lack of interest at best, class bias, racism and fear at worst, newsmen take pains to disassociate themselves from addicts.
4. Myths are reported as fact by newspapers largely because newsmen place excessive reliance on official sources of information, the local police in particular.
5. Reporters too seldom attempt to cross-check official information with sources on the street.
6. Most major newspapers do not have "drug beats." General assignment reporters often lack substantial knowledge of the drug problem and drug abuse policy, and they don't have the opportunity to develop street sources of information that would give them some perspective on the information handed out by officials.
7. Newspapers are unwilling or unable to go beyond government-provided propaganda to reach their own conclusions about the merits of one drug policy vis-à-vis another. Most newspapers simply do not have a well-formed, seriously constructed conception of the drug abuse problem.
No other studies have been undertaken on the news coverage of drug issues since Bomboy's 1973 report. Some recent developments would nonetheless suggest that the news media are now better equipped to deal with drug issues. For one, the newer and younger reporters seem to be more familiar with, and thus less afraid of, illicit drugs and their users than their counterparts from earlier years. Also, there is now a greater number of sources of information in the drug field, more readily available than in the past; today even the relatively uninformed reporter has no need to be solely dependent upon official sources of information. Finally, the tendency in the post-Watergate era is toward more aggressive reporting and more skepticism regarding the tone and substance of government reports and policies.
On the other hand, public interest in the drug issue has by now subsided and the amount of news space and time devoted to it has been substantially reduced. Thus there are fewer and less effective opportunities for the news media to convey to the general public the new insights which have developed in recent years. In addition, while there are no studies to be cited one way or the other, our impression is that newspaper editorials have generally remained wedded to old concepts and strict, punitive antidrug stands.
Perhaps of even greater impact than newspaper coverage is television news coverage. Within the brief time-frame of television news reporting, the emphasis has consistently been on dramatic "scare" stories. Spreading warnings of potential disaster—no matter how disputed the evidence—usually draws accolades as being the performance of a valuable public service. On the other hand, reports of research that do not establish that substantial harm can result from even moderate use of illicit drugs make for rather bland news. And indicating to the public that many fears about illicit drugs may be exaggerated or that not all drug use is necessarily destructive runs the risk of being accused of softness or, worse, being implicated in causing harm. The competitive nature of the television industry, where viewer approval is so aggressively pursued, makes it unlikely that it ever can or will challenge popular public attitudes toward illicit drugs on its own accord.
Apart from newscasts, television also influences public beliefs and attitudes toward licit and illicit drugs through commercial advertising and the entertainment programs which comprise the bulk of prime-time programming. The extent of television's influence on a wide range of viewer attitudes and behavior is the subject of heated controversy. Particularly with respect to drugs is there considerable disagreement. A former commissioner of the Federal Communications Commission, for instance, has referred to television as the prime pusher of drugs in American society." The research director for a marketing research company contends, on the other hand, that drug advertising is being used as a "scapegoat."72
Whatever the precise degree of television influence, commercial advertising of over-the-counter legal drugs is unquestionably extensive. The 1973 Report of the National Council of Churches Drug Advertising Project noted that four of the five biggest television advertisers were pharmaceutical manufacturers, and that one out of every eight television commercials advertised some type of drug.73 One study of 126 hours of commercial television in Boston recorded 132 over-the-counter drug commercials (5.5 percent of all commercials aired) .74 Another researcher identified 465 drug commercials in a 250-hour composite week of network programming; those 465 commercials constituted 13.4 percent of all advertisements during this period.75 A third study identified 88 over-the-counter drug commercials aired between 7:00 and 11:00 P.M. on the three major networks during a selected week in March 1973.76 Critics of television drug advertising (including alcohol and tobacco products as well as over-the-counter non-prescription medications) have argued that these commercials contribute to patterns of drug misuse in American society.77 The National Commission on Marihuana and Drug Abuse characterized those arguments as reasonable, but urged more effective industry self-regulation rather than government intervention, recommending further longitudinal research into the effects of various forms of communication on behavior.78
Particular attention has been directed towards the impact of television advertising on children, widely believed to be an audience particularly vulnerable to commercial messages. The Council on Children, Media, and Merchandising has been an especially strong critic of television advertising of potentially dangerous substances.79 Although the television industry had issued detailed guidelines to guard against product misuse by children, these applied only to Saturday and Sunday-morning children's programs, when the advertising market consisted almost wholly of children. Critics pointed out, however, that children also watch television during prime-time hours when adults are also watching, and therefore view commercial advertisements directed towards adult audiences. In 1975, fourteen states petitioned the Federal Communications Commission to ban television advertising of OTC drugs before nine o'clock in the evening. The petition was denied, largely because of a lack of scientific research and empirical data showing a cause-and-effect relationship.80
Although the television industry has been criticized for airing commercial advertisements which some contend suggest and even increase the harmful use of certain licit drugs, the medium has also aired public-service advertisements warning against "drug abuse." These advertisements most often focus on the illicit drugs, although alcohol and tobacco have also been included. However, these public-service spots are shown far less often than commercial advertisments promoting various legal psychoactive substances. For example, in the March 1973 study mentioned above, only one public-service message on drug misuse was observed in those prime-time hours of programming in the week-long period when eighty-eight commercial advertisements for OTC drugs were recorded.81 Some have criticized the television networks for airing public-service announcements during low audience-viewing periods, thereby diminishing whatever effectiveness they may have.82
As with the commercial advertisements for OTC drugs, the actual effect of public-service messages seems to be uncertain. Granted the extent to which they are effective, it is still difficult to overlook the conflicting messages conveyed. When, as one researcher has noted, a commercial beer advertisement urging viewers to "live life with gusto" is immediately followed by a public service announcement warning against the "dangers of drug abuse," it becomes understandably difficult to help the public grasp the subtleties and complexities of drug and drug-related problems.83
Even more important and less well-understood is the impact of the entertainment programs which dominate the commercial television schedule during periods of highest viewing. The use of alcohol and tobacco products in television programs is fairly common. McEwen and Hanneman report that alcohol is the most frequently depicted drug on television, and that its use is portrayed in generally positive contexts and as having "positive social (though mixed physical) consequences."84 The authors report that tobacco products are used rather than discussed, and that possible adverse consequences of tobacco use are ignored. With respect to prescription drugs and medications, the authors note that their use in television programs is generally confined to the treatment of physical ailments, and that reference to the possible misuse of licit drugs is avoided.
The illicit drugs are handled differently in television entertainment. In general, their use—particularly that of heroin—is portrayed in negative situations. One study characterizes television's portrayal of the drug culture as "uniformly ugly."85 Most often illicit drug use on these programs is found in the various detective and police stories. Overall, it appears that entertainment programming on television simply reflects and reinforces the stereotypes the American public has of licit and illicit drugs.
Changing Concepts in the Drug Field
The preceding sections of this chapter suggest widespread public confusion about many drug issues. 'The long history of misinformation which has often guided discussions of illicit drugs and drug policies cannot be easily overcome. However, the logical place to begin that process is to examine the basic terms and concepts which apply to and affect nearly every public determination about the use of psychoactive drugs.
The popular belief is that we need to prevent "drug abuse." However, the prevention of a problem requires a clear definition of it. The medical problem of an outbreak of malaria will send public health officials out searching for possible breeding grounds for mosquitos known to spread the disease; by eliminating these breeding grounds, malarial infections of humans can be prevented. Prevention with respect to drugs, however, is not so clear-cut.
What is a drug problem? Does a drug problem result from any use of a psychoactive drug? Or does it result only from the use of more than a specified amount of such a drug? Neither is a sufficient condition. Contrary to popular assumptions, problems resulting from the use of psychoactive drugs are more complex than this. In addition to the amount of a drug used, drug problems are also influenced by a variety of other factors, including the setting or circumstances in which it is used, the attitudes or expectations of the user, and the specific pharmacological effects of the drug. To complicate matters further, the problems a user may have which seem to be the result of drug use may remain, unchanged, even after drug taking ceases.
It has been common to use the term "drug abuse" to refer to the existence of a drug problem. But "drug abuse" is an ambiguous and pejorative term, one to which the American public has been conditioned to respond negatively. The fear that "drug abuse" may be spreading in our society has often been considered sufficient grounds to support harsh measures to eliminate a perceived social evil. When the term "drug abuse" is more closely examined, however, it will be seen to be imprecise, value-laden, and therefore of little utility.86 It remains easier to urge the prevention of "drug abuse" than it has been to clearly define the term.
"Drug abuse," instead of referring to a typology of drug-using behaviors, has become a shorthand term society uses to differentiate between licit and illicit drug use.87 Any use of an illicit drug is automatically labeled "drug abuse." The term is typically avoided when describing the excessive, indiscfiminate, nonmedical use of licit drugs. Those drugs of which we as a society disapprove are classified as illegal, and any use of them becomes "drug abuse," and "drug abuse" is something we all intuitively want to prevent. The reasoning here is circular, and indicative of the problems encountered in trying to improve public knowledge and understanding of drug issues and problems. Such reasoning leads to the assumption that only illicit drugs can cause drug problems, and thus permits us to circumvent, when convenient to do so, the reality that serious drug problems can result from the misuse of legally available drugs as well.
It seems apparent therefore that the classification of drugs as licit or illicit is a root cause of public confusion. The rigidity imposed by this classification creates unnecessary difficulties in addressing contemporary drug problems. Such classification often reflects solely the question of social acceptability, and has nothing to do with potential health hazards or demonstrated risks to life or property from the drug in question. The labels "licit" and "illicit" tend to overlook such important variables as the frequency with which a drug is used, the method of administration, dosage, and the situations in which particular drugs are most commonly used. Edward Brecher, author of the reputable Consumers Union report Licit and Illicit Drugs, elaborated in that work on this crucial point.
A sound classification program should concern itself with modes of drug use as well as drugs themselves; it should recognize, for example, the vast difference between sniffing, smoking, or swallowing a drug and mainlining it.(Society, laws and law enforcement policies already differentiate the occasional drinker of a glass of wine or beer, the social drinker, the problem drinker, and the alcoholic. Similar distinctions should be made with respect to various modes of use of marijuana, LSD, the barbiturates, and the amphetamines.88
The Liaison Task Panel on Psychoactive Drug Use/Misuse of the President's Commission on Mental Health recently highlighted Brecher's point, concluding, "Clearer distinctions need to be made among the variety of psychoactive drugs other than their licitness or illicitness.... "89 Since the use of psychoactive drugs is endemic to American life, we need to identify where possible general principles of drug use and apply them consistently to drug-using behavior, regardless of whether the drug is alcohol, nicotine, marijuana, or cocaine. As long as arbitrary standards governing each individual drug remain, however, there will always be serious doubt expressed by some members of society whether the drug use in question has been a violation of some logical principle of pharmacology or whether it has only been a violation of social acceptability. It is, for example, an easy matter to say that no one should drive when intoxicated, no matter what the drug; such a statement applies consistently to all psychoactive drugs. Similarly, it would be just as logical to say that relaxation achieved by using a moderate amount of a drug other than alcohol in appropriate circumstances by someone over the age of consent is reasonable behavior. But there has been great resistance to this concept.
Reliance on such terms as "drug abuse" and the classification of drugs as either licit or illicit have obstructed public understanding of the need for a consistent approach to the use of all psychoactive substances, including alcohol and nicotine. The understanding that both licit and illicit drugs can be used or misused is a concept of paramount importance, one which could greatly influence public drug policies and programs.
There is evidence that, despite the lack of official approval, many users of illicit psychoactive drugs have developed patterns and standards of drug consumption that encourage and reinforce behavior more moderate and responsible than was previously assumed possible. For example, while all recent surveys of student drug use indicate that experimental and recreational use of a variety of drugs is extensive, none of the surveys point to an alarming number of intensive or compulsive student drug users. Millions of high school and college students have experimented with illicit drugs, but the vast majority discriminate among the different drugs available and exercise some degree of personal control and restraint in their drug-taking behavior.90 Had this been understood earlier, it might have precluded the rush to school-based antidrug campaigns—or would at least have altered their tone and direction.
Similarly, greater public understanding of drug problems could be facilitated if public discussion were cast in terms of different types of drug-using behaviors. The National Commission on Marihuana and Drug Abuse identified five distinct categories of drug-using behaviors, each of which poses a different potential for individual dysfunction.
• Experimental—short-term, non-patterned trial of one or more drugs, motivated primarily by curiosity or a desire to experience an altered mood state.
• Recreational—occurs in social settings among friends or acquaintances who desire to share an experience which they define as both acceptable and pleasurable. Generally, recreational use is both voluntary and patterned and tends not to escalate to more frequent or intensive use patterns.
• Circumstantial—generally motivated by the users' perceived need or desire to achieve a new and anticipated effect in order to cope with a specific problem, situation or condition of a personal or vocational nature. This category would include the use of stimulants for work-related tasks, and the use of sedatives or stimulants to relieve tension or boredom.
• Intensive—drug use which occurs at least daily and is motivated by an individual's perceived need to achieve relief or maintain a level of performance.
• Compulsive—consists of a patterned behavior at a high frequency and high level of intensity, characterized by a high degree of dependency, such as with chronic alcoholics, heroin dependents and compulsive users of barbiturates. B1
Others have offered somewhat different typologies by which to view different patterns of drug-taking behavior.92 The point central to all these classification schemes, however, is that the types identified are as applicable to licit as to illicit drugs, and are intended not only to help separate use from misuse but to look at different gradations of use and misuse. Yet the concept that there are different levels of drug-using behavior has never really taken hold among the general public. The more traditional, arbitrary generalizations about "drug abuse" and licit and illicit drugs remain in vogue even though the simplicity of these categories ignores the true complexities of drug-using behavior. There is simply enormous public resistance to moving away from certainty about the evil of "drug abuse" (i.e., any use of an illicit drug) to more exacting and accurate definitions of what constitutes a drug problem on an individual, pharmacological, and situational basis.
It is this inability to develop public acceptance of the more subtle and complex perspectives which have emerged that does not bode well for the refinement of American drug policies. It is this difficulty that explains the emphasis placed on the lack of general public understanding in a chapter on drug education and prevention.
In considering the changing concepts in the drug field, it is clear that we need to rethink our approach to drug education and prevention. It is a mistake to think of drug education only in the narrow terms of teaching young people; all the available evidence points to the need for a much broader educational effort. American society cannot transmit to younger generations knowledge and understanding about drugs and their effects that the public at large does not yet possess.
It is also impractical to think in terms of absolute prevention of psychoactive drug use. This goal is simply impossible to achieve, as man's historical experience with an increasing variety of psychoactive substances has shown. Moreover, as our understanding of the role of drug use in American life changes, we as a society may no longer want to so avidly pursue "drug abuse prevention" as we have commonly thought of it. The price paid in terms of social dissension, confusion, and misunderstanding has been very high.
The authors acknowledge with gratitude contributions of John Swisher, Rayburn Hesse, Robert R. Carr, John R. Pekkanen, and Norman Zinberg.