appointed not to fan public anxiety, but to convert it into meaningful activity with constructive proposals. This can be done only by refusing to accept at face value many of the common assumptions about drugs and the drug problem. We must examine the reasons behind the fears, conducting the inquiry without passion and with candor. Confident social action comes from an understanding of the problem and from an impartial assessment of the impact of alternative strategies. We have sought to define the problem and to provide at least an initial assessment of the possible responses to it. The Commission has carefully surveyed the social response to the contemporary drug problem, and has been struck by a persisting uneasiness which seems to color the entire effort. On the street and in the councils of government, increasing numbers of drug abuse “experts" wonder whether their commitment and efforts have had any actual impact on the problem. Many of them assume optimistic positions in public, while suspecting privately that no solution will be found. The Commission understands the reasons for this malaise. We are convinced that public policy, as presently designed, is premised on incorrect assumptions, is aimed at the wrong targets, and is too often unresponsive to human needs and aspirations. In this Chapter, the Commission seeks to bring the issue of drug use into focus. First, we will explore the way our society thinks about drugs by analyzing both the vocabulary of the drug problem and the historical roots of contemporary attitudes. After considering the way in which the drug problem is presently defined, we will redefine it, first by broadening the scope to cover the entire range of drug use in America and then by narrowing it to that drug-using behavior which properly should arouse social concern. After the problem has been carefully defined, the policy-making task begins. In this sense, this Chapter, and the two which follow, are designed primarily to create a climate for the formulation of new policy concepts. Chapter Four details the policy-making process and sets forth specific recommendations for immediate implementation by governmental and private institutions. Chapter Five will then provide a broad perspective on the development of a long-term social response to drug-using behavior. DEFINITIONAL CONFUSION: WHAT IS DRUG ABUSE? The use of psychoactive drugs is commonplace in American life. Distribution of these drugs is an integral part of the social and economic order. In 1970, 214 million prescriptions for psychoactive drugs were issued, representing annual retail sales of approximately $1 billion (Balter and Levine, 1971). The alcohol industry produced over one billion gallons of spirits, wine and beer for which 100 million. consumers paid about $24 billion. What is the pertinence of this information for a Commission mandated to report to the American people on drug "abuse?" Can such familiar American behavior include drug abuse, even though that term is generally thought to refer only to the consumption of psychoactive substances obtained illicitly from a market with an estimated annual volume of $2 billion? The Commission concluded early in its deliberations that the focus of inquiry should not be determined by general impressions or facile labels. Instead, formulation of a coherent social policy requires a consideration of the entire range of psychoactive drug consumption, and a determination as to whether and under what circumstances drug-using behavior becomes a matter of social concern. For example, does youthful experimentation with alcohol involve different social policy considerations than experimentation with marihuana? Do alcoholism and heroin dependence present similar or dissimilar social policy questions? Do the social policy implications of repeated use of barbiturates or minor tranquilizers depend solely on whether a physician has prescribed the drug or on the motivations for such use? In order to deal coherently with such questions, it is necessary to examine how this society thinks about drugs and their use. "Drug"-The All-Purpose Concept The meaning of the word drug often varies with the context in which it is used. From a strictly scientific point of view, a drug is any substance other than food which by its chemical nature affects the structure or function of the living organism. From this perspective, the term includes some agricultural and industrial chemicals. The physician might define a drug as any substance used as a medicine in the treatment of physical or mental disease; when treatment of illness is the referent, the lay public may use the word in the same sense. However, when used in the context of drug "abuse" or the drug "problem," the meaning of "drug" becomes social rather than scientific. In its social sense, drug is not a neutral term. This point is best illustrated by the fact that "drug problem" is frequently used not as a descriptive phrase, but a substitute for the word drug. In our visits to communities throughout this country and other nations, we have noted that local leaders often feel compelled to report not simply that drugs are available or that they are used, but that there is a "drug problem." This value component of the word drug is reflected in the selective application of this term by the general public. Table I-1, drawn from trates that the public tends uniformly to regard heroin as a drug, as well as other substances associated with the drug problem, such as marihuana, cocaine, the amphetamines and the barbiturates. Some psychoactive substances, such as alcohol and tobacco, are generally not regarded as drugs at all. In neither public law nor public discussion is alcohol regarded as a drug. It may be called a beverage, a food, a social lubricant or a relaxant, but rarely is it called a drug. Depending on the context in which the term "drug" is used, statements about what a given drug does are liable to differ. If the therapeutic meaning is employed, for example, the characterization is likely to involve the reasons for using the drug, the dose, the frequency of use and an evaluation of its effects in terms of medical benefits. It might be asked whether the drug made an individual feel better, cured his illness, or made him less anxious or depressed. If the social meaning is being used, however, the analysis generally focuses on toxicity, lethality, dependence liability, possible genetic defects, psychosis and effects of high doses; that is, on drug effects in terms of their risks. The imprecision of the term "drug" has had serious social consequences. Because alcohol is excluded, the public is conditioned to regard a martini as something fundamentally different from a marihuana *The survey, conducted by Response Analysis, involved face-to-face interviews with a random sample of 2,411 adults and 880 young persons age 12-17 in the contiguous states. Findings from the Survey are reported and discussed throughout this Report. The reader should note that surveys which employ probability samples may be generalized to the population as a whole within known limits. It should also be noted that the Survey data presented here involve unweighted bases with percentages calculated on weighted bases. cigarette, a barbiturate capsule or a bag of heroin. Similarly, because the referents of the word "drug" differ so widely in the therapeutic and social contexts, the public is conditioned to believe that "street" drugs act according to entirely different principles than "medical" drugs. The result is that the risks of the former are exaggerated and the risks of the latter are overlooked. This confusion must be dispelled. Alcohol is a drug. All drugs act according to the same general principles. Their effects vary with dose. For each drug there is an effective dose (in terms of the desired effect), a toxic dose and a lethal dose. All drugs have multiple effects. The lower the dose, the more important non-drug factors become in determining drug effect. At high dose levels, and for some individuals at much lower dose levels, all drugs may be dangerous. The individual and social consequences of drug use escalate with frequency and duration of use. American drug policy will never be coherent until it is founded on uniform principles such as these, which apply to all drugs.1 Drug Abuse: Synonym for Social Disapproval Drug abuse is another way of saying drug problem. Now immortalized in the titles of federal and state governmental agencies (and we might add, in our own), this term has the virtue of rallying all parties to a common cause: no one could possibly be for abuse of drugs any more than they could be for abuse of minorities, power or children. By the same token, the term also obscures the fact that "abuse" is undefined where drugs are concerned. Neither the public, its policy makers nor the expert community share a common understanding of its meaning or of the nature of the phenomenon to which it refers. The Commission has noted over the last two years that the public and press often employ drug abuse interchangeably with drug use. Indeed, many "drug abuse experts," including government officials, do so as well. The Commission was curious about whether the public had any more. precise conception of the meaning of drug abuse than the experts. In our second National Survey, public attitudes on this issue were probed. The public was requested to give a free-response explanation of what drug abuse meant. (See Table I-2.) 1 Unless otherwise noted, the word drug is intended to encompass only "psychoactive drugs," or those which have the capacity to influence behavior by altering feeling, mood, perception or other mental states. (Multiple responses; main mentions included here) Adults Youth (N=880) Any nonmedical purpose, or purpose not intended for the drug; purpose not prescribed; if prescription was not for you..... Use for pleasure; to feel good; to get high; for kicks; for fun; take a trip...... Taking or using marihuana, 'heroin, dope, acid, LSD, mescaline (or other drugs which are illegal to possess)......... Taking an overdose; overdoing; taking to excess; taking too much........ Anything that is addictive; habit forming; where you become dependent on it.. Any use that damages health, is bad for you, does damage to the person......... If it is a distortion of reality; makes you unable to cope In this multiple-response question, the public was divided between perceptions related to the purpose or motivation of drug taking (the first three responses) on the one hand, and to the consequences of use on the other (the remaining responses). Roughly 30% of both youth and adult populations associate drug abuse with the use of drugs for other than medical purposes, including any use of those substances which have been prohibited because they have no medical uses. In contrast, large numbers of both adults and youth relate the term to the consequences of drug taking. Excessive doses (27% and 16%), dependence (17% and 15%) and danger to health (11% and 10%) are the most common examples. Also of interest were those respondents who indicated that they didn't know what drug abuse meant (13% and 20%). In another part of the Survey, the respondents were asked whether they regarded ten specific drug-using behaviors as drug abuse. These data illustrate that drug abuse is an entirely subjective concept. It is any drug use the respondent frowns upon. Most respondents disapprove of the use of medically-distributed pills for other than medical purposes (those sanctioned by a physician), any use of heroin, and any use which suggests that the user is dependent or seeking pleasure. |