Use/Abuse Model Obstructs Prevention Efforts

The effectiveness of the use = abuse model is now in question.

Zinberg's underlying assumption is that we can learn a lot about drug abuse by studying drug use. Of course, that requires accepting a distinction between the two. The Office of Technology Assessment of the U.S. Congress reported on emerging technologies for fighting substance abuse. One of these "technologies" is a different paradigm for studying drug abuse than that which currently drives policy, and one similar to Zinberg's position and that of other drug policy reformers. According to OTA, this emerging technology is called the "Public Health Model" for understanding abuse and addiction.

"The legality or illegality of a drug is an artificial barrier that is not as relevant as the health-related considerations stemming from all types of drug use. Rather than using legal/illegal, the public health approach categorizes drugs by such characteristics as addictive potential and long-term health risks. . .Dealing with the drug problem primarily as a moral problem is considered inappropriate and counterproductive (as part of the public health model)."(4)

The Office of Technology Assessment also notes movement towards Zinberg's advice to study drug use as well as drug abuse.

" "What prevents some individuals from progressing from initial use to abuse to addiction? . . . Studying those individuals who do not progress from use to addiction may provide insights and lessons about how to prevent progression among those who do progress."(5)

This emerging trend has a name--harm reduction. In sharp contrast to existing policy, which self-consciously advocates increasing the consequences and harm of drug use, harm reduction policies pursue distinct obtainable objectives and are based on well-grounded analyses of scientific research and program experience. This trend will be examined in more detail in section 6 on the public health consequences of marijuana use. However it must be realized that harm reduction is not a new policy innovation.

The legislation creating the Controlled Substances Act also created a national commission to study marijuana and other drug abuse. The first report of this commission is well-known for recommending decriminalization of marijuana throughout the United States.(6) The Commission issued a less-publicized second report a year later in 1973.(7) Like Brady and Cicero 15 - 20 years later (see section 1), the Commission greatly objected to the unscientific and un-useful terminology employed to discuss public policy and drug-using behavior.

"Drug abuse may refer to any type of a drug or chemical without regard to its pharmacologic actions. It is an ecletic concept having only one uniform connotation: societal disapproval.

"The Commission believes that the term drug abuse must be deleted from official pronouncements and public policy dialogue. The term has no functional utility and has become no more than an arbitrary codeword for that drug use which is presently considered wrong. Continued use of this term, with its emotional overtones, will serve only to perpetuate confused public attitudes about drug-using behavior.

"Drug abuse, or any similar term, creates an impression that all drug-using behavior falls into one of two clear-cut spheres: drug use which is good, safe, beneficial and without social consequence; and drug "abuse" which is bad, harmful, without benefit and carrying high social cost. From either a descriptive or an evaluative standpoint, the matter is much too complex to be handled in such a polarized fashion. The Commission urges that the public and its policy makers avoid such labels and focus instead on the relative risks and social consequences of various patterns of drug-taking behavior."(8)

Chapter One of the Commission's second report is one of the most lucid discussions on record in the last 25 years of the policy problems presented by prejudicial terminology . The Commission quite rightly predicted that a failure to distinguish between use and abuse in policy making and implementation would not help to reduce the various risks associated with different drugs and their use. The Commission endorses the cost/benefit analysis approach implicit in considering the scope of use in scheduling determinations.

"In the Commission's view, problem definition should take into account the relationship between the maximum potential social cost of use of a particular drug under given conditions of availability, compared with the verified social costs at a particular point in time. In this context, the most serious concern in contemporary America should attach to the use of alcohol and heroin. Moderate social concern should attach to the use of amphetamines, barbiturates, hallucinogens, methaqualone and cocaine, the use of which is relatively well-controlled within the present time [1973]. Present trends do suggest, however, that the incidence of use of and dependence on barbiturates and cocaine may be increasing and may demand increased social attention."(9)

The Commission was influenced by the same scientific and extra-scientific theories and findings that resulted in the Controlled Substances Act which created it. This is not at all surprising. What is surprising is the increasing popularity of this analytical view among scientists twenty to twenty five years later.

In 1990 Joseph Brady was awarded the Nelson Eddy Lifetime Achievement award by the College on the Problems of Drug Dependence. In his acceptance speech, Brady directed his comments to the oddity this recognition posed--Brady is a behaviorist, and describes the CPDD as a "once exclusive opiod club" of pharmacologists.(10) In what he describes as "the short answer" Brady describes the synergy between the two disciplines.

"The short answer to the title question is that drugs interact in profound and broad-ranging ways with the transactions between individuals and their environment -- the unique domain of the behavioral sciences and the root subject matter of radical behaviorists. But let me reassure you about radical -- not to worry, neither violent nor terrorist proposals are in the offspring. Simply defined, radical means root and calls attention to an important difference between behaviorists, all of whom are not created equal. There are many, perhaps, most, whose interest in behavior is primarily methodological in the sense that what goes on at the interface between individuals and their environment is of concern primarily if not solely as a reflection of other activities of presumably greater import like central nervous system functions or so-called cognitive processes. Without denying these methodological claims to the territory, root behaviorists view the transactions as the interface between individual and environment as a legitimate subject matter in its own right and the source of an orderly and systematic body of empirical knowledge that does not require reduction to other levels of analysis or appeals to other levels of explanation.

"It follows of course, that card-carrying root behaviorists tend to favor alternatives to the dominant "inner states" orientation of the "psych" disciplines. Among the most compatible of these alternatives is environmentalism which has two main tenets. The first of these is that knowledge comes from experience rather than from innate ideas, divine revelation, or other obscure sources. And the second is that action is governed by consequences rather than by instinct, will, beliefs, attitudes, or even the currently fashionable cognitions. These two constructs about the nature of human conduct -- the experimental basis of knowledge and the governance of action by consequences -- define a philosophy of social optimism that says if you want people to do certain things or to manage their lives in certain ways with respect for example, to drugs and alcohol, circumstances can be arranged. These two features of environmentalism also provide a productive framework for the analysis of drug-behavior interactions as well as an operational basis for the development of effective drug abuse treatment and prevention."(11)

It should be clear by now that self-administration of a drug indicates a situation in which the drug is having a stronger effect on the individual's behavior than mental disposition or environment. In therapeutic contexts, this is usually positive, whereas in some behavioral contexts this can be negative; this explains all the controversy over terminology. Language and theoretical choices indicate significance. The animal models used to evaluate a substance's dependence liability are part of a conceptual paradigm, developed by Brady and others, which holds that it is significant to separate the effects of the drug from the influence of set and setting. This is precisely what Norman Zinberg asserted was necessary for successful harm reduction policies.

"In order to distinguish use from misuse, greater attention will have to be paid to how drugs are used (the conditions of use) than to the prevention of use. Researchers must study both the conditions under which dysfunctional use occurs and how these can be promulgated. The goal of prevention should not be entirely abandoned, but emphasis should be shifted from the prevention of all use to the prevention of dysfunctional use. When this new focus is adopted, policymakers may decide not to treat all intoxicating substances as if they were alike. Careful studies of the use of various kinds of drugs and of the varying conditions of use may reveal the need to create a different policy strategy for each type of drug.

"To study the conditions of use for each drug will require consideration of the following topics: dosage, method of administration, pattern of use (including frequency), and social setting, as well as the pharmacology of the drug itself. Consider, for example, the question of frequency of use. It is only at the extremes that frequency is not necessarily related to the harmfulness of a drug, . . .A policy aimed solely (or mainly) at reducing frequency would not only mask the significant differences between the drugs themselves but would deny the importance of the social setting, including when, where, and with whom the drug is used. These social factors, which may vary across cultural and ethnic lines, combine with frequency and quantity of use to determine the quality of use. A policy aimed at encouraging a shift from those drugs that are generally considered to be the most harmful to those that on all counts are the least harmful (even though some may at present be illicit) would result in a considerable reduction of social cost."(12)

In 1994 OTA reported that

"substantial U.S. ethnographic research on marijuana use in the United States has been generally lacking, despite the fact that marijuana has been the most commonly used illicit substance for decades."(13)

If ethnographic research existed, it would be the primary material for this section. However a policy based on marijuana's schedule I status holds that there is no use of marijuana to study; all use is misuse. Consequently, marijuana's schedule I status create obstacles to the development of effective research-based policy.

There is an extensive body of ethnographic material on marijuana's use as a therapeutic agent. Rather than recognize the valuable data such material presents, the U.S. government has been doing all it can to suppress marijuana's medical use and official study of the data that results from such use. The discussion below does not concern this ethnographic material, but the government's attempts to discredit it.