2 The Social Basis of Drug Dependency
We have seen how the nature of dependency and the life of the drugtaker cannot be understood merely in terms of the drug. Heroin addicts in Britain, in the United States, in Hongkong, in Japan all take the same drug but the pattern of their addiction is remarkably different. The social reaction against the drugtaker, the policies which are designed to control the drug, have remarkable effects on the role within which the drugtaker finds himself. For example, in the United States he is cast as a criminal, he is legally harassed, he is forced into crime (thus substantiating the stereotype) in order to find money for the high black market prices. As a consequence of this illegality organized crime grows up as an unintended consequence of the narcotics legislation. An exploitative culture is set up which dominates the life of the addict. The very strength of the drug is low, variable and adulterated, this having very tangible effects on the type of addiction found in the States. Death itself is not an inevitable consequence of the drug heroin but is related to these exigencies of the market. The addict is periodically and coercively institutionalized, he is subject to therapeutic onslaughts from a body of experts who have themselves particular conceptions of the 'essential' nature of the addict. Criminal exploitation, police harassment, therapeutic correction, social stigmatization all give rise to a culture partly defensive against these agencies, partly introjecting and accepting their notions of him, altogether an adaption to his situation. It is not then the study of drugs in a vacuum, as isolated pharmacological effects, which will help us understand drug addiction; rather it is the social meanings ascribed to a particular drug in a specific society or culture that we must analyse. But further than this: it is not only the life style of the addict which is shaped by social forces; the very effects of the drugs themselves are intimately related to the social values, expectations and milieu in which they are taken.
In 1968, N. Zinberg and A. Weill 1 performed the first controlled experiment on the effects of marihuana. They compared the effects of smoking the drug on a series of naive subjects contrasting them with a control group of chronic users.
I have detailed the results in Table 2. As can be seen, the only common effects between users and naive subjects were conjunctival reddening, increase in pulse rate and distortion of time sense. Blood sugar level and pupil size did not alter, disproving much of the literature. But the most important finding was the divergent effects found between the naive subjects and chronic users. Both motor and cognitive performance improved in the regular users but deteriorated in the naive subjects. The latter did not feel any euphoria whereas the users experienced a characteristic high. Moreover, the naive subjects had only a slight increase in pulse rate and no increase in respiratory rate whereas the chronic users had an increase on both counts.
Examining this data, Zinberg and Weil note how: 'there are suggestions in this study — like greater increase in the heart rate and respiratory rate of chronic users — that users and non-users react differently to the drug not only subjectively but also physiologically' (p. 86).
To explain this, the authors suggest two hypotheses:
1. That marihuana has a cumulative effect in the body. This they reject as unlikely because once a user is able to get high, the amount of drug necessary remains the same.
2. That some sort of pharmacological sensitization occurs giving rise to a unique example of 'reverse tolerance', i.e., unlike other drugs — such as alcohol — one does not become more but less tolerant of its effects. This I feel is not substantiated by the evidence: a user, for example, can quit smoking marihuana for several years but can come back to it and experience a high readily. Rather I wish to suggest a third hypothesis:
3. That chronic users learn to experience a high and that this learning process has physiological consequences. In other words, that the subjective and physiological levels are tightly interrelated and users in the process of achieving a high effect changes on their own metabolism. This notion is akin to the classic trauma reaction in the individual, where he subjectively experiences fear and this fear translates itself on the physiological level in the release of adrenaline into his bloodstream. Fear is a socially defined process where the subjective state of the individual effects his metabolism and, moreover, fear like a high is experienced by the individual as a subjective mood which is automatically substantiated on the bodily level. But this is, of course, only half of the process. Drugs by their very nature affect the metabolism of the individual, but the ways the individual interprets these changes in his body are related to his own subjective notions of what is happening to him. What I am arguing is that a two-way process occurs in drugtaking: the drug alters the metabolism of the individual, he interprets these bodily changes into subjective experiences according to his expectations, social situation and prevailing mood, and these subjective experiences react back on to and change the already altered metabolism. In short, the drug experience can only be understood in terms of an ongoing dialectic between the subjective mood of the individual and the objective psychotropic effects of the drug. I wish now to turn to the various authors who have studied precisely this type of relationship.
H. S. Becker, in his classic article 'Becoming a Marihuana User',2 outlines the learning process involved in marihuana use. The novice — the naive user — does not experience a high at first; he may feel, it is true, slightly strange but that is all; he is unable to interpret the meaning of the physiological sensations that he is experiencing. Indeed, as Becker notes, the novice may feel nothing at all has happened to him — he may feel totally cheated by the drug — and it is not until a sophisticated user has indicated to him the likely effects that he realizes that he is in fact being affected by the drug. Moreover, it is not until the naive user learns firstly how to smoke marihuana and then — more importantly — how to interpret his feelings as pleasurable that he experiences a high. Before this the effects of the drug are physically unpleasant or at least ambiguous.
A situation very similar to this exists with the opiate drugs. Thus Lindesmith writes:
Perhaps one of the most interesting features of the effects of drugs is the marked differences at all stages of drug use between the reports of addicts and those of non-addicts or persons who do not know what they are receiving. It has been observed, for example, that when non-addicts were given small injections of heroin or placebos without knowing which, those who received the placebos reported somewhat greater pleasurabgeffects than those who took heroin.3
Isbell and White 4 note how effects generally perceived as unpleasant by the uninitiated, when the heroin is first used, are valued positively by the addict who has learned to regard them as evidence of the potency of the shot. Lindesmith in another context writes:
The learning process involved in the first trials of the drug is illustrated by incidents related to me by addicts. For example, a man who experimented with opiates in the presence of two addicts reported that he felt nothing except nausea, which occurred about half an hour after injection. It took a number of repetitions and some instruction from his more sophisticated associates before this person learned to notice the euphoric effects. In another instance an individual who claimed that she felt nothing from two closely spaced injections amused her addicted companions by rubbing her nose violently while she made her complaints. A tingling or itching sensation in the nose or other parts of the body is the common effect of a large initial dose.5
The effect of subjective beliefs on the metabolism of the individual is clearly indicated when 'fake' withdrawal symptoms are evidenced by individuals who are in fact not at all addicted.
Lemert 6 notes in a similar vein how pharmacological generalizations about alcohol are often manifestly applicable to particular cultures only:
At this point it is necessary to interject a note of caution with reference to various physiological and psychological studies on the effects of alcohol consumption. We should not let ourselves forget that the subjects for these investigations have been drawn from our own culture and that there are very few cross-cultural studies of the physiology and 'psychology' of alcohol ingestion. Such comparative studies as have been made raise more than fleeting doubts that what often passes for constant 'physiological effects' of alcohol in American research in reality may be manifestations of a variable cultural overlay. Thus, for example, in one study of the function of alcohol in a primitive Mexican culture located in the mountains of Chiapas few of the more extreme types of behaviour which arise in connection with intoxication in our culture were found to occur. There, in the stage of feeling high, native men could play guitars or handle a machete with perfect safety. In extreme intoxication there seemed to be less interference with speech than that observable in inebriation in our culture, and even in stuporous states the natives carried through with familiar routines and transacted complicated business of which later they had no memory. There seemed to be very little vomiting after overindulgence, and there was little evidence of hang-overs beyond mild tremors and shakiness. Little fighting arose in drinking parties, and there was no evidence of lowered inhibition in erotic behaviour. These people typically drank for the sense of warmth it induced and as a prelude to sleep.
It is impossible then to make generalizations about the effects of drugs in a vacuum. For the effects of drugs are shaped by the culture of the user and are learned by the novice from the more sophisticated drugtaker. To this extent, the effects of a particular drug form a role in that group, in so far as they are shaped in terms of certain permitted and prohibited behaviour and that other drug users have a set of expectations vis-a-vis a person under the influence of a particular drug. Such roles are the heavy drinker, the comic drunk, the cool marihuana smoker, the righteous dope fiend. Now and then deviations occur from these roles especially when an overdose of a particular drug puts the individual in a position where he cannot control the effects he is experiencing. But drug groups contain lore of administration, dosage and use which tend to keep this lack of control in check, plus, of course, informal sanctions against the person who goes beyond these bounds. Witness the shame experienced by the man the morning after who hasn't been able to hold his liquor or the LSD user who has freaked out and has to be talked down (i.e., back to normative limits) by his fellows.
Not all drugs, of course, have finely spun norms surrounding their use, and even where such norms do exist, not all people have a working knowledge of them. Becker 7 has suggested that in these instances there is a high incidence of psychosis associated with drug use. Psychotropic drugs have, by definition, effects on the subjective experience of individuals. If there is a body of culture available to interpret these experiences, to say that such and such a mental state is pleasant — or at least normal in the circumstances — then the individual will feel in control of the situation. But if he has perceptual distortions, hallucinations, physical sensations which he does not know how to interpret, he may well think that his sanity has become impaired, that his mind is out of control. Such unstructured drug experiences may trigger off bouts of extreme alarm and anxiety. Unfortunate mental or physical harm to the individual may ensue from such a panic. Moreover, Becker notes that in the absence of a drug subculture the isolated individual's only knowledge of the effects of the drug which he has taken may derive from the mass media. Such reports are invariably 'newsworthy', that is they emphasize bizarre, psychotic effects of drugs. The individual's interpretation of his experiences may thus be both shaped and understood in alarming terms. Furthermore, even if he seeks help from a physician his fears may remain undiminished; for the psychiatrist will often regard dabbling in drugs as indicative of personality problems and his diagnosis will merely confirm the patient's suspicions about himself. Becker substantiates his thesis by referring to the history of marihuana use in America, noting how, as a subculture concerned with its use built up, the reports of cannabis psychosis gradually disappeared. This is corroborated by events in this country where in the fifties it was quite common to hear of individuals who experienced the horrors after smoking marihuana but such incidents — despite the increase in marihuana smokers — are rarer today.
THE IMPORTANCE OF THE DRUG SUBCULTURE
This approach to the sociology of drug use may be summed up in the following eight postulates:
I. Different groups in society have different problems. z. Drugs are a common means of problem-solving.
3. Groups select drugs which have psychotropic properties seemingly suitable for their problems.
4. The effects of the drugs are shaped and interpreted in terms of the culture of the drugtaker.
5. If the drug is seen as unsuitable, dangerous, or uncontrollable, in terms of the aims of the group, its use is discontinued.
6. Individual drug users usually learn the necessary dose, administration of drug and interpretation of the resulting experience, from individuals who are already drug users.
7. If there are no norms surrounding drug use there is danger of overdosage, psychosis and physical harm occurring to the individual.
8. That such normiess or anomie situations occur when:
(a) The individual is isolated from any subculture which possesses knowledge as to appropriate use of the drug, e.g., the middle-aged barbiturate addict.
(b) The drug has only recently been introduced, e.g., LSD on its introduction in Britain.
(c) The number of drugtakers is increasing rapidly without an adequate transmission of subcultural norms, e.g., heroin addiction in Britain.
(d) Harsh social reaction disintegrates an originally viable culture, e.g., the recent disintegration of hippie 'subculture' in San Francisco.
Now the usual assumption implicit in theories of drug control is that subcultures connected with drug use must be eliminated in order to limit the spread of the 'epidemic'. My contention here is that the notion of an automatic transmission of drug use whenever individuals contact drug subcultures is a fallacy based on analogies with the germ theory of disease. People accept socialization into drug culture because they find the cultures attractive in terms of solving problems which they face; they do not 'catch' drug addiction, they embrace it. To end drug abuse you must find alternative solutions to these problems which do not involve the use of drugs. Meanwhile, the cultures themselves serve to contain and regulate drug use. True, they often contain false premises: beliefs about drugs that are not necessarily rational. For instance, to believe that cigarette smoking calms your nerves isolates the fact that the nicotine content of tobacco is more likely to exacerbate the situation by making you jittery. Further, to believe that cigarettes are harmless is a 'product of the 'taken-for-granted' innocuousness foisted on the individual by advertising and his fellow smokers. What must be attempted here is to feed rational tested information into the cultures which support drug use. This may seem to be only a useful interim palliative in tackling the problem of drug abuse, but until we make determined efforts to tackle the root causes of drugtaking, it remains the most likely way of minimizing deleterious physical and psychological effects in the populations at risk.
At first glance, this distinction would seem to be one of considerable convenience. Thus hashish was commonly regarded as a drug of habituation and heroin as one of addiction. But unfortunately this distinction led to considerable confusion and to debate as to the correct classification of particular drugs which involved terminological disputes having little connection with reality.
The reasons for this were as follows:
1. The pharmacological profiles of already known drugs and the rapid number of newly introduced drugs did not fit this simple dichotomy. For example, amphetamines produce tolerance but not physical dependence; there is therefore doubt whether they should be called habituative or addictive. Or more significantly there is considerable controversy over whether hashish is socially harmful or not, and how to distinguish the desire for it from the notion of a compulsion.
2. Addiction and habituation tend to be constantly used inappropriately. Thus addiction is often seen as being equivalent to any misuse of drugs outside of medical practice. It has - become an emotive term based more on the implicit demand that something should be done to stop a drug's use than on any empirical description of how a drugtaker relates to a specific drug. Habituation, in contrast, is often applied merely to indicate that a person is dependent on a drug which is socially acceptable.
The distinction between habituation and addiction assumes that a drug's effects can be studied apart from the social context in which they are taken. This, I have argued, is palpably false — thus, the degree of compulsion involved in heroin use depends to an extent on the social beliefs as to the reality of this addiction. For instance: does the individual addict believe that it is impossible once he sees himself as 'hooked' ever to give up the drug ('once a hype always a hype' as some junkies put it) ? Does he see his addiction as an alien force compelling him to continue use or as merely a desire which he has decided to continue fulfilling ('you either ride the horse or let the horse ride you') ? Similarly, the actual severity of withdrawal symptoms where physical dependence occurs varies — as we will see later — with the lore surrounding a particular drug. Nor is the pattern of drug use divorced from the market in which the drug is purchased. For this determines the quality, quantity and often mode of administration of the drug. Thus the detrimental effects of a drug are closely related to the social factors which surround its use. we have seen the mortality rate of heroin users in Britain and America differs both quantitatively and qualitatively. Even the question of whether heroin is detrimental to the individual depends on the social setting in which it is used. Furthermore, judgements of social harm are even more variable. Amphetamines taken by people in periods of stress (astronauts and soldiers for instance) are approved of whereas when the same drug is taken for hedonistic reasons it is deemed socially culpable. Thus I would argue that the distinctions between habituation and addiction are fallacious in that they assume that the same drug in different social settings will have essentially similar effects. Compulsion, tolerance, psychic and physical dependence, social and individual disfunctions, are all factors which vary not only with the drug but with the individual or group who have cause to use that drug.
The World Health Organization Expert Committee on Addiction Producing Drugs decided in 1965 to combat the confusion in existing terminology by invoking a concept which would be wide enough to cover all kinds of drug abuse. With this in mind they introduced the umbrella term 'drug dependence', which was defined as: 'A state, psychic and sometimes also physical, resulting from the interaction between a living organism and a drug, characterized by behavioural and other responses that always include a compulsion to take the drug on a continuous or periodic basis in order to experience its psychic effects and sometimes to avoid the discomfort of its absence. Tolerance may or may not be present . .
'Dependence' adequately answers two of the three criticisms of the use of 'habituation' and addiction. It does not assume that there are automatically deleterious effects, either social or individual, of drug use; this is a matter that must be decided apart from the fact of dependence; nor does it presume that all drugs can be described in terms of two profiles: habituation and addiction. Instead it argues that: 'it is neither possible nor desirable to delineate or define the term drug dependence independently of the agent involved. It should be remembered that it was the desire to achieve the impossible and define a complex situation by a single term (addiction or habituation) which has given rise to confusion in many cases. Therefore, the description of drug dependence as a state is a concept for clarification and not, in any sense, a specific definition.8 Thus, within the broad spectrum of drugs of dependence there are detailed a series of specific 'dependencies' based on the particular pharmacological action of the drugs involved, e.g., drug dependence of morphine type, i.e., morphine, heroin, methadone, etc.; drug dependence of barbiturate-alcohol type.
Now this reformulation by the Expert Committee is undoubtedly a step in the right direction. Its single fault is that it fails to answer my third criticism concerning the relationship between drug use and the social context of drug uses. For as I have argued the focus for the study of drug use must be neither concentrated on the norms of the group involved nor the pharmacological effects of the drug but on both. The Expert Committee being composed of pharmacologists and medical doctors has been understandably myopic in its concentration on drugs as the basis of a suitable classification. To describe adequately a particular form of drug use, then, we must use what I will term a socio-pharmacological classification. Thus we will need to divide drug users up into categories which describe patterns of drug use involving similar social meanings and beliefs, on one hand, and drugs with closely related pharmacological effects on the other:
e.g., morphine/meperidine/pethidine, dependency by members of medical and allied professions which occurs in most advanced industrial countries,
or marihuana dependency by bohemians which occurs chiefly in Britain, North America, France and Holland.
Implicit in this revised terminology is the notion that it is invalid to generalize about drug use without reference to a specific cultural context. Thus, to explain and describe marihuana dependency in Morocco may throw light on but does not warrant the construction of immediate parallels and conclusions as to the likely causes and outcomes of pot smoking amongst British hippies. The problem of the proper classification of drug use is, in this light, not a mere academic whim, but a necessity if we are to create meaningful categories with which to explain the reasons why certain groups of individuals take drugs and the likely consequences of such behaviour.
At the same time it is essential that we make clear what we mean by dependence on a drug so that when referring to two types of drug dependency we may have some ready means of comparison. The Expert Committee insists that the primary criteria of dependency is compulsion to take a drug because of its psychic effects; physical dependence is a variable which may or may not be present. To this extent they are in agreement with the majority of authorities like Lindesmith and Chein and Rosenfield, for whom craving is the central characteristic of addiction. But concepts such as 'craving' and 'psychic dependence' are, I feel, not sufficiently elaborated to be useful. With this in mind I would suggest that dependency is best understood in terms of three interrelated levels: physiological, subjective and social.
1. Physiological level. A person is physiologically dependent on a drug to the extent that he experiences withdrawal symptoms when its use is abruptly terminated. This bodily discomfort may be because constant use of the drug has brought about a situation where it plays an intimate role in the body's metabolism (such as in the case of heroin, alcohol and the barbiturates); or it may be merely because the body has become so used to its effects that it takes a while to adjust to its absence (e.g., amphetamines, tobacco, caffeine).
But it should be stressed that the extent to which withdrawal symptoms are evidenced is closely related to social beliefs as to the addictive powers of a drug, and the degree of discomfort experienced is evaluated by individuals who vary in their tolerance of what they are suffering and the degree to which they crave a renewal of the drug's effects. Thus, it is impossible to speak of a physiological level in isolation from the individual who is conscious of changes in his metabolism and who belongs to a group who have a given set of beliefs as to the meaning of this experience.
2. Subjective level. A person is subjectively dependent on a drug to the extent which he craves for its effects. This desire may be to a limited extent, related to its ability to remove unpleasant withdrawal symptoms, but is more usually explicable in terms of the effects being deemed pleasant in terms of the values of the individual drugtaker. Thus, subjective craving relates both to the physiological and the social level and must be viewed in this context.
It is important here to make a distinction between a craving which is seen as a desire which is freely fulfilled and which is compatible with the individual's values and self image (e.g., the bohemian's desire to smoke marihuana), and a craving which is seen as a compulsion, enslaving and compelling the individual despite himself (e.g., heroin addicts). Alienated compulsions to take drugs often but not necessarily have a physiological basis, but the degree to which people embrace the notion of themselves being powerless to control their activities is related to their social conceptions of themselves.
3. Social level. A person's dependency on a drug is related to the degree to which his self-conception involves viewing himself as a drugtaker. For example, the role bohemian involves smoking marihuana, just as the role merchant seaman involves heavy drinking. Such people find themselves because of their position in society in a matrix of social pressures which make for continued dependency, and espousing values which evaluate the effects of the particular drug as desirable. A special case is the individuals mentioned earlier who feel that they are compelled to use a particular drug despite themselves. These people are in fact embracing a role which is characterized by their feeling alienated and powerless over their own actions. This 'sick' role is common in drugtaking and is maintained both because of its advantages to the individual himself — which we shall explore later — and because of the pressures of outsiders who insist on viewing the drugtaker in such a light. There are, after all, no physiological reasons why a person should not be able to terminate the use of any drug whatsoever, but there are a multitude of social and individual reasons why this does not occur.
A person becomes dependent on a drug to the extent that — in his reckoning — efficiently produces effects which he judges as valuable. Moreover, the calculus of value against which such effects are judged is derived from the group of which he is a member. Thus the doctor who becomes a secret morphine addict often does so in order that he may work hard under pressure without fatigue and depression; the bohemian smokes marihuana so that he can more easiry enjoy aesthetic, sensual and group experiences; and — more subtly — the heroin addict may find the abdication of responsibility which the role junkie gives him the only way of avoiding the pursuit of values which he is loath, or unable, to achieve.
The need for drug use is therefore, in the last analysis, a product of discrepancy between the ideals espoused by a group or individual and the absence of any means of achieving them without recourse to drugs. Cultures, like individuals, can become dependent on drugs in order to promote the type of behaviour which they value.
Our analysis of the meaning of drug dependency has led us to pursue what I have called a socio-pharmacological approach. That is, we must focus not on the isolated individual taking a drug with foregone effects, but on the drugtaker as a person belonging to a particular culture in terms of which the effects of the drug are structured and his drug use understandable. Similarly, when we refer to dependency we must state both the drug and the group or individual we are concerned with. And in our description of the nature of this dependency we must not talk of physiological needs for drugs or a subjectively experienced craving in isolation from the social context in which they occur. We must see the physiological, subjective and social levels of dependency as a highly interrelated whole.
1 Cannabis: The First Controlled Experiment', New Society, 16 January 1969.
2 Outsiders, The Free Press, Glencoe, IlL, 1963.
3 'Problems in the Social Psychology of Addiction', in Narcotics, (ed.) D. Wilner and G. Kassebaum, 1965, p. 123.
4 H. Isbell and W. White, 'Clinical Characteristics of Addiction', American Journal of Medicine, no. 14, 3953, p. 558.
5 A. Lindesmith, Addiction and Opiates, Aldine, Chicago, 2968, PP. 24-5.
6 E. Lemert, Sodal Pathology, McGraw Hill, New York, 195x, p. 341.
7 H. S. Becker, 'History, Culture and Subjective Experience', The Journal of Health and Social Behaviour, no. 8, 1967, pp. 563-76.
8 Eddy et al., 'Drug Dependence: Its Significance and Characteristic?, World Health Organization Bulletin, no. 32,1965, pp. 721-33.