DrugsSocietyandCriminalJustice
DrugsSocietyandCriminalJustice
Boston Columbus Indianapolis New York San Francisco Amsterdam Cape Town Dubai London Madrid Milan Munich Paris Montreal Toronto Delhi
Mexico City Sao Paulo Sydney Hong Kong Seoul Singapore Taipei Tokyo
FoUrth eDition
Editorial Director: Andrew Gilfillan Senior Acquisitions Editor: Gary Bauer Editorial Assistant: Lynda Cramer Program Manager: Tara Horton Director of Marketing: Dave Gesell Marketing Manager: Thomas Hayward Senior Marketing Assistant: Les Roberts Project Management Team Lead: Bryan Pirrmann Project Manager: Susan Hannahs Operations Manager: Mary Fischer Operations Specialist: Deidra Skahill
Creative Director: Andrea Nix Art Director: Diane Ernsberger Cover Designer: Melissa Welch, Studio Montage Cover Art: Emilio100/Shutterstock; Tatiana Popova/Shutterstock Full-Service Project Management: Integra Software, Inc., LLC/ Abinaya Rajendran Composition: Integra Software, Inc., LLC Text Printer and Bindery: R. R. Donnelley, Roanoke Cover Printer: Lehigh-Phoenix Color Text Font: 10/12, Electra LT Std
Credits and acknowledgments borrowed from other sources and reproduced, with permission, in this textbook appear on the appropriate page within the text.
Acknowledgements of third party content appear on page with the borrowed material, which constitutes an extension of this copyright page.
Copyright © 2016, 2012, 2008, 2006 by Pearson Education, Inc. or its affiliates. All Rights Reserved. Printed in the United States of America. This publication is protected by copyright, and permission should be obtained from the publisher prior to any prohibited reproduction, storage in a retrieval system, or transmission in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise. For information regarding permissions, request forms and the appropriate contacts within the Pearson Education Global Rights & Permissions department, please visit www.pearsoned.com/permissions/.
Many of the designations by manufacturers and sellers to distinguish their products are claimed as trademarks. Where those designations appear in this book, and the publisher was aware of a trademark claim, the designations have been printed in initial caps or all caps.
Library of Congress Cataloging-in-Publication Data Levinthal, Charles F. Drugs, society, and criminal justice/Charles F. Levinthal.—Fourth edition. pages cm ISBN 978-0-13-380258-0 (alk. paper)—ISBN 0-13-380258-2 (alk. paper) 1. Drug abuse. 2. Drugs of abuse. 3. Drug abuse and crime. 4. Drug abuse—Prevention. I. Title. HV5801.L493 2016 363.290973—dc23 2015016772
10 9 8 7 6 5 4 3 2 1
ISBN 10: 0-13-380258-2 ISBN 13: 978-0-13-380258-0
Unless otherwise indicated herein, any third-party trademarks that may appear in this work are the property of their respective owners and any references to third-party trademarks, logos or other trade dress are for demonstrative or descriptive purposes only. Such references are not intended to imply any sponsorship, endorsement, authorization, or promotion of Pearson’s products by the owners of such marks, or any relationship between the owner and Pearson Education, Inc. or its affiliates, authors, licensees or distributors.
For my wife, Beth,
our sons, David and Brian, Daughters-in-law, Sarah and Karen,
and Grandchildren all
This page intentionally left blank
BrieF ContentS
Part One the Challenge of Drugs in Our Society 1
Chapter 1 Understanding the Drug problem in america 1
Chapter 2 Understanding the Drug problem in Global perspective 25
Chapter 3 the history of Drug Use and Drug-Control policy 46
Chapter 4 Fundamentals of Drug-taking Behavior 66
Part twO Drugs, Crime, and Criminal Justice 84
Chapter 5 theoretical perspectives on Drug Use and abuse 84
Chapter 6 Drugs and Crime 103
Chapter 7 Drugs and law enforcement 121
Chapter 8 Drugs, Courts, and Correctional Systems 138
Part three Legally restricted Drugs and Criminal Justice 155
Chapter 9 opioids: heroin and prescription pain Medications 155
Chapter 10 Cocaine and Methamphetamine 181
Chapter 11 lSD and other hallucinogens 205
Chapter 12 Marijuana 227
Chapter 13 performance-enhancing Drugs and Drug Screening tests 253
Chapter 14 Depressants and inhalants 277
Part FOur On the Margins of Criminal Justice: regulating Legal Drugs 299
Chapter 15 alcohol Use and Chronic alcohol abuse 299
Chapter 16 nicotine and tobacco Use 335
Part Five Drug–Control Policy and intervention Strategies 363
Chapter 17 Substance abuse prevention and treatment 363
This page intentionally left blank
Contents ■ vii
ContentS
preface xvii
Part One the Challenge of Drugs in Our Society 1
Chapter 1
Understanding the Drug problem in america 1
Numbers Talk … 2 Social Messages about Drug Use 3 Two Ways of Looking at Drugs and Society 4
A Matter of Definition: What is a Drug? 5 Instrumental Drug Use/Recreational Drug Use 5
■■ DruGS . . . in FOCuS : Understanding Drug Names 6 Drug Misuse or Drug Abuse? 7
■■ POrtra i t : From Oxy to Heroin: The Life and Death of Erik 8
The Problem of Drug Toxicity 8
■■ DruGS . . . in FOCuS : Acute Toxicity in the News: Drug-Related Deaths 11
■■ QuiCk COnCePt CheCk 1 .1 : Understanding Margins of Safety 12
The DAWN Reports 12 Emergencies Related to Illicit Drugs 13 Drug-Related Deaths 13 Judging Drug Toxicity from Drug-Related Deaths 13 Demographics and Trends 13
Multiplying the Problem of Drug Toxicity: How Many Drug Users? 15 Prevalence Rates of Drug Use in the United States 15 Illicit Drug Use among High School Seniors 16 Illicit Drug Use among Eighth Graders and Tenth Graders 16 Illicit Drug Use among College Students 17 Alcohol Use among High School and College Students 17 Tobacco Use among High School and College Students 18 Drugs among Youth in a Diverse Society 18 Drug Use and Perceived Risk 18 Illicit Drug Use among Adults Aged 26 and Older 19
■■ QuiCk COnCePt CheCk 1 .2 : Understanding Prevalence Rates of Drug Use in the United States 19
Continuing Challenges 20
■■ DruG enFOrCeMent . . . in FOCuS : Dealing with High-Tech Drug Dealing: Policing the “Dark Web” 21
Looking Ahead 21 Summary 22 / Key Terms 22 / Review Questions 22 Critical Thinking: What Would You Do? 23 / Endnotes 23
Chapter 2
Understanding the Drug problem in Global perspective 25
Numbers Talk … 26 Worldwide Prevalence Rates of Illicit Drug Use 27 European Prevalence Rates for Illicit Drugs, Alcohol,
and Tobacco 27 The Global Problem of New Psychoactive
Drugs 28
■■ QuiCk COnCePt CheCk 2 .1 : Understanding Prevalence Rates of Drug Use in America and Elsewhere 28
The Global Problem of Drug Trafficking 29 The Trafficking of Heroin 29
Heroin, Turkey, and the “French Connection” 29 The Golden Triangle and the Golden Crescent 30 Heroin Trafficking in Mexico and Colombia 32
The Trafficking of Cocaine 32
■■ POrtra i t: Pablo Escobar: The Violent Life of the King of Cocaine 34
The Trafficking of Marijuana: Foreign and Domestic 35
■■ DruG enFOrCeMent . . . in FOCuS : Massive Cross-Border Drug Tunnel Detected (Again) 35
The Trafficking of Methamphetamine: Foreign and Domestic 36
The Trafficking of LSD, PCP, and Ketamine 37 Drug Trafficking as a Moving Target 37
Drug Trafficking/Violence: The Mexican Connection 37
■■ QuiCk COnCePt CheCk 2 .2 : Understanding Global Drug Trafficking 39
Drugs and Narcoterrorism 39 Narcoterrorism in Afghanistan and Colombia 39
■■ DruGS . . . in FOCuS : Life and Death in Mexico: Don Garza Tamez and a Man Called Z-40 40 Transnational Narcoterrorism 41
viii ■ Contents
Chapter 4
Fundamentals of Drug-taking Behavior 66
Numbers Talk … 67 How Drugs Enter the Body 67
Oral Administration 67 Injection 68 Inhalation 68 Absorption through the Skin or Membranes 69
■■ DruGS . . . in FOCuS : Ways to Take Drugs: Routes of Administration 70
How Drugs Exit the Body 70 Factors Determining the Behavioral Impact of Drugs 71
Timing 71 Drug Interactions 71 Tolerance Effects 73
■■ heLP L ine : The Possibility of a Drug-Drug or Food-Drug Combination Effect 73
■■ QuiCk COnCePt CheCk 4 .1 : Understanding Drug Interactions 74
■■ POrtra i t: Mithridates VI of Pontus: Drug Tolerance and the Story of the Poison King 74
■■ DruGS . . . in FOCuS : Conditioned Tolerance in Alcoholic Beverages: The Four-Loko Effect 75 Cross-Tolerance 75 Individual Differences 75
■■ QuiCk COnCePt CheCk 4 .2 : Understanding Behavioral Tolerance through Conditioning 76
Psychological Factors in Drug-Taking Behavior 76 Expectation Effects 77 Drug Research Methodology 77
Physical and Psychological Dependence 78 Physical Dependence 78 Psychological Dependence 78
Drug-Taking Behavior and Treatment: The Health Professional Perspective 79
Summary 81 / Key Terms 81 / Review Questions 81 Critical Thinking: What Would You Do? 82 / Endnotes 82
Part twO Drugs, Crime, and Criminal Justice 84
Chapter 5
theoretical perspectives on Drug Use and abuse 84
Numbers Talk … 85 Biological Perspectives on Drug Abuse 85
■■ DruGS . . . in FOCuS : Sarin and Chemical Warfare: Neurotoxicity on the Battlefield 41
Looking Ahead 42 Summary 42 / Key Terms 43 / Review Questions 43 Critical Thinking: What Would You Do? 43 / Endnotes 43
Chapter 3
the history of Drug Use and Drug-Control policy 46
Numbers Talk … 47 Drugs in Early Times 47 Drugs in the Nineteenth Century 48
■■ DruGS . . . in FOCuS : Abraham Lincoln, Depression, and Those “Little Blue Pills” 49
Drug Regulation in the Early Twentieth Century 50
■■ QuiCk COnCePt CheCk 3 .1 : Understanding the Early History of Drugs and Drug-Taking Behavior 50
Drug Regulation, 1914–1938 50 The Harrison Act of 1914 51 Alcohol in America before Prohibition 52 The Rise of the Temperance Movement 52 The Road to National Prohibition 53
The Beginning and Ending of a “Noble Experiment” 53
■■ POrtra i t: Eliot Ness and the Untouchables 54 Marijuana and the Marijuana Tax Act of 1937 54 The Federal Food, Drug, and Cosmetic
Act of 1938 55 Drugs and Society from 1945 to 1960 55
Turbulence, Treatment, and the War on Drugs, 1960–1980 56
■■ DruG enFOrCeMent . . . in FOCuS : The Drug Enforcement Administration Today 57
Renewed Efforts at Control, 1980–2000 58
■■ DruGS . . . in FOCuS : A History of American Drug- Control Legislation 59
Global Politics and National Security: 2001–Present 60
■■ QuiCk COnCePt CheCk 3 .2 : Understanding the History of U.S. Drug-Control Legislation 60
Domestic Drug Trafficking and National Security: 2001–Present 61
The Aims of Drug-Control Policy: Public Health and Public Safety 61
Drug-Control Policy Today: Five Schedules of Controlled Substances 62
Summary 63 / Key Terms 64 / Review Questions 64 Critical Thinking: What Would You Do? 64 / Endnotes 64
Contents ■ ix
■■ POrtra i t: David Laffer—Pharmacy Robber and Killer of Four 111 Regarding Systemic Crime 112
The Three Fundamental Questions about Drugs and Crime 113 Does Drug Use Cause Crime? 113 Does Crime Cause Drug Use? 113 Do Drug Use and Crime Share Common Causes? 113
Social Structures in Illicit Drug Trafficking 113
■■ QuiCk COnCePt CheCk 6 .1 : Understanding the Drug–Crime Connection 114
Gangs and Drug-Related Crime 115 Outlaw Motorcycle Gangs 115 Street Gangs 115
■■ QuiCk COnCePt CheCk 6 .2 : Understanding Gangs and Social Structures in Illicit Drug Trafficking 116
Money Laundering in Drug-Related Crime 116
■■ DruG enFOrCeMent . . . in FOCuS : The New Money Laundering: Digital Currency Exchanges 117
Summary 117 / Key Terms 118 / Review Questions 118 Critical Thinking: What Would You Do? 119 / Endnotes 119
Chapter 7
Drugs and law enforcement 121
Numbers Talk … 122 Source Control 122
Crop Eradication 123 Chemical Controls 123 U.S. Certification 124
Drug Interdiction 124 Federal Agencies Involved in Drug Interdiction 125
Military Operations and Domestic Law Enforcement 127
■■ QuiCk COnCePt CheCk 7 .1 : Understanding Law Enforcement Agencies in Drug Control 127
Profiling and Drug-Law Enforcement 127 Street-Level Drug-Law Enforcement 128 Undercover Operations in Drug Enforcement 128
■■ DruG enFOrCeMent . . . in FOCuS : Updating Police Behavior During Traffic and Street Stops 129
■■ DruG enFOrCeMent . . . in FOCuS : The Anatomy of a Reverse Sting Operation 130 Undercover Operations and the Issue of Entrapment 131
■■ POrtra i t: Commissioner William J. Bratton— New York’s Top Cop Second Time Around 131 A Nonundercover Operation: Knock and Talk 132
Genetic Factors 85 Physiological Factors 86 Neurochemical Systems in the Brain 87
■■ DruGS . . . in FOCuS : Understanding the Biochemistry of Psychoactive Drugs 87
■■ POrtra i t: Dr Nora D. Volkow—Imaging the Face of Addiction in the Brain 88
Psychological Perspectives on Drug Abuse 89 Psychoanalytic Theories 89 Nonpsychoanalytic Personality Theories 89 Behavioral Theories 90
Sociological Perspectives on Drug Abuse 90
■■ QuiCk COnCePt CheCk 5 .1 : Understanding Biological and Psychological Perspectives on Drug Use and Abuse 91 Anomie/Strain Theory 91 Social Control/Bonding Theory 92 Differential Association Theory 93 Subcultural Recruitment and Socialization Theory 93
■■ DruGS . . . in FOCuS : The Private Language of a Drug Subculture 94 Labeling Theory 94
Integrating Theoretical Perspectives on Drug Abuse 95 Risk Factors and Protective Factors 95
■■ QuiCk COnCePt CheCk 5 .2 : Understanding Sociological Perspectives on Drug Use and Abuse 96 Specific Risk Factors 96 Specific Protective Factors 96
■■ DruG enFOrCeMent . . . in FOCuS : Harm Reduction: A Strategy for Controlling Undesirable Behavior 98
Summary 99 / Key Terms 100 / Review Questions 100 Critical Thinking: What Would You Do? 100 / Endnotes 100
Chapter 6
Drugs and Crime 103
Numbers Talk … 104 Defining the Terms 104 Perspectives on Drug Use and Crime 106 Collecting the Statistics on Drugs and Crime 106
Drugs and Delinquency 106 Drugs and Adult Crime 106
What the Statistics Tell Us and What They Do Not 108 Regarding Psychopharmacological Crime 108
■■ DruGS . . . in FOCuS : From HeroinGen and CrackGen to BluntGen: The Rise and Fall of Drugs and Violence 109 Regarding Economically Compulsive Crime 110
x ■ Contents
What are Opioids? 157 Opioids in History 158 The Opium War 158 Opium in Britain and the United States 159 Morphine and the Advent of Heroin 160 Opioids in American Society 161
Opioid Use and Heroin Abuse after 1914 161 Heroin Abuse in the 1960s and 1970s 162 Heroin since the 1980s 163
■■ QuiCk COnCePt CheCk 9 .1 : Understanding the History of Opium and Opioids 164
Effects on the Mind and the Body 164 How Opioids Work in the Brain 164 Patterns of Heroin Abuse 165
Tolerance and Withdrawal Symptoms 166 The Lethality of Heroin Abuse 166
■■ DruGS . . . in FOCuS : The Heroin Surge and Narcan for First Responders 168
■■ QuiCk COnCePt CheCk 9 .2 : Understanding the Effects of Administering and Withdrawing Heroin 168
Heroin Abuse and Society 168 Treatments for Heroin Abuse 169
Heroin Detoxification 169 Methadone Maintenance 169 Alternative Maintenance Programs 170 Behavioral and Social-Community Programs 170
■■ heLP L ine : Buprenorphine: The Bright/ Dark Side of Heroin-Abuse Treatment 171 The Reality of Opioid Abuse Treatment and Recovery 171
Medical Uses of Opioid Drugs 172 Beneficial Effects 172 Prescription Opioid Medication Side Effects 173
Prescription Opioid Medication Abuse 173 Patterns of OxyContin Abuse 173 Prescription Opioid Medication Abuse, Overdose,
and Drug Diversion 174
■■ POrtra i t: Billy Thomas and Ricky Franklin— The Two Sides of OxyContin 175 Abuse of Other Opioid Pain Medications 175
■■ DruG enFOrCeMent . . . in FOCuS : National Prescription Drug Take-Back Day and Rogue Pharmacies 176 Responses to Prescription Opioid Medication Abuse 176
Summary 177 / Key Terms 177 / Review Questions 178 Critical Thinking: What Would You Do? 178 / Endnotes 178
Chapter 10
Cocaine and Methamphetamine 181
Numbers Talk … 182
■■ QuiCk COnCePt CheCk 7 .2 : Understanding Drug-Law Enforcement Operations 132
Asset Forfeiture and the RICO Statute 132 Summary 134 / Key Terms 135 / Review Questions 135 Critical Thinking: What Would You Do? 135 / Endnotes 136
Chapter 8
Drugs, Courts, and Correctional Systems 138
Numbers Talk … 139 Drug-law Violators in the Criminal Justice System 140 Criminal Penalties for Drug-law Offenses 142
Federal Penalties for Drug Trafficking 142 Federal Penalties for Simple Possession of Controlled
Substances 142 Felonies, Misdemeanors, and State Drug Laws 143 Drug Paraphernalia 144
Rethinking Drug-law Penalties: 1970s–Present 144
■■ QuiCk COnCePt CheCk 8 .1 : Understanding the Criminal Justice System 145 The Issue of Mandatory Minimum Sentencing 145
■■ DruG enFOrCeMent . . . in FOCuS : Penalties for Crack versus Penalties for Cocaine: Correcting an Injustice 146 The Advent of Drug Courts 147
■■ POrtra i t: State Senator John R. Dunne—Drug War- rior/Drug-War Reformer 147
■■ DruG enFOrCeMent . . . in FOCuS : Specialty Courts in Today’s Criminal Justice System 148
Correctional Systems 149
■■ DruGS . . . in FOCuS : A Simulated Debate: Should We Legalize Drugs? 150 Prison-Based Treatment Programs 151
■■ QuiCk COnCePt CheCk 8 .2 : Understanding Problem-Solving Courts 152
Summary 152 / Key Terms 153 / Review Questions 153 Critical Thinking: What Would You Do? 153 / Endnotes 153
Part three Legally restricted Drugs and Criminal Justice 155
Chapter 9
opioids: heroin and prescription pain Medications 155
Numbers Talk … 156
■■ DruGS . . . in FOCuS : Two Small Towns Contending with the Heroin Epidemic 156
Contents ■ xi
Chapter 11
lSD and other hallucinogens 205
Numbers Talk … 206 A Matter of Definition 206 Categories of Hallucinogens 207 Lysergic Acid Diethylamide 207
The Beginning of the Psychedelic Era 208
■■ DruGS . . . in FOCuS : Strange Days in Salem: Witchcraft or Hallucinogens? 209
■■ POrtra i t: Timothy Leary: Mr. LSD and the Psychedelic Era 210 Acute Effects of LSD 211 Effects of LSD on the Brain 211 Patterns of LSD Use 212
Facts and Fictions about LSD 212 Will LSD Produce Substance Dependence? 212 Will LSD Produce a Panic Attack or Psychotic Behavior? 212
■■ heLP L ine : Emergency Guidelines for a Bad Trip on LSD 213 Will LSD Increase Your Creativity? 213 Will LSD Damage Your Chromosomes? 213 Will LSD Have Residual (Flashback) Effects? 214 Will LSD Increase Criminal or Violent Behavior? 214
Psilocybin and Other Hallucinogens Related to Serotonin 214 Lysergic Acid Amide (LAA) 215 Dimethyltryptamine (DMT) 215 Harmine 215
■■ DruGS . . . in FOCuS : Bufotenine and the Bufo Toad 216
Hallucinogens Related to Norepinephrine 216 Mescaline 216
■■ DruGS . . . in FOCuS : Present-Day Peyotism and the Native American Church 217 DOM 217 MDMA (Ecstasy) 218
■■ heLP L ine : An Examination of MDMA Toxicity 218
■■ DruG enFOrCeMent . . . in FOCuS : Who (or What) Is Molly? 219
Hallucinogens Related to Acetylcholine 219 Amanita muscaria 219 The Hexing Drugs and Witchcraft 220
■■ QuiCk COnCePt CheCk 11 .1 : Understanding the Diversity of Hallucinogens 221
Miscellaneous Hallucinogens 221 Phencyclidine 221
The History of Cocaine 182 Coca and Cocaine in Nineteenth-Century Life 183 Commercial Uses of Coca 183
■■ heLP L ine : Cocaine after Alcohol: The Risk of Cocaethylene Toxicity 183 Freud and Cocaine 184
■■ DruGS . . . in FOCuS : What Happened to the Coca in Coca-Cola? 184
Acute Effects of Cocaine 185
■■ QuiCk COnCePt CheCk 10 .1 : Understanding the History of Cocaine 185
Chronic Effects of Cocaine 186 Medical Uses of Cocaine 186 How Cocaine Works in the Brain 186 Present-Day Cocaine Abuse 187
From Coca to Cocaine 187 From Cocaine to Crack 188
Patterns of Cocaine Abuse 189 Treatment for Cocaine Abuse 189
■■ DruGS . . . in FOCuS : Cocaine Contamination in U.S. Paper Currency 190
■■ POrtra i t: Robert Downey, Jr.—Cleaned Up After Cocaine 191
■■ DruG enFOrCeMent . . . in FOCuS : Comparison Shopping Inside the Global Cocaine Black Market 192
Amphetamines 192 The History of Amphetamines 192 The Different Forms of Amphetamine 193 Acute Effects of Amphetamines 193 Chronic Effects of Amphetamines 194 How Amphetamines Work in the Brain 194
Methamphetamine 194 Methamphetamine in the Heartland of America 194 Present-Day Methamphetamine Abuse 195
■■ DruG enFOrCeMent . . . in FOCuS : North Korea: A New Player in Methamphetamine Trafficking 196 Patterns of Methamphetamine Abuse 196
■■ QuiCk COnCePt CheCk 10 .2 : Understanding Patterns of Stimulant Drug Abuse 196 Treatment for Methamphetamine Abuse 197
Cathinone as a New Form of Stimulant Abuse 197 Amphetamines and Other Stimulants as Medications 197
Stimulant Medications for ADHD 198 Other Medical Applications 199 Ritalin and Adderall Abuse 199
Stimulant Medications as Cognitive Enhancers 199 Summary 199 / Key Terms 201 / Review Questions 201 Critical Thinking: What Would You Do? 201 / Endnotes 201
xii ■ Contents
■■ heLP L ine : Spice and other Designer Synthetic Cannabinoids 243
Medical Marijuana 243 Treating Muscle Spasticity and Chronic Pain 244 Treating Nausea and Weight Loss 244 The Evolving Status of Medical Marijuana Laws 244 Medical Marijuana Today 245
Medical Marijuana: Federal versus State Drug Enforcement 245
Medical Cannabinoids 245 Decriminalization and Legalization 245
Decriminalization by State Referendum 246 Legalization by State Referendum 246
■■ DruG enFOrCeMent . . . in FOCuS : Local Communities in Washington State Just Say No 247 Public Sentiment for a Liberalization of Marijuana
Laws 247 The Ramifications of Decriminalization and Legalization 248
Summary 248 / Key Terms 249 / Review Questions 249 Critical Thinking: What Would You Do? 250 / Endnotes 250
Chapter 13
performance-enhancing Drugs and Drug Screening tests 253
Numbers Talk … 254 Performance-Enhancing Drugs in Sports 255
What Are Anabolic Steroids? 255 Anabolic Steroids at the Modern Olympic Games 256
■■ POrtra i t: Lance Armstrong—From Honor to Dishonor 257 Anabolic Steroids in Professional and Collegiate Sports 258 Performance-Enhancing Drug Abuse and Baseball 258
The Hazards of Anabolic Steroids 258
■■ DruG enFOrCeMent . . . in FOCuS : Suspension Penalties for Performance-Enhancing Drug Use in Sports 259 Effects on Hormonal Systems 259 Effects on Other Systems of the Body 260 Psychological Problems 260 Special Problems for Adolescents 261
■■ QuiCk COnCePt CheCk 13 .1 : Understanding the Effects of Anabolic Steroids 261
Patterns of Anabolic Steroid Abuse 261 The Potential for Steroid Dependence 262
■■ heLP L ine : The Symptoms of Steroid Abuse 263 Counterfeit Steroids and the Placebo Effect 263
Nonsteroid Hormones and Performance-Enhancing Supplements 264
■■ QuiCk COnCePt CheCk 11 .2 : Understanding PCP 222 Patterns of PCP Abuse 222
Ketamine 222 Salvia divinorum 223
Summary 223 / Key Terms 224 / Review Questions 224 Critical Thinking: What Would You Do? 225 / Endnotes 225
Chapter 12
Marijuana 227
Numbers Talk … 228 A Matter of Terminology 228
■■ DruGS . . . in FOCuS : Growing Hemp in America: Coming Full Circle 229
The History of Marijuana and Hashish 230 Hashish in the Nineteenth Century 230 Marijuana and Hashish in the Twentieth Century 231 The Anti-Marijuana Crusade 231
■■ POrtra i t: Commissioner Harry J. Anslinger—From Devil Rum to Devil Weed 232 Challenging Old Ideas about Marijuana 233
Acute Effects of Marijuana 234 Acute Physiological Effects 234 Acute Psychological and Behavioral Effects 234
■■ QuiCk COnCePt CheCk 12 .1 : Understanding the Effects of Marijuana 235
Cannabinoids and Endocannabinoids 236
■■ DruGS . . . in FOCuS : The Neurochemical “Yin and Yang” of Cannabis 236
Chronic Effects of Marijuana 237 Tolerance 237 Withdrawal and Dependence 237 Cardiovascular Effects 238 Respiratory Effects 238 Risks of Lung Cancer 238 Effects on the Immune System 239 Effects on Sexual Functioning and
Reproduction 239 Long-Term Cognitive Effects and the Amotivational
Syndrome 239 Examining the Gateway Hypothesis 240
The Sequencing Question 241 The Association Question 241 The Causation Question 241
■■ QuiCk COnCePt CheCk 12 .2 : Understanding the Adverse Effects of Chronic Marijuana Abuse 242
Patterns of Marijuana Smoking 242 Current Trends in Marijuana Smoking 242
Contents ■ xiii
Glue, Solvent, and Aerosol Inhalation 286 Acute Effects of Glues, Solvents, and Aerosols 287
■■ heLP L ine : The Signs of Possible Inhalant Abuse 287
Patterns of Inhalant Abuse 288
■■ DruGS . . . in FOCuS : Resistol and Resistoleros in Latin America 289 Dependence Potential of Chronic Inhalant Abuse 289
Responses of Society to Inhalant Abuse 289 Amyl Nitrite and Butyl Nitrite 290 Depressants and Drug-Facilitated Sexual Assault 290
■■ QuiCk COnCePt CheCk 14 .2 : Understanding the History of Inhalants 291 The Scope of the Problem 291
■■ POrtra i t: Patricia White—GHB and Drug- Facilitated Sexual Assault 292 Involvement of Drugs Other Than Alcohol 292
■■ DruGS . . . in FOCuS : Rohypnol and Sexual Assaults 293 Efforts to Reduce Drug-Facilitated Sexual Assaults 293
■■ heLP L ine : Drug-Facilitated Sexual Assault: Protective Strategies 294
Summary 294 / Key Terms 296 / Review Questions 296 Critical Thinking: What Would You Do? 296 / Endnotes 296
Part FOur On the Margins of Criminal Justice: regulating Legal Drugs 299
Chapter 15
alcohol Use and Chronic alcohol abuse 299
Numbers Talk … 300 The Making of an Alcoholic Beverage 300 Processing of Alcohol in the Body 301
The Breakdown and Elimination of Alcohol 302 Alcohol on the Brain 303 Measuring Alcohol Levels in the Blood 303 Measuring Alcohol Consumption 304
■■ DruGS . . . in FOCuS : Multiple Ways of Getting a Standard Drink 304
■■ DruGS . . . in FOCuS : Visualizing the Pattern of Alcohol Consumption in the United States 305
Patterns of Alcohol Consumption 306
■■ QuiCk COnCePt CheCk 15 .1 : Understanding Alcoholic Beverages 307 Alcohol Consumption among College Students 307 Alcohol Consumption among Underage Drinkers 307
Human Growth Hormone 264 Dietary Supplements as Performance-Enhancing Aids 264 Nonmedical Use of Stimulant Medication in Baseball 265 Current Drug-Testing Procedures and Policies 265
■■ DruGS . . . in FOCuS : ADHD/ADD Exemption Requirements for the Use of Adderall in Sports 266 The Forensics of Drug Testing 266
■■ DruG enFOrCeMent . . . in FOCuS : Pharmaceutical Companies and Anti-Doping Authorities in Alliance 267 Sensitivity and Specificity in Drug Testing 268
■■ DruGS . . . in FOCuS : Typical Urine Specimen Drug Screening Tests 268 Masking Drugs and Chemical Manipulations 269 Pinpointing the Time of Drug Use 269
■■ QuiCk COnCePt CheCk 13 .2 : Understanding Drug Testing 270
Drug Screening Testing in the Workplace 270 The Social Context of Performance-Enhancing Drugs 271 Summary 272 / Key Terms 273 / Review Questions 273 Critical Thinking: What Would You Do? 273 / Endnotes 274
Chapter 14
Depressants and inhalants 277
Numbers Talk … 278 Barbiturates 278
Categories of Barbiturates 279 Acute Effects of Barbiturates 279
■■ DruG enFOrCeMent . . . in FOCuS : Is There Any Truth Regarding “Truth Serum”? 280 Chronic Effects of Barbiturates 280 Barbiturate Use and Abuse 281
Nonbarbiturate Sedative-Hypnotics 281 The Development of Anxiolytic Drugs 281 Benzodiazepines 282
Medical Uses of Benzodiazepines 282 Acute Effects of Benzodiazepines 283 Chronic Effects of Benzodiazepines 283
Nonbenzodiazepine Medications 283 Zolpidem and Eszopiclone 284 Buspirone 284 Beta Blockers 284 Antidepressants 284
■■ QuiCk COnCePt CheCk 14 .1 : Understanding the Abuse Potential in Drugs 285
Inhalants through History 285 Nitrous Oxide 285 Ether 286
xiv ■ Contents
Risk Factors for Developing Alcoholism 325 Diagnosis, Treatment, and Legal Responsibility 325 Treatment Options 326
Biologically Based Treatments 326 Alcoholics Anonymous 327 SMART Recovery 328
■■ QuiCk COnCePt CheCk 15 .3 : Understanding Alcoholics Anonymous 328
■■ DruGS . . . in FOCuS : The Nondisease Model of Alcoholism 329
Summary 329 / Key Terms 330 / Review Questions 331 Critical Thinking: What Would You Do? 331 / Endnotes 331
Chapter 16
nicotine and tobacco Use 335
Numbers Talk … 336 Tobacco Use through History 336
Politics, Economics, and Tobacco 337 Snuffing and Chewing 337 Cigars and Cigarettes 338 Tobacco in the Twentieth Century 338
Health Concerns and Smoking Behavior 338
■■ DruGS . . . in FOCuS : African Americans, Smoking, and Mentholated Cigarettes 340 The Legacy of the Surgeon General’s Reports,
1964–2014 340 Changing Times: Tobacco Control since 1990 341
The Tobacco Settlement of 1998 341 The Tobacco Control Act of 2009 341 Tobacco Control and Global Economics 342
What’s in Tobacco? 342 Carbon Monoxide 342 Tar 343 Nicotine 343
The Dependence Potential of Nicotine 343 The Titration Hypothesis of Nicotine Dependence 344 Tolerance and Withdrawal 344
Health Consequences of Tobacco Use 344 Cardiovascular Disease 344
■■ DruGS . . . in FOCuS : Visualizing 480,000 Annual Tobacco-Related Deaths 345 Respiratory Diseases 345 Lung Cancer 346 Other Cancers 346
■■ heLP L ine : Signs of Trouble from Smokeless Tobacco 347 Special Health Concerns for Women 348 The Hazards of Environmental Smoke 348
Alcohol Consumption in the Workplace 308 Acute Physiological Effects of Alcohol 308
Toxic Reactions 308
■■ heLP L ine : Emergency Signs and Procedures in Acute Alcohol Intoxication 309 Heat Loss and the Saint Bernard Myth 309 Diuretic Effects 309 Effects on Sleep 309 Effects on Pregnancy 310 Interactions with Other Drugs 310 Hangovers 310
Acute Behavioral Effects of Alcohol 311 Blackouts 311 Driving Skills 311 Violence and Aggression 311
■■ DruG enFOrCeMent . . . in FOCuS : Alcohol, Security, and Spectator Sports 312 Sex and Sexual Desire 312
Strategies for Regulating Alcohol Consumption 313 Present-Day Alcohol Regulation by Restricted Access 313 Present-Day Alcohol Regulation by Taxation 313 Regulations to Reduce Alcohol-Related Traffic Fatalities 314
■■ POrtra i t: Candace Lightner—Founder of MADD 314 Regulations Based on Ignition Interlock Technology 314
On the Other Hand: Alcohol and Health Benefits 315
■■ heLP L ine : Guidelines for Responsible Drinking 316 Chronic Alcohol Abuse and Alcoholism 316
Alcoholism: Stereotypes, Definitions, and Criteria 317 Problems Associated with a Preoccupation
with Drinking 317 Emotional Problems 317 Vocational, Social, and Family Problems 319 Physical Problems 319
The Interpersonal Dynamics of Alcoholism 319
■■ QuiCk COnCePt CheCk 15 .2 : Understanding the Psychology of Alcoholism 319
Alcohol Use Disorder: The Health Care Professional’s View 319
■■ DruGS . . . in FOCuS : Behavioral Criteria for Alco- hol Use Disorder 320
Patterns of Chronic Alcohol Abuse 320 Physiological Effects of Chronic Alcohol Use 321
Tolerance and Withdrawal 321 Liver Disease 322 Cardiovascular Problems 323 Cancer 323 Dementia and Wernicke-Korsakoff Syndrome 323 Fetal Alcohol Syndrome (FAS) 324
The Family Dynamics of Alcoholism 324
Contents ■ xv
Resilience and Primary Prevention Efforts 366 Measuring Success in a Substance Abuse Prevention
Program 366 Substance Abuse Prevention in the Context of National
Drug-Control Policy 367 Substance Abuse Prevention and Public Health Policy 367
■■ DruGS . . . in FOCuS : The Public Health Model and the Analogy of Infectious Disease Control 368
Prevention Approaches That Have Failed 368 Reducing the Availability of Drugs 368 Punitive Measures 369 Scare Tactics and Negative 369 Objective Information Approaches 369 Magic Bullets and Promotional Campaigns 370 Self-Esteem Enhancement and Affective
Education 370 Components of Effective School-Based Prevention
Programs 370 Peer-Refusal Skills 370 Anxiety and Stress Reduction 371 Social Skills and Personal Decision Making 371 An Example of an Effective School-Based Prevention
Program 371 Drug Abuse Resistance Education (DARE) 372 Community-Based Prevention Programs 372
■■ QuiCk COnCePt CheCk 17 .2 : Understanding Substance Abuse Prevention Strategies 373 Components of an Effective Community-Based
Program 373 Alternative-Behavior Programming 373 The Impact of the Media 373 An Example of an Effective Community-Based Prevention
Program 374 Family Systems in Primary and Secondary Prevention 375
Special Role Models in Substance Abuse Prevention 375 Parental Communication in Substance Abuse
Prevention 376
■■ DruG enFOrCeMent . . . in FOCuS : Testing for Drugs in the Home: Whom Can You Trust? 376 The Triple Threat: Stress, Boredom, and Spending
Money 376 Substance Abuse Prevention and the College Student 377
Changing the Culture of Alcohol in College 377 Substance Abuse Prevention on College
Campuses 377
■■ DruGS . . . in FOCuS : Alcohol 101 on College Campuses 378
Prevention and Treatment in the Workplace 378 The Economic Costs of Substance Abuse in the
Workplace 379 The Impact of Drug-Free Workplace Policies 379
■■ QuiCk COnCePt CheCk 16 .1 : Understanding the Effects of Tobacco Smoking 348
Patterns of Smoking Behavior in the United States 348 The Youngest Smokers 349 Attitudes toward Smoking among Young People 349
Regulatory Policy and Strategies for Tobacco Control 349 Regulation by Taxation 349 Regulation by Reduced Access to Young People 350
■■ DruG enFOrCeMent . . . in FOCuS : Reducing Youth Access to Tobacco—The Synar Amendment, 1992 350 Regulation by Increased Awareness of Potential Harm 350
Other Forms of Present-Day Nicotine Consumption 351 Smokeless Tobacco 351 Cigars: Big and Little 352
■■ POrtra i t: Sigmund Freud—Nicotine Dependence, Cigars, and Cancer 352 E-Cigarettes and Nicotine Toxicity 352
The Global Perspective: Tobacco Use around the World 353 Tobacco Use in other Countries 353
■■ QuiCk COnCePt CheCk 16 .2 : Present-Day Tobacco Control Policy and Strategies 354
Quitting Smoking: The Good News and the Bad 354 The Good News: Undoing the Damage 355 The Bad News: How Hard It is to Quit 355
■■ heLP L ine : Ten Tips on How to Succeed When Trying to Quit Smoking 355 Medications for Smoking Cessation 355 Nicotine Gums, Patches, Sprays, and Inhalers 356 The Role of Physicians in Smoking Cessation 356 A Final Word on Quitting 357
Summary 357 / Key Terms 358 / Review Questions 358 Critical Thinking: What Would You Do? 359 / Endnotes 359
Part Five Drug–Control Policy and intervention Strategies 363
Chapter 17
Substance abuse prevention and treatment 363
Numbers Talk … 364 Levels of Intervention in Substance Abuse Prevention 364
■■ DruGS . . . in FOCuS : National Drug-Control Policy and the War on Drugs 365
■■ QuiCk COnCePt CheCk 17 .1 : Understanding Levels of Intervention in Substance Abuse Prevention Programs 366
Strategies for Substance Abuse Prevention 366
xvi ■ Contents
Needing Versus Receiving Substance Abuse Treatment 383
For Those Who Need Help and Want to Get It 384
■■ POrtra i t: Meeting the Challenge—The Long Island Council on Alcoholism and Drug Dependence 384
Summary 385 / Key Terms 386 / Review Questions 386 Critical Thinking: What Would You Do? 386 / Endnotes 387
photo Credits 391 index 392
Multicultural Issues in Prevention and Treatment 379 Latino Communities 380 African American Communities 380 Native American Communities 380
Substance Abuse Treatment: The Journey to Recovery 380 A Common Feature of Substance Abuse Treatment: Stages of
Change 381
■■ DruGS . . . in FOCuS : Reviewing Specific Treatment Strategies for Six Substances of Abuse 381 Stages of Change for Other Problems in Life 382 The Challenges of the Recovery Process 382
■■ QuiCk COnCePt CheCk 17 .3 : Understanding the Stages of Change 383
Preface ■ xvii
preFaCe
Drugs, Society, and Criminal Justice, Fourth Edition, has been specifically designed to provide the means for under- standing (1) the multiple challenges that drug abuse brings to our society, (2) the drug-control policies we have enacted to meet those challenges, (3) the range of international and domestic law enforcement efforts that provide the implemen- tation of our present-day drug-control strategy, and (4) the systems of criminal justice that have been established to deal with the prosecution and adjudication of drug-law offend- ers. In short, here is an introduction to the major facts and issues concerning criminal justice and drug-taking behavior in America today.
A comprehensive understanding of the relationship between drug use and the American criminal justice system requires recognition of the enormous diversity that exists among drugs that affect the mind and the body. Accordingly, the chapters in this book are not only about “street drugs” such as cocaine, amphetamines, heroin, hallucinogens, and (in most U.S. states) marijuana but also about legally avail- able drugs such as alcohol and nicotine. Special attention has been paid to anabolic steroids and other performance- enhancing drugs, as well as the abuse of specific prescription medications.
What’s New in the Fourth Edition?
■■ A redesign of the chapters in Drugs, Society, and Criminal Justice, Fourth Edition, provides a greater focus on the connection between drug-taking behavior and the crimi- nal justice system. The new five-part organization of chapters reflects the emphasis on criminal justice in the context of drug use and abuse. Part One (Chapter 1–4) reviews the domestic and international challenges that drug abuse brings to American society, the history of na- tional drug-control policy, and the fundamental princi- ples of drug-taking behavior that can lead to drug abuse. Part Two (Chapter 5–8) addresses the problems of drug abuse specifically in the context of criminal behavior, law enforcement, courts, and correctional systems. Part Three (Chapter 9–14) reviews the issues of criminal jus- tice that relate to illicit (illegal) drugs, while Part Four (Chapter 15–16) reviews the issues of regulatory policy for licit (legal) drugs such as alcohol and nicotine. Part Five (Chapter 17) deals with the impact of national drug- control policy on prevention and treatment.
■■ New and expanded coverage of drugs and drug abuse in this edition reflects the attention given to contin- ual changes in drug-taking behavior in America. Most
recently, heroin abuse has become a serious and highly visible drug-abuse issue (Chapter 9), as has the prolifera- tion of synthetic formulations of drugs with essentially un- known and sometimes toxic ingredients, putting unwary drug users at risk (Chapters 11 and 12). The newest infor- mation about the neurochemical basis for drug abuse is reviewed in Chapter 4.
■■ New and expanded coverage of the criminal justice re- sponse in this edition reflects the attention given to drug- related crime, law enforcement, courts, and correctional systems. An important focus of concern is the increas- ingly sophisticated system of global illicit drug traffick- ing in today’s world. New topics include the unending challenges brought by the influx of illicit drugs across the U.S.-Mexico border, and the destabilizing impact of nar- coterrorist organizations in Afghanistan and Colombia as well as transnational narcoterrorist organizations operating across international borders (Chapter 2). Closer to home, new topics include law-enforcement challenges with re- spect to drug-related street gang activity and money laun- dering (Chapter 6) and the prosecution and prevention of drug-facilitated sexual assaults (Chapter 14). There is updated coverage of various areas of jurisdictional conflict between the federal government and individual U.S. states with regard to medical marijuana, marijuana decriminal- ization, and (in the case of four U.S. states) marijuana le- galization (Chapter 12).
■■ Drug Enforcement . . . in Focus is a new feature in this edition, emphasizing the important role that domes- tic and international law enforcement agencies play in the implementation of drug-control policies. Examples include: Dealing with High-Tech Dealing: Policing the “Dark Web” (Chapter 1), Massive Cross-Border Drug Tunnel Detected (Again) (Chapter 2), The Drug Enforcement Administration Today (Chapter 3), The New Money Laundering: Digital Currency Exchanges (Chapter 6), The Anatomy of a Reverse Sting Operation (Chapter 7), Specialty Courts in Today’s Criminal Justice System (Chapter 8), and North Korea: A New Player in Methamphetamine Trafficking (Chapter 10).
■■ Numbers Talk is a new feature in this edition, posi- tioned at the beginning of each chapter, providing an often surprising insight into aspects of current patterns of drug-taking behavior. Short listings of thought-provoking “numerics” summarize specific facts about drug use and abuse. They serve to draw the reader into the chapter and help to set the stage for further exploration.
■■ New Drugs . . . in Focus features in this edition include: Life and Death in Mexico: Don Garza Tamez and a Man Called Z-40 (Chapter 2), Sarin and Chemical Warfare:
xviii ■ Preface
Instructor Supplements instructor’s Manual with test Bank Includes content outlines for classroom discussion, teaching suggestions, and answers to selected end-of-chapter questions from the text. This also contains a Word document version of the test bank.
testGen This computerized test generation system gives you maximum flexibility in creating and administering tests on paper, electronically, or online. It provides state-of-the- art features for viewing and editing test bank questions, dragging a selected question into a test you are creating, and printing sleek, formatted tests in a variety of layouts. Select test items from test banks included with TestGen for quick test creation, or write your own questions from scratch. TestGen’s random generator provides the option to display different text or calculated number values each time questions are used.
powerpoint presentations Our presentations offer clear, straightforward outlines and notes to use for class lec- tures or study materials. Photos, illustrations, charts, and tables from the book are included in the presentations when applicable.
To access supplementary materials online, instruc- tors need to request an instructor access code. Visit www. pearsonhighered.com/irc, where you can register for an instructor access code. Within 48 hours after registering, you will receive a confirming email, including an instruc- tor access code. Once you have received your code, go to the site and log on for full instructions on downloading the materials you wish to use.
Alternate Versions eBooks This book is available in multiple ebook formats including CourseSmart and Adobe Reader. CourseSmart is an exciting new choice for students looking to save money. As an alternative to purchasing the printed text- book, students can purchase an electronic version of the same content. With a CourseSmart eTextbook, students can search the text, make notes online, print out reading assignments that incorporate lecture notes, and bookmark important passages for later review. For more information, or to purchase access to the CourseSmart eTextbook, visit www.coursesmart.com.
Acknowledgments
In the course of preparing the fourth edition of this book, I have received much encouragement, assistance, and expert advice from a number of people. I have benefited from their sharing of materials, knowledge, and insights. My thanks go
Neurotoxicity on the Battlefield (Chapter 2), Conditioned Tolerance in Alcoholic Beverages: The Four-Loko Effect (Chapter 4), The Heroin Surge and Narcan for First- Responders (Chapter 9), Growing Hemp in America: Coming Full Circle (Chapter 12), The Neurochemical “Yin and Yang” of Cannabis (Chapter 12), and ADHD/ADD Exemption Requirements for the Use of Adderall in Sports (Chapter 13).
■■ New Portrait features in this edition include: Mithridates VI of Pontis—Drug Tolerance and the Story of the Poison King (Chapter 4), Commissioner William J. Bratton— New York’s Top Cop Second Time Around (Chapter 7), State Senator John Dunne—Drug Warrior/Drug-War Reformer (Chapter 8), Commissioner Harry J. Anslinger— From Devil Rum to Devil Weed (Chapter 12), Lance Armstrong—From Honor to Dishonor (Chapter 13), and Meeting the Challenge—The Long Island Council on Alcoholism and Drug Dependence (Chapter 17). Each portrait puts a human face on the discussion of drugs, society, and criminal justice. They remind us that we are dealing with issues that affect real people in all walks of life, now and in the past.
■■ Enhanced pedagogical features of this edition include an expanded set of Quick Concept Checks, embedded in the chapters, providing opportunity to test oneself on basic con- cepts in the text. Two new features are Review Questions and an assignment called Critical Thinking: What Would You Do? at the end of each chapter. They provide the means for summarizing your knowledge about facts in the chapter and re-examining the information in the text through the application to a real-world situation. Running Glossaries and Pronunciation Guides are helpful to see the definition of terms in the immediate context of the ma- terial and to have difficult-to-pronounce terms spelled out phonetically.
■■ On a personal level, Help Line features provide impor- tant facts that can be used to recognize the specific signs of drug misuse or abuse, effective ways to respond in drug- related emergency situations, and guidance concerning circumstances that may present some degree of personal harm. At the end of each Help Line, there is a Web site that provides further assistance. Examples include: The Possibility of a Drug–Drug or Food–Drug Combination (Chapter 4), Emergency Guidelines for a Bad Trip on LSD (Chapter 11), Emergency Signs and Procedures in Acute Alcohol Intoxication (Chapter 15), and Signs of Trouble from Smokeless Tobacco (Chapter 16).
An Invitation to Readers
I welcome your reactions to Drugs, Society, and Criminal Jus- tice, Fourth Edition. Please send any comments or questions to the following e-mail address: charles.f.levinthal@hofstra. edu. I hope to hear from you.
Preface ■ xix
of Central Florida; John Padgett, Capella University; Kelly Roth, McCann School of Business & Technology; Arkil Starke, Keiser University; and Anne Wade, Rockingham Community College.
I also acknowledge the professionalism of the editorial and production team at Pearson Education: Executive Editor Gary Bauer and Production Liaison Susan Hannahs in Columbus, Ohio, and Project Manager Abinaya Rajendran at Integra Software Services in Pondicherry, India. It was a pleasure to work with them all.
As always, my family has been a continuing source of strength and encouragement. I will always be grateful to my wife, Beth, and our wonderful sons, David and Brian for their love and understanding.
Charles F. Levinthal
to Dr. Patrick M. O’Malley, Institute for Social Research, University of Michigan, Ann Arbor, Michigan; Lawrence Payne of the Office of Public Affairs, Drug Enforcement Administration, U.S. Department of Justice, Washington DC; Sgt. Philip Hernandez of the Police Academy of the New York City Police Department; Kara Kaplan, Esq., Assis- tant District Attorney in Nassau County, New York; Gregg Roth, Esq. of the Center for Court Innovation, New York State; Dr. Elizabeth Crane of the Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration in Rockville, Maryland; and Dr. David J. Levinthal, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
I wish to thank the reviewers who provided feedback on the third edition and enhanced the quality and effectiveness of the fourth edition: Nancy Alleyne, Keiser University; Nicola Bivens, Johnson C. Smith University; Susan Craig, University
This page intentionally left blank
Pa r t O n e
The Challenge of Drugs in
Our Society
Understanding the Drug Problem in
America
1 chapter
Mike was 17, a high school junior—an age when life can be both ter-
rific and terrifying. He looked at me with amazement, telling me by
his expression that either the question I was asking him was ridiculous
or the answer was obvious. “Why do kids do drugs?” I had asked.
“It’s cool,” he said. “That’s why. Believe me, it’s important to
be cool. Besides, in my life, drugs just make me feel better. Smok-
ing a little weed, mellowing out with some Perks or a little Vicodin,
spinning with Molly—it’s a way of getting away from ‘stuff.’ And
you know that everybody does it. At least all of my friends do it. It’s
easy to get them. All you need to know is where to go. You folks
think I’m getting all this stuff from some dirty old man on a street
corner. You would be amazed to know where I am getting it.”
I asked Mike whether he ever thought about his future. “Yeah,
once in a while,” he said, “but not all that often. After all, I’m
seventeen.”
I knew the meeting was over. But as he started to leave, Mike
seemed to notice a look of concern on my face. “Don’t worry
about me,” he said. “I can handle it. I can handle it just fine. It’ll all
work out.”
after you have completed this chapter, you should have an understanding of the following:
●● Basic terminology concern- ing drugs and drug-taking behavior
●● The nature of drug toxicity
●● The DAWN statistics as a measure of acute drug toxicity
●● Judging drug toxicity from drug-related deaths
●● Prevalence rates of illicit and licit drug use in the United States
●● Problems associated with new drugs and new drug formulations
2 ■ Part One The Challenge of Drugs in Our Society
illegal drugs such as cocaine, methamphetamine, heroin, LSD and other hallucinogens, and (except for certain U.S. states) marijuana. Certainly, these “street” drugs continue to wreak havoc on lives and communities throughout America and more than 22,000 American lives are lost each year as a consequence, but there are 25 times more deaths each year as a result of the effects of legal drugs such as nicotine and alcohol. Issues with respect to these particular drugs will be examined in Chapters 15 and 16.
Second, we need to recognize the magnitude of the impact that drug-taking behavior has on our society. As a nation, we have designed a system of criminal justice with respect to illegal drugs and a regulatory system with respect to legal drugs, but despite our efforts, we continue to pay a heavy price. The direct and indirect monetary costs of drug- taking behavior in our society are enormous, amounting to
There is no question that we live in a world where drugs are all around us. Thousands of Internet Web sites offering information (and sometimes misinformation) about drug use are just a click away. We are continually bombarded with news about drug-related arrests of major drug traffick- ers and ordinary citizens, news about people in the world of sports and entertainment who experience and often suffer the consequences of drug-taking behavior, news about drugs intercepted and confiscated at our borders, as well as widespread drug use in major cities and small towns of America.
It also seems impossible to avoid the problems of drugs in our personal lives. One in five adults in the United States reports that drugs have been a cause of trouble in his or her family. At a time when the economy and related matters are the main focus of our concerns about the present and the future, about two out of three Americans continue to worry about drug use either a fair amount of time or a great deal. In school, you have been taught the risks involved in drug use, and most of you have contended with the social pres- sure to engage in drug-taking behavior with your friends. You may or may not have been successful in doing so. You may have noticed your local pharmacy looking like a bank, with the installation of panic alarms, bulletproof glass, and security cameras as pharmacists turn to protect- ing themselves from people robbing them for their supplies of oxycodone and other prescription pain medications. A range of societal and personal problems surrounding drug use present a continuing challenge to our public health and public safety.1
Three central facts should be kept in mind as we begin an exploration of issues surrounding drug use and abuse in our society today.
First of all, we need to recognize that the challenges we face with respect to drug-taking behavior extend beyond
439,000,000 The number of results that come up on searching the word “drug” on the Google® search engine. Search time elapsed: approximately one-third of a second.
784 Number of armed robberies of pharmacies in the United States in 2012, with 104 being committed in Indiana alone.
53,300 On an average day in 2013, the approximate number of U.S. adolescents, aged 12–17 years old, who had binged on alcohol.
34 Percentage of approximately 2.5 million drug-related emergency department visits in the United States in 2011 that were due to the nonmedical use of prescription or nonprescription drugs alone.
Sources: Armed robbery pharmacy incident data, courtesy of the Drug Enforcement Administration, U.S. Department of Justice, September 2013. Information from the Google® search engine, April 7, 2015. Center for Behavioral Health Statistics and Quality (2013). Drug Abuse Warning Network, 2011: National estimates of drug-related emergency department visits. Rockville, MD: Substance Abuse and Mental Health Services Administration. Center for Behavioral Health Statistics and Quality (2014, September 4). Results from The 2011 National Survey on Drug Use and Health: Detailed Tables. The 2013 National Survey on Drug Use and Health: Overview of findings. The NSDUH Report. Rockville, MD: Substance Abuse and Mental Health Services Administration.
Numbers Talk…
An accused drug-law violator is led away by an agent of the Drug Enforcement Administration (DEA) on an otherwise quiet, residential street in Billings, Montana.
Chapter 1 Understanding the Drug Problem in America ■ 3
Social Messages about Drug Use
We live in a world that sends us mixed messages about drug- taking behavior. The images of Joe Camel, the Marlboro Man, and the Virginia Slims Woman in print advertise- ments for cigarettes are remnants of an increasingly distant past, but at one time they were iconic (and highly effec- tive) features in marketing campaigns designed to convey the attractiveness of smoking to the public, particularly to young people. They are gone now as a result of federal regulations over cigarette advertising, established in 1998 (see Chapter 16). For decades, warning labels on cigarette packs and public service announcements have cautioned us about the serious health hazards of tobacco use, but the fact remains that about one in five adult Americans today is a current cigarette smoker. Young people begin smoking well before the minimum age requirement for the purchase of tobacco products. The popularity of flavored cigars and e-cigarettes is of particular concern.
Beer commercials during telecasts of football games and other sports events are designed to be entertaining and to encourage us to associate beer drinking with a lifestyle filled with fun, friendship, sex, and romance, but we are then expected to abide by the tagline at the end of the ad to “drink responsibly” or “know when to say when.” The ramifications of these messages are significant. It has been established that the degree of positive expectancies about alcohol (viewing drinking as a way of gaining social accep- tance, for example) predicts the onset age of drinking and the tendency to engage in high-risk alcohol use over time. This is a significant problem with respect to underage alco- hol drinking. One out of four eighth graders, for example, reports that he or she has consumed alcohol and one out of eight reports that he or she has been drunk sometime in his or her life (see Chapter 15).3
Major political figures, including U.S. presidents and vice presidents, as well as candidates for these offices and a host of public officials on local and national levels, have admitted smoking marijuana earlier in their lives. In recent years, regulatory policy in some U.S. states has changed dra- matically, making marijuana legally available either for medi- cal purposes or for general use by adults (see Chapter 12). Yet the U.S. federal government’s position on marijuana remains unchanged, stipulating that the drug is an illegal substance, officially classified since 1970 as a Schedule I controlled sub- stance, defined as a drug with a high potential for abuse and no accepted medical use—in the same category as heroin (see Chapter 3). The conflicting position of federal and state drug-control authorities with respect to marijuana policy and law enforcement is one of the present-day challenges we face as we proceed through the second decade of the twenty-first century.
Anti-drug media campaigns continue to discourage young people from getting involved with drugs in general. At the same time, we observe a never-ending stream of sports
hundreds of billions of dollars each year.2 These costs are traditionally classified in four major areas:
●■ Economic costs of lost workplace productivity due to absenteeism, industrial accidents, and premature death of workers.
●■ Health care expenditures required to treat individuals with illnesses related to drug use, particularly with respect to the abuse of tobacco and alcohol.
●■ Costs of drug-related crime borne by the victims of crimi- nal behavior and the community in which the criminal activity occurs.
●■ Expenses of maintaining a criminal justice system devoted to the control of illegal drugs.
There are also costs that cannot be calculated in monetary terms. They include the decline in our collective sense of social order, the diminishment of personal dignity and self-worth, and, most importantly, the devastating effect on relationships we have with our families and individuals around us.
Third, we need to recognize that it is not just a “young people’s issue.” Whether we like it or not, the decision to use drugs of all types and forms, legally sanctioned or not, has become one of life’s choices in every segment of the society in America, as well as societies around the world. The avail- ability of drugs and the potential for drug abuse present dif- ficulties for people of all ages, from the young to the elderly. The consequences of drug-taking behavior can be observed in the workplace and retirement communities as well as on street corners, in school yards, and on college campuses. Drug use is going on in the homes of every community, large or small. The social and personal problems associated with drug use extend in one way or another to men and women of all ethnic and racial groups, geographic regions, and socioeconomic lev- els. No groups and no individuals should believe themselves exempt.
The purpose of this book is to explore the full range of drug-taking behaviors in our lives, from a biological, psycho- logical, and sociological point of view. Four major areas will be examined:
●■ The drug problem in America as well as elsewhere in the world in order to understand the enormous challenges we face today.
●■ Drug-taking behavior over the many centuries of human history in order to understand why drug-taking behavior remains so compelling for us in our modern-day society.
●■ The ways our society has responded to the problems of crime and violence associated with drug use.
●■ The present-day system of criminal justice in the United States, extending from drug trafficking control and street- level law enforcement to courts and correctional facilities, that has been created with the goal of reducing the nega- tive impact of drug-taking behavior.
4 ■ Part One The Challenge of Drugs in Our Society
family, to our friends and acquaintances, to our life experi- ences, and to the community in which we live. The reasons why some individuals engage in drug- taking behavior (and others do not) will be an important topic in Chapter 5.
Figure 1.1 shows the interplay between drug-taking behavior and society as we consider the dangerous poten- tial for drug use to turn into drug dependence. As many of us know all too well, a vicious circle can develop in which drug-taking behavior fosters more drug-taking behavior in a spiraling pattern that can be extremely difficult to break. Individuals showing signs of drug dependence display intense cravings for the drug and, in many cases, require increasingly greater quantities to get the same desired effect. They become preoccupied with their drug-taking behavior, and it becomes evident that their lives have got- ten out of control.
Current research on drug dependence points to the need for us to examine the issue on a biological level, psychologi- cal level, and sociological level. On a biological level, the use of psychoactive drugs modifies the functioning of the brain, both at the time during which the drug is present in the body and later when the drug-taking behavior stops. Drug depen- dence, therefore, produces long-lasting brain changes. It is as if a “switch” in the brain has been thrown following pro- longed drug use. At the beginning, drug-taking behavior is a voluntary act, but once that “switch” is thrown, a pattern of drug dependence takes over. On a sociological level, drug dependence can be viewed as a result of a complex interac- tion of the individual and his or her environment. We cannot
drug dependence: A condition in which an individual feels a compulsive need to continue taking a drug. In the pro- cess, the drug assumes an increasingly central role in the individual’s life.
figures, entertainers, and other high-profile individuals engaging in drug-taking behavior. Even though the careers of these people are frequently jeopardized, and in some instances, as we will see later in the chapter, lives are lost, powerful pro–drug-use messages continue to influence us. These messages come from the entertainment industry and traditional media sources, as well as from Web sites on the Internet.4
Two Ways of Looking at Drugs and Society
In the chapters ahead, we will look at the subject of drugs and society in two fundamental ways.
First, we will examine the biological, psychologi- cal, and sociological consequences in the consumption of certain types of drugs. The focus will be on the study of drugs that alter our feelings, our thoughts, our percep- tions of the world, and our behavior. These substances are referred to as psychoactive drugs because they influence the functioning of the brain and hence our behavior and experience.
Psychoactive drugs that traditionally receive the great- est amount of attention are the ones officially defined in the United States as illicit (illegal) drugs. Criminal penal- ties are imposed on their possession, manufacture, or sale. The best-known examples are heroin, cocaine, and (except in some U.S. states) marijuana, as well as “club drugs” such as methamphetamine (meth), Ecstasy, LSD, PCP, ket- amine, and GHB. Other equally important psychoactive substances, however, are licit (legal) drugs, such as alco- hol, nicotine, caffeine, and certain prescription medicines used to treat a wide range of mental disorders. In the cases of alcohol and nicotine, legal access carries a minimum- age requirement. In the case of prescription medicines, legal access is limited to approval by specific health care professionals. In the case of caffeine, legal access carries no restriction at all.
Second, we can focus on the interplay of circumstances in our lives that lead to drug-taking behavior. We will exam- ine the possibility that drug use is, at least in part, a conse- quence of how we feel about ourselves in relation to our
psychoactive drugs: Drugs that affect feelings, thoughts, perceptions, or behavior.
illicit drugs: Drugs whose manufacture, sale, or possession is illegal.
licit drugs: Drugs whose manufacture, sale, or possession is legal.
Society
Physiological Impact on the Brain
Psychoactive Drugs
Biological Factors
Psychological Factors
Sociological Factors
Drug-Taking Behavior
F igure 1 .1
Understanding the interplay of drug-taking behavior and society through the biopsychosocial model of drug use.
Chapter 1 Understanding the Drug Problem in America ■ 5
pressure, or quicken your heart rate, then it could possibly be considered a drug (see Drugs . . . in Focus for a guide to the categories of drug names).
Ultimately, the problem is that we are trying to reach a consensus on a definition that fits our intuitive sense of what constitutes a drug. We may find it difficult to define pornog- raphy, but (as has been said in the halls of the U.S. Supreme Court) we know it when we see it. So it may be with drugs. Whether we realize it or not, when we discuss the topic of drugs, we are operating within a context of social and cultural values, a group of shared feelings about what kind of behavior (that is, what kind of drug-taking behavior) is acceptable and what kind is not. These values have manifested themselves over the years in social legislation and a criminal justice sys- tem for the purpose of regulating the use of specific drugs and specific forms of drug-taking behavior (see Chapter 3).
The judgments we make about drug-taking behavior even influence the terminology we use when referring to that behavior. When we speak of “drug misuse” and “drug abuse,” for example, we are implying that something wrong is happening, that a drug is producing some harm to the physi- cal health or psychological well-being of the drug user or to society in general.
But by what criteria do we decide that a drug is being misused or abused? We cannot judge on the basis of whether the drug is legal or illegal, since decisions about the legality of a psychoactive drug are more often made as a result of histori- cal and cultural circumstances than on the physical property of the drug itself. Tobacco, for example, has deeply rooted associations in American history, dating to the earliest colo- nial days. Although it is objectionable to many individuals and harmful to the health of the smoker and others, tobacco is nonetheless a legal commodity and legally available to adults. Alcohol is another substance that is legal, within the bounds of the law, even though it can be harmful to individuals who become inebriated and potentially harmful to others who may be affected by the drinker’s drunken behavior. The difficulty of using a criterion based on legality is further complicated by differences in religious attitudes toward these substances in some societies in the world.
Instrumental Drug Use/ Recreational Drug Use It is useful to base our discussion about drug abuse and misuse by answering a simple but fundamental question: What is the intent or motivation of the drug user with respect to this kind of behavior? Given that the attitudes toward specific drugs are so different across cultures and societies, it is useful to look closely at the relationship between drugs and behavior in terms of the intent or motivation on the part of the user.
fully understand the problem of drug dependence without being aware of the social context in which drug- taking behav- ior occurs. As we will see in Chapter 17, an examination of drug dependence in terms of biological as well as social perspectives will be important in designing effective treat- ment programs.5
Which drugs have the greatest potential for creating drug dependence? How can someone escape drug dependence once it is established? What factors increase or decrease the likelihood of drug-taking behavior in the first place? What is the relationship between drug-taking behavior and crime? What effect have social policies and our system of criminal justice had on drug-taking behavior? The essential question will be this: What is the impact of drugs and drug-taking behavior on our society and our lives.
A Matter of Definition: What Is a Drug? Considering the ease with which we speak of drugs and drug use, it seems as if it should be relatively easy to define what we mean by the word drug. Unfortunately, there are significant problems in arriving at a clear definition.
The standard approach is to characterize a drug as a chemical substance that, when taken into the body, alters the structure or functioning of the body in some way. In doing so, we are accounting for examples such as medications used for the treatment of physical disorders and mental ill- nesses, as well as for alcohol, nicotine, and the typical street drugs. Unfortunately, this broad definition also could refer to ordinary food and water. Because it does not make much sense for nutrients to be considered drugs, we need to refine our definition, adding the phrase, excluding those nutrients considered to be related to normal functioning.
We may still be on slippery ground here. It is true that we can now effectively eliminate the cheese in your next pizza from consideration as a drug, but what about some exotic ingredient in the sauce? Sugar is safely excluded, even though it has significant energizing and therefore behavioral effects on us, but what about the cayenne pepper that burns your tongue? Where do we draw the line between a drug and a nondrug? It is not an easy question to answer.
There are two major lessons that we can learn from the seemingly simple task of arriving at a definition. First, there is probably no perfect definition that would distinguish a “drug” from a “nondrug” without leaving a number of cases that fall within some kind of gray area. The best we can do is to set up a definition, as we have, that handles most of the substances we are likely to encounter.
The second lesson is more subtle. We often draw a distinc- tion between drugs and nondrugs not in terms of their physical characteristics but rather in terms of whether the substance in question has been intended to be used primarily as a way of inducing a bodily or psychological change.6 By this reasoning, if the pizza maker intended to put that spice in the pizza to make it taste better, the spice would not be considered a drug; it would simply be another ingredient in the recipe. If the pizza maker intended the spice to intoxicate you, raise your blood
drug: A chemical substance that, when taken into the body, alters the structure or functioning of the body in some way, excluding those nutrients considered to be related to normal functioning.
6 ■ Part One The Challenge of Drugs in Our Society
are unquestioned. In these cases, drug-taking behavior occurs as a means toward an end that has been defined by our society as legitimate.
The legal status of the drug itself or whether we agree with the reason for the drug-taking behavior is not the issue here. The instrumental use of drugs can involve prescription and nonprescription (over-the-counter, abbreviated OTC) drugs that are licitly obtained and taken for a particular medical purpose. Examples include an antidepressant prescribed for depression, a cold remedy for a cold, an anticonvulsant drug to control epileptic seizures, or insulin to maintain the health of a person with diabetes. The instrumental use of drugs also can involve drugs that are illicitly obtained, such as an amphetamine that has been procured through illegal means to help a person stay awake and alert after hours without sleep.
Based upon on the intent of the individual, drug use can be categorized as either instrumental or recreational.7
By instrumental use, we mean that a person is taking a drug with a specific socially approved goal in mind. The user may want to stay awake longer, fall asleep more quickly, or recover from an illness. If you are a medical professional on call over a long period of time, taking a drug with the goal of staying alert is considered acceptable by most people as long as the drug does not interfere with one’s duties. Recovery from an illness and achieving some reduction in pain are goals that
instrumental use: Referring to the motivation of a drug user who takes a drug for a specific purpose other than getting “high.”
understanding Drug names The names we give to a particular drug can range from a tongue-twisting generic or pharmaceutical term to a catchy commercial word selected for marketing purposes to often- colorful street slang. It is important to keep straight the different circumstances in which a drug name might be used. We will focus on four major categories of drug names: brand names, generic names, natural-product names, and street names.
Brand names Once a pharmaceutical manufacturer receives official governmental approval to hold a patent on a new drug, it has exclusive rights to sell the drug under a name referred to as its brand name. The brand name is a registered trademark of the manufacturer and cannot be used by any other manufacturer for the life of the patent. As examples, while the drugs are on patent, the drug Januvia, used in the treatment of Type 2 diabetes mellitus, is marketed under that brand name exclusively by AstraZeneca Pharmaceuticals, and the cholesterol-lowering drug Crestor is marketed under that brand name exclusively by Merck & Co., Inc. Illicit drugs do not have brand names.
generic names Pharmaceutical drugs have a generic name as well. Doctors will often write prescriptions for a particular drug using its generic name (if available), since it is less expensive than its brand name. Once a drug patent has expired, a drug formerly available under its brand name is now available under its generic name, sometimes alongside its brand name equivalent. For example, the nonprescription analgesic drug Tylenol is marketed by McNeil Consumer HealthCare in North America and its “sibling” Panadol is marketed by GlaxoKlineSmith in the United Kingdom and other countries outside North
America under their original brand names. Since the patents have long since expired, they are also marketed as generic drugs under their generic names, acetaminophen and paracetamol (para-acetylaminophenol), respectively. Illicit drugs are referred to by federal and state authorities by their generic names, unless they are botanical products (see below). Examples are cocaine hydrochloride, heroin, dextroamphetamine, methamphetamine, lysergic diethylamide (LSD), and phencyclidine.
natural-product names In some cases, drugs names refer to (1) plants from which the drugs originate (examples: marijuana, opium, coca, amanita mushrooms), (2) chemical entities isolated directly from plants (examples: morphine and codeine from opium poppies, cocaine hydrochloride from the coca plant, THC from marijuana, psilocybin from psilocybe mushrooms, mescaline from peyote cactus), or (3) chemical entities derived directly or indirectly from plants through a specific process (examples: alcohol creat- ed as a result of the fermentation of grains, free-base cocaine and crack cocaine created from a chemical modification of cocaine hydrochloride).
Street names Street names refer to slang terms generated by a subculture of drug users for a particular illicit drug or combination of illicit drugs. Any listing of street names is bound to be incomplete, as the slang is continually changing. Nonetheless, some street names have been around for a long time. Examples are “speed” for methamphetamine, “smack” for white heroin, “black tar” for Mexican heroin, “speedball” for a combination of heroin and cocaine, “grass” or “weed” for marijuana, and “coke” for cocaine. More extensive listings of street names for major drugs can be found on pages 167, 188, 196, 222, and 281.
Drugs … in Focus
Chapter 1 Understanding the Drug Problem in America ■ 7
goal in mind but in an inappropriate manner. For example, drug doses may be increased beyond the level recommended for its use in the mistaken idea that if a little is good, more is even better. Or doses may be decreased from the level rec- ommended for its use with the intention of saving money by making the drug supply last longer. Prescription drugs may be continued longer than they were intended to be used or combined with some other drug.
Drug misuse can be dangerous and potentially lethal, particularly when alcohol is combined with drugs that depress the nervous system. Drugs that have this particu- lar feature include antihistamines, antianxiety medications, and sleeping medications. Even if alcohol is not involved, however, drug combinations can still represent serious health risks, particularly for the elderly, who often take a large number of separate medications. This population is especially vulnerable to the hazards of drug misuse.
In contrast, drug abuse is typically applied to cases in which a licit or illicit drug is used in ways that produce some form of physical, mental, or social impairment. The primary motivation for individuals involved in drug abuse is recreational. Drugs with abuse potential include not only the common street drugs but also legally
drug abuse: Drug-taking behavior resulting in some form of physical, mental, or social impairment.
In contrast, recreational use means that a person is tak- ing the drug not as a means to a socially approved goal but for the purposes of acquiring the effect of the drug itself. The motivation is to experience a pleasurable feeling or achieve a positive state of mind. Whatever happens as a consequence of recreational drug-taking behavior is viewed not as a means to an end but as an end onto itself. Drinking alcohol and smok- ing tobacco are two examples of licit recreational drug-taking behavior. Involvement with street drugs, in that the goal is to alter one’s mood or state of consciousness, falls into the cat- egory of illicit recreational drug-taking behavior.
Although this four-group classification scheme, as shown in Figure 1.2, can help us in understanding the complex relationship between drugs and behavior, there will be instances in which the category is less than clear. Drinking an alcoholic beverage, for example, is considered as recreational drug-taking behavior under most circum- stances. If it is recommended by a physician for a speci- fied therapeutic or preventative purpose (see Chapter 15), however, the drinking might be considered instrumental in nature. You can see that whether drug use is judged to be recreational or instrumental is determined in no small part by the circumstances under which the behavior takes place. As mentioned earlier, these attitudes have a direct influence on the establishment of drug-control policy and drug-control laws.
Drug Misuse or Drug Abuse? How do the terms “drug misuse” and “drug abuse” fit into this scheme?
Drug misuse typically applies to cases in which a pre- scription or OTC medication is used with an instrumental
recreational use: Referring to the motivation of a drug user who takes a drug only to get “high” or achieve some pleasurable effect.
drug misuse: Drug-taking behavior in which a prescription or nonprescription drug is used inappropriately.
Taking Xanax with a prescription to relieve anxiety
Taking No Doz to stay awake on a long road trip
Taking Adderall without a prescription to stay awake the night before a test
Taking Percocet without a prescription to relieve pain
Having an alcoholic drink to relax before dinner
Smoking a cigarette or a cigar for enjoyment
Smoking marijuana to get high
Taking Ecstasy
Licit Illicit
Instrumental use
Recreational use
Legal Status
Goal
F igure 1 .2
Four categories of drug-taking behavior derived from combinations of the user’s goal and the drug’s legal status.
Source: Based on information from Goode, Erich (2008). Drugs in American Society (7th ed.). New York: McGraw-Hill, p. 14.
8 ■ Part One The Challenge of Drugs in Our Society
the chapters that follow, as drug use. Regardless of whether drug use, drug abuse, or drug misuse is taking place, how- ever, there is always the potential for harmful physiological effects to occur. The next section will examine a major area of concern with respect to drug-taking behavior—the poten- tial of drug toxicity.
The Problem of Drug Toxicity
When we say that a drug is toxic, we are referring to the fact that it is, to some degree, dangerous or in some way interfer- ing with a person’s normal functioning. Technically, any sub- stance, no matter how benign, has the potential for toxicity if the dose—the amount of the substance taken—is high enough. The question of a drug’s safety, or its relative safety, when compared to other drugs, centers on the possibility that
toxicity (tox-iS-ih-tee): The physical or psychological harm that a drug might present to the user.
dose: The quantity of drug that is taken into the body, typically measured in terms of milligrams (mg) or micrograms (µg).
available psychoactive substances, such as caffeine and nicotine (stimulants), alcohol, sedatives, and inhaled sol- vents (depressants), and a number of prescription or OTC medications designated for medical purposes but used by some individuals exclusively on a recreational basis. In Chapter 9, we will examine significant concerns about the abuse of prescription pain medications, such as Vicodin, Percocet, and OxyContin.
When there is no intent to make a value judgment as to the motivation or consequences of a particular type of drug- taking behavior, the behavior will simply be referred to, in
POrtrait From Oxy to Heroin: The Life and Death of Erik
Erik lived in a suburban Long Island, New York com- munity, and heroin killed him in 2008 at the age of 19. His mother, Linda D. never imagined what she was up against. “You worry,” she has said, “about them smoking pot. You worry about them driving recklessly. You worry about them not using their seat belt. You worry about that phone call in the middle of the night. You don’t worry about heroin. Because it didn’t exist in my mindset.”
In the last few years, the reality of heroin in the suburbs and small towns of America, previously considered to be immune from its deadly reach, has hit home with a sudden and unexpected vengeance. As a director of a local drug- counseling center has expressed it, “They’re starting younger, they’re starting with more substances, they have better access, everything is cheaper, and they have more money.” You would call a per- fect storm. Heroin arrests have doubled; rehabilitation-facility admissions of those 21 and under for prescription pain reliever dependence have tripled or qua- drupled in many cases.
In the case of Erik, it began after an emergency appendectomy with a prescription for Vicodin. Erik gradually entered into a shadowy world of drug- taking behavior. Finding new supplies of Vicodin, then shifting to OxyContin, was
easy. “It sounded grimy and sleazy,” a teenager would say in reference to her
own dependence on prescription pain relievers, “but at the time it was just what I did. Everyone knows someone who can get them for you.”
At some point in early 2008, accord- ing to Linda, “The oxys dried up.” Erik turned from pills to heroin. “It started at a party,” she has said, “Someone said to him, ‘Oh, try this.’” By May, Linda and her husband realized Erik was using heroin. In the weeks that followed, they tried to convince him to get help. The family’s insurance covered Erik’s first trip to a rehabilitation facility in update New York, but when Erik left after three days, they told the family that he had used up their insurance company’s “once in a lifetime” rehabilitation coverage. They tried to convince public hospitals to admit Erik, but he was denied. In the meantime, Erik’s parents were finding injection needles around the house and discarded rubber tubing. They desper- ately tried to cobble together funds to pay for rehabilitation, but they didn’t succeed in time. Erik died in July.
If Erik had rejected his parents’ efforts to get him help, they would have faced considerable legal obstacles. In New York State, no one, even a minor, is required to get treatment for substance abuse. Parents can petition a county probation
department to have a drug-abusing child designated as a Person in Need of Super- vision (PINS), but a court order has to be issued by a judge for a PINS child to be admitted for treatment. Even then, the child may leave at any time regardless of medical advice to stay.
In the meantime, medical examiner statistics indicate that a steady increase in heroin-related deaths since 2006. Individuals using prescription pain relievers for nonmedical purposes have a 19 times greater risk of initiating heroin use. This is not to say, however, that the transition is inevitable, or even likely. Approxi mately, 96 percent of nonmedical pain relievers do not become heroin users.
Sources: Alterr, Stacey (2009, November 12). Push for heroin help. Newsday, p. A5. Archibold, Randal C. (2009, May 31). In heartland death, traces of heroin’s spread. New York Times, pp. 1, 24. Lefrowitz, Melanie (2009, June 14). Heartbreak of addiction hits home. Newsday, pp. A4–A6. Muhuri, Pradip K.; Gfoerer, Joseph C.; and Davies, Christine (2013, August). Associations of nonmedical pain reliever use and initiation of heroin use in the United States. CBHSQ Data Review. Rockville, MD: Substance Abuse and Mental Health Services Administration. Deutsch, Kevin
Chapter 1 Understanding the Drug Problem in America ■ 9
Now we can look at Figure 1.3b, where the effec- tive dose-response curve is represented next to another S-shaped dose-response curve, also gathered from labora- tory testing, only in this case the “response” is death. It makes sense that the second curve is shifted to the right because the lethal dose (LD) would generally require a higher dosage of a drug than the dosage necessary to pro- duce a nonlethal effect.
Emphasis should be placed on the word “generally,” because the lethal dose-response curve may overlap with the effective dose-response curve (as it does in this example). In the example shown, although a 100-mg dose needs to be taken to kill 50 percent of the test population, a dose of as little as 50 mg (or less) is lethal for at least a few of them. The LD50 of a drug refers to the lethal dose for 50 percent of the population; LD1 refers to a relatively lower dose that is lethal for only 1 percent of the population.
In order to arrive at an idea of a drug’s overall toxic- ity, we need to combine the effective and lethal doses of a drug in a ratio. The ratio of LD50/ED50 is called the
lethal dose (LD): The minimal dose of a particular drug capable of producing death in a given percentage of the population.
it can be toxic at relatively low doses. We certainly do not want people to harm themselves accidentally when taking the drug in the course of their daily lives. When there is a possibility that the short-term effects of a particular drug will trigger a toxic response, then this drug is identified as having some level of acute toxicity.
To understand the concept of toxicity in more detail, we need to examine an S-shaped graph called the dose-response curve (Figure 1.3a). Let us assume we have the results of data collected from laboratory tests of a hypothetical sleep- inducing drug. Increases in the dose level of the drug will produce the desired sleep-inducing effect in an increasingly large percentage of a test population of mice. As illustrated in Figure 1.3a, a dose of 10 mg will cause 50 percent of the population to fall asleep; with a dose of 50 mg, 100 percent will have done so. Some variability always exists in an indi- vidual reaction to any drug; some mice may be internally resistant to the drug’s effect, while others may be quite sus- ceptible. We cannot predict which specific animal might fall asleep with 10 mg of the drug, only that the probability of a given animal doing so is 50 percent.
We define the effective dose (ED) of a drug having a specific effect on a test population in terms of probabilities, from 0 to 100 percent. For example, the ED50 of a drug refers to the effective dose for 50 percent of the population; ED99 refers to the effective dose for 99 percent of the population. In this example, the ED numbers refer to the drug’s effect of producing sleep on a specific proportion of the population being exposed to the drug. The same drug may be produc- ing other effects (muscular relaxation, for instance) at lower doses; these drug effects would have their own separate dose- response curves. Remember that we are looking at the proper- ties of a specific drug effect here, not at the overall properties of the drug itself.
acute toxicity: The physical or psychological harm a drug might present to the user immediately or soon after the drug is ingested into the body.
dose-response curve: An S-shaped graph showing the increasing probability of a certain drug effect as the dose level rises.
effective dose (eD): The minimal dose of a particular drug necessary to produce the intended drug effect in a given percentage of the population.
0
50
0
100
50
0
100
0 105 50 100 2005 10 50
Pe rc
en ta
ge o
f s ub
je ct
s fa
lli ng
a sl
ee p
Pe rc
en ta
ge o
f s ub
je ct
s sh
ow in
g a
gi ve
n re
sp on
se
Dose of a sleep-inducing drug (in mg)
(a)
Dose of a sleep-inducing drug (in mg)
(b)
50% fall asleep with 10 mg
100% fall asleep with 50 mg
ED -re
sp on
se c
ur ve
ED -re
sp on
se cu
rve
LD -re
sp on
se cu
rve
100% fall asleep with 50 mg
50% fall asleep with 10 mg
10–12% die with 50 mg
50% die with 100 mg
100% die with 200 mg
F igure 1 .3
(a) An effective dose (ED)-response curve, and (b) an ED-response curve (left) alongside a lethal dose (LD)-response curve (right).
10 ■ Part One The Challenge of Drugs in Our Society
the content of heroin may be unexpectedly high and lead to a lethal overdose, or the adulterated product may contain animal tranquilizers, arsenic, strychnine, insecticides, or other highly toxic substances.8 Cocaine, LSD, marijuana, and all the other illicit drugs that are available to the drug abuser, as well as look-alike drugs that are unauthorized cop- ies of popular prescription medications, present hidden and unpredictable risks of toxicity. Even if drugs are procured from a friend or from someone you know, these risks remain. Neither of you is likely to know the exact ingredients. The potential for acute toxicity is always present.
Given the uncertainty that exists about the contents of many abused drugs, what measure or index can we use to eval- uate the effects of acute toxicity on individuals in our society? A natural tendency is to look first to the news headlines; think of all the well-known public figures who have died as a direct consequence of drug misuse or abuse (Drugs . . . in Focus).
Such examples, however, can be misleading. Celebrities are not necessarily representatives of the drug-using popula- tion in general, and the drugs prevalent among celebrities, because of their expense, may not represent the drugs most frequently encountered by the rest of society. To have some idea of the toxic effects of psychoactive drugs in a broader context, we have to turn to the institutions that contend with drug toxicity on a daily basis: the emergency departments of hospitals around the country. As we will see, the drugs involved in hospital emergencies are not necessarily the ones that are associated with illicit drug use.
therapeutic index. For example, if the LD50 for a drug is 450 mg, and the ED50 is 50 mg, then the therapeutic index is 9. In other words, you would have to take nine times the dose that would be effective for half of the popu- lation in order to incur a 50 percent chance of death in that population.
It can be argued that a 50 percent probability of dying represents an unacceptably high risk even for a drug that has genuine benefits. To be more conservative in the direction of safety, the ratio of LD1/ED99 is often calculated. Here we are calculating the ratio between the dose that produces death in 1 percent of the population and the dose that would be effective in 99 percent. Naturally, this second ratio, called the margin of safety, should be as high as possible for a drug to be considered relatively safe to use. As before, the higher the ratio, the greater the difference between effectiveness and lethality. In other words, the wider the margin of safety, the safer (less toxic) the drug in question. Clearly, the margin of safety for the hypothetical drug examined in Figure 1.3 would present serious toxicity issues. Bear in mind, however, that any index of drug toxicity assumes that the drug is being consumed by itself, without any other substances being con- sumed at the same time. If something else is administered along with the drug in question (whether it is another drug or some food product), then the margin of safety can potentially change. The important issue of drug interactions, particularly drug interactions with alcohol, will be taken up in Chapter 4.
The U.S. Food and Drug Administration (FDA) requires that therapeutic index and the margin of safety are calculated by recognized pharmaceutical companies during the develop- ment of new drugs. Obviously, the goal is for these ratios to be as large as possible, considering that an individual might unin- tentionally take a higher-than-recommended dose of the drug. We do not want the consumer to be in danger if this happens. But what about the toxicity estimates in the consumption of illicit drugs? The unfortunate reality of street drugs is that the buyer has no way of knowing what he or she has bought until the drug has been used, and then it is frequently too late. It is an extreme case of caveat emptor (“Let the buyer beware”).
Few if any illicit drug sellers make any pretense for being ethical businesspeople; their only objectives are to make money and avoid prosecution by the law. Frequently, the drugs they sell are diluted with either inert or highly danger- ous ingredients. Adulterated heroin, for example, may con- tain a high proportion of milk sugar as inactive filler and a dash of quinine to simulate the bitter taste of real heroin, when the actual amount of heroin that is being sold is far less than the “standard” street dosage. At the other extreme,
therapeutic index: A measure of a drug’s relative safety for use, computed as the ratio of the lethal dose for 50 percent of the population to the effective dose for 50 percent of the population.
margin of safety: The ratio of a lethal dose for 1 percent of the population to the effective dose for 99 percent of the population.v Emergency medical service (EMS) crews frequently have to deal
with drug-related cases.
Chapter 1 Understanding the Drug Problem in America ■ 11
acute toxicity in the news: Drug-related Deaths The following famous people have died either as a direct consequence or as an indirect consequence of drug misuse or abuse.
Name Year of Death Age Reasons Given for Death
Marilyn Monroe, actress 1962 36 Overdose of Nembutal (a sedative-hypnotic medication); circumstances unknown
Lenny Bruce, comedian 1966 40 Accidental overdose of morphine Judy Garland, singer and actress
1969 47 Accidental overdose of sleeping pills
Janis Joplin, singer 1970 27 Accidental overdose of heroin and alcohol Jimi Hendrix, singer and guitarist
1970 27 Accidental overdose of sleeping pills
Elvis Presley, singer and actor 1977 42 Cardiac arrhythmia suspected to be due to an interaction of antihistamine, codeine, and Demerol (a painkiller), as well as Valium and several other tranquilizers
John Belushi, comedian and actor
1982 33 Accidental overdose of heroin combined with cocaine
David A. Kennedy, son of U.S. senator Robert F. Kennedy
1984 28 Accidental interaction of cocaine, Demerol, and Mellaril (an antipsychotic medication)
Len Bias, college basketball player
1986 22 Cardiac-respiratory arrest from accidental overdose of cocaine
River Phoenix, actor 1993 23 Cardiac-respiratory arrest from accidental combination of heroin and cocaine
Jonathan Melvoin, keyboardist for the Smashing Pumpkins rock band
1996 34 Accidental overdose of heroin
Chris Farley, comedian and actor
1998 33 Accidental overdose of heroin and cocaine
Bobby Hatfield, singer, the Righteous Brothers
2003 63 Heart failure following overdose of cocaine
Mitch Hedberg, comedian 2005 37 Heart failure due to “multiple-drug toxicity,” including heroin and cocaine
Heath Ledger, actor 2008 28 Acute intoxication from combined use of six prescription medicines for pain, anxiety, insomnia, and nasal congestion
Michael Jackson, songwriter and entertainer
2009 50 Cardiac arrest due to an intramuscular administration of propofol (brand name: Diprivan), possibly interacting with a number of antianxiety medications
Greg Giraldo, comedian 2010 44 Accidental overdose of prescription medication and alcohol
Amy Winehouse, singer 2011 27 Accidental alcohol poisoning, resulting from a lethal blood-alcohol concentration of 0.42 percent
Whitney Houston, singer and actress
2012 48 Accidental drowning, with chronic cocaine use and heart disease as contributing factors
Cory Monteith, television actor “Glee”
2013 31 Overdose of heroin and alcohol
Philip Seymour Hoffman, actor 2014 46 Heroin overdose
Note: Celebrities whose drug-related deaths have been attributed to the toxicity of nicotine, tars, or carbon monoxide in tobacco products are not included in this listing.
Source: Various media reports.
Drugs … in Focus
12 ■ Part One The Challenge of Drugs in Our Society
The DAWN Reports
Information concerning drug-related medical emergen- cies has been based on surveys of patients admitted to major metropolitan hospitals, through a federal program called the Drug Abuse Warning Network (DAWN). Two basic types of information are reported. The first concerns the number of times an individual visits an emergency department or ED (not to be confused with the ED used to indicate “effective dose”) for any reason that is connected to recent drug use. These drug-related ED visits involve a wide range of drug-related situa- tions: suicide attempts, malicious poisoning, overmedi- cation, and adverse reactions to medications, as well as the use of illicit drugs, the use of dietary supplements, and the nonmedical use of prescription or OTC drugs.
Drug abuse Warning network (DaWn): A federal program in which metropolitan hospitals report the incidence of drug-related lethal and nonlethal emergencies.
drug-related eD visit: An occasion on which a person visits an emergency department (ED) for a purpose that is related to recent drug use.
Quick Concept Check
Understanding Margins of Safety Check your understanding of the concept, margin of safety, by answering the following questions.
The following seven drugs have been studied in large populations of laboratory animals and the LD1 and ED99 dosages for each drug has been established.
LD1 ED99
DRUG A 100 mg 50 mg DRUG B 40 mg 2 mg DRUG C 500 mg 10 mg DRUG D 35 mg 5 mg DRUG E 140 mg 20 mg DRUG F 150 mg 1 mg DRUG G 150 mg 10 mg
Rank order Drugs A through G in terms of their margins of safety, from the greatest margin of safety (safest) to the smallest margin of safety (least safe). Determine which drugs might be “tied” in their margins of safety.
Answer: The correct rank order is Drug F (safest), Drug C, Drug B, Drug G, Drugs D and E (tied), and Drug A (least safe).
1.1
Medications only
Illicit drugs with alcohol and medications
Illicit drugs only
Alcohol with medications
Illicit drugs with
medications
Illicit drugs with alcohol
11%
10%
10%
3%
34%
27%
5%
Alcohol only (age <21)
F igure 1 .4
Distribution of drug-related ED visits in 2011 by type of drug involvement. Here, and in the accompanying text discussion, ED stands for “emergency department.”
Source: Based on data from Center for Behavioral Health Statistics and Quality (2013). Drug Abuse Warning Network, 2011: National estimates of drug-related emergency department visits, 2004–2011. Rockville, MD: Substance Abuse and Mental Health Services Administration.
The second type of information concerns the number of drug-related deaths, as determined by a coroner or medical examiner.9
The most currently available statistics regarding ED visits come from the 2011 DAWN survey. Approximately 2.5 million ED visits in the United States in 2011 (one-half of the total number of drug-related ED visits) were associ- ated with either drug abuse or drug misuse with an aver- age of two drugs being reported in a given drug-related ED visit. If you are considering drug-related ED visits resulting from ingestion of a single drug, then the greatest number of cases involved either a prescription or a non- prescription medication. There was a greater percentage of drug-related ED visits of this kind (47%) than those involving an illicit drug (44%). However, about a third of the time, a drug-related ED visit involved more than one drug. In some cases, there might have been five or more drugs mentioned at the time. These circumstances are referred to as arising from multiple-drug (polydrug) use. Figure 1.4 shows the distribution of drug-related ED visits due to seven situations, including both single-drug and multiple-drug circumstances.10
The proportion of drug-related ED visits involving alco- hol use (see Figure 1.4) requires some explanation. Statistics about ED visits related to the use of alcohol alone are limited in the DAWN reporting system to such use by individuals younger than 21 years of age. In other words, such medi- cal emergencies are resulting, by definition, from underage drinking. DAWN statistics are not collected for ED visits involving alcohol use alone by individuals who are 21 years old or older.
polydrug: Involving multiple drugs.
Chapter 1 Understanding the Drug Problem in America ■ 13
opioid pain medications) are the most frequently reported drug involved in a drug-related death.
●■ Cocaine was typically reported in 2010 among the “top three” drugs in these circumstances, while it had been more frequently reported in earlier years.
●■ Alcohol (that is, alcohol in combination with some other drug) is commonly in the “top three” and is almost always in the “top five.”
●■ Medications used to treat anxiety or depression are almost always among the “top five” most-frequently reported drugs in drug-related death cases. However, the presence of these categories of licit drugs in the “top five” listing should be interpreted carefully. The amounts ingested in these circumstances far exceed the recommended dosage levels and have been combined with one or more other drugs.
●■ Marijuana is far less prominent in drug-related deaths, and when there are reports of its involvement, it is almost exclusively in the context of multiple-drug rather than single-drug use.
●■ Methamphetamine use as a cause of a drug-related death is largely underestimated in the DAWN statistics, because of reliance on reports from large metropolitan areas rather than from less populated, rural areas in the United States, where methamphetamine has been a significant public health concern (see Chapter 10).13
Judging Drug Toxicity from Drug-Related Deaths The finding that the use of heroin or cocaine alone is frequently involved in drug-related deaths is particularly striking when you consider that heroin and cocaine users constitute a relatively small proportion of the total number of illicit drug users, and certainly of the general population. The fact that there are more instances of drug-related deaths resulting from heroin use than instances of cocaine use under- estimates the potential lethality of heroin, since there are far fewer heroin users than cocaine users in the United States. In contrast, the rare association of marijuana with a drug-related death actually overestimates its potential lethality, given its widespread use within a much larger group of people.
In short, a judgment about the relative toxicity of illicit drugs requires an understanding of how frequently a partic- ular drug is used in the general population. All other facts being equal, if one illicit drug produces twice as many deaths as a second drug, but the number of users of the first drug is twice that of the second, then the toxicity levels of the two drugs should be considered equivalent.
Demographics and Trends By examining DAWN statistics over the last 30 years or so, we can arrive at some idea of the changes that have taken place in the frequency of medical emergencies. For example, a dramatic increase in the number of cocaine-related emer- gencies occurred in the 1980s as a result of the rise of cocaine
There is a very good reason for this exclusion. If all emergencies related to alcohol use alone were reported, the numbers would far exceed those related to any other drug. Considering the number of alcohol-related automobile accidents and alcohol-related personal injuries that end up in emergency departments each year (see Chapter 15), the examination of ED visits related to other circumstances would be totally obscured if all alcohol-related ED visits were included.
An important message in the DAWN statistics is the considerable toxicity that is reflected in the alcohol-in- combination category of ED visits. In these circumstances, the ingestion of alcohol has occurred in conjunction with the ingestion of another drug, regardless of one’s age. One- fourth (24%) of drug-related ED visits in 2011 involved some use of alcohol in combination with either an illicit drug, with a prescription or nonprescription medication, or an illicit drug along with a medication.11
Emergencies Related to Illicit Drugs What types of illicit drugs are most likely to result in an ED visit? Among drug-abuse and drug-misuse ED visits reported in 2011, the largest number involved cocaine (40%), fol- lowed by marijuana (36%), heroin (21%), and methamphet- amine (13%). Note that the percentages for these drugs add up to more than 100 percent because of the involvement of two or more drugs at a time. In general, patients admitted for an illicit-drug-related ED visit in 2011 were about twice as likely to be male as female.12
Drug-Related Deaths The most currently available statistics regarding drug-related deaths come from the 2010 DAWN survey and are reported (unlike information about drug-related emergencies) in terms of selected metropolitan areas rather than on a nationwide basis. This presents certain challenges in drawing conclusions about lethality of drug-taking behavior in a particular region of the country. For example, a similar number of drug-related deaths in 2010 in metropolitan Washington, DC, and met- ropolitan Denver, Colorado (353 versus 356), with very dif- ferent populations (5.5 versus 2.5 million), is indicative of a substantially greater drug problem in Denver as compared to Washington, DC. In mathematical terms, we are using two different denominators in arriving at the prevalence rate.
In addition, metropolitan area in the DAWN survey may have somewhat different “profiles” in terms of five drugs most frequently reported in drug-related death cases (see Figure 1.5). Despite these differences, however, a number of generaliza- tions can still be made, based on the 2010 statistics.
●■ It is far more common for drug-related deaths to be a result of multiple-drug (polydrug) use than a result of single-drug (monodrug) use.
●■ In nearly all metropolitan areas surveyed in the DAWN report, opioid drugs (heroin, morphine, methadone, and
14 ■ Part One The Challenge of Drugs in Our Society
Note: The population in parentheses refers to the population surveyed in the DAWN report. Opiates/opioids refers primarily to heroin.
Boston, Cambridge, Quincy, MA (4.6 million)
600
500
400
300
200
100
0
365
Opiates/opioids Alcohol Cocaine Antianxiety medications
Antidepressant medications
143 66 66
139
Detroit, Warren, Livonia, MI (4.3 million)
600
700
500
400
300
200
100
0
680
Opiates/opioids Antianxiety medications
AlcoholCocaine Antidepressant medications
261 204 187
226
Minneapolis- St. Paul- Bloomingston, MN (2.7 million)
200
150
100
50
0
150
Opiates/opioids Alcohol Cocaine Antianxiety medications
Antidepressant medications
44 32 18
38
Houston, Baytown, Sugar Land, TX (4.0 million)
400
300
200
100
0
260
Opiates/opioids Antianxiety medications
Cocaine Muscle relaxants
Alcohol
194
89 87
155
San Diego, Carlsbad, San Marcos, CA (3.0 million)
250
150
200
100
50
0
240
Opiates/opioids Stimulants in general
Antianxiety medications
AlcoholAntidepressant medications
118 83 71
117
Washington DC; Arlington, VA; Alexandria, MD (5.5 million)
300
250
200
50
100
150
0
227
Opiates/opioids Cocaine Alcohol Antidepressant medications
Antianxiety medications
124
44 35
102
Multiple-drug deaths
Single-drug deaths
F igure 1 .5
Drug-related deaths in 2010: A tale of six cities. Numbers above each bar indicate total deaths from the ingestion of a specific drug or drug category, including single-drug and multiple-drug circumstances.
Source: Based on data from the Center for Behavioral Health Statistics and Quality (2012). Drug Abuse Warning Network, 2010. Area profiles of drug- related mortality. Rockville, MD: Substance Abuse and Mental Health Services Administration, pp. 51, 67, 110, 122, 128, and 227.
Chapter 1 Understanding the Drug Problem in America ■ 15
period of time. Examples of chronic toxicity can be found in a wide range of psychoactive drugs, either legally or illegally obtained. As mentioned at the beginning of this chapter, it is the chronic use of alcohol and tobacco, both of which are legally available in our society, that causes by far the greatest adverse health effects (Figure 1.6).
We would not be so concerned about the acute or chronic toxicity levels of psychoactive drugs if we lived in a society in which few or any individuals were engaged in that form of behavior. Unfortunately, drug toxicity is a major problem today because substantial numbers of individuals are drug users and, in particular, substantial numbers of drug users are young people. Therefore, in order to fully appreciate the scope of the drug problem in America, we need to examine the prevalence rates of drug use. You can think of prevalence rates as a “multi- plier” to provide a rough estimate of the impact of drug toxicity on our society as a whole. How many people have been or are presently engaging in drug-taking behavior?
Prevalence Rates of Drug Use in the United States We begin with the problem of obtaining information about drug use that would give us a statistical picture of drug- taking behavior today. Assuming that we cannot conduct large-scale random drug testing, the only alternative we
chronic toxicity: The physical or psychological harm a drug might cause over a long period of use.
abuse and crack cocaine abuse. A decade later, an upturn in heroin-related emergencies took place, as the purity of available heroin increased and the availability of heroin use without a needle injection caused heroin-related emergency rates to rise.
In the mid-1990s, significant concerns emerged about the increase in ED visits due to the use of illicit “club drugs” that included Ecstasy, GHB, ketamine, LSD, and methamphet- amine. More than a decade later, the class of drugs that raised the greatest concern among health care professionals included opioid (opiate-related) prescription medications, also known as narcotic analgesics (see Chapter 9). In 2011, nearly 17,000 people in the United States died from these medications, four times more than in 1999. The principal medications of this type were methadone, oxycodone (brand name: Percocet), controlled-release oxycodone (brand name: OxyContin), and hydrocodone (brand name: Vicodin). More recently, it is heroin that has been most prominently associated with drug- related (overdose) deaths.14
Multiplying the Problem of Drug Toxicity: How Many Drug Users?
Through the DAWN surveys, we can appreciate the extent of acute toxicity involved in the ingestion of a particular drug, but we are unable to get an illuminating picture of the negative consequences of using a particular drug over a long
R.I.P.
Alcohol
R.I.P.
Tobacco
480,000
83,000
R.I.P.
Illicit Drugs
22,500
More than four times as many Americans die from tobacco-related illnesses such as cardiovascular and respiratory diseases and cancer as die from alcohol-related and illicit drug-related problems combined. Numbers of tobacco-related deaths include tobacco users or nonusers exposed to tobacco smoke.
F igure 1 .6
U.S. deaths per year from tobacco, alcohol, and illicit drug use.
Source: Based on data from Centers for Disease Control and Prevention (2014, February 6). Fact sheet: Tobacco-related mortality. Atlanta, GA: Centers for Disease Control and Prevention. Harwood, Henrick (2011, October 23). Recent findings on the economic impacts of substance abuse. Presented at the American Psychological Association 2011 Science Leadership Conference, Psychological Science and Substance Abuse, Washington DC. Slide 12. Mokdad, A. H.; Marks, J. S.; Stroup, D. F.; and Gerberding, .J. L. (2004). Actual causes of death in the United States, 2000. Journal of the American Medical Association, 291, 1238–1245.
16 ■ Part One The Challenge of Drugs in Our Society
ride since the Michigan survey began in 1975. The early statistics were indeed scary. By the end of the 1970s, preva- lence rates for illicit drug use had reached historically high levels. About one-half of high school seniors reported smok- ing marijuana or using an illicit drug of some kind in the past year. At that time and continuing into the mid-1980s, 12 percent (one in eight seniors) reported using cocaine or crack cocaine in the past year. Fortunately, annual preva- lence rates for illicit drug use among high school seniors showed a steep decline through the 1980s, ending at a historically low level (27%) around 1992. In other words, illicit drug use had dropped by about 50 percent. But at that point, a dramatic reversal occurred. Prevalence rates took a sharp upward turn during the decade of the 1990s. From 2000 to 2013, rates have been fairly steady at a level of about 40 percent (Figure 1.7). The bottom line is that, in terms of illicit drug use in this demographic group, the present is somewhere between the worst of times (in 1979) and the best of times (in 1992).
But looking at the numbers more closely, we can see the current pattern of drug use among high school seniors in a somewhat different light. If we examine the annual preva- lence rates for the use of illicit drugs other than marijuana, the trend is down from about 20 percent in 2000 to about 17 percent in 2013.
This good news, however, is counterbalanced by a more complicated trend with respect to using marijuana alone. In 2000, about 37 percent of seniors reported smoking marijuana in the past year, having risen steadily through the 1990s. In the next few years, the prevalence rate declined. By 2007, however, the trend reversed itself (again). In 2013, annual marijuana use stood at 36 percent (essentially the level observed in 2000). This percentage had risen for over the previous five years. The rate of daily marijuana smoking in 2013 stood at 7 percent, the highest it has been since 1981. In other words, about one out of three high school seniors used marijuana over the past year and one out of 14 seniors used marijuana on a daily basis in 2013.
Illicit Drug Use among Eighth Graders and Tenth Graders Since 1991, the Michigan survey has collected extensive information about illicit drug use among students as early as the eighth grade. As Figure 1.7 shows, the upward trend in the percentages of annual drug use among eighth and tenth graders in the years 1991–1996 parallels a similar trend among high school seniors. At the time, the data from these two groups reflected a level of drug involvement that was quite alarming. Drug-abuse professionals were left to specu- late about the negative effect on still younger children, as they observed the drug-taking behavior of their older brothers and sisters. In general, as you would expect, changes in the trend of prevalence rates among high school seniors have been pre- ceded, four years or so earlier, by the shifting prevalence rates among eighth graders.16
have is simply to ask people about their drug-taking behavior through self-reports. We encourage honesty and arrange the data-collection procedure so as to convince the respondents that their answers are confidential, but the fact remains that any questionnaire is inherently imperfect because there is no way to verify the truthfulness of what people say about themselves. Nevertheless, questionnaires are all we have, and the statistics on drug use are based on such survey measures.
One of the best-known surveys, referred to as the Monitoring the Future study, has been conducted by the University of Michigan every year since 1975. Typically, approximately 41,000 American students in the eighth, tenth, and twelfth grades participate in a nationally representative sampling each year, as well as more than 7,000 American col- lege students and adults between 19 and 55 years old.
The advantage of repeating the survey with a new sample year after year is that it enables us to examine trends in drug- taking behavior over time and compare the use of one drug relative to another over the years. We can assume that the degree of overreporting and underreporting stays relatively constant over the years and does not affect interpretation of the general trends.15
Survey questions concerning drug use have been phrased in four basic ways:
●■ Whether an individual has ever used a certain drug in his or her lifetime. The percentage of those saying “yes” is referred to as the lifetime prevalence rate.
●■ Whether an individual has used a certain drug over the past year. The percentage of those saying “yes” is referred to as the annual prevalence rate.
●■ Whether an individual has used a certain drug within the past 30 days. The percentage of those saying “yes” is referred to as the past-month prevalence rate.
●■ Whether an individual has used a certain drug on a daily basis during the previous 30 days. The percentage of those saying “yes” is referred to as the daily prevalence rate.
You can see that these questions distinguish three important degrees of involvement with a given drug. The first question focuses on the extent of experimentation, including individuals who may have taken a drug only once or twice in their lives but may have stayed away from it ever since. The second and third questions focus on the extent of current but moderate drug use, and the fourth ques- tion focuses on the extent of heavy drug use. What do the numbers tell us?
Illicit Drug Use among High School Seniors Understanding the present-day drug-taking behavior among U.S. high school seniors is not an easy task. In order to see the total picture, we have to look to the past as well as the pres- ent, and make some educated guesses for the future based on current trends. It has been something of a roller-coaster
Chapter 1 Understanding the Drug Problem in America ■ 17
shows the lifetime, annual, and 30-day prevalence rates among college students with respect to five major types of drugs: the use of marijuana, hallucinogens, cocaine, crack cocaine, and heroin.17
Alcohol Use among High School and College Students Not surprisingly, the prevalence percentages related to the use of alcohol are much higher than for illicit drugs. Whereas about 25 percent of high school seniors in 2013 reported use of illicit drugs in the past month, 39 percent drank an alco- holic beverage in the past month, and 22 percent reported an instance of binge drinking, defined as having five or more drinks in a row at least once in the past two weeks. These figures are at historic lows, down substantially from those found in surveys conducted in 1980, when 72 percent of high school seniors reported that they had consumed alcohol in the past month, and 41 percent reported binge drinking.18
The general decline in alcohol use and heavy drinking among adolescents from 1980 to 2013, particularly since the mid-1990s, stems from a number of factors. National campaigns aimed at reducing drunk driving, the encourage- ment of nondrinking designated drivers, as well as a general personal disapproval of binge drinking, have all played a role. An additional factor is the reduced accessibility to alcohol for this age group; all U.S. states have now adopted a 21-years- or-older requirement. While efforts to reduce underage drinking by enforcing restrictions of alcohol sales to minors
Illicit Drug Use among College Students According to the Michigan survey, when compared to high school seniors, college students reported in 2013 a slightly lower annual prevalence rate (39%) in the use of illicit drugs in general. As it has been the case for younger people, illicit drug use was clearly dominated by marijuana smoking. Table 1.1
taBLe 1.1
Prevalence rates for five types of illicit drug use among college students, aged 19–22
ever in LiFetime
in PaSt 12 mOnthS
in PaSt 30 DaYS
Marijuana 47.7 35.5 20.8
Hallucinogens 7.8 4.5 1.0
Cocaine 5.1 2.7 0.9
Crack cocaine 0.7 0.3 0.3
Heroin 0.4 0.3 0.2
Note: For current information, consult the Web site for the Monitoring the Future study: http://www.monitoringthefuture.org.
Sources: Based on data from Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald, G.; Schulenberg, John E.; and Miech, Richard A. (2014). Monitoring the Future: National survey results on drug use, 1975–2013, Vol. II: College students and adults ages 19–55. Ann Arbor, MI: Institute for Social Research, University of Michigan, Tables 2-1, 2-2, and 2-3.
0
40
60
Year
20
Twelfth graders
Tenth graders
Eighth gradersP er
ce nt
ag e
of s
tu de
nt s
’75 ’77 ’79 ’81 ’83 ’85 ’87 ’89 ’91 ’93 ’95 ’97 ’99 ’01 ’03 ’05 ’07 ’09 ’11 ’13
F igure 1 .7
Trends in annual prevalence of illicit drug use among eighth, tenth, and twelfth graders.
Note: Updated statistical information from the University of Michigan survey is available at the end of December of each year through the Web site: http://www.monitoringthefuture.org.
Source: Based on data from Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; Schulenberg, John E., and Miech, Richard A. (2014). Monitoring the Future: National survey results on drug use, 1975–2013, Vol. I: Secondary school students, 2013, Ann Arbor, MI: Institute for Social Research, University of Michigan, Table 2-2.
18 ■ Part One The Challenge of Drugs in Our Society
LSD, and OxyContin, but higher with respect to inhal- ants, Ecstasy, and cocaine. Daily cigarette smoking was less prevalent among Latino students, relative to white students, but alcohol use and drunkenness were roughly equivalent. Finally, annual prevalence rates for marijuana were roughly equivalent for all three demographic categories.23
Drug Use and Perceived Risk The decision to engage in a specific form of drug-taking behavior is intermeshed with individual perceptions about the drug in question. How risky would it be to use a par- ticular drug? How dangerous would it be? These questions have been asked of high school seniors in the Michigan survey since 1975, and the relationship is clear. Figure 1.8 shows an almost exact “mirror image” in the trends over more than 35 years between the perceived risk of harm in regular marijuana smoking and the 30-day prevalence rate.24 In the 1990s, there was a steady decline in the percentages of high school students, college students, and young adults who regarded regular drug use (regular marijuana use in par- ticular) as potentially dangerous. These responses contrasted with reports beginning in 1978 that had shown a steady increase in such percentages. At the time, Lloyd Johnston, chief researcher for the Michigan survey, offered one possible reason for this reversal:
This most recent crop of youngsters [in 1996] grew up in a period in which drug use rates were down substantially from what they had been 10 to 15 years earlier. This gave youngsters less opportunity to learn from others’ mistakes and resulted in what I call “generational forgetting” of the hazards of drugs.25
Also troubling during much of the 1990s were changes in the way our society dealt with the potential risks of drug use. Drug abuse prevention programs in schools were scaled back or eliminated because of a lack of federal funding, parents were communicating less with their chil- dren about drug use, anti-drug public service messages were less prominent in the media than they were in the 1980s, and media coverage in this area declined. At the same time, the cultural influences of the music and enter- tainment industry were, at best, ambivalent on the ques- tion of drug-taking behavior, particularly with respect to marijuana smoking (see Chapter 12). All these elements can be seen as having contributed to the upward trend in drug use during this period.
Another question that has been asked in the Michigan survey is, “Would you experience disapproval if you used a particular drug?” Not surprisingly, the likelihood of using a drug is inversely related to how much disapproval might be experienced. This is particularly the case in the life of an ado- lescent, when peer approval is such an important element in guiding his or her behavior.
The perception of possible risk or danger and the perception of disapproval are useful indices in predicting future trends in drug use, because shifts in perception often
has been credited with reducing adolescent alcohol use, how- ever, the statistics show that more work needs to be done. In 2013, more than half of eighth graders (56%) found it “fairly easy” or “very easy” to obtain alcoholic beverages, down from 71 percent in 2000. About 90 percent of seniors reported the same, down from 95 percent in 2000.19 The drinking hab- its of college students have shown relatively little change since the mid-1990s. In 2013, 63 percent of college students surveyed had consumed an alcoholic beverage at least once in the previous month, and 35 percent reported an instance of binge drinking.20
Tobacco Use among High School and College Students Roughly 9 percent of high school seniors in 2013 had estab- lished a regular habit of nicotine intake by smoking at least one cigarette every day. In fact, nicotine remains the drug most frequently used on a daily basis by high school students, although present-day rates are substantially lower than those observed when the Michigan survey began in 1975. Three times as many high school seniors (27%) smoked cigarettes at that time. From the mid-1990s, there has been a steady decline in smoking rates in eighth and tenth graders as well as seniors, owing to the national attention directed toward cigarette smoking among young people. Nonetheless, in 2013, about 4 percent of seniors and 3 percent of tenth grad- ers reported smoking at least half a pack of cigarettes per day—a strikingly high level for these age groups, consider- ing the legal obstacles they face when attempting to obtain cigarettes.21
It is true that somewhat fewer college students smoke cigarettes than high school seniors, but the reason is not a matter of a change in smoking behavior from high school to college. It is a reflection of differences between the two popu- lations. Non–college-bound seniors are about three times more likely than college-bound seniors to smoke at least a half-pack of cigarettes per day. Therefore, the difference in smoking rates between seniors and college students is chiefly a result of excluding the heavier smokers in the survey as stu- dents progress from secondary to postsecondary education. In 2013, about 6 percent of college students smoked cigarettes on a daily basis (nearly 25% fewer than in 2011), with about 2 percent smoking more than half a pack per day.22
Drugs among Youth in a Diverse Society Over the years, the University of Michigan survey has identi- fied racial and ethnic differences in illicit and licit drug use among American adolescents. In 2013, annual prevalence rates among African American seniors were lower than that among white students with respect to inhalants, hallucino- gens, LSD, Ecstasy, cocaine, OxyContin, and alcohol, as well as levels of daily cigarette smoking and drunkenness. Annual prevalence rates among Latino seniors were lower than that among white students with respect to hallucinogens,
Chapter 1 Understanding the Drug Problem in America ■ 19
precede in time the observed changes in behavior. A lower level of disapproval of marijuana smoking, for example, may reflect a lower perception of riskiness, which might in turn reflect later in an increased prevalence rate.26
Illicit Drug Use among Adults Aged 26 and Older A comprehensive report of the prevalence rates of illicit drug use among Americans in several age groups across the life span is made possible on an annual basis by the National Survey on Drug Use and Health (formerly the National Household Survey on Drug Abuse). Table 1.2 shows the estimated number of illicit drug users aged 26 or older in the United States in 2013. About 12 percent of this popu- lation (approximately 24 million people) reported using an illicit drug over the past 12 months, about 9 percent (more than 18 million people) used marijuana or hashish, and about 5 percent (approximately10 million people) engaged in the nonmedical (recreational) use of a prescription pain reliever, tranquilizer, stimulant, or sedative. As with the results of the Michigan survey, however, there are some lim- itations on the interpretation of these estimates. In the case of the national survey, neither patients institutionalized for medical or psychiatric treatment nor homeless people are included in the collection of sample data.27
0
10
30
50
Use: % using once or more
in past 30 days (on left-hand scale)
20
40
U se
( pe
rc en
ta ge
)
R isk and availability (percentage)
Risk: % saying great risk of
harm in regular use (on right-hand scale)
Availability: % saying fairly easy
or very easy to get (on right-hand scale)
0
20
60
100
40
80
Availability
Risk
Use
’76 ’78 ’80 ’82 ’84 ’86 ’88 ’90 ’92 ’94 ’96 ’98 ’00 ’02 ’04 ’06 ’08 ’10 ’12 ’14
F igure 1 .8
Trends in perceived availability of marijuana, perceived risk of marijuana use, and prevalence of marijuana use in the past month for high school seniors.
Note: Updated statistical information from the University of Michigan survey is available at the end of December of each year through the Web site: http://www.monitoringthefuture.org.
Source: Based on data from Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; Schulenberg, John E.; and Miech, Richard A. (2014). Monitoring the Future: National survey results on drug use, 1975–2013, Vol. I: Secondary school students 2013. Ann Arbor, MI: Institute for Social Research, University of Michigan, Tables, 5-3, 8-3, and 9-8.
Quick Concept Check
Understanding Prevalence Rates of Drug Use in the United States Check your understanding of prevalence rates of drug use in the United States by marking the following statements as true or false.
1. The University of Michigan survey represents responses from all 17–18-year-old individuals in the United States.
2. With the exception of alcohol and nicotine, the trend in drug use from the early 1980s to the present has been a steady decline.
3. Tobacco use among college students has always been greater than among high school seniors.
4. Marijuana is more available and its use is more prevalent now than it was in 1980.
5. Prevalence rates of alcohol use and heavy drinking among adolescents have remained relatively stable from 1980 to 2013.
Answers: 1. false 2. false 3. false 4. false 5. false
1.2
20 ■ Part One The Challenge of Drugs in Our Society
recent years. Hydrocodone (brand name: Vicodin), oxyco- done (brand names: Percodan, Percocet), and sustained- release oxycodone (brand name: OxyContin) have been the principal prescription pain medications involving recreational drug-taking behavior (see Chapter 9). Meth- ylphenidate (brand name: Ritalin) and a combination of dextroamphetamine and levoamphetamine (brand name: Adderall) used for the treatment of attention deficit disor- der continue to be popular either for recreational use (to get high) or for instrumental use (to be able to stay awake longer) or achieve a degree of “cognitive enhancement” (see Chapter 10).
●■ Newly established Internet Web sites have made it pos- sible for individuals to make illicit drug transactions using virtual currencies, allowing purchases to be made with greater anonymity and ease than had ever been pos- sible. Online marketplaces of this type have facilitated international arms trafficking as well. Because of the advanced technology employed by these Web sites, law enforcement authorities have found it frustratingly diffi- cult to close down these operations (Drug Enforcement . . . in Focus).
Continuing Challenges
At present, the challenges facing public-health profession- als and criminal-justice professionals with respect to prob- lems of drugs in America center on three principal areas of concern:
●■ Advanced technologies employed by chemical laborato- ries situated in Asia have made it possible to produce syn- thetic “designer drugs” in unprecedented quantities and chemical variations. These new formulations are flooding the country at the present time. In some cases, they are promoted and distributed as though they are pure forms of existing drugs, when they are not. In other cases, they con- tain chemical combinations that present significant health risks. Nothing is known about the specific chemical com- position of these drugs without a forensic laboratory analy- sis, which is carried out only after sufficient quantities have been seized by drug-control authorities. Until then, drug users are essentially in the dark.28
●■ The incidence of nonmedical use of prescription and nonprescription medications has risen enormously in
taBLe 1.2
Illicit drug use during the past year among persons in the United States aged 26 or older in 2012 and 2013
eStimateD numBerS OF uSerS in 2012
eStimateD numBerS OF uSerS in 2013
Percentage change FrOm 2012 tO 2013
Any illicit drug 24,461,000 24,056,000 –1.6
Marijuana and hashish 17,263,000 18,606,000 7.7
Cocaine 2,890,000 2,507,000 –13.3
Crack cocaine 762,000 527,000 –30.8
Heroin 366,000 406,000 10.9
Hallucinogens 1,516,000 1,610,000 6.2
LSD 282,000 253,000 –10.3
Ecstasy 910,000 977,000 7.4
Methamphetamine 732,000 795,000 8.6
Nonmedical use of any psychotherapeutic medication (not including OTC drugs)
10,296,000 9,662,000 –6.2
Pain relievers 7,650,000 6,864,000 –10.3
OxyContin 723,000 819,000 13.3
Any illicit drug other than marijuana 12,753,000 12,035,000 –5.6
Note: Updated statistical information is available each year from the National Survey on Drug Use and Health through the Web site: http://www.samhsa.gov.
Source: Based on data from the Center for Behavioral Health Statistics and Quality (2014). Results from the 2013 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration, Tables 1.7A and 1.8A.
Chapter 1 Understanding the Drug Problem in America ■ 21
A screen shot of the now-defunct Web site “Silk Road 2.0,” showing various items available for sale.
Source: U.S. Department of Justice, Washington, DC.
Looking Ahead
The drug problem in America is, by no means, limited to concerns within our borders. We are undoubtedly part of a global community. Every day, enormous quantities of illicit drugs, as well as unauthorized medications manufactured in foreign laboratories, flow into the United States through elaborate drug trafficking routes, despite the efforts to inter- dict them and restrict their availability. As we will see in Chapter 2, the impact of drug use and abuse upon citizens of other countries is more intense than they are on individuals in America.
Dealing with high-tech Drug Dealing: Policing the “Dark Web” In October 2013, the FBI in conjunction with the Drug Enforcement Administration succeeded in shutting down an online Web-based marketplace called Silk Road. From February 2011 to October 2013, Silk Road was available as a means for Internet customers to buy a range of illicit drugs (among other items such as weapons) in an anonymous and untrace- able fashion. Silk Road users could access the Web site using encrypted software that hid their personal computer IP addresses. As a result, they could not be identified. Money transactions were accomplished via Bitcoins, a digital form of currency that could be purchased online with real money. Buyers were instructed to have shipments delivered to post office boxes or locations other than their home. When deliveries were completed, Bitcoins were transferred from buyer to seller through a secure escrow account on the site. At the time it was shut down, Silk Road was estimated to have 900,000 active users and annual sales worth $30 million. The FBI had identified Silk Road as the most sophisticated and extensive criminal marketplace on the Internet.
From a criminal justice perspective, here was an example of the difficulty in keeping up with present-day technologies that, while originally developed for legitimate applications, could be exploited for carrying out illegal transactions. Department of Justice and Postal Service authorities struggled to track down the server location of Silk Road and prosecution proceeded slowly, until the owner, 29-year-old Ross William Ulbricht, made a
simple mistake. According to court records, the U.S. Customs and Border Protection agency had intercepted at the Canadian border a package of allegedly forged identification documents containing Ulbricht’s photograph. More than 100 undercover purchases through Silk Road had been made by authorities, as they built a criminal case.
After the original Silk Road was closed down, however, Web sites similar to Silk Road, collectively referred to as the Dark Web, took its place. Marketplace sites such as Agora, White Rabbit Anonymous, Silk Road 2.0, Outlaw Market, and Evolution made use of increasingly sophisticated encryption technology to allude law enforcement agencies in their effort to identify the customers involved. In 2014, the number of illegal drug listings on 10 of the largest online drug markets had risen to more than 40,000, twice the number in the previous year.
In late 2014, an international raid jointly conducted by cybercrime units of Europol and federal agencies in the United States succeeded in closing down Silk Road 2.0 and as many as 400 other Web sites. The man behind the operations of Silk Road 2.0 and some individuals in Europe were arrested.
Sources: Deutsch, Kevin (2013, October 3). Drug mart shut. Newsday, p. A3. Deutsch, Kevin (2013, September 23). High-tech drug dealers: Sources say Feds are probing. Newsday, p. A3. Segal, Laura (2013, November 6). How the Silk Road was reborn. CNN Money. http://money.cnn.com/2013/11/06/technology. Wakefield, Jane (2014, November 7). Huge raid to shut down 400-plus dark net sites. BBC News Technology. http://www.bbc. com/news/technology-29950946.
Drug Enforcement … in Focus
22 ■ Part One The Challenge of Drugs in Our Society
a matter of Definition ●● Psychoactive drugs are those drugs that affect our feelings,
perceptions, and behavior. Depending on the intent of the individual, drug use can be considered either instrumen- tal or recreational.
●● Drug abuse refers to cases in which a licit (legal) or illicit (illegal) drug is used in ways that produce some form of impairment. Drug misuse refers to cases in which a pre- scription or nonprescription drug is used inappropriately.
the Problem of Drug toxicity ●● A drug’s harmful effects are referred to as its toxicity. Acute
toxicity can be measured in terms of a drug’s therapeutic index or its margin of safety, each of which can be com- puted from its effective and lethal dose-response curves.
the DaWn reports ●● Drug Abuse Warning Network (DAWN) statistics,
which reflect drug-related lethal and nonlethal emer- gencies in major metropolitan hospitals in the United States, offer another measure of acute drug toxicity. In general, DAWN statistics show that both opioid drugs (primarily heroin) and cocaine are highly toxic and that many emergencies are due to drugs being taken in combination with alcohol. There are also concerns for the number of emergencies associated with prescription pain relievers.
Prevalence rates of Drug use in the united States ●● Surveys of illicit drug use among high school seniors in
2013 have shown that 40 percent used an illicit drug over the last 12 months, and 36 percent smoked marijuana.
●● During the 1990s, marijuana use among high school seniors rose significantly, as did the use of other illicit
drugs. Since 1997, however, there has been a steady decline in illicit drug use among eighth graders.
●● The prevalence rate for alcohol use in the past month among high school seniors in 2013 was 39 percent and among college students in 2013 was 63 percent. Roughly 9 percent of high school seniors smoked at least one ciga- rette every day in 2013.
●● Over the last 30 years or so, the prevalence trends for regular drug use and perceived risk form an almost exact mirror image of each other. As perceived risk goes up, the level of regular drug use goes down.
●● In 2013, approximately 24 million Americans aged 26 or older had used an illicit drug of some kind during the past 12 months. More than 18 million Americans used mari- juana or hashish, and approximately 10 million Americans engaged in the recreational use of a prescription pain reliever or other medication during this time period.
continuing challenges ●● In recent years, synthetic “designer drugs” have become
available in unprecedented quantities and chemical varia- tions. While promoted as synthetic forms of existing illicit drugs, the chemical composition in the formulation of these drugs is frequently unknown. As a result, they present significant health risks.
●● The nonmedical use of prescription pain medications, prescription stimulant medications, and nonprescription medications has become a significant focus of concern.
●● Increasing sophisticated online Web sites have made it possible for individuals to remain anonymous as they conduct illicit drug transactions using virtual currencies. Online marketplaces of this type have also facilitated inter- national arms trafficking.
Summary
1. Distinguish between brand names, generic names, and street names of drugs.
2. Distinguish between (a) instrumental and recreational drug use, (b) drug misuse and drug abuse, and (c) ED dosages and LD dosages.
3. Define the following: ED, LD, ED99, LD1, ED50, and LD50. Explain how these terms are used in the computation of a therapeutic index and a margin of safety.
4. Summarize the 2011 estimates of ED visits with respect to cocaine, marijuana, heroin, and methamphetamine. Why do
Review Questions
Key Terms
acute toxicity, p. 9 chronic toxicity, p. 15 dose, p. 8 dose-response curve, p. 9 drug, p. 5 drug abuse, p. 7
Drug Abuse Warning Network (DAWN), p. 12
drug dependence, p. 4 drug misuse, p. 7 drug-related ED visit, p. 12 effective dose (ED), p. 9
illicit drugs, p. 4 instrumental use, p. 6 lethal dose (LD), p. 9 licit drugs, p. 4 margin of safety, p. 10
polydrug, p. 12 psychoactive drugs, p. 4 recreational use, p. 7 therapeutic index, p. 10 toxicity, p. 8
Chapter 1 Understanding the Drug Problem in America ■ 23
the percentages of ED visits involving these four drugs add up to more than 100 percent?
5. Summarize the general trends in the pattern of illicit drug use among high school seniors in the United States from 1975 to 2013.
6. Describe the relationship between year-to-year trends in the prevalence rate of drug use and the percentage of individuals saying that a particular drug presents “great risk of harm in regular use.”
1. The Gallup Organization (2013, March). Gov’t budget, healthcare join economy in top U.S. concerns. Washington, DC: The Gallup Organization. The Gallup Organization (2005, October). Gallup historical trends: Illegal drugs. Washington, DC: The Gallup Organization. Center for Behavioral Health Statistics and Quality (2013, August 29). A day in the life of American adolescents: Substance use facts update. The CBHSQ Report. Rockville, MD: Substance Abuse and Mental Health Services Administration. Wax, Paul M. (2002). Just a click away: Recreational drug Web sites on the Internet. Pediatrics, 109(6): e96.
2. Eckholm, Erik (2009, May 28). Governments’ drug-abuse costs hit $468 billion, study says. New York Times, p. A15. National Institute on Drug Abuse (2007). The economic costs of drug abuse in the United States, 1992–2002. Washington, DC: Office of National Drug Control Policy.
3. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; Schulenberg, John E.; and Miech, Richard A. (2014). Monitor- ing the Future: National survey results on drug use, 1975–2013, Vol. I: Secondary school students 2013. Ann Arbor, MI: Institute for Social Research, University of Michigan, Table 2.1. Patel, Amee B.; and Fromme, Kim (2010). Explicit outcome expectancies and substance abuse: Current research and future directions. In Lawrence M. Scheier (Ed.), Handbook of drug use etiology: Theory, methods, and empirical findings. Washington, DC: American Psychological Association, p.153.
4. Primack, Brian; Dalton, Madeline A.; Carroll, Mary V.; Agarwal, Aaron A.; and Fine, Michael J. (2008). Content analysis of tobacco, alcohol, and other drugs in popular music. Archives of Pediatric and Adolescent Medicine, 162(2), 169–175. Ridout, Victoria; Roberts, Donald F.; and Foehr, Ulla G. (2005). Generation M: Media in the lives of 8–18 year-olds. Menlo Park CA: Kaiser Family Foundation.
5. Leshner, Alan I. (1998, October). Addiction is a brain disease— and it matters. National Institute of Justice Journal, 2–6.
6. Jacobs, Michael R.; and Fehr, Kevin O’B. (1987). Drugs and drug abuse: A reference text. Toronto: Addiction Research Foun- dation, pp. 3–5.
7. Goode, Erich (2012). Drugs in American society (8th ed.). New York: McGraw-Hill Higher Education, pp. 11–15.
8. Treaster, Joseph B.; and Holloway, Lynette (1994, September 4). Potent new blend of heroin ends eight very different lives. New York Times, pp. 1, 37.
9. Center for Behavioral Health Statistics and Quality (2013). Drug Abuse Warning Network: National estimates of drug- related emergency department visits 2004–2011. Rockville, MD: Substance Abuse and Mental Health Services Administration, Excel files. Center for Behavioral Health Statistics and Quality (2012). Drug Abuse Warning Network, 2010: Area profiles of drug-related mortality. Rockville, MD: Substance Abuse and Mental Health Services Administration.
10. Center for Behavioral Health Statistics and Quality, Drug Abuse Warning Network, National estimates.
11. Ibid. 12. Ibid. 13. Center for Behavioral Health Statistics and Quality, Drug
Abuse Warning Network, 2010, Area profiles of drug-related mortality, pp. 59–60 and 67–68.
14. Centers for Disease Control and Prevention (2014, July 3). Prescription drug overdose in the United States: Fact Sheet. Atlanta, GA: Centers for Disease Control and Prevention. Cen- ters for Disease Control and Prevention (2011, November). Prescription painkiller overdoses in the US. Atlanta, GA: Cen- ters for Disease Control and Prevention.
15. Johnston; O’Malley; Bachman; Schulenberg; and Miech, Monitoring the Future: National survey, Vol. I: Secondary school students; and Vol. II: College students and adults ages 19–55, 2013. Ann Arbor, MI: Institute for Social Research, University of Michigan.
16. Johnston; O’Malley; Bachman; Schulenberg; and Miech, Monitoring the Future, Vol. I: Table 2-2.
17. Johnston; O’Malley; Bachman; Schulenberg; and Miech, Monitoring the Future, Vol. II: Tables 2-2, and 2-3.
18. Johnston; O’Malley; Bachman; Schulenberg; and Miech, Monitoring the Future, Vol. I: Tables 2-3 and 2-4.
19. Ibid., Tables 9-6 and 9-8. 20. Johnston; O’Malley; Bachman; Schulenberg; and Miech,
Monitoring the Future, Vol. II: Tables 2-3 and 2.4. 21. Ibid., Table 2-4. 22. Ibid. 23. Johnston; O’Malley; Bachman; Schulenberg; and Miech,
Monitoring the Future, Vol. I: Tables 4-6 and 4-8. 24. Ibid., Tables 5-3, 8-3, and 9-8. 25. Johnston, Lloyd. D. (1996, December 19). The rise in drug use
among American teens continues in 1996. News release from the University of Michigan, Ann Arbor, MI, pp. 6–7.
Endnotes
Suppose that you were a legislator considering new regulatory laws with respect to psychoactive drugs. What would be your argument in favor of making a distinction between “hard drugs,” such as heroin,
cocaine, and methamphetamine, and “soft drugs” such as marijuana and hallucinogens? On what basis would you make such a distinc- tion? What would be the counterarguments to this proposal?
Critical Thinking: What Would You Do?
24 ■ Part One The Challenge of Drugs in Our Society
about molly. Retrieved from http://www.cnn.com/2013/11/22/ health/9-things-molly-drug/index.html?iref=storysearch (accessed March 2014). DEA Office of Public Affairs (2011, March 1). Chemicals used in “spice” and “K2” type prod- ucts now under federal control and regulation. Washington, DC: Drug Enforcement Administration, U.S. Department of Justice. Substance Abuse and Mental Health Services Administration (2013, September 17). “Bath salts” were involved in over 20,000 drug-related emergency department visits in 2011. The DAWN Report. Rockville, MD: Substance Abuse and Mental Health Services Administration, p. 1. Yee, Vivian; and Rashbaum, William K. (2013, September 13). Weekend revelry abruptly ends after 2 die at electronic music festival. New York Times, pp. A11, A15.
26. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; and Schulenberg, John E. (2011, December 14). Marijuana use continues to rise among U.S. teens, while alcohol use hits historic lows. Ann Arbor, MI: University of Michigan News Ser- vice. Johnston; O’Malley; Bachman; Schulenberg; and Miech, Monitoring the Future, Vol. I: Table 8-6.
27. Center for Behavioral Health Statistics and Quality (2014). Results from the 2013 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration, Tables 1.22A, 1.22B, 1.27A, 1.27B, 1.52A, and 1.52B.
28. Aleksander, Irina (2013, June 23). Pure, but not so simple. New York Times, Sunday Styles, pp. 1–2. Csomor, Marina (2013, August 16). There’s something (potentially dangerous)
Understanding the Drug Problem
in Global Perspective
2chapter
In a small village in the Kandahar province of Afghanistan, less than
50 kilometers from the border with Pakistan, a farmer named Ali
spoke to me through a trusted interpreter, looking aside from time to
time to check if anyone else was listening. “Spies are everywhere,”
he explained. With an exaggerated gesture that he wanted people
around him to see, Ali pointed to the fields of melons and saffron
behind him:
“See these fields? That’s what I want you to see” he said in
a loud voice. “But what you can’t see,” Ali’s voice now down to
a whisper,”is a little field in the back. That’s where the opium
poppies are. My father and his father grew opium poppies.”
“Are the Taliban pressuring you to do this?” I asked,
“People don’t understand,” Ali said impatiently. “This is our
economy, not a political act. Taliban aren’t pressuring me—that’s
just the story you see on TV. I grow for myself, for my family. I smug-
gle for myself, for my family. Taliban are not the reason. Being able
to feed my family is the reason.”
After you have completed this chapter, you should have an understanding of the following:
●● The nature of the global illicit drug trade
●● Prevalence rates of illicit drug use in the United States and around the world
●● Patterns of heroin trafficking
●● Patterns of cocaine and methamphetamine trafficking
●● Patterns of marijuana trafficking
●● Patterns of methamphetamine and hallucinogen trafficking
●● Present-day Mexican involvement in illicit drug trafficking
●● International and transnational narcoterrorism
26 ■ Part One The Challenge of Drugs in Our Society
to divert relatively small amounts of funds into the opera- tions of multiple legitimate businesses, which then funnel their profits back to them. This practice is known as money laundering (the name derived from the early practice of American gangsters who owned laundry establishments for the purpose of channeling their illegal profits through legal operations). The modern-day practice of money launder- ing in the context of drug trafficking will be examined in Chapter 6.
Ultimately, financial success for the suppliers of the world’s illicit drugs depends upon a demand for their prod- ucts. In this respect, they are no different from leaders of legitimate businesses. As long as demand stays high, suppliers will have the upper hand. So, where are the customers for this enormous business enterprise? How many people worldwide are currently illicit drug users? How does the United States compare to other nations in this respect? These are impor- tant questions as we examine the global illicit drug trade as it exists today.
Two international surveys provide information on the question of drug-taking behavior around the world. The first one is the World Drug Report, a study of prevalence rates of illicit drug use over the previous 12 months among individu- als aged 15–64 years in more than 150 nations. This report is compiled and published annually by the United Nations Office on Drugs and Crime (UNODC), an agency that coor- dinates data on illicit drug-related issues. The second one is the European School Survey Project on Alcohol and Other Drugs (ESPAD), a study of prevalence rates for illicit drug, alcohol, and tobacco use among adolescents 15–16 years old in 36 European nations. Since nearly all European nations prohibit the sale of alcohol and tobacco to minors in a similar way to that of the United States (see Chapters 15 and 16), prevalence rates in the ESPAD survey can be considered to reflect the prevalence of underage drinking and underage smoking, in addition to illicit drug use. Together, the two sur- veys allow us a glimpse into the global picture of drug-taking behavior.
“Listen to me, we’ll keep growing poppies here
forever. My children will grow poppies. Their children
will grow poppies. And who will stop us, the authori-
ties, the police? It’s the police who deliver our
opium!”
Illicit drugs are a global problem and a global business. They represent a global problem because illicit drugs are impacting millions of individuals in other nations of the world just as they are impacting Americans. In fact, in some countries, the problems are more far-reaching. The focus of this chapter will be on the international business of illicit drugs, referred to as the global illicit drug trade. As we will see, this enterprise encompasses the cultivation, manu- facture, distribution, and sale of illicit drugs in practically all regions of the world today. An enormous and ever-changing drug-trafficking system enables the global illicit drug trade to function. Fundamentally, it is a business sustained on brutal- ity, opportunism, greed, and, in some countries, a continuing pattern of political corruption.1
Estimates of the total worth of the global illicit drug trade range from $28 billion to $280 billion or upward of $400 billion.2 Understandably, it is difficult to come up with an exact figure or anything close to it, but it is safe to say that the global illicit drug trade has always been and will continue to be a financial success. Given its success, however, there needs to be an outlet for spending all that money. International monetary authorities are continually monitoring financial transactions, particularly in amounts that the illicit drug trade handles every day. A principal tac- tic has traditionally been for drug-trafficking organizations
60,000 The number of killings and disappearances of Mexico citizens over a six-year period as result of drug-related violence. Some estimates have been higher, up to 70,000 killings.
98 Percentage of drug-related murders and disappearances in Mexico that are never followed up or possible perpetrators hunted down. In some regions of Mexico, the percentage is 100 percent.
300,000 The estimated death toll in Colombia during the La Violencia period (1948–1958)
Sources: AnimalPolitico (2013, July 17). Retrieved from http://www.animalpolitico.com/2013/07/98-de-los-homicidios-de-2012- en-la-impunidad/#axzz2ZJH5vQG5. (accessed in translation, September 1, 2013). Miroff, Nick (2012, December 2). A new General in Mexico’s drug war. Newsday, pp. A32–A33. Richani, Nazih (2002). Systems of violence: The political economy of war and peace in Colombia. Albany, NY: State University of New York Press, pp. 23–28. Second statistic, information courtesy of InsightCrime.org.
Numbers Talk…
global illicit drug trade: An international business encom- passing the cultivation, manufacture, distribution, and sale of illicit drugs in practically all regions of the world.
Chapter 2 Understanding the Drug Problem in Global Perspective ■ 27
the higher prevalence rates in the United States, relative to other nations, are due, in part, to cultural and demographic factors.5
European Prevalence Rates for Illicit Drugs, Alcohol, and Tobacco
While the World Drug Report provides information about worldwide illicit drug use in a population ranging from 15 to 64 years old, the focus of the ESPAD survey is on adoles- cents. The ESPAD statistics regarding lifetime prevalence rates for a wide range of drugs are based on a sample of more than 100,000 European students aged 15–16 years old, closely matched in methodology to the tenth-grade sample of American students as reported in the University of Michigan survey (Chapter 1). The average lifetime prevalence rates for illicit drugs, marijuana or hashish, illicit drugs other than marijuana or hashish, inhalants, Ecstasy, alcoholic beverages, and tobacco (cigarettes) are shown in Table 2.2, alongside comparable data for American tenth graders in the University of Michigan survey.6
The bottom line is that American adolescents are less likely than their European counterparts to use ciga- rettes and alcohol, but more likely to use illicit drugs. The United States ranks second-lowest in the proportion of stu- dents using tobacco or alcohol, compared to students in 36 European countries. With respect to other forms of drug use, however, the United States ranks near the top of the list. Among European nations, the highest level of illicit drugs is found in the Czech Republic (43%) and France
Worldwide Prevalence Rates of Illicit Drug Use
According to the 2013 World Drug Report, between 167 and 315 million people, 15–64 years old, are estimated to have used an illicit drug in the past year. These numbers represent between 4 and 7 percent of the adult population in the world, roughly one in every 20 individuals. The prevalence rates for specific illicit drugs in specific nations, however, vary con- siderably. One nation might have a high prevalence rate for Drug X and a low prevalence rate for Drug Y, while another nation might show a low prevalence rate for Drug X and a high prevalence rate for Drug Y.
Fortunately, the World Drug Report breaks down the prevalence rates for individual illicit drugs among individual nations. For example, among an estimated 16 million heroin users worldwide (representing about 0.4 percent of this popu- lation), the prevalence rates range from less than 0.1 percent in Finland, Switzerland, and New Zealand to more than 1.0 percent in the Russian Federation (1.6%), Afghanistan (2.1%), and Iran (2.3%). As a comparison, the annual preva- lence rate of 0.6 percent in the United States is somewhat above the average. The annual prevalence rate for cocaine use worldwide is approximately the same as that of heroin (0.4%), but the distribution among nations is quite differ- ent. The annual prevalence for cocaine rises to considerably higher-than-average levels in Australia (2.1%), Italy (2.1%), the United States (2.2%), the United Kingdom (2.2%), and Chile (2.4%).
In sharp contrast, more than 180 million people are cannabis (marijuana or hashish) users, representing about 3.9 percent of the world’s population. In other words, can- nabis users outnumber heroin and cocaine users combined by more than five to one, but, once again, the differences among nations are substantial. Annual prevalence rates range from less than 2 percent in Mexico, Dominican Republic, and several Caribbean nations to 8 percent or higher in France (8.4%), Czech Republic (9.7%), Jamaica (9.9%), Canada (10.9%), the United States (14.0%), and New Zealand (14.6%).3
Overall, how does the United States compare to other nations in terms of illicit drug use, according to the World Drug Report? Table 2.1 provides a summary of annual preva- lence rates in the United States for five major illicit drugs rel- ative to the worldwide average, in the 15–64-year age range. In general, the U.S. rates are higher than the worldwide aver- age in all five categories, four to five times higher in the use of cocaine and cannabis, and about three times higher in the use of Ecstasy.4
These statistical comparisons provide useful informa- tion, but interpretations should be made with caution. The affordability of illicit drugs in a relatively affluent society such as the United States are quite different from that in many impoverished nations elsewhere in the world, many of them with considerably greater populations. It is possible that
TAble 2.1
Annual prevalence rates for five major illicit drugs among users (15–64 years old) in the United States and worldwide
DRUG
UNITeD STATeS (%)
AVeRAGe WORlDWIDe (%)
Heroin 0.6 0.4
Cocaine 2.2 0.4
Amphetamine- type Stimulants (primarily metham- phetamine)
1.8 0.7
Ecstasy 1.2 0.4
Cannabis 14.0 3.9
Source: Based on data from United Nations Office on Drugs and Crime (2013). World drug report 2013. Vienna: United Nations Office on Drugs and Crime, pp. ix–xiv, 1–16, Table: Prevalence of drug use among the general population, Excel files.
28 ■ Part One The Challenge of Drugs in Our Society
cannabinoid JWH-018 (known as Spice or K2) appeared on the scene in 2010 as a new recreational drug, several countries placed it on their own prohibited-drug lists. It was not long, however, before another compound with similar psychoac- tive properties, referred to as JWH-073, took its place. At that point, JWH-073 was added to the prohibited-drugs list, only to be followed by further variations. Making matters worse,
(39%), with comparable levels to that of the United States. In general, with respect to the use of illicit drugs includ- ing cannabis, American adolescents most closely resemble Czech and French adolescents, and are most dissimilar to Norwegians!
The Global Problem of New Psychoactive Drugs
A major concern among drug-control authorities is the emer- gence of hundreds of newly synthesized psychoactive drugs. With present-day technologies, it has been relatively easy for foreign laboratories, principally in Asia, to create new drug formulations by making minor alterations in the molecular structure of known psychoactive compounds. The prolif- eration of these new formulations (referred to as “designer drugs”) have greatly complicated drug-control efforts. It is as if a well-understood set of viruses that have been tracked over the years were now mutating into new forms. In 2013, UN members reported that, by mid-2012, more than 250 new psy- choactive drugs, developed primarily in Asia, had emerged on the drug scene, an increase of more than 50 percent over the previous year.7
One category of new drugs, based on variations in the molecular structure of compounds in marijuana plants called cannabinoids (see Chapter 12), illustrates the chal- lenges faced by drug-control officials. Soon after the synthetic
Quick Concept Check
Understanding Prevalence Rates of Drug Use in America and Elsewhere Check your understanding of the annual prevalence rate in the U.S. adult population relative to the average worldwide by circling “Higher” or “Lower,” as appropriate.
1. Heroin Higher Lower 2. Cocaine Higher Lower 3. Amphetamine-type Simulants
(primarily methamphetamine) Higher Lower
4. Ecstasy Higher Lower 5. Cannabis Higher Lower
Answers: 1. Higher 2. Higher 3. Higher 4. Higher 5. Higher
2.1
TAble 2.2
Lifetime prevalence rates for illicit drugs, alcohol, and tobacco among users 15–16 years old in the United States, Europe, and selected European countries
DRUG/DRUG ACTIVITY
UNITeD STATeS (%)
eUROPe (%)
CZeCH RePUblIC (%)
FRANCe (%)
UNITeD KINGDOM (%)
NORWAY (%)
Illicit drugs 38 23 43 39 27 5
Illicit drugs other than marijuana or hashish
16 6 8 10 9 2
Marijuana or hashish 35 22 42 39 25 5
Ecstasy 7 4 3 3 4 1
Any alcoholic beverage 56 87 98 91 90 70
Been drunk from alcoholic beverages
37 47 65 50 55 36
Tobacco (cigarettes) 30 56 75 63 47 37
First cigarette, age 13 years or younger
18 31 52 30 25 20
Note: More recent statistics for users 15–16 years old in the United States are available (see Figure 1.7), but 2011 prevalence rates are entered here for comparable analyses to European counterparts.
Sources: Based on data from Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.;; and Schulenberg, John E. (2012). Monitoring the Future national results on drug use: 2011 Overview. Key findings on adolescent drug use. Ann Arbor, MI: Institute for Social Research, The University of Michigan, Table 2.1. The European Monitoring Centre for Drugs and Drug Addiction (2012). The 2011 ESPAD report: Substance use among students in 36 European countries. Stockholm: The European Monitoring Centre for Drugs and Drug Addiction, Tables 2a, 4, 8a, 20a, 28a, 29a, 33a, and 34a.
Chapter 2 Understanding the Drug Problem in Global Perspective ■ 29
the information we have at our disposal in order to gain an understanding of the global forces at work. The focus here will be on the best known international trafficking routes, past and present, of five major illicit drugs: heroin, cocaine, mari- juana, methamphetamine, and selected hallucinogens (LSD, PCP, and ketamine). In the past, a particular drug has had its unique trafficking pattern. In recent years, however, there has been a growing trend toward “multitasking” in the global illicit drug trade, with distribution systems designed to deliver multiple categories of illicit drugs through the same pipe- line. As we will see, this is particularly the case with regard to present-day drug trafficking in Mexico.
The Trafficking of Heroin
The origin of heroin is opium, produced from the cultivation of the opium poppy, a plant that is native to the Mediterranean region of the world but grows well in any warm and moist climate. Heroin is produced from morphine, the active ingre- dient in raw opium (see Chapter 9). As a result, heroin traf- ficking requires a multistage operation, beginning with the cultivation of opium itself, then the refinement of opium to morphine and eventually morphine to heroin.
Heroin, Turkey, and the “French Connection” From the 1930s to the 1960s, heroin trafficking into the United States centered on a close association of American and Corsican Mafia organizations with clandestine heroin- producing laboratories in Marseille, France. Although most of the raw opium itself was produced and transported from Southeast Asia, Turkish farmers grew opium poppies as well. The main markets for these local farmers were the pharma- ceutical companies that manufactured morphine and other opium-based medications for legitimate purposes, but part of their crop would be left to the side and later diverted to mor- phine laboratories operated by criminal groups in the area. Morphine would then be shipped to Corsican-controlled heroin laboratories in Marseilles. From Marseilles, the heroin would be transported to New York, where American Mafia groups controlled its distribution in major U.S. cities.9 The pattern of heroin trafficking during this period of time became known as the “French Connection.”
By the late 1960s and 1970s, a series of successful “French Connection” prosecution cases, conducted by a coordinated team of international law enforcement agencies, had led to the demise of this heroin trafficking system. The supply of opium to Marseilles was cut off when production in Turkey was curtailed, beginning with the 1968 opium crop. Major traffickers were either captured and imprisoned by French and American authorities or killed by fellow criminals within their own organizations.10 Heroin trafficking shifted from France and Turkey to more direct sources in Southeast Asia and Southwest Asia.
regulatory agencies in some countries have been slow in their response to the emergence of new psychoactive drugs, allow- ing a foothold to be established among drug users.8
The Global Problem of Drug Trafficking
It is clear that prevalence rates for illicit drugs around the world constitute a substantial “demand” for the global illicit drug trade to match the “supply.” Obviously, the “suppliers” are highly motivated to get their product to the customer, and they do so with great success, despite the concerted efforts of international drug-control authorities to thwart their operations. How does the global illicit drug trade do it? What are the drug-trafficking patterns with respect to illicit drugs? What is the “collateral damage” in terms of social and personal chaos brought on by the global illicit drug trade?
It would be an ideal situation if international drug- control authorities were able to identify, at any precise moment, all of the illicit drug-trafficking routes in the world and all of the means by which drugs are distributed. But unfortunately, two principal factors are working against them in this respect.
The first factor is the extraordinary agility on the part of the global illicit drug trade in adapting to changing law enforcement circumstances. Typically, drug-trafficking opera- tions are highly mobile; operations can often be moved within hours, making it relatively easy to shift illicit drug activity to another location. One country might be dominant with respect to drug trafficking one year, while a neighboring country might be dominant the next year. The reality is that drug-trafficking patterns are in a constant state of flux, with drug-control agencies playing “catch up” time after time. In effect, updated maps of drug-trafficking routes cannot ever be completely accurate because the “ink never dries” fast enough before routes change again.
The second factor is the limited ways that are available for keeping track of drug-trafficking activities. The principal method is to examine on an ongoing basis confiscated ship- ments of illicit drugs in drug-seizure operations and raids on illicit drug laboratories and distribution sites. While capable of yielding information about drug trafficking, this approach is far from perfect. First of all, the confiscated drugs are by no means a random sample of the drugs involved in a particular trafficking system. Drug seizures and laboratory raids may correlate with the extent of drug trafficking in a particular region, but the quantity of confiscated drugs may be related to the intensity of drug-control campaigns in that region or else the ease by which drugs are intercepted by drug-control authorities. In other words, we cannot know the extent to which the magnitude of a drug seizure is related to law enforcement agents being clever or drug traffickers being stupid!
While we recognize that illicit drug-trafficking patterns can and do change, it is nonetheless useful to draw upon
30 ■ Part One The Challenge of Drugs in Our Society
role of the Golden Triangle region as a source of heroin in the United States has greatly diminished as heroin traffick- ing to American users has shifted to sources in the Western Hemisphere. Today, direct Southeast Asian heroin markets are primarily in Asia and Australia.11
Currently, the single largest source of heroin for world- wide consumption is the so-called Golden Crescent of Southwest Asia, an area comprising the countries of Pakistan, Afghanistan, Turkey, Iran, and regions of the former Soviet Union. Within the Golden Crescent, the dominant player is clearly Afghanistan and, in particular, the southern Afghan provinces of Hilmand and Kandahar. In years when crop yields are high, Afghanistan alone has the capacity to supply approximately 94 percent of the world’s heroin; in years of rela- tively low crop yields, the percentage dips to about 75 percent, with other regions in Myanmar and Laos (part of the Golden Triangle) making up the extra quantities needed for the global marketplace. From 2011 to 2013, however, opium production in Afghanistan has been at record high levels. Worldwide high selling prices for opium has spurred Afghan farmers to increase opium poppy cultivation. Interestingly, the reason given for increased opium poppy growing is essentially economic; less than 1 percent of the Afghan farmers claim that their decisions are dictated by the encouragement of the Taliban or other antigovernment groups.12
Yet, as we will see, relatively little of the heroin from Afghanistan or other countries in the Golden Crescent
The Golden Triangle and the Golden Crescent In the 1960s and 1970s, the dominant source of heroin for the U.S. market was the so-called Golden Triangle of Southeast Asia, an area comprising the countries of Thailand, Burma (Myanmar), Laos, and Vietnam (Figure 2.1). Heroin from the Golden Triangle was usually sold as a white or off-white powder, and, considering its place of ori- gin, was called China White on the street. Southeast Asian heroin was smuggled into the United States primarily via containerized maritime cargo from such locations as Taiwan and Hong Kong and often was concealed among legitimate commodities. The cargo shipments traveled to major ports of entry along the West Coast of the United States and west- ern Canada, where they were transported eastward to cities such as Chicago and Detroit. Since the 1980s, however, the
F IGURe 2 .1
The nations of the Golden Triangle (lower left) and Golden Crescent (lower right).
Source: National Drug Intelligence Center (2004). National drug treat assessment 2005. Washington, DC: U.S. Department of Justice.
Golden Crescent: A major opium-producing region of Southwest Asia, comprising Pakistan, Afghanistan, Turkey, Iran, and former regions of the Soviet Union.
China White: A street name for heroin from the Golden Triangle nations of Southeast Asia.
Golden Triangle: A once-dominant opium-producing region of Southeast Asia, now eclipsed by opium-producing nations of the Golden Crescent.
Chapter 2 Understanding the Drug Problem in Global Perspective ■ 31
area is destined for the United States market. Nonetheless, owing to its importance with respect to heroin traffick- ing for the rest of the world, it is important to examine the ways in which heroin trafficking from this region is accomplished.
In recent years, three major trafficking systems for Golden Crescent heroin have been identified by international drug- control agencies: (1) a northern route, (2) a Balkan route, and (3) a southern route through East, West, and Central Africa. The northern route extends through Tajikistan, Kyrgyzstan, Uzbekistan, and Turkmenistan to Kazakhstan (formerly part of the Soviet Union) and the Russian Federation itself. The Balkan route is the principal trafficking corridor for Afghan heroin to sizable markets in the Russian Federation and Western Europe, extending through Iran (via Pakistan), Turkey, Greece, and Bulgaria. Judging from data gained through heroin seizures, a relatively minor but growing south- ern trafficking route extends from the East African nations of Benin and Tasmania to Nigeria with destinations in Western Europe. In the case of the southern route, Golden Triangle nations have traditionally supplied the bulk of the raw opium for processing, but in recent years the demands from Western Europe have increased to such an extent that “the African connection” now brings significant quantities of heroin from Afghanistan as well (Figure 2.2).13
An Afghan district police chief shows confiscated hashish (in his right hand) and heroin folded into pieces of paper (in his left hand) after a routine drug bust in the southern province of Kandahar, Afghanistan.
450
2,700
10 5 150
95
82
88
95
77
Oceania
Africa
USA, Canada
Gulf area, Middle East
South-East Europe Caucasus
West, Central, East Europe
South-East Asia
Central Asia
Russian Federation
China
India Myanmar
Pakistan
Islamic Republic of Iran
Afghanistan Turkey
Flows of heroin (in metric tons) (not actual trafficking routes)
Opium production (in metric tons)
6-10
11
1-5
38 5,300
500
MyanmarAfghanistan
Opium
Transformed into heroin
F IGURe 2 .2
Patterns of heroin trafficking from Southwest and Southeast Asian origins.
Source: United Nations Office on Drugs and Crime (2010). World Drug Report 2010. Vienna: United Nations Office of Drugs and Crime, Map 2, p. 45.
32 ■ Part One The Challenge of Drugs in Our Society
in Miami, Atlanta, or New York. Couriers (known as “drug mules”) often swallowed small pellets of heroin that had been placed in condoms or balloons, or wrapped in latex from surgical gloves. They also concealed heroin in body cavities, taped it to their bodies, or concealed it in their clothing or shoes. Larger quantities of heroin into the United States were smuggled by transporting the drug in suitcases contain- ing heroin sewn into the seams of clothing. Alternatively, Colombian heroin traffickers recruited Mexican couriers to transport South American heroin into the United States through rural areas of Mexico then across the Mexico-U.S. border via private or commercial vehicles crossing at border checkpoints. As already noted, Mexico has since developed its own heroin production and trafficking system.16
The Trafficking of Cocaine
Cocaine is derived from the leaves of the coca shrub, grown in the high-altitude rain forests and fields that run along the slopes of the Andes in South America (see Chapter 10). Due to the volatility of the global illicit drug market, the country with the “distinction” of being the number-one coca producer in the world varies from year to year. At one time, virtually all the world’s coca was cultivated in Bolivia and Peru, but frequent crop eradication campaigns resulted in a decline in coca production in these countries. In recent years, Colombia has been dominant in coca cultivation, but international pres- sures have resulted in a reduction in Colombian coca produc- tion by about 25 percent. At the present time, Peru appears to have passed Colombia as the world’s largest coca cultivating nation. Not surprisingly, the price of cocaine in Peru is rela- tively cheap, compared to prices in other nations of the world (see Drug Enforcement…in Focus in Chapter 10).17
Cocaine trafficking, however, remains a predominantly Colombian enterprise (Figure 2.3). Coastlines on both the Pacific Ocean and the Caribbean have enabled Colombian traffickers to smuggle cocaine to the United States by a variety of air and sea routes. Shipments of cocaine typically move from Colombia to other South American countries such as Ecuador, Venezuela, and Brazil and on to Mexico, Puerto Rico, the Bahamas, and the Dominican Republic, where it is repackaged for shipment to south Florida, south Texas, and California. There are more than 100,000 islands along the coastlines of Central America alone, providing ideal logistical transit points for cocaine trafficking.
Smuggling techniques used for transferring cocaine to U.S. markets include small commercial fishing vessels that “hug” or keep close to the coasts of eastern Caribbean islands, allowing them to blend in with other vessel traffic and mini- mizing the opportunity for detection. Waterproof bundles of cocaine are air-dropped to waiting boat crews, who then deliver the shipment to shore in speedboats. Multiton ship- ments of cocaine also are smuggled through the port of Miami by concealing them in the compartments of large commer- cial cargo vessels and specially constructed submarines.
Heroin Trafficking in Mexico and Colombia At the present time, despite their dominant role in the world- wide heroin trade, heroin trafficking systems originating from Golden Triangle or Golden Crescent regions of the world have little or no impact on heroin consumption in the United States. Instead, the dominant players in heroin trafficking to markets in the United States in the twenty-first century are the Western Hemisphere nations of Mexico and Colombia.
For many years, Mexican heroin was crudely processed with many impurities, resulting in a much disparaged powder version (called brown heroin) that was, at the time, consid- ered inferior to the more refined China White heroin coming out of Southeast Asia. The Mexican variety is typically black or brown in color and has a sticky consistency, hence its name Black Tar or “Tootsie Roll” on the street. Despite its darker color, Mexican heroin processing methods have “improved” so as to achieve high levels of purity.
Although Mexico cultivates only 2–7 percent of the world’s opium, Mexico’s opium production is significant because virtually all the Mexican opium that is converted into heroin is destined for the United States. Most of the opium in Mexico is grown by small, independent farmers known as campesinos in rural areas of Sinoloa, Chihuahua, Durango, and Guerrero. Typically, individual traffickers or trafficking organizations pay a prearranged price for the opium crop, the equipment used in harvesting, and food for the farmer’s fam- ily. A middleman or opium broker then collects the opium and transports it to a clandestine laboratory to be processed into heroin. Mexican heroin is smuggled into the United States primarily overland across the Mexico-U.S. border via private and commercial vehicles that have been equipped with hidden compartments. Smaller quantities of Mexican heroin often are carried across the border by illegal aliens or migrant workers who hide the drugs in backpacks, in the soles of their shoes, or on their bodies.14
By global standards, Colombia produces relatively little heroin (less than 5 percent of the world’s total estimated production). However, most of the heroin used in the United States is produced in Colombia. Until the 1980s and 1990s, Southeast and Southwest Asian heroin had dominated the U.S. market, but as the demand for cocaine in the United States declined in the 1990s, Colombians began to encour- age cultivation of opium poppies as an independent source of heroin in remote areas of the country near the Andes Mountains. Currently, high-quality heroin is manufactured from home-grown opium poppy fields within Colombia. In addition, supplies of raw opium are transported from opium poppy fields in neighboring Bolivia and Peru.15
At one time, heroin was transported from Colombia to the United States by couriers travelling on commercial flights from one of the Colombian airports to international airports
black tar: A potent form of heroin, generally brownish in color, originating in Mexico.
Chapter 2 Understanding the Drug Problem in Global Perspective ■ 33
and groups of self-contained cells were managed by a small number of cartel managers. Each cell specialized in a dif- ferent aspect of the drug business, such as production, distribution, smuggling, or money laundering. If police arrested members of one cell, a second or third cell would step up operations to fill the vacuum. Members of each of cells rarely were connected directly with any of the leaders of the cartel.
During his ascendency to power, Pablo Escobar and the other leaders of the Medellin Cartel set out to crush any oppo- sition from law enforcement or the Colombian government by a campaign of terror and brutality. They were considered responsible for the murder of hundreds of government offi- cials, police, prosecutors, judges, journalists, and innocent bystanders. Their flamboyant life-style, combined with their total disregard for human life, became their trademark, and eventually their downfall. By the early 1990s, the leaders of
Until the early 1970s, Cuban-organized crime groups controlled the importation of cocaine from Colombia into the United States, but, by the mid-1970s, control of the cocaine industry had shifted from Cubans to Colombians themselves.18 For the next two decades, its production and distribution would be under the control of well- organized Colombian-led criminal organizations (referred to as cartels). The most powerful organizations of this type were the Medellin and Cali drug cartels (named after cities in Colombia that were their home bases).
Before the advent of drug cartels, cocaine smuggling had been on a small scale and quite primitive by today’s standards. As the demand for cocaine in the United States exceeded supplies, more sophisticated trafficking methods were devel- oped. The Medellin Cartel, led by Pablo Escobar, employed fleets of small airplanes loaded with cocaine into the remote airfields (see Portrait)19
The huge profits gained from Medellin operations were invested in increasingly sophisticated cocaine labs, better airplanes, and even a private island in the Bahamas where their planes could refuel. In the meantime, the Medellin Cartel became known as the prototype for the modern-day drug cartel with an organization that can be characterized as an onion-like layering of power and responsibility. Kingpins at the center directed operations,
ANDEAN REGION
USA
Canada
Europe
Brazil
Mexico
B.R. of Venezuela
Caribbean
Pacific
165
124
17
14 U
N O
D C
/ S
C IE
N C
ES P
O
West Africa
Southern Africa
Cocaine trafficking* (in metric tons)
140
60
15
Cocaine consumption (in metric tons)
Main cocaine producers
6
F IGURe 2 .3
Patterns of cocaine trafficking from Andean Region origins.
Source: United Nations Office on Drugs and Crime (2010). World Drug Report 2010. Vienna: United Nations Office of Drugs and Crime, Map 6, p.70.
cartel: An organization centered on the manufacture, distribution, and/or sale of illicit drugs.
Medellin and Cali drug cartels: Two major Colom- bian drug cartels that controlled much of the illicit drug distribution in South America from the mid-1970s to the mid-1990s.
34 ■ Part One The Challenge of Drugs in Our Society
the drugs in all types of legitimate cargo, from cement blocks to bars of chocolate. The Cali Cartel outlasted the Medellin Cartel until 1995, when Cali Cartel leaders themselves were tracked down and arrested.
the cartel either had been gunned down by police or had turned themselves over to the government in exchange for lenient prison sentences.
While law enforcement authorities were focused on the high-profile Medellin Cartel, the less flashy Cali Cartel managed to operate without the same degree of interference. Members of the Cali Cartel were more subtle in their opera- tions than their Medellin counterparts, relying on political cor- ruption over violence, conducting their business in a discreet and business-like manner, and reinvesting much of their prof- its from the illicit drug trade into legitimate businesses. The Cali Cartel relied heavily on political bribes for protection. At one point, the former president of Colombia, Ernesto Samper, and hundreds of Colombian congressmen and senators were accused of accepting campaign financing from the cartel.
During the 1980s, while the Medellin Cartel controlled the cocaine market in south Florida, the Cali Cartel con- trolled the distribution of cocaine in New York, later expand- ing its market to Europe and Asia and forming alliances with other organized-crime groups such as the Japanese Yakuza. Cali smuggling techniques also differed greatly from those of the Medellin Cartel. Members of the Medellin Cartel relied on small airplanes and speedboats, whereas the Cali Cartel smuggled most of its shipments in large cargo ships, hiding
A Colombian solder stands next to a 33-foot-long semi-submersible vessel captured off the coast of Colombia in 2007. Because they leave very small wakes, the crude subs are difficult to detect visually from the air or by radar.
PORTRAIT Pablo Escobar: The Violent Life of the King of Cocaine
The criminal career of Pablo Escobar began in earnest at the age of 26 with his first drug bust. We can be certain that he had been in trouble before, but this was his first drug bust, an arrest for possession of 39 pounds of cocaine. What made this arrest unusual was that the arresting officer was later mysteriously murdered and as many as nine judges were so intimidated by death threats that they refused to hear the case. In the succeeding years, Escobar joined two other criminal entrepreneurs to form the Medellin Cartel, named after their home town. The cartel they created was to set the standard for its organization- al discipline as well as the vicious b rutality by which the cartel operated.
In a fleeting attempt to legitimize him- self, Escobar at one point ran for political office. It may not be surprising that he won the election and became a member of the Colombian Congress. In effect, his intention was to gain immunity by being part of the government. His politi- cal career did not last very long, however, and soon Escobar returned to a more lucrative renegade status in Colombia.
In 1984, the Medellin Cartel con- trolled 80 percent of the Colombian
drug trade in cocaine. Escobar’s annual income exceeded $2.75 billion, placing him on the Forbes Magazine listing of the wealthiest people in the world.
Violence and assassination were the tools of his trade. Police officers, judges, public officials, and journalists were his targets. Public bombings and drive-by shootings were commonplace. Three presidential candidates, the Colombian attorney general, more than 200 judges, 100 police officers, and dozens of jour- nalists were murdered, their deaths attributed to Escobar and his cartel. A Colombian jetliner was bombed, resulting in 107 deaths. In 1990, Escobar offered a “bounty” of $4,000 (a huge amount by Colombian standards) for each police officer killed. In the follow- ing month, 42 police officers had been murdered.
In 1991, the Colombian government offered immunity from prosecution and the use of extravagant facilities of a moun- tainside ranch if Escobar would turn himself in. He accepted this arrangement,
though his criminal activities were merely directed from the ranch itself and the vio- lence continued. When the government decided to move him from the ranch, Escobar was tipped off and escaped. What followed was the most famous manhunt in history, lasting for over a year. The Central Intelligence Agency (CIA) and the Drug Enforcement Administration (DEA) joined Colombian police in the chase. In 1993, a brief telephone call to his family was intercepted by authorities and telephone lines were cut off, isolat- ing Escobar (before the advent of cell phones) from communicating with the outside. A relatively small 17-men swat team surrounded his last stand. As he tried to escape from the rooftop, he was killed by a barrage of bullets. So ended the ignominious career of Pablo Escobar— the Colombian King of Cocaine.
Sources: Brooke, James (1990, June 7). In the capital of cocaine, savagery is the habit. New York Times, p. 4. Watson, Rus- sel; and Katel, Peter (1993, December 13). Death on the spot: The end of a drug king. Newsweek, pp. 18–23.
Chapter 2 Understanding the Drug Problem in Global Perspective ■ 35
drug in false vehicle compartments located in doors, fuel tanks, seats, or tires. Marijuana often is hidden in tractor-trailer trucks among shipments of legitimate agriculture products, such as fruits and vegetables. Smaller quantities of marijuana can be smuggled across the border by horse, raft, and backpack. Once the marijuana is smuggled successfully across the border,
The arrest of the top leaders of the Medellin and Cali drug cartels in the 1990s led to a decentralization of the cocaine trade in which the control of production and traf- ficking was taken over by smaller independent Bolivian, Peruvian, and Mexican organizations (called “cartelitos”). The “new cocaine traffickers” operated in smaller, more controllable groups, having realized that large organizations were too vulnerable to prosecution. Newer, more sophisti- cated means of smuggling cocaine, such as semi-submersible vessels (mini submarines), have been designed for maximal evasion of drug-control authorities.
The Trafficking of Marijuana: Foreign and Domestic
Mexico is currently the major foreign source for marijuana smuggled into the United States. Most of the marijuana traf- ficking, whether grown in Mexico or transported through Mexico from other locations such as Colombia, takes place at the U.S.-Mexico border.
As a result of increased detection and monitoring of air traf- fic at the border, most of the marijuana that enters the United States from Mexico is smuggled by land. Drug-trafficking organizations operating from Mexico employ a wide variety of methods for smuggling marijuana, such as concealing the
Massive Cross-border Drug Tunnel Detected (Again) From 2008 to 2013, more than 75 cross-border drug-traffick- ing tunnels were detected and shut down (most of them in California and Arizona), reflecting a trend in getting illicit drugs into the United States from Mexico. An image comes to mind of tunnels barely wide enough for one man to crawl through (see the above photo ), and many of the tunnels have been indeed small. But some of them have been substantially bigger. In 2013, a massive and sophisticated tunnel was uncovered by the San Diego Tunnel Task Force, comprised of agents with ICE, DEA, and Customs and Border Protection. Stretching the length of five football fields (about one-third of a mile) at a depth of about 35 feet, it was equipped with lighting, ventilation, and an electric rail system.
The tunnel connected a warehouse in Tijuana, Mexico, with a warehouse in the Otay Mesa industrial park south of downtown San Diego, just north of the Mexico border. It was estimated that it had taken years and tens of millions of dollars to build the tunnel, and it was just completed and ready for operation when federal agents descended (literally) and closed
it down. More than eight tons of marijuana and several hundred pounds of cocaine were seized.
As it often happens in interdiction cases, careful surveillance and a few lucky breaks made the difference. Earlier in the week, a box truck was pulled over by police in a nearby town for traffic violations and three tons of marijuana was found concealed inside. Another five tons of marijuana was found in another box truck attempting to leave the Otay Mesa warehouse that turned out to be the “U.S. entrance” to the tunnel. The cocaine was found in a van that authorities had earlier observed leaving the same warehouse site.
Despite the success of the operation, drug-control authori- ties expect that more tunnels will be built. Whether or not all of them will be detected is another matter. The tunnel uncovered in 2013 was the eighth large-scale drug tunnel discovered in the San Diego area since 2006.
Sources: Feds shut down massive new cross-border drug tunnel south of San Diego. News Release, Drug Enforcement Administration, U.S. Department of Justice, Washington, DC, October 31, 2013. Massive new cross-border drug tunnel shut down south of San Diego. News Release, Immigration and Customs Enforcement, U.S. Department of Homeland Security, Washington, DC, October 31, 2013.
Drug Enforcement … in Focus
A Mexican federal agent crawls through a hidden U.S-Mexico border tunnel, previously used to transport drugs from Mexico to the United States. See Drug Enforcement . . . in Focus for an update on DEA operations on the U.S.-Mexico border.
36 ■ Part One The Challenge of Drugs in Our Society
over the last decade or so as a result of two important political developments. The first is the approval by voters (as of 2014) in 23 U.S. states and the District of Columbia for the legaliza- tion of marijuana smoking for medical purposes. The second is the approval by voters (as of 2014) in Alaska, Colorado, Oregon, and Washington for the legalization of marijuana smoking by adults for medical or nonmedical purposes. In these four states, marijuana has essentially become a licit, rather than illicit, drug, while remaining an illicit drug on the basis of federal statutes and statutes in other regions of the country. The problem of reconciling contradictory positions in the statutes of U.S. states and the U.S. federal government on the legality of marijuana will be examined in Chapter 12.
The Trafficking of Methamphetamine: Foreign and Domestic
During the early 1990s, methamphetamine reemerged as a pop- ular recreational drug in the United States after an earlier period of popularity in the 1960s and 1970s. Methamphetamine’s chemical structure is similar to that of amphetamine, but it has a more pronounced effect on the central nervous system (see Chapter 10). It is a white, odorless, bitter-tasting crystalline powder and is commonly referred to as “speed,” “meth,” and “crank.” The primary precursor chemicals for the manufacture of methamphetamine, ephedrine and pseudoephedrine, are obtained by purchasing inexpensive over-the-counter cough- and-cold medications. Throughout the 1970s and 1980s, the production and trafficking of methamphetamine were con- trolled by motorcycle gangs such as Hell’s Angels and other groups. It has estimated that between 1979 and 1981, money obtained from selling methamphetamine accounted for 91 percent of the Hell’s Angels finances. Today, methamphet- amine is still often referred to as “crank” because motorcyclists would hide the drug in the crankshafts of their motorcycles.
In the mid-1990s, drug-trafficking organizations based in Mexico and California began to take control of the produc- tion and distribution of methamphetamine, setting up large- scale “superlabs” that were capable of producing as much as 10 pounds of methamphetamine in a 24-hour period. The entry of these organizations into the methamphetamine trade resulted in a significant increase in the supply of high-purity, low-cost methamphetamine.
At the same time, supplies of methamphetamine appeared as produced by smaller independent “mom and pop” laboratories, obtaining the ingredients necessary for manufacture from retail and convenience stores. The rural regions of southern and midwestern U.S. states were par- ticularly suited for small-time methamphetamine (meth) cookers with operations in trailers or mobile homes located in secluded heavily forested areas. Cooks would typically dis- pose of highly toxic wastes from the production process by dumping the material into a nearby lake, pond, or stream.
traffickers consolidate the shipments at “safe houses” in south- ern U.S. cities. From these distribution sites, marijuana is trans- ported to American communities, large and small.20
Foreign trafficking routes into the United States origi- nate from the north as well as the south, with Canadian growers in British Columbia representing major suppliers for marijuana users in the United States, particularly for markets in the Northwest and on the West Coast. Having developed a sophisticated cultivation technique, called hydroponic cultivation, in which marijuana plants are grown in nutrient- rich water rather than soil, Canadians have been able to pro- duce potent varieties of marijuana, commonly referred to as BC Bud. Increased potency can be achieved in hydroponic cultivation because nutrients are more readily supplied to the plant than when marijuana is grown in soil. There is just enough growth in the roots of the marijuana plant to keep its stem immobile. Plants therefore can grow faster and grow larger leaves, flowers, and buds. BC Bud has been found to have a THC content ranging from 15 to 25 percent, more potent than commonly available hashish (see Chapter 12).
The marijuana market also draws upon supplies of “home-grown” marijuana cultivated within the United States. Domestic cultivation of marijuana exists throughout the United States and ranges from a few plants grown for personal use to thousands of plants cultivated by organized criminal groups. Large-scale domestic growers most frequently plant marijuana in remote areas, often camouflaging it in surround- ing vegetation. Mountainous terrain offers the opportunity to grow marijuana in hollows and other secluded areas in relative isolation from public view. Major outdoor cannabis cultivation takes place in such states as California, Hawaii, Washington, Oregon, and the Appalachian region of Kentucky and Tennessee. Approximately 80 percent of all outdoor-cultivated plants eradicated by law enforcement in 2007 originated in California, Oregon, and Washington.21
In response to an increase in domestically grown mari- juana, law enforcement agencies have come to rely on the use of military helicopters to carry out clandestine monitoring of marijuana plots from the air. Growers have countered by cover- ing the plots with camouflage netting or by tying the stems and branches of marijuana plants to small stakes on the ground. Out of fear of civil forfeiture, growers also have begun culti- vating plants on governmental lands, such as national forests and national parks. Like these Canadian counterparts, many domestic marijuana traffickers have taken to hydroponic culti- vation indoors. Law enforcement has responded by equipping helicopters with heat-detecting devices to identify unusual sources of light or by checking for unusually high power bills of suspected growers (see Chapter 7). Growers have, in turn, countered by setting up hydroponic plots in chicken houses, which often rely on intense light and heat sources.
The question of drug trafficking of marijuana, particu- larly with regard to domestic trafficking, has been complicated
bC bud: British Columbia–grown marijuana, produced under hydroponic (water-based) cultivation methods.
Chapter 2 Understanding the Drug Problem in Global Perspective ■ 37
distributing LSD. Throughout the 1970s and 1980s, traffickers used concerts of the rock band The Grateful Dead as a network to distribute and sell both large and small quantities of LSD.23
Phencyclidine (PCP), a synthetic drug first used in medical anesthesia but now classified as an illicit hallucino- gen (see Chapter 11), is produced in clandestine laboratories either in Mexico or in the United States and distributed under a variety of street names, such as angel dust, rocket fuel, killer weed, embalming fluid, ozone, or Sherman (because the drug supposedly “hits you like a Sherman tank”).24
Ketamine (known by the street names, Special K or sim- ply K) is a drug that is chemically similar to PCP but produces less confusion, irrationality, and violence. Since ketamine is currently marketed as a general anesthetic for veterinary use, most of the ketamine sold on the street is stolen from supplies kept in veterinary facilities. In veterinary clinics, ketamine is found in liquid form for injection, but ketamine sellers pre- fer to market the drug in a powdered or crystallized form. Ketamine powder can be snorted, smoked (sprinkled on tobacco or marijuana), or ingested by being dropped into a drink, with an effect similar to that of PCP.25
Drug Trafficking as a Moving Target The emphasis in examining drug-trafficking patterns has been on nations that have historically participated in the global illicit drug trade. In recent years, however, drug- trafficking routes have splintered and diverged in directions that involve nations that had not been part of the traditional illicit drug cultivation and trafficking business. The motiva- tion, of course, is to evade international drug-control authori- ties by keeping their operations as mobile as possible. As a consequence, Mexican drug-trafficking organizations have managed to establish strongholds in other Central American countries such as Guatemala and Honduras. Colombian traffickers now have major operations in nearby Venezuela; trafficking routes extend as far as West Africa.26
Drug Trafficking/Violence: The Mexican Connection
During the 1980s and early 1990s, the United States began to exert immense pressure on drug-trafficking organizations operating in the Caribbean and south Florida. As a response, traffickers in Colombia formed alliances with Mexican traf- ficking groups in order to transport cocaine across the south- western border of the United States. With the disruption of the Medellin and Cali drug cartels in Colombia, Mexican cartels groups such as the Amado Carrillo-Fuentes Organization (ACFO) and the Arellano-Felix Organization (AFO) began to consolidate their power and dominated drug trafficking along the Mexico-U.S. border and in many American cities. By the late 1990s and early 2000s, after the loss of their leaders who were either imprisoned or killed during capture, the power and influence of these particular organizations declined
The proliferation of laboratories was fueled by the expan- sion of Internet sites providing access to methamphetamine “recipes.” At the time, these methamphetamine laboratories were described as “chemical time bombs” because of the frequent explosions and fires that are triggered by the highly flammable and toxic chemicals needed for methamphet- amine production (see Chapter 10).
Since 2005, methamphetamine trafficking has shifted from the domestic meth labs to foreign sources. The federal Combat Methamphetamine Epidemic Act, passed in 2005, drastically reduced the availability of large quantities of precursor chemi- cals such as pseudoephedrine. As a result, domestic laboratories capable of producing a large amount of meth became “stove- top” laboratories sufficient to produce only enough meth for a small number of people. Today, methamphetamine has once more become a foreign trafficking concern, with supplies of the drug coming largely from production facilities in Mexico. There is recent evidence that meth trafficking has expanded to countries in Asia as well (see Drug Enforcement … in Focus, North Korea on page 192 in Chapter 10).22
The Trafficking of LSD, PCP, and Ketamine
Lysergic acid diethylamide (LSD) is a clear or white, odorless crystalline material that is soluble in water (see Chapter 11). The drug is usually dissolved in a solvent for application onto paper, commonly referred to as blotter paper or blotter acid. Blotter acid consists of sheets of paper soaked or sprayed with LSD and decorated with a variety of colorful designs and sym- bols. A sheet of paper LSD blotter may contain hundreds of small, perforated, one-quarter-inch squares, with each square representing one individual dose. LSD may also be found in tablet form (microdots), in thin squares of gelatin (“window panes”), or in a dissolved liquid form that can be stored in an eye-drop container or glass vial. Eyedroppers allow users to disperse hundreds of doses of LSD at large parties or concerts by administering the drug on the tongue.
LSD is commonly produced from lysergic acid, which, in turn, is chemically derived from the ergot fungus. Since ergot is not readily available in the United States and is regu- lated under the Chemical Diversion and Trafficking Act, most of the production of LSD is believed to come from sources located abroad, such as Europe and Mexico. Since the 1960s, nearly all the LSD that is produced in the United States has originated from a small number of laboratories operating in northern California.
Typically, LSD trafficking is accomplished in two ways. The primary method of transportation is by mail, using over- night delivery services. LSD is frequently concealed in greet- ing cards, plastic film containers, or articles of clothing that are mailed to a post office box established by the recipient. The post office box is usually listed under a fictitious name or business, and no return address is typically provided on the package or envelope. Rock concerts also have been a traditional means of
38 ■ Part One The Challenge of Drugs in Our Society
The statistics of drug-related violence in Mexico are stag- gering. There have been more than 60,000 casualties over a six-year period, from 2006 to 2012, many of them reported as “disappearances.” The horrific effects on daily life in the countryside is difficult for most Americans to grasp. It is dif- ficult for Mexico to come up with a total number, since sev- eral thousands of Mexicans are kidnapped, or simply vanish and are never seen again. Paraphrasing the words of a cabinet member in the Mexican government, the nation has become a society in which killing someone is viewed as normal or natural.28
The capture of several major cartel leaders since 2013 has been cited as a major victory for law enforcement agencies in the war against Mexican drug organizations. As a result, the operations of the Sinaloa, Beltran-Leyva, Gulf, Juarez, and Los Zetas cartels have been disrupted. If the history of prosecutions of drug cartel leaders is any guide, however, there is little optimism that the culture of drug trafficking in Mexico will change significantly. All too often, power struggles among cartels and within each organization are cre- ated, resulting in increased violence rather than a period of calm. Competing cartels will sense a vacuum in the power structure of Mexican drug trafficking and an opportunity to
significantly, only to be replaced by other trafficking groups that are seemingly intent on outdoing each other in brutality and callous disregard for human life (see Chapter 6).
Today, it is difficult to fully appreciate the scope of the involvement of Mexico in illicit drug trafficking and the impact of Mexican drug trafficking on American illicit drug users (Figure 2.4). As indicated in previous sections of this chapter, it is evident that Mexico is responsible for the traffick- ing of a wide range of illicit drugs, not only heroin and cocaine but marijuana, methamphetamines, and hallucinogens as well. Prescription opioid medications such as OxyContin as well as other prescription drugs are manufactured in clandes- tine Mexican laboratories.27 At the same time, Mexico con- tinues to be a major transit location for illicit drugs destined to the United States from South America. According to the U.S. Department of Justice, Mexican drug cartels have gained drug-trafficking operations in more than 1,000 U.S. cities and towns, smuggling multiton quantities of illicit drugs and unauthorized prescription drugs across the U.S.-Mexico bor- der. From a media standpoint, however, the drug distribution network in Mexico has recently taken a secondary place to depictions of a culture of drug-related violence within Mexico and the social disruption that has resulted.
Culiacan
Pacific Ocean
Acapulco
Nuevo Laredo
Texas UNITED STATESEI Paso
Juarez
Douglas
Agua Prieta
Mexicali San Diego
Tijuana
California Arizona New Mexico
MEXICO
Laredo
Reynosa
Tampica
Mexico City Veracruz
BELIZE
HONDURAS
Caribbean Sea
Merida
Cancun
Gulf of Mexico
from Colombia
from Asi a
fro m
Co lom
bia,
Ven ezuela,
Brazil
McAllenMcAllen
Reynosa
Cocaine traffic
Ephedra traffic
Marijuana and meth traffic All drug traffic
Mazatlan
Nogales
Lazaro Cardenas
Puerto Vallarta
F IGURe 2 .4
Drug trafficking routes in Mexico. Ephedra refers to a plant-based stimulant, once marketed as a dietary supplement. The FDA banned its sale in 2004.
Source: Google image. http://geo-mexico.com/wp-content/uploads/2011/01/Drug_routes_2010_800.jpg
Chapter 2 Understanding the Drug Problem in Global Perspective ■ 39
has been applied to the violence waged by Afghan insurgent groups such as the Taliban, using profits from heroin trafficking as a means for funding their political activities. In the case of Colombia, narcoterrorism has referred to the violence stem- ming from a long-standing political struggle between the Colombian government and powerful cocaine trafficking orga- nizations within Colombia. As we will see, there exists an exten- sive network of “transnational” narcoterrorism as well, operating throughout the world with no regard to international borders.
Narcoterrorism in Afghanistan and Colombia In Afghanistan, the blurriness between drug trafficking and political insurgency has been particularly significant, given the recent history of American military engagement in that coun- try. Profits from Afghan heroin, for example, allegedly helped to finance Taliban terrorist activities within Afghanistan during the 1990s, although that Al Qaeda forces benefited directly from the heroin trade has been largely refuted. The U.S. 9/11 Commission Report on the September 11, 2001 attacks concluded in 2004 that the drug trade was a source of income for the Taliban, but it did not serve the same purpose for Al Qaeda. Specifically, there is no reliable evidence that Osama bin Laden was personally involved in drug trafficking or that he made his money through drug trafficking.30
Interestingly, in 2001, the Taliban announced a com- prehensive ban on the cultivation of the opium poppy, purportedly for religious reasons. As a result, opium produc- tion plummeted from 3,676 metric tons the previous year to 74 metric tons by the end of 2001. U.S. officials believe that the ban was most likely an attempt by the Taliban to raise the price of opium, which had declined significantly following a particu- larly abundant crop season in 2000. After the fall of the Taliban in 2002, Afghan growers resumed opium cultivation, and pro- duction increased to 2,865 metric tons in 2003. Although the Afghanistan government has officially banned the cultivation of opium poppies, decades of war and political unrest have left the criminal justice system in disarray, and it has been difficult for the ban to be enforced. From the standpoint of U.S. strate- gic interests in Afghanistan, there has been a troublesome con- flict between efforts to reduce the cultivation of opium in the rugged, mountainous areas of Afghanistan, on the one hand, and efforts to encourage regional Afghan warlords in these regions to divest themselves from a profitable opium-trade involvement in order to support the central government and oppose the Taliban, on the other.31
With respect to Colombia, U.S. foreign policy was origi- nally focused strictly on supporting anti-drug programs in that country. During the Clinton presidency in the 1990s, eco- nomic aid to Colombia rose to a previously unprecedented level of $88 million, but this money was tightly restricted to
become the new dominant drug cartel in Mexico; individu- als within cartels will begin to outdo each other in brutality, vying for the vacant top spot in the organization. It is not sur- prising that in a 2013 survey, more than 72 percent of the Mexican population reported feeling insecure in their own country, and more than half reported that insecurity was their main concern in their lives (Drugs … in Focus on page 40).29
Drugs and Narcoterrorism
The term, narcoterrorism, has been used in a number of ways when referring to the intermingling of political activity with illicit drug trafficking. In the case of Afghanistan, narcoterrorism
Quick Concept Check
Understanding Global Drug Trafficking Check your understanding of global drug trafficking by matching the organization name or term (on the left) with the appropriate identification (on the right). Note: Some of the answers may not at all be used.
1. The French Connection
2. The Golden Crescent
3. Black tar
4. Medellin Cartel
5. Los Zetas
6. Hell’s Angels
7. FARC
8. China White
9. Drug mules
10. The Golden Triangle
a. A present-day drug cartel in Mexico
b. Human couriers carrying drugs either in their bodies or on their person
c. A major antigovernment organization in Colombia
d. A form of Mexican heroin
e. Southeast Asian nations, including Laos and Vietnam
f. Southwest Asian nations, including Afghanistan
g. The chemical name for PCP
h. A major drug cartel in Colombia, disbanded in 1991
i. A name for Asian heroin in the 1960s and 1970s
j. An early trafficking organization of methamphetamine
k. Animals used to transport illicit drugs across the Rio Grande River from Mexico to the United States
l. A trafficking route of heroin in Europe, discontinued in the late 1960s and 1970s.
Answers: 1. l 2. f 3. d 4. h 5. a 6. j 7. c 8. i 9. b 10. e
2.2
narcoterrorism: A term referring to antigovernment political groups in which their operations have combined political insurgency and illicit drug trafficking.
40 ■ Part One The Challenge of Drugs in Our Society
political influence by other nations, specifically the United States. In reality, it has been the agent of widespread kid- nappings, murders, and social intimidation. In recent years, several world governments, including the United States, European Union, and Canada, have officially classified FARC as a terrorist organization, though several others, including nations in South America, have not done so.34 At the present time, FARC claims approximately 18,000 members, though a substantial number of them have been identified as minors forced to join and fight along with the adults. The organi- zation is concentrated primarily in the southeast region of Colombia, in an area of more than 42,000 square kilometers (16,200 square miles), the approximate size of Kentucky.
In the late 1990s, several cocaine producers elsewhere in Colombia shifted their crops to FARC-controlled terri- tory, and experimentation with coca plants resulted in a stronger coca leaf with a higher cocaine yield. Since then, FARC has essentially created a coca-based economy within its sphere of influence. Due to a scarcity of paper currency in the area, farm workers are paid in coca paste (see Chapter 10). They sell their excess “wages” to cocaine traffickers, who in turn refine the coca paste into cocaine and ship it to the United States. Meanwhile, FARC collects taxes on the trade, charges the traffickers for protection from authorities, and collects a fee for the use of remote runways for planes to take the cocaine away. There is even an “export tax” on all cocaine shipped from FARC-controlled territory. It is
police and counterdrug efforts and not intended to support Colombia’s war against insurgent groups. The focus was to reduce the influence of major drug cartels that were domi- nant in Colombia at the time. In 2002, George W. Bush changed the U.S. strategy by granting the Colombian govern- ment the funding to combat terrorism as well as drug traffick- ing, two struggles that in the view of the Bush administration had become one. Under the Bush administration, Colombia was awarded $650 million, an eightfold increase, in U.S. aid, to begin a unified campaign against drug trafficking and the activities of groups designated as terrorist organizations.32
For more than a half-century, rebel insurgency in the form of leftist guerrilla organizations opposed to the estab- lished Colombian government has dominated the political landscape. It is estimated that from 1948 to 1958, more than 300,000 people were killed during a civil war within Colombia, a horrific period that has since been referred to as La Violencia (the Violence).33 Combined with a history of unstable central governments and a long-standing culture of violence, illicit drug trafficking in Colombia was bound to exacerbate an already volatile political situation. It was evitable that political insurgency would become intertwined with illicit drugs.
Since 1960, the public agenda of the Revolutionary Armed Forces of Colombia (known as FARC by its initials in Spanish) has been to represent the people of rural Colombia against repression under the central government, exploita- tion of natural resources by multinational corporations, and
life and Death in Mexico: Don Garza Tamez and a Man Called Z-40 The brutality of the illicit drug traffickers and the everyday violence they bring to present-day Mexico is an ever-present reality. To be witness to tens of thousands of Mexicans who are suddenly never seen by their families again, most likely never found again, must constitute essentially a national nightmare. Two cases, one barely noticed in the American media and the other receiving headline coverage, are presented here.
In 2010, Don Alejo Garza Tamez was a 77-year-old business- man, simply a man wanting to keep what was his. A local drug lord appeared at his door, demanding that Tamez hand over his ranch. Tamez refused. After all, no one had a right to take his land. Demands were repeated. Finally, an ultimatum was given: surrender your ranch or else. Tamez refused. He told his employees to stay far away for their safety, barricaded himself in his home and waited. The drug lord came back, now with a small army at his side. Grenades were thrown into the home. Tamez shot back with hunting rifles. He managed to kill four of his assailants and wounded two of them, before dying himself. The ranch was taken over.
In 2013, the head of the Zetas drug cartel, Miguel Angel Treviño (known as “Z40”), was captured by Mexican marines. His capture was greeted by Mexican authorities as an element of success in their long-suffering and frequently unsuccessful struggle with drug cartels in Mexico. Treviño was regarded as an “über-thug” by experts in the field of drug-law enforce- ment. Beginning as a soldier in the Gulf Cartel and at one time leader of the “enforcement unit” for the cartel, Treviño became known for his brutal carrying card: beheaded victims, body parts strewn on highways, dismembered bodies hanging from bridges. The northern provinces of Mexico, particularly the city of Nuevo Laredo, near the Texan border, were held in abject terror. While the capture of Treviño’s successor, Alejandro Treviño Morales (known as “Z42”) in 2015 was hailed as another blow to the Zetas cartel, it is difficult to determine whether the organization has been weakened over the long run.
Sources: Adelmann, Bob (2010, November 30). Don Alejo Garza Tamez: True grit. http://www.thenew american.com-news/ north-america. Archibold, Randal C. (2013, July 16). Leader of brutal drug gang is captured in Mexico. New York Times, p. A6.
Drugs … in Focus
Chapter 2 Understanding the Drug Problem in Global Perspective ■ 41
without specific allegiances to individual nations. They are financed by powerful private donors (called shadow facilitators), and their criminal operations include arms trafficking, money laundering (see Chapter 6), kidnap- for-ransom, extortion, and racketeering, as well as drug trafficking. According to the Counter-Narcoterrorism Operations Center of the DEA, an Algeria-based Muslim jihadist group called Al Qaeda in the Lands of the Islamic Maghreb (AQIM), designated by the U.S. Department of State as a foreign terrorist organization, has been active for several years in West African nations such as Kenya, Tanzania, Ghana, Guinea-Bissau, and Nigeria, with a primary focus on trafficking Colombian cocaine through West Africa to destinations in Europe. Some of the AQIM profits have financed the Hezbollah in the Middle East, who in turn has received support from the government of Iran. The DEA has identified Hezbollah as having a sig- nificant role in cocaine trafficking and drug-related money laundering between South America, West Africa, Europe, and the Middle East.
Besides concerns about illicit drug trafficking, there is the extremely worrisome prospect of terrorist organizations acquiring access to highly toxic substances, such as chemical weapons, for use as weapons of mass destruction (Drugs . . . in Focus).37
no surprise that FARC is considered to be the richest insur- gent organization in history.35
Yet, despite the riches that FARC has accumulated from cocaine trafficking, there are signs that its political power has begun to wane. Major FARC leaders have been arrested on charges of cocaine importation conspiracy and extradited to the United States. A ceasefire and talks of a negotiated peace settle- ment between FARC and the Colombian government began in 2011, but it is unclear whether a political agreement will ever be achieved. As a testament to the fact that terrorist activity is nowhere near to an end, 19 Colombian soldiers were killed in 2013 in a FARC ambush near the Venezuelan border.
To conclude, Colombians have paid a very heavy price for decades of political conflict and illicit drug trafficking in their country. An independent commission reported in 2013 that, since 1958 (the year that La Violencia supposedly ended), there have been more than 220,000 conflict-related deaths, 27,000 forced disappearances, and 5.7 million peo- ple forced from their homes.36
Transnational Narcoterrorism A significant development in narcoterrorism has been the emergence and continuing influence of individu- als and groups, operating across international borders,
Sarin and Chemical Warfare: Neurotoxicity on the battlefield The compound, sarin, is considered the most toxic and rapid acting of known chemical warfare agents. It can be easily and quickly evaporated from a liquid to a gaseous state and released into the environment. People can be exposed to sarin by breath- ing sarin gas, consuming food or water that has been contami- nated with sarin, or touching surfaces containing sarin residue. It is essentially a toxic psychoactive drug in a form that can be readily used as a weapon of mass destruction. Victims exposed to sarin have difficulty in breathing, lose control of bodily func- tions, and at a later stage develop violent twitching and jerking of the body. Ultimately, exposure to sarin can lead to death by asphyxiation as victims become comatose and suffocate in a series of convulsive spasms.
Sarin is classified as a nerve agent, since it affects a critical function of the central nervous system, specifically the control of muscle contraction and relaxation. Normally, brief muscle contractions are controlled by the release of the neurotransmit- ter, acetylcholine, which causes a stimulation of muscle fibers. Shortly afterward, the enzyme acetylcholinesterase causes a breakdown of the acetylcholine molecule, resulting in a period of relaxation. Relaxation of muscle fibers is critical because
the muscle must “rest” before contracting again. Sarin works by inhibiting the action of acetylcholinesterase. As a result, acetylcholine is continually released, and without an “off- switch,” muscle fibers are constantly stimulated. The twitching and jerking of the body are consequences of the continual contraction of muscles. Eventually, diaphragm muscles cannot function to allow air into the lungs, and the victim no longer can breathe.
An international agreement, the United Nations Chemical Weapons Convention, was established in 1997 and, as of September 2013, it has been ratified by 189 nations. The treaty stipulates that the development, production, stockpiling, and use of all forms of chemical weapons, including sarin and a varia- tion called VX, are prohibited. Sarin gas has been used during the Iran–Iraq War in the late 1980s and in a terrorist attack on a subway station in Tokyo in 1995. In August 2013, sarin was used in an attack on civilians in the Syrian civil war. Reports of the death toll from the Syrian attack have ranged from 322 to more than 1700, including children.
Sources: Centers for Disease Control and Prevention (2013, May). Facts about Sarin. Atlanta, GA: Centers for Disease Control and Prevention. Gussow, Leon (2005). Nerve agents: Three mechanisms, three antidotes. Emergency Medicine News, 27, 12.
Drugs … in Focus
42 ■ Part One The Challenge of Drugs in Our Society
as a drug problem until the twentieth century. How did this happen? What factors were responsible for producing the all-too-familiar problems we face in America and around the world? And once we recognized that we had a problem, what have we done about it?
Looking Ahead
As we will see in the next chapter, psychoactive drugs have been around for thousands of years of human history. Strangely enough, however, the use of these drugs has not been defined
The Global Illicit Drug Trade and Drug-Use Prevalence Rates Worldwide and in europe
●● The global illicit drug trade encompasses the cultivation, manufacture, distribution, and sale of illicit drugs in prac- tically all regions of the world.
●● Worldwide annual prevalence rates for illicit drugs are between 4 and 7 percent of the adult population, aged 15–64 years. Prevalence rates for heroin, cocaine, and can- nabis (marijuana and hashish) are 0.4 percent, 0.4 percent, and 3.9 percent, respectively. Lifetime prevalence rates, on average, among adolescents, aged 15–16 years, in European countries for illicit drugs, marijuana, Ecstasy, alcohol, and tobacco are 23 percent, 22 percent, 4 percent, 87 percent, and 56 percent, respectively.
Trafficking of Heroin ●● The Golden Crescent nations of Southwest Asia, com-
prising Afghanistan, Pakistan, Turkey, Iran, and former regions of the Soviet Union, represent the single largest source of heroin for worldwide consumption. The domi- nant source in this regard is Afghanistan. However, most of the heroin consumed in the United States comes from Mexico and Colombia.
●● In recent years, Mexico has not only been a nation trans- porting South American heroin but has also been a pro- ducer of heroin on its own.
Trafficking of Cocaine ●● Most of the world’s coca cultivation and cocaine produc-
tion takes place in the Andean countries of South America, Bolivia, Peru, and Colombia. Of these nations, Colombia is the leading trafficker of cocaine for the U.S. market.
●● Drug cartels have long dominated cocaine trafficking in Colombia. The leading Medellin and Cali cartels in the 1970s, 1980s, and 1990s were particularly effective in infiltrating political life at all levels throughout Colombia and were responsible for the murder of hundreds of gov- ernment officials, police, prosecutors, judges, and inno- cent bystanders during the height of their power. In recent years, the operation of a large number of smaller cartels has led to a more decentralized approach in drug trafficking.
Drug Trafficking, Insurgency, and Narcoterrorism ●● In recent years, the United States has taken up, as a mat-
ter of foreign policy, the concept of narcoterrorism in the context of American support for both counterinsurgency
in Afghanistan (specifically with regard to the Taliban) and anti-drug-trafficking programs. There has often been a conflict between efforts to reduce the cultivation of opium in Afghanistan, on the one hand, and efforts to encourage regional Afghan warlords in these regions to divest them- selves from a profitable opium-trade involvement in order to support the central government and oppose antigovern- ment groups, specifically the Taliban, on the other.
●● In Colombia, narcoterrorism has taken the form of a decades-long political struggle of the central govern- ment with the Revolutionary Armed Forces of Colombia (known as FARC, by its initials in Spanish). The FARC organization has functioned as a nation within a nation, controlling coca cultivation and cocaine trafficking.
The Trafficking of Marijuana, Methamphetamine, and Hallucinogens
●● Most of the imported marijuana consumed in the United States is smuggled from Mexico. In some cases, the mari- juana is grown in Mexico; in other cases, it is transported from other locations such as Colombia. Foreign traffick- ing routes originate from Canada as well, particularly with respect to a potent variety of marijuana, known as BC Bud (the name derived from its origin in British Colombia). Patterns of domestic marijuana production have changed recently as a result of approval by voters in four U.S. states (as of 2014) for the legalization of marijuana smoking by adults for medical or nonmedical purposes.
●● Methamphetamine has been manufactured by domes- tic clandestine laboratories from ingredients that can be acquired through retail outlets. In recent years, metham- phetamine has become a foreign trafficking concern, with supplies of the drug smuggled into the United States from production facilities in Mexico.
●● Hallucinogens, such as LSD, PCP, and ketamine, are typi- cally produced in the United States in clandestine labora- tories operating in northern California, although traffick- ing has increased recently from sources in Mexico.
Drug Trafficking and Social Violence in Mexico and elsewhere
●● The extent of drug-related violence in Mexico has in recent years reached horrific levels. An estimated 60,000 casualties over six years, with thousands of police person- nel killed and unknown numbers of “disappearances” have plagued Mexico and Mexican life. Captures of drug cartel leaders have had only minimal impact, since successors to
Summary
Chapter 2 Understanding the Drug Problem in Global Perspective ■ 43
these leaders are ready to assume command and often are more brutal than their predecessors.
●● Drug-trafficking patterns are in a continual state of flux, as operations are highly mobile and manage to evade drug-control authorities. Mexican drug cartels can expand their operations to nearby nations such as Guatemala and
Honduras; Colombian drug cartels can expand their oper- ations to nearby nations such as Venezuela. Toxic psycho- active drugs, such as sarin, are capable of being delivered to multiple individuals at a time. The potential for sarin to be used as a form of chemical warfare continues to be a matter of great concern around the world.
Key Terms
BC Bud, p. 36 black tar, p. 32 cartel, p. 33
China White, p. 30 global illicit drug trade, p. 26 Golden Crescent, p. 30
Golden Triangle, p. 30 Medellin and Cali drug
cartels, p. 33
narcoterrorism, p. 39
1. How do American adults compare to adults around the world with respect to the annual prevalence rates for illicit drugs in general, heroin, cocaine, and marijuana? How do American adolescents compare to their European counterparts with respect to the lifetime prevalence rates for illicit drugs in general, heroin, cocaine, marijuana, and Ecstasy, as well as alcohol and tobacco?
2. Describe the patterns of heroin trafficking for most of the world and for the United States specifically. Describe the
present-day Mexican involvement in the trafficking of a range of illicit drugs.
3. Discuss the use of the term narcoterrorism as it has been applied to drug-control initiatives in Afghanistan and Colombia. How are these nations different with respect to narcoterrorism?
4. Why would drug-trafficking cartels be particularly dominant in the northern regions of Mexico?
Review Questions
You are a Mexican official determined to reduce drug-related vio- lence in the region over which you have jurisdiction. Given the
present-day situation in Mexico, what positive policies and actions could be put into place to help the citizens you serve?
Critical Thinking: What Would You Do?
1. Archibold, Randal C. (2012, May 30). Adding to unease of a drug war alliance: Corruption case reinforces U.S. reluctance to rely on the Mexican Army. New York Times, pp. A4, A7. Excerpts from Bureau of International Narcotics and Law Enforcement Affairs (2013, March). International narcotics control strategy report, Vol. 1: Drug and chemical control. Wash- ington, DC: United States Department of State, pp. 130, 236.
2. Thoumi, Francisco E. (2005, Winter). The Numbers Game: Let’s all guess the size of the illegal drug industry! Journal of Drug Issues, 35, 185–200. United Nations Office on Drugs and Crime (2013). Drug trafficking: Introduction. Vienna: United Nations Office on Drugs and Crime. Zagaris, Bruce; and Ehlers, Scott (2001, May). Drug trafficking and money laundering. Foreign Policy in Focus, p. 1.
3. United Nations Office on Drugs and Crime (2013, March). World Drug Report 2013. Vienna: United Nations Office on Drugs and Crime, pp. ix–xiv, 1–29, Prevalence of drug use among the general population: Excel files.
4. Ibid. 5. United Nations Development Programme (2011). Human Devel-
opment Report 2011. Sustainability and equity: A better future for all. New York: United Nations Development Programme.
6. Hibell, Björn; Guttormsson, Ulf; Ahlström, Salme; Balakireva, Olga; Bjarnason, Thoroddur; Kokkevi, Anna; and Kraus, Lud- wig (2012). The 2011 ESPAD Report: Substance use among students in 36 European countries. Stockholm: The Swedish Council for Information on Alcohol and Other Drugs, pp. 63–100. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; and Schulenberg, John E. (2012). Monitoring the Future: National results of adolescent drug use: 2011 Overview. Key findings 2011. Ann Arbor, MI: Institute for Social Research, University of Michigan, Table 2.1.
7. United Nations Office on Drugs and Crime, World Drug Report 2013, pp. xi, 59–113.
8. Macher, Roland; Burke Tod W.; and Owen, Stephen S. (2012, May). Synthetic marijuana. FBI Law Enforcement Bulletin. Retrieved from http://www.fbi.gov/stats-services/publications/ law-enforcement-bulletin/may-2012/synthetic-marijuana (accessed August 2013). United Nations Office on Drugs and Crime (2013). New psychoactive substances (NPS). Press Report. Vienna: United Nations Office on Drugs and Crime.
9. McCoy, Alfred W. (2003). The politics of heroin: CIA com- plicity in the global drug trade. Revised edition. Chicago, IL: Chicago Review Press, pp. 46–77.
Endnotes
44 ■ Part One The Challenge of Drugs in Our Society
25. National Drug Intelligence Center, National drug threat assess- ment 2005. Drug Enforcement Administration, Club drugs: An update. Washington DC: U.S. Department of Justice.
26. Agence France-Press (2013, February 22). Guatemala checking whether Mexico drug lord was killed in clash. (Accessed August 29, 2013). Archibold, Randal C.; and Cave, Damien (2011, March 24). Drug wars push deeper into Central America. New York Times, pp. A1, A4. Cave, Damien (2012, May 24), Drug trafficking and raids stir danger on the mosquito coast. New York Times, pp. A1, A4. Neuman, William (2012, July 27). Cocaine’s flow is unchecked in Venezuela. New York Times, A1, A3. O’Regan, Davin; and Thompson, Peter (2013, June), Advancing stability and recon- ciliation in Guinea-Bissau: Lessons from Africa’s first narco- state. ACSS Special Report. No. 2. Washington, DC: Africa Center for Strategic Studies. Savage, Charlie; and Shanker, Thom (2012, July 22). The drug war shifts to Africa, hub for cartels. New York Times, pp. 1, 8.
27. Cave, Damien; and Schmidt, Michael S. (2012, July 17). Rise in pill abuse forces new look at U.S. drug fight. New York Times, pp. A1, A3.
28. Archibold, Randal C. (2013, June 23). Mexico’s pursuing vanished victims of its drug wars. New York Times, pp. A1, A14. Sanchez, Mary (2010, December 12). United States has a role in Mexican drug wars. Newsday, p. A35.
29. Archibold, Randal C. (2013, July 16). Leader of brutal drug gang is captured in Mexico. New York Times, p. A6. Associ- ated Press (July 24, 2013). Mexico’s drug war boils over again in Michoacan as gang gunmen stage attacks on federal police. Results of the National Survey on Victimization and Perception of Public Safety 2013, National Institute of Statistics and Geography, Aquacalientes, Mexico. Drug Enforcement Administration (2014, October 21). DEA announces Texas arrest of Gulf Cartel leader. News release. U.S. Department of Justice, Washington, DC. Dudley, Steven (2015, February 27). Mexico captures ‘La Tuta’ but Michoacan struggles on. http:// insightcrime.org/news-analysis. Human Rights Watch (2013, February). Mexico’s disappeared: The enduring cost of a crisis ignored. New York: Human Rights Watch. Pachio, Elyssa (2015, March 4). Zetas leader Z42 reportedly captured in Mexico. http:/insightcrime.org/new-analysis. Thompson, Ginger; and Archibold, Randal C. (2014, February 26). Arrest unlikely to break cartel. New York Times, pp. A1–A11.
30. National Commission on Terrorist Attacks upon the United States (2004). The 9/11 Commission Report. New York: W. W. Norton, Chapter 5, Section 4.
31. Filkins, Dexter (2010, June 22). U.S. money-financing Afghan warlords for convoy protection, report says. New York Times, p. A4. Risen, James (2010, September 12). Propping up a drug lord, then arresting him. New York Times, pp. A1, A18. Shah, Taimoor; and Rubin, Alissa J. (2012, April 12). In poppy war, Taliban aim to protect a cash crop. New York Times, pp. A4, A7.
32. Adam, Isacson (2003). Washington’s new war in Colombia: The war on drugs meets the war on terror. NACLA Report on the Americas, 36, pp. 5–11.
33. Palacios, Marco (2007). Between legitimacy and violence: A history of Colombia, 1875-2002. Durham, NC: Duke University Press. Richani, Nazih (2002). Systems of violence: The political economy of war and peace in Colombia. Albany, NY: State University of New York Press, pp. 23–28.
10. Ibid. 11. Drug Enforcement Administration (2002, August). Drug
intelligence brief: Anatomy of a Southeast Asian heroin con- spiracy. Washington, DC: Drug Enforcement Administration. National Drug Intelligence Center (2008). National Drug Threat Assessment 2009. Washington DC: U.S. Department of Justice, pp. 25–32. Yong-an, Zhang (2012, February). Asia, international drug trafficking, and U.S-China counternarcotics cooperation. Washington, DC: Brookings Institution Center for Northeast Asian Policy Studies.
12. Fuller, Thomas (2015, January 3). Myanmar returns to what sells: Heroin. New York Times, pp. A6, A9. United Nations Office on Drugs and Crime (2013, April). Afghanistan: Opium risk assessment 2013. Vienna: United Nations Office on Drugs and Crime, Figure 1. United Nations Office on Drugs and Crime (2011). The global Afghan opium trade: A threat assess- ment 2011. Vienna: United Nations Office on Drugs and Crime, Figure 2.
13. United Nations Office on Drugs and Crime, World Drug Report 2013, pp. 35–36.
14. International Narcotics Control Strategy Report, pp.234–235. National Drug Intelligence Center (2009). National Drug Threat Assessment 2009.
15. National Drug Intelligence Center (2011). National Drug Threat Assessment 2011. Washington, DC: U.S. Department of Justice, pp. 8–9.
16. International Narcotics Control Strategy Report, pp. 233–235. 17. Drug Enforcement Administration (2006, September 26).
Cali cartel leaders plead guilty to drug and money launder- ing conspiracy charges. News release. Washington, DC: U.S. Department of Justice. United Nations Office on Drugs and Crime (2013, September). Peru: Coca cultivation survey, 2012. Vienna: United Nations Office on Drugs and Crime. United Nations Office on Drugs and Crime (2013, June). Colombia: Coca cultivation survey, 2012. United Nations Office on Drugs and Crime.
18. Gootenberg, Paul (2007). The “pre-Colombian” era of drug trafficking in the Americas: Cocaine, 1945–1965, The Americas, 64, 133–176.
19. Fedarko, Kevin (1993). Escobar’s dead end. Time, p. 46. 20. Drug Enforcement Administration (2001). Drug trafficking
in the United States. Washington, DC: U.S. Department of Justice. Office of National Drug Control Policy (2002). Pulse check: Trends in drug abuse, marijuana section. Washington, DC: Office of National Drug Control Policy.
21. Drug Enforcement Administration (2000, December). Intelligence brief: BC bud. Washington, DC: U.S. Department of National Drug Intelligence Center (2009). National drug threat assessment 2009, pp. 17–24. National Drug Intelligence Center. (2004). National drug threat assessment 2005. Washington, DC: U.S. Department of Justice.
22. McDermott, Edward J. (2006, Winter). Motorcycle gangs: The new face of organized crime. Journal of Gang Research, 13, 27–36. National Drug Intelligence Center (2010). National drug threat assessment 2010. Washington DC: U.S. Department of Justice, pp. 32–35.
23. National Institute on Drug Abuse (2003, January). Infofacts: LSD. Washington, DC: National Institute on Drug Abuse.
24. Drug Enforcement Administration. (2003, May). Drug intelligence brief: PCP: The threat remains. Washington, DC: U.S. Department of Justice.
Chapter 2 Understanding the Drug Problem in Global Perspective ■ 45
Colombia-FARC peace talks eye political participation in hope of integrating rebel army into government. Huffington Post. Retrieved from http://www.huffingtonpost.com/2013/08/10/ colombia-farc-political-participation_n_3737572.html (accessed March 2014).
37. Counter-Narcoterrorism Operations Center (2013, November). Combating transnational organized crime. Washington, DC: Drug Enforcement Administration, U.S. Department of Justice..
34. Livingstone, Grace (2004). Inside Colombia: Drugs, democracy, and war. New Brunswick, NJ: Rutgers University Press, p. 180. Shanty, Frank G.; and Moshra, Patit P. (2007). Organized crime: From trafficking to terrorism. Santa Barbara, CA: ABC-CLIO, p. 323.
35. Guillermoprieto, Alma (2002, May). Waiting for war. New Yorker, pp. 48–55.
36. Brodzinsky, Sibylla (2013, July 29). FARC peace talks stoke hope—and unrest in Colombia. Christian Science Monitor, Weekly Digital Edition (accessed August 29, 2013).
The History of Drug Use and
Drug-Control Policy
3chapter
Miguel proudly calls himself a fourth-generation Mexican American.
Today, he works for a major accounting firm in Los Angeles, and he
and his family live in the suburbs. I asked Miguel (he refuses to be
called Mike) if he would tell me some of the family stories about mari-
juana and the old days.
“It’s funny,” he said, “Marijuana has really gone mainstream.
It’s all around you. Even my boss smokes marijuana!”
“But it wasn’t funny back in my great-grandfather’s day.
Damn, the prejudice was out there. White people didn’t like us,
even though we were picking their fruits and vegetables twelve,
fourteen hours a day. Sure we had marijuana then; our families
brought it with us when we came across from Mexico. It was how
we relaxed, probably the only way we could.”
Miguel grew more serious. “But whites didn’t see it that way.
The stories you would hear about us. . . . they would say that mari-
juana made us violent and angry. They would spread outlandish
After you have completed this chapter, you should have an understanding of the following:
●● The origins and history of drugs and drug-taking behavior
●● Drug regulation in the early twentieth century
●● Drug regulation legislation, 1914–1980
●● Drug regulation legislation, 1980–2000
●● Global drug trafficking and issues of national security: 2001–present
●● Domestic drug trafficking and issues of national security: 2001–present
●● Public safety and public health as overall aims of drug-control policy
●● The present status of drug-control policy today
●● The five schedules of controlled substances
Chapter 3 The History of Drug Use and Drug-Control Policy ■ 47
Drugs in Early Times
Try to imagine the accidental circumstances under which a psychoactive drug might have been discovered. Thousands of years ago, perhaps a hundred thousand years ago, the process of discovery would have been as natural as eating and the moti- vation as basic as simple curiosity. In cool climates, next to a cave dwelling may have grown a profusion of blue morning glories or brightly colored mushrooms, plants that produce hallucinations similar to LSD. In desert regions, yellow-orange fruits grew on certain cacti, the source of the hallucinogenic drug peyote. Elsewhere, poppy plants, the source of opium, covered acres of open fields. Coca leaves, from which cocaine is made, grew on shrubs along the mountain valleys through- out Central and South America. The hardy cannabis plant, the source of marijuana, grew practically everywhere.1
It is entirely possible that our curiosity was inspired by observing the unusual behavior of animals as they fed on these plants. There may have been other accidental discover- ies that offered genuine benefits. Somewhere along the line people made the connection between the chewing of willow bark (the source of modern-day aspirin) and the relief of a headache or the eating of the senna plant (a natural laxative) and the relief of constipation.
Of course, some plants made people sick, and many were sufficiently poisonous to cause death. The plants that had the strangest impact, however, were the ones that produced hal- lucinations. Having a sudden vision of something totally for- eign to everyday life must have been overwhelming, like a visit to another world. Individuals with prior knowledge about such plants, as well as about plants with therapeutic powers, would eventually acquire great power over others in the com- munity. This knowledge was the beginning of shamanism, a practice among primitive societies dating back, by some esti- mates, more than 40,000 years, in which an individual called a shaman acts as a healer through a combination of trances
shaman (SHAH-men): A healer whose diagnosis or treatment of patients is based at least in part on trances. These trances are frequently induced by hallucinogenic drugs.
stories that marijuana made us fearless and super-
strong, that we were ready to attack a police offi-
cer, even if a gun was drawn on us. They would
claim that it took two or three policemen just to hold
us down. Can you believe that?”
The use of psychoactive drugs has been a part of human life in almost every culture and in every age of recorded history. Drugs have been used in the context of religious rituals, health care, celebration, and recreation. An understanding of the history of drug use and our efforts to control drug use forms the basis for an understanding of present-day drug abuse and the problems associated with it.
Over the course of our nation’s history, attitudes toward certain drugs and certain forms of drug-taking behavior have fluctuated between enthusiastic acceptance and passionate rejection. Heroin, marijuana, cocaine, and numerous other drugs all have had periods of approval and periods of disap- proval. In the late 1800s, for example, cocaine was widely accepted as a stimulant drug (see Chapter 10). This was fol- lowed by a rejection in the early 1900s and a brief reemer- gence of approval in the early 1980s, followed by another period of rejection beginning in the miid-1980s and extend- ing to the present day.
American drug-control policy also has had its own his- torical swings, with policies themselves not always being founded on rational decision making and empirical data. Decisions to outlaw some drugs while legalizing others have been all-too-often based on fear, hysteria, politics, ethnic prejudice, and racism. As we will see, public disapproval of a particular drug has been instigated by attitudes toward a specific minority group associated with the drug, rather than genuine concerns about the effects of the drug itself. The negative associations of opium with Chinese workers in the nineteenth century, cocaine with African Americans, alco- hol (specifically beer) with Germans, and marijuana with Mexican immigrants in the twentieth century have been unfortunately a part of the history of drugs in America. It is important to examine the history of drugs and drug-taking behavior and the history of drug-control policy in the United States in order to arrive at the best strategies for dealing with present-day drug use and abuse.
shamanism: The philosophy and practice of healing in which the diagnosis or treatment is based on trancelike states, on the part of either the healer (shaman) or the patient.
Numbers Talk… .38 Caliber bullets in revolvers adopted by many southern police departments in the early 1900s, believing that cocaine would
make African Americans unaffected by .32 caliber bullets. 11 Estimated percentage of American troops in Vietnam in 1971, who were regular users of heroin.
Sources: Musto, David F. (1989, Summer). America’s first cocaine epidemic. The Wilson Quarterly, pp. 59-64. McCoy, Alfred W. (1972). The politics of heroin in Southeast Asia. New York: Harper & Row, pp. 220-221.
48 ■ Part One The Challenge of Drugs in Our Society
placebo (pla-CEE-bo) effect: Any change in a person’s condition after taking a drug, based solely on that person’s beliefs about the drug rather than on any physical effects of the drug.
and plant-based medicines, usually in the context of a local religious rite. Shamans still function today in many areas of the world, often alongside practitioners of modern medicine, and hallucination-producing plants still play a major role in present-day shamanic healing.2
With the development of centralized religions in Egyptian and Babylonian societies, the influence of shaman- ism would gradually decline. The power to heal through one’s knowledge of drugs passed into the hands of the priest- hood, which placed a greater emphasis on formal rituals and rules than on hallucinations and trances.
The most extensive testament to the development of priestly healing during this period is a 65-foot-long Egyptian scroll known as the Ebers Papyrus, named after the German Egyptologist and novelist, Georg Ebers, who purchased it in 1872. This mammoth document, dating from 1500 b.c., contains more than 800 prescriptions for practically every ail- ment imaginable, including simple wasp stings and croco- dile bites, baldness, constipation, headaches, enlarged pros- tate glands, sweaty feet, arthritis, inflammations of all types, heart disease, and cancer. More than a hundred of the prepa- rations contained castor oil as a natural laxative. Some con- tained the “berry of the poppy,” which is now recognized as a reference to opium. Other ingredients were quite bizarre: lizard’s blood, the teeth of swine, the oil of worms, the hoof of an ass, putrid meat with fly specks, and crocodile dung (excrement of all types being highly favored for its ability to frighten off the evil spirits of disease).3
How successful were these strange remedies? It is impos- sible to know because records were not kept on whether or
not patients were cured. Although some of the ingredients, such as opium and castor oil, had true medicinal value, it may be that much of the improvement achieved from these con- coctions was psychological rather than physiological. In other words, improvement in the patient’s condition resulted from the belief on the patient’s part that he or she would be helped, a phenomenon known as the placebo effect (see Chapter 4).
Along with substances that had genuine healing prop- erties, other psychoactive drugs were put to other uses. In the early Middle Ages, Viking warriors ate the mushroom Amanita muscaria (known as “fly agaric”) and experienced increased energy, which resulted in wild behavior in battle. They were called “Berserkers” because of the bear skins they wore, and reckless, violent behavior has come to be called “berserk.” Later, witches operating on the periphery of Christian society created “witch’s brews,” which were said to induce hallucinations and a sensation of flying. The brews were mixtures made of various plants such as mandrake, henbane, and belladonna. The toads that they included in their recipes did not hurt either: We know now that the sweat glands of toads contain a chemical related to DMT, a power- ful hallucinogenic drug, as well as bufotenine, a drug that raises blood pressure and heart rate (see Chapter 11).4
Drugs in the Nineteenth Century
By the end of the nineteenth century, the medical profession had made significant strides with respect to medical healing. Morphine was identified as the active ingredient in opium, a drug that had been in use for at least 3,000 years and had become the physician’s most reliable prescription to control the pain of disease and injury. The invention of the syringe made it possible to inject morphine directly and speedily into the bloodstream.
Morphine quickly became a common treatment for pain during the Civil War, a time during which a surgeon’s skill was often measured by how quickly he could saw off a wounded patient’s limb. Unfortunately, in subsequent years, morphine dependence among Civil War veterans would be so widespread that it was called the “soldier’s disease.” Doctors also recommended morphine injections for women to treat the pain associated with “female troubles,” and by the late 1890s, morphine dependence among women made up almost half of all cases of drug dependence in the United States (see Chapter 9).5
Cocaine, having been extracted from South American coca leaves, was also a drug in widespread use and taken quite casually in a variety of forms. The original formula for Coca-Cola (as the name suggests) contained coca until 1903, as did Dr. Agnew’s Catarrh Powder, a popular rem- edy for chest colds. In the mid-1880s, Parke, Davis, and Company (merged with Pfizer, Inc. in 2002) was sell- ing cocaine and its botanical source, coca, in more than a dozen forms, including coca-leaf cigarettes and cigars, cocaine inhalants, a coca cordial, and an injectable cocaine
Ebers Papyrus: An Egyptian document, dated approxi- mately 1500 b.c., containing more than 800 prescriptions for common ailments and diseases.
In a wide range of world cultures throughout history, hallucinogens have been regarded as having deeply spiritual powers. Under the influence of drugs, this modern-day shaman communicates with the spirit world.
Chapter 3 The History of Drug Use and Drug-Control Policy ■ 49
During the nineteenth century, America’s public atti- tude toward drug use was one of laissez-faire, roughly translated from the French as “allow [people] to do as they please,” which means that there was little regulation or con- trol of drugs. In fact, the United States was the only major Western nation that allowed the unlimited distribution, sale, and promotion of psychoactive drugs during this period. The result was a nation of medicinal and recreational drug users that has been described as a “dope fiend’s paradise.”8
Two major factors explain why there were no major drug-control policies during this period. First, unlike many European nations, the United States did not have any agen- cies regulating the medical field, and because doctors and pharmacists were unlicensed, it was not difficult to call one- self a doctor and distribute drugs. The American Medical Association (AMA) was established in 1847, but only a frac- tion of practicing health professionals were members during the 1800s. Doctors of this era had no choice but to rely upon untested and potentially toxic chemicals to treat both physical and psychological disorders (Drugs … in Focus). A second
solution.6 A Viennese doctor named Sigmund Freud, who was later to gain a greater reputation for his psychoanalyti- cal theories than for his ideas about psychoactive drugs, called cocaine a “magical drug.” Freud would later reverse his position when a friend and colleague became depen- dent on cocaine (see Chapter 10).7
In the latter part of the nineteenth century in the United States, cocaine was a popular ingredient in over-the-counter medications. These products were totally unregulated, and customers included children as well as adults.
laissez-faire (LAY-say FAIR) (Fr.): The philosophy of exert- ing as little governmental control and regulation as possible.
Abraham Lincoln, Depression, and Those “Little Blue Pills” It is well known to historians that Abraham Lincoln suffered from long bouts of melancholy, a condition that would today be diagnosed as major depression. What is less known is that Lincoln had been advised by his physician to take what he called his “little blue pills” to help him elevate his mood.
A few months into his presidency, in 1861, however, Lincoln stopped taking these pills, complaining that they made him “cross.” During the late 1850s, Lincoln had experienced episodes of bizarre behavior that included towering rages and mood changes that appeared out of nowhere or were responses to innocuous and sometime trivial circumstances. It is reason- able to assume that the symptoms were, as Lincoln himself surmised, due to the “little blue pills.”
It is a good thing that Lincoln made this decision. The medi- cation he was taking was a common nineteenth-century remedy for depression, called blue mass. It consisted of licorice root, rosewater, honey, sugar, and rose petals. But the main ingredient in these blue-colored pills, about the size of peppercorns, was approximately 750 micrograms of mercury, a highly toxic sub- stance. At the common dosage level of two or three pills per day, individuals ingested nearly 9,000 times the amount of mercury that is considered safe by current health standards.
If Lincoln had continued to take blue mass for his depres- sion, he undoubtedly would have continued to experience the behavioral and neurological symptoms common to chronic mercury poisoning as he led the nation during the Civil War. Fortunately, the symptoms of mercury poisoning in Lincoln’s case were reversible after he stopped taking blue mass. Lincoln would suffer from severe bouts of depression until his death in 1865, but America was spared what might have been a catastro- phe of historic proportions.
Postscript: Mercury poisoning was quite common through- out the nineteenth century, as this substance’s toxic properties had not yet been discovered or fully appreciated. Hat makers were particularly susceptible to mercury toxicity because they would routinely rub mercury into the felt material of hats to preserve them for commercial sale, absorbing the substance into the bloodstream through their fingers. Symptoms of severe mood swings and eventually dementia were commonly observed among people in this profession, and eventually the association with hat makers in general became the basis for the expression “mad as a hatter” as well as the “Mad Hatter” character in Lewis Carroll’s Alice in Wonderland.
Source: Hirschhorn, Norbert; Feldman, Robert G.; and Greaves, Ian (2001, Summer). Abraham Lincoln’s blue pills: Did the 16th President suffer from mercury poisoning? Perspectives in Biology and Medicine, pp., 315–322.
Drugs … in Focus
50 ■ Part One The Challenge of Drugs in Our Society
factor was the issue of states’ rights. During the nineteenth century, the prevailing political philosophy, especially in southern states, was a belief in the strict separation of state and federal powers. Therefore, the regulation of drugs was left to the states, most of which had few, if any, drug laws. For the federal government to pass laws limiting the use of any drug would have been viewed as a serious challenge to the concept of states’ rights.9
Drug Regulation in the Early Twentieth Century
By 1900, the promise of medical advances in the area of drugs was beginning to be matched by concerns about the health risks that some of these drugs could produce. Probably the two most important factors that fueled the movement toward drug regulation in the beginning of the twentieth century were (1) the abuse of patent medicines and (2) the associa- tion of drug use with certain minority groups. Between the late 1800s and early 1900s, hundreds of patent medicines were sold that included such ingredients as alcohol, opium, morphine, cocaine, and marijuana. The term “patent medi- cine” can be misleading. Generally, one thinks of a patented product as one that is registered with the government, provid- ing the producers with the exclusive right to sell that product. However, patent medicines around the turn of the twentieth century were not registered with the federal government or any regulatory agency, and their formulas were usually kept secret. Manufacturers did not have to list the ingredients of patent medicines on the bottle label or the package in which they were sold. Patent medicines were advertised for mail- order purchase in newspapers and magazines or available through traveling medicine shows.
As the popularity of patent medicines grew, cases of accidental poisoning from ingredients in these medicines became widespread. In 1905, a series of scathing articles appeared in the widely read Collier’s Weekly magazine that documented the dangers of unregulated patent medi- cines. These articles were followed the next year by Upton Sinclair’s novel, The Jungle, depicting in gruesome detail the unsanitary conditions of the meat packing industry in Chicago. Responding to public outcry for regulatory reform, President Theodore Roosevelt proposed a federal law that would regulate misbranded and adulterated foods, drinks, and drugs. The Pure Food and Drug Act of 1906 became the first drug regulatory law in American history, establish- ing the requirement that all packaged foods and drugs list the ingredients on the label of the product.10
The new law did not prevent potentially harmful drugs from being sold, but it did require manufacturers to iden- tify specific drugs that were contained in these patent medi- cines. Thus, cocaine, alcohol, heroin, and morphine could still be in patent preparations as long as they were listed as ingredients.11
Drug Regulation, 1914–1938
It is an unfortunate truth that by the second decade of the twentieth century, calls for expanded drug regulation were spurred in large part by a growing prejudice against minority groups in America that were believed to be involved in drug use. As we will see, this social phenomenon impacted upon the eventual prohibition of opium and heroin, cocaine, and marijuana, as well as the temporary prohibition of alcohol.
Quick Concept Check
Understanding the Early History of Drugs and Drug-Taking Behavior Test your understanding of the early history, (prior to 1914) of drugs and drug-taking behavior by matching the statement on the left with one of the associated drugs, names, or terms on the right.
3.1
1. Dependence on this drug among Civil War veterans was so common that it was called the “soldier’s dis- ease” or the “army disease.”
2. This drug was associated with Chinese immigrants working on American railroads during the 1800s.
3. This individual in a primitive soci- ety used a combination of trances and plant-based medicines in the practice of healing.
4. In the early Middle Ages, Viking warriors ate this mushroom for its psychoactive properties.
5. This major figure of the twentieth century gained an early reputation for promoting cocaine as a “magi- cal drug.”
6. The novel, The Jungle, by this American author, was influential in gaining public support for the Pure Food and Drug Act of 1906.
a. opium
b. Amanita muscaria
c. Upton Sinclair
d. Ebers Papyrus
e. morphine
f. Sigmund Freud
g. shaman
h. marijuana
Answers: 1. e. 2. a. 3. g. 4. b. 5. f. 6. c.
Pure Food and Drug Act of 1906: Federal legislation requir- ing all packaged foods and drugs to list the ingredients on the label of the product.
patent medicine: A drug or combination of drugs sold through peddlers, shops, or mail-order advertisements.
Chapter 3 The History of Drug Use and Drug-Control Policy ■ 51
Harrison Act of 1914: Federal legislation regulating through government taxation the importing, manufacturing, selling, or dispensing cocaine or opiate drugs. The law effectively changed the status of cocaine and opiates from licit to illicit substances in the United States.
The movement toward federal drug-control legislation, in general, was met with resistance from southern politi- cians, who believed that such actions were yet another intru- sion of the federal government into state affairs. It has been suggested that, in order to overcome this resistance from southerners during this time, a propaganda campaign was launched that associated African Americans with cocaine. Southern newspapers began publishing “reports” of the cocaine-induced raping of white women and demonstra- tions of superhuman strength.12 One of the more bizarre myths was that cocaine made African Americans unaf- fected against .32 caliber bullets, a claim that is said to have caused many southern police departments to switch to .38 caliber revolvers. The propaganda campaign was successful; southerners became more afraid of African Americans and cocaine than of an increase in federal power and eventually offered their support for the Pure Food and Drug Act and later the Harrison Act of 1914.13
Another example of how racism became interwoven with drug policy was the identification of Chinese workers with the smoking of opium. After the Civil War, the United States had imported Chinese workers to help build the rapidly
In a June 1905 issue of the widely read Collier’s Weekly magazine, the cover (entitled “Death’s Laboratory”) dramatically depicted the dangers of patent medicines. A scathing exposé of the patent medicine industry written by Samual Hopkins Adams appeared in the magazine four months later.
expanding railroads. The Chinese brought with them the habit of smoking opium, which many Americans believed led to prostitution, gambling, and overall moral decline. When the major railroad systems were completed, Chinese workers began to migrate into western cities such as San Francisco. Working for low wages, the Chinese, some Americans feared, would take jobs from whites and the “big bosses” of business would use cheap Chinese labor as a means of preventing the organizing of unions. Hostility and violence against the Chinese became commonplace. The first anti-drug legisla- tion in the United States was an ordinance enacted in 1875 by the City of San Francisco prohibiting the operation of opium dens—establishments where smoking of opium took place. Other states followed San Francisco’s lead by prohibit- ing opium smoking, and in 1887, Congress prohibited the possession of smokable opium by Chinese citizens.14
The Harrison Act of 1914 The origins of the landmark Harrison Act of 1914 can be traced back to an issue of foreign trade. While many Americans detested the Chinese and their habit of smoking opium, at the same time, the U.S. government wanted to open up trade with China. China refused to purchase American goods, however, because of the poor treatment of Chinese people in the United States. To establish some degree of goodwill with China and to improve its trade position, the United States ini- tiated a number of international conferences in an attempt to control the worldwide production and distribution of narcot- ics, especially opium. Recognizing the enormous population of opium abusers within their own country, Chinese leaders were eager to participate in such conferences.
At an international conference held in The Hague in 1912, the United States was accused of maintaining a double standard. According to the Chinese delegation, the U.S. gov- ernment was attempting to establish international agreements to regulate the drug trade while at the same time having no domestic policy over drug production and distribution within its own borders. In response, Congress passed the Harrison Act in 1914, named after its sponsor, Representative Francis Burton Harrison of New York.15
The Harrison Act was designed to regulate drug abuse through government taxation and became the basis for narcot- ics regulation in the United States for more than a half century. The act required anyone importing, manufacturing, selling, or dispensing cocaine or opiate drugs to register with the Treasury Department, pay a special tax, and keep records of all transac- tions. Because the act was a revenue measure, enforcement was made the responsibility of the Department of the Treasury and the commissioner of the Internal Revenue Service.
52 ■ Part One The Challenge of Drugs in Our Society
at Mount Vernon in 1797, eventually establishing the largest whiskey distillery of his time.17
The Rise of the Temperance Movement In the late 1700s, prominent physicians, writers, and scien- tists began to consider the adverse effects of alcohol con- sumption and tried to formulate some kind of social reform to mitigate them. The goal at that time was to reduce the consumption of distilled spirits (liquor) only. It was a temper- ate attitude toward drinking (hence the phrase temperance movement) rather than an insistence on the total prohibition of alcohol in all forms.
In nineteenth-century America, political and religious groups, particularly in primarily nonurban U.S. states, saw excessive alcohol consumption in social and moral terms. In their view, drunkenness led to poverty, a disorderly society, and civil disobedience. In short, it was unpatriotic at best and subversive at worst. When we hear the phrase “demon rum,” we have to recognize that many Americans during the nineteenth century took the phrase quite literally. Liquor was demonized as a direct source of evil in the world.
The temperance point of view toward liquor consumption spread like wildfire. In 1831, the American Temperance Society reported that nearly 2 million Americans had renounced strong liquor and that more than 800 local societies had been estab- lished. With characteristic succinctness, Abraham Lincoln
Cocaine was not defined as a narcotic under the law, but it became lumped together with opiates and often was referred to as a narcotic as well. Although application of the term “narcotic” to cocaine was incorrect (“narcotic” liter- ally means “stupor-inducing,” and cocaine is anything but that), the association has unfortunately stuck. Later, several restricted drugs, including marijuana and the hallucinogen peyote, also were officially classified as narcotics without regard to their pharmacological characteristics. Today, many people still think of any illegal drug as a narcotic, and for many years, the bureau at the Treasury Department charged with drug enforcement responsibilities was the Bureau of Narcotics, and its agents were known on the street as “narks.”
Technically, the Harrison Act did not make opiates and cocaine illegal. Physicians, dentists, and veterinarians could prescribe these drugs “in the course of their professional prac- tice only.” What this phrase meant was left to a good deal of interpretation. The Treasury Department viewed the main- tenance of patients on these drugs, particularly opiates, as beyond medical intentions, and the Supreme Court upheld this interpretation. As a result, thousands of physicians in the United States found themselves in violation of the law.
Eventually, physicians stopped issuing prescriptions for drugs now covered under the Harrison Act. A new class of criminal was created as a consequence, driving individuals to seek drugs through the black market. In what would become a continuing and unfortunate theme in the history of drug enforcement legislation, the Harrison Act failed to reduce drug-taking behavior. Instead, it created a new lucrative mar- ket for organized crime that continues to the present day.
Alcohol in America before Prohibition From its earliest days as a nation to the nineteenth century, alcohol use was a fact of life in America. Not surprisingly, the social focus of American communities during this time was the tavern. Not only did taverns serve as public dispensers of alcoholic beverages, but they also served as centers for local business dealings and town politics. Mail was delivered there; travelers could stay the night; elections were held there. As an institution, the tavern was as highly regarded, and as regularly attended, as the local church.16
By today’s standards, it is difficult to imagine the extent of alcohol consumption in the early decades of American his- tory. In 1830, the average per capita intake of alcohol was an immoderate five drinks a day, roughly four times the level of consumption today. It was common to take “whiskey breaks” at 11 a.m. and 4 p.m. each day (except Sunday), much as we take coffee breaks. As far as types of liquor were concerned, rum was the favorite in New England and along the North Atlantic coast, while in the South and West whiskey was king. George Washington himself went into the whiskey business
temperance movement: The social movement in the United States, beginning in the nineteenth century, that advocated the renunciation of liquor consumption.
Even though this 1874 engraving shows a temperance crusader in full battle regalia, relatively few temperance activists resorted to physical violence.
Chapter 3 The History of Drug Use and Drug-Control Policy ■ 53
movement, prohibition represented a cultural battle between America’s Protestant rural towns and America’s “sinful,” immigrant-filled cities.20
The Beginning and Ending of a “Noble Experiment”
The era in American history commonly known as Prohibition began in December 1917, when Congress passed a resolu- tion “prohibiting the manufacture, sale, transportation, or importation of intoxicating liquors,” the simple wording that would form the basis for the Eighteenth Amendment to the U.S. Constitution. It should be noted that it did not forbid purchase or use of alcohol, only in its production and distribu- tion. The Volstead Act of 1919, authored by Representative Andrew Volstead of Minnesota, provided for the mechanism for federal enforcement by creating a Prohibition Bureau under control of the Treasury Department. By the end of the year, the necessary 36 states had ratified the amendment, and Prohibition took effect in January 1920.
Prohibition failed to produce an alcohol-free society and spurred numerous social problems. Many citizens had little regard for the new law and continued to consume alcohol in nightclubs and bars known as speakeasies or “blind pigs.” Alcohol itself became dangerous to consume. Dangerous adulterants such as kerosene were found in the cheaper “brands” of liquor, producing paralysis, blindness, and even death.
Because of Prohibition, the “Roaring Twenties” became one of the most lawless periods in American history. Criminal organizations controlled the manufacture and distribution of “boot-leg” alcohol, smuggling huge quanti- ties of liquor into the country. Court systems handling the prosecution of violators of the Volstead Act were stretched beyond their limits. By the time Prohibition ended, nearly 800 gangsters in the city of Chicago alone had been killed in bootleg-related battles. In the countryside, operators of ille- gal stills (called “moonshiners” because they worked largely at night) continued their production despite the efforts of an occasional half-hearted raid by Treasury agents (known as “revenooers”).
Unfortunately, federal agents in the Prohibition Bureau soon developed a reputation as being inept and corrupt. The bureau itself became viewed as a training school for boot- leggers because agents frequently left law enforcement to embark upon their own criminal enterprises. One of the
observed, in an 1842 address before a national temperance organization, that prior to the temperance era, the harm done by alcohol was considered to be a result of the “abuse of a very good thing,” whereas his contemporaries now viewed the harm as coming “from the use of a bad thing.”18 By the 1850s, 12 U.S. states (more than one-third of the nation at the time) and two Canadian provinces had introduced legislation forbidding the sale of “alcoholic” (distilled) drink.
Whether or not they were justified in doing so, temper- ance groups took credit for a drastic change that was occur- ring in the levels of alcohol consumption in the United States. From 1830 to 1850, consumption of all types of alcohol plum- meted from an annual per capita level of roughly 7 gallons to roughly 2 gallons, approximately today’s consumption level. It is quite possible that this decline encouraged the temper- ance movement to formulate its ultimate goal: a prohibition of alcohol consumption in any form.
The Road to National Prohibition In 1880, the Woman’s Christian Temperance Union (WCTU) was formed, and its primary target was a highly vis- ible fixture of late-nineteenth-century masculine American life: the saloon. No longer having the benign image of a local tavern, these establishments were now vilified as the source of all the troubles alcohol could bring. Saloons were seen as a significant threat to American women in general:
Bars appeared to invite family catastrophe. They intro- duced children to drunkenness and vice and drove hus- bands to alcoholism; they also caused squandering of wages, wife beating, and child abuse; and, with the patron’s inhibitions lowered through drink, the saloon led many men into the arms of prostitutes (and not inciden- tally, contributed to the alarming spread of syphilis).19
No wonder the WCTU hated the saloon, and no saloon in the country was safe from their “pray-in” demonstrations, vocal opposition, and, in some cases, violent interventions. Their influence eventually extended into every aspect of American culture. The WCTU and other anti-alcohol groups, such as the newly formed Anti-Saloon League and National Prohibition Party, were soon electing congressional candidates, who pledged to enact national legislation ban- ning alcohol consumption throughout the land.
The American experience in World War I proved the turning point in the path toward national prohibition. During the war, anti-immigrant sentiment had begun to flourish, especially against German Americans, who were prominent in the beer industry. A campaign was launched to convince Americans that the production of beer was part of a German plot to undermine America’s willpower and deplete the cereal grains that were needed to make food for the soldiers in Europe. Prohibitionists were rural white Protestants, gen- erally antagonistic toward Irish and Italian immigrants, who were gaining political power in metropolitan areas such as Chicago and New York. To many who were behind the
speakeasies: Business establishments that sold liquor illegally during the Prohibition era.
Volstead Act of 1919: Federal legislation establishing the enforcement of the Eighteenth Amendment (Prohibition) of the U.S. Constitution.
Prohibition: A period between 1920 and 1933 in the United States when alcohol manufacture and sale was illegal.
54 ■ Part One The Challenge of Drugs in Our Society
PoRTRAIT Eliot Ness and the Untouchables
Shortly after graduating from the University of Chicago with a degree in business admin- istration and political science, Eliot Ness accepted an appointment as an agent with the U.S. Treasury Department’s Prohibition Bureau during a time when bootlegging was rampant throughout the nation. The Chicago branch of the Prohibition Bureau had a particular repu- tation for corruption, and it was difficult to find an honest law enforcement agent working in the city. Widely regarded as a model of reliability and honesty, Ness was given the job of assembling and leading a team to go after the liquor operations of famous gangster Al Capone. Capone was one of the most powerful bootleggers in the country with a multi-million dollar operation of distilleries, breweries, and speakeasies in the Chicago area.
Ness was given the personnel records of the entire Prohibition Bureau, from which he carefully selected a special team to serve under his direction. One of Ness’s first operations was to close down 18 of Capone’s operations in Chicago in one night. The raids were all scheduled to occur simultaneously at 9:30 at night so that they could make a clean sweep before the news got out to Capone. Ness’s men
led the raiding parties, and given the poor reputation of the average prohibi-
tion agent, Ness’s men made sure that no one in the raiding parties had the oppor- tunity to make a telephone call before the raid. With a sawed-off shotgun in his arms, Ness and his men charged through the front door, yelling, “Everybody keep his place! This is a federal raid!” The opera- tion was a success. Eighteen stills were shut down, and 52 people were arrested. Over the coming months, Ness and his team closed down numerous illegal stills and breweries worth an estimated $1 million.
Capone, feeling the pinch of Ness’s operations, believed that every man had his price and made several attempts to bribe Ness and his men, but he had no success. In one instance, a man threw an envelope filled with cash into a car driven by one of Ness’s men. Ness’s agents caught up with the car and threw the money back into the gangster’s car! Ness later called a press conference to talk about Capone’s failed bribery attempt. Ness wanted Capone’s organization to realize that there were still law enforcement agents who could not be bought. The press confer- ence was carried by newspapers all over the country, one of which coined the term “The Untouchables.”
Ness’s war with Capone came to an end in 1931 when Al Capone was convicted of tax evasion. Capone, with his extravagant lifestyle, had not filed an income tax return for several years, and even though his lawyers continually warned him of his vulnerability to the Internal Revenue Service, Capone always felt that he was above the law. Some have claimed that Ness was an egomaniac, who craved the spotlight and used his crusade against Capone to gain atten- tion. Ness responded to the issue of his motivation by explaining why he took the job: “Unquestionably, it was going to be highly dangerous. Yet I felt it was quite natural to jump at the task. After all, if you don’t like action and excitement, you don’t go into police work. And what the hell, I figured, nobody lives forever!”
Many years later, Ness and his unit’s exploits became popularized through a TV series The Untouchables (1959–1963) and the 1987 film costarring Kevin Costner and Sean Connery.
Sources: Heimel, Paul W. (1997). Eliot Ness: The real story. Coudersport, PA: Knox Books. Kobler, John (1971). The life and world of Al Capone. New York: G. P. Putnam’s Sons.
Prohibition Bureau’s heroes, Eliot Ness, became famous for organizing a team of agents known as “The Untouchables,” so-named because of their reputation for honesty and refusal to take bribes. In 1931, Eliot Ness and his Untouchables were able to arrest, prosecute, and eventually convict one of the most notorious crime figures of the time, Al Capone (Portrait).21
The early years of Prohibition did, however, show posi- tive effects in the area of public health. Alcohol-related deaths, cirrhosis of the liver, mental disorders, and alcohol- related crime declined in 1920 and 1921, but in a few years, the figures began to creep up again, and the level of criminal activity associated with illegal drinking was clearly intolerable.22
By the end of the decade, it was obvious for the vast majority of Americans that the “noble experiment” (as it was called at the time), despite its lofty aims, was not working. The significant social problems brought on by Prohibition were beginning to put pressure on political leaders to reconsider the concept of alcohol prohibition. In addition, there was an increasing need to restore the federal reve- nue dollars from taxes on alcohol, in order to help finance
Depression-era programs. Before Prohibition, taxes on alco- hol had been one of the primary sources of revenue for the federal government.
In 1933, President Franklin D. Roosevelt, having cam- paigned on a platform to repeal the Volstead Act, signed the necessary legislation that became the Twenty-first Amendment; ratification was swift. Alcohol was restored as a legal commodity, and regulatory control over alcohol was returned to the individual states. Prohibition as a national pol- icy was over.23 State prohibition laws were gradually repealed. In 1966, Mississippi, the last “dry” state, became “wet” as alco- hol regulation returned once more to local authorities.
Marijuana and the Marijuana Tax Act of 1937 As with opium, cocaine, and alcohol, public concerns about marijuana did not surface until the drug was linked to a minority group—namely, migrant Mexican workers. During the 1920s, Mexican laborers emigrated to the United States to perform jobs that white workers refused to do, such as picking cotton, fruit, and vegetables on large farms in the
Chapter 3 The History of Drug Use and Drug-Control Policy ■ 55
Southwest. Some of the Mexican workers would smoke mari- juana as a drug of entertainment and relaxation. When the Depression struck the United States, many white workers would take just about any job they could get, and public opin- ion supported sending the Mexican workers home. Many white laborers in the Southwest began to band together and form organizations such as the “Key Men of America” and the “American Coalition,” whose goal was to “Keep America American.” Leaders of these organizations believed that mar- ijuana and the problems with Mexican immigration were closely connected, and many southwestern police chiefs agreed. Newspaper stories began to circulate telling of how marijuana made users become sexually excited and violently insane (see Chapter 12).24
The first commissioner of the newly formed Federal Bureau of Narcotics (FBN), Harry J. Anslinger, saw the mari- juana issue as a way to gain national attention and extend the power of FBN. Congressional committees heard testimony from Anslinger, who relied on sensational tales of murder, insanity, and sexual promiscuity that were brought on by marijuana, referred to as the “killer weed.” Movies produced and released in the 1930s, such as Reefer Madness (now a cult classic on many university campuses) and Marihuana: Weed with Roots in Hell, supported Anslinger’s propaganda campaign by depicting innocent young people committing terrible acts under the influence of marijuana. The result was the Marijuana Tax Act of 1937, which did not outlaw marijuana but required that a tax be collected on its manu- facture and sale. Each time marijuana was sold, the seller had to pay a tax of as much as $100 per ounce for a trans- fer tax stamp. Failure to possess such a stamp was a federal offense, and not surprisingly, tax stamps were rarely issued. The 1937 law effectively made marijuana illegal, and the drug was prohibited in this manner until the Controlled Substances Act of 1970.
The Federal Food, Drug, and Cosmetic Act of 1938 When the Pure Food and Drug Act was passed in 1906, consumer protection was limited to the accurate labeling of the product being sold. A particular drug could be totally useless or dangerous (or both) and still be legally sold as long as the label itself listed everything that was in it. In answering the public outcry over the thousands of unsafe and ineffective drugs on the market, President Roosevelt signed into law the Federal Food, Drug, and Cosmetic Act of 1938. The law mandated for the first time that drugs and cosmetic products not only had to be accurately identified, but manufacturers were required to demonstrate through research studies that their products were safe (when used as directed) prior to being marketed. The law also estab- lished the U.S. Food and Drug Administration (FDA) as the enforcement agency to insure the safety of commercial drugs. The Kefauver-Harris Amendment of 1962 extended the power of the FDA to insure that commercial drugs would be effective as well as safe.
Kefauver-Harris Amendment of 1962: Federal legislation extending the Federal Food, Drug, and Cosmetic Act to include a requirement that commercially marketed drugs are effective as well as safe.
Federal Food, Drug, and Cosmetic Act of 1938: Federal legislation requiring that commercially marketed drug have been determined to be safe when used as directed. The law also established the U.S. Food and Drug Administration (FDA) as the enforcement agency for regulating the safety and later, through further legislation, the effectiveness of commercially marketed drugs.
Marijuana Tax Act of 1937: Federal legislation regulating through government taxation the manufacture and sale of marijuana. The law effectively changed the status of mari- juana from a licit to an illicit substance in the United States.
Drugs and Society from 1945 to 1960
In the recreational drug scene of post–World War II United States, smoking was considered romantic and sexy. It was the era of the two-martini lunch, when social drinking was at its height of popularity and acceptance. Cocktail parties dominated the social scene. There was little or no public awareness that alcohol or tobacco consumption could be considered drug-taking behavior.
On the other hand, the general perception of certain drugs such as heroin, marijuana, and cocaine was simple and nega- tive: They were considered bad and illegal, and “no one you knew” had anything to do with them. Illicit drugs were seen as the province of criminals, the urban poor, and nonwhites.25 The point is that, during this period, a whole class of drugs and drug-taking behavior was outside the mainstream of American life. Furthermore, an atmosphere of fear and suspicion sur- rounded people who took such drugs. Commissioner Anslinger
The television series, Mad Men, has effectively depicted the casual glamor of cigarette smoking in the late 1950s and early 1960s.
56 ■ Part One The Challenge of Drugs in Our Society
heroin from Mexico, known as “black tar,” was beginning to be sold throughout western United States. Heroin abuse increased in many inner cities, and heroin abuse was later connected to a rise in the crime rate, specifically a growing number of robberies and burglaries committed by heroin abusers to get money to buy drugs (see Chapter 6).26
For President Richard Nixon, elected in 1968 on a platform of law and order, illicit drug use became a major political issue. He declared a “total war on drugs,” order- ing his senior staff to make the reduction of drug abuse one of its top priorities. In 1970, the Nixon administra- tion persuaded Congress to pass the Comprehensive Drug Abuse Prevention and Control Act, popularly known as the “Controlled Substances Act.” The act was passed to con- solidate the large number of diverse and overlapping drug laws as well as the duplication of efforts by several different federal agencies. The act established five schedules for the classification of drugs, based upon their approved medical uses, potential for abuse, and potential for producing depen- dence. As a result of the 1970 Controlled Substances Act, the control of drugs was placed under federal jurisdiction regardless of state regulations.
The 1970 act also shifted the administration of fed- eral drug enforcement from the Treasury Department to the Department of Justice, creating the Drug Enforcement Administration (DEA). The DEA was given the control of all drug enforcement responsibilities, except those related to ports of entry and borders, which were given to the U.S. Customs Service (now renamed as the U.S. Customs and Border Protection). DEA agents were to conduct drug investigation, collect intelligence about general trends in drug trafficking and drug production, and coordinate efforts among federal, state, and local law enforcement agencies. The DEA’s mission today remains both domestic and for- eign. Agents are stationed in foreign countries, and although they do not possess arrest powers, they act as liaisons with foreign law enforcement agencies. Both the DEA and the Federal Bureau of Investigation (FBI) share responsibility for enforcement of the Controlled Substances Act of 1970, and the director of the DEA reports to the director of the FBI, who in 1982 was given responsibility for supervising all drug- law enforcement efforts and policies (Drug Enforcement . . . in Focus).
President Nixon also believed that reducing the sup- ply of drugs from overseas sources could curb drug abuse in the United States. In the 1970s, the federal govern- ment estimated that 80 percent of the heroin reaching the United States was produced from opium poppies grown in Turkey. In an attempt to reduce the amount of heroin com- ing into the United States, the Nixon administration threat- ened to cut off aid to Turkey if that country did not put an end to the export of opium. Nixon also promised Turkey millions of dollars in aid to make up for the subsequent losses resulting from reduced poppy cultivation. Initially, this action did lead to a shortage of heroin on American streets in 1973. The decline in heroin availability, however, did not last long. In 1974, Mexico became a primary source
in the 1950s accused the People’s Republic of China of selling opium and heroin to finance the expansion of communism. Drug abuse now became un-American, and Congress became convinced that penalties for illicit drug use were too lenient. Federal legislation in 1951 and 1956 increased the penalties of previously enacted marijuana and narcotics laws, lumping together marijuana and opiates under uniform penalties. A minimum sentence of two years imprisonment was mandated for first-time offenders and up to 10 years imprisonment for repeat offenders; the sale of heroin to individuals under the age of 18 was made a capital offense. The basis of these laws was the belief that strict drug laws and an increase in drug-law enforcement would curb future drug demand.
Turbulence, Treatment, and the War on Drugs, 1960–1980
During the 1960s, the basic premises of American life—the beliefs that working hard and living a good life would bring happiness and that society was stable and calm—were being undermined by the reality of the Vietnam war abroad and social unrest at home. The large adolescent and college- aged cohort born after World War II, often referred to as the “baby boomers” or “hippie” generation, was challenging many accepted cultural norms and the established hierar- chy. Many young people were searching for new answers to old problems, and their search led to experimentation with drugs that their parents had been taught to fear. The prin- cipal symbol of this era of defiance against the established order, or indeed against anyone over 30 years of age, was marijuana. No longer would marijuana be something for- eign to Middle America. Marijuana, as well as new drugs such as LSD and other hallucinogens, became associated with the sons and daughters of white middle-class families. Illicit drug use, once a problem associated with minority populations, inner cities, and the poor, was now too close to our personal lives for us to ignore.
Along with the turbulence of the period came a disturb- ing increase in heroin abuse across the country. In the early 1970s, reports surfaced estimating that up to 15 percent of the American troops returning home from Vietnam had been her- oin abusers. As detailed in Chapter 2, organized crime groups in Europe established the “French connection,” in which opium grown in Turkey was converted into heroin in south- ern French port cities, smuggled into America, and then sold on the streets of major cities. A new form of crudely processed
Comprehensive Drug Abuse Prevention and Control Act of 1970 (Controlled Substances Act): Federal legislation establishing five categories (schedules) of controlled substances based on their approved medical uses, potential for abuse, and potential for producing dependence. The law also shifted the jurisdiction for drug-law enforcement from the Treasury Department to the Department of Justice.
Chapter 3 The History of Drug Use and Drug-Control Policy ■ 57
Drug Enforcement … in Focus
The DEA Special Agent badge marks the entrance to the DEA Museum in Arlington, Virginia.
of opium production, and in response, the U.S. govern- ment began to finance opium poppy eradication programs in Mexico (see Chapter 2).27
Another response of the Nixon administration to drug abuse, particularly with regard to the increase in heroin dependence, was to finance a number of treatment programs for drug-dependent individuals. These treatment programs ranged from inpatient detoxification and therapeutic com- munities to newly created methadone outpatient programs. Methadone is a long-acting opiate that is taken orally in order to prevent heroin withdrawal symptoms for up to 24 hours (see Chapter 9). Methadone maintenance pro- grams were designed to wean heroin abusers off of heroin by allowing them to have a better chance at employment and ending the need to commit crimes to maintain their abuse. After an initial report of the drug’s success in 1966,
methadone’s popularity quickly spread. Methadone mainte- nance programs represented the first time that the federal government made a commitment to drug-abuse treatment in the community.
By 1972, some of the Nixon administration’s anti-drug programs appeared to be working. There was a national net- work of methadone treatment centers and evidence of suc- cessful eradication efforts. Turkey had agreed to stop growing opium, and Mexico was cooperating with U.S. law enforce- ment. The price of heroin was up, the purity level was down, and there was a decrease in the number of drug overdose cases. When President Gerald Ford took office in 1974, how- ever, the nation’s attention was diverted from drug abuse to other issues, such as unemployment, inflation, and an energy crisis. Illicit drug use was no longer a dominating issue. Ford’s policy toward illicit drug use was based on the attitude
• The National Forensic Laboratory Information System (NFLIS) is a nationwide system of nearly 300 federal, state, and local forensic laboratories that analyze the contents of drugs seized by the DEA and report to the DEA Diversion Control office as to patterns of illicit drug availability. Nearly 300 forensic chemists employed by the DEA are involved in this program. The annual budget of the DEA is approximately $2.87 billion.
The agency is officially under the U.S. Department of Justice in Washington, DC.
Source: The Drug Enforcement Administration, U.S. Department of Justice, Washington, DC.
The Drug Enforcement Administration Today The Drug Enforcement Administration was established in 1973 to create a single federal agency for the enforcement of federal drug laws and consolidate drug-control responsibilities previously held by the Bureau of Narcotics and Dangerous Drugs (formerly the Federal Bureau of Narcotics under Harry J. Anslinger), the Office of Drug Abuse Law Enforcement, and other federal agencies. The DEA became the lead agency for domestic enforcement of the Controlled Substances Act of 1970 in conjunction with the FBI and Immigration and Customs Enforcement (ICE) as well as sole responsibility for U.S. drug investigations in foreign countries. These responsibilities remain the mission of the DEA today.
The DEA currently employs more than 9,600 men and women, including nearly 5,000 Special Agents (see badge in photo). In addition, nearly 2,000 DEA employees are specialists in three programs: • The DEA Intelligence Program is responsible for tactical
intelligence information that facilitates the arrests, seizures, and interdiction of violators of the Controlled Substances Act and strategic intelligence information focusing on patterns of drug trafficking around the world. Nearly 700 Intelligence Specialists are employed in the El Paso Intelligence Center (EPIC) in Texas.
• The DEA Diversion Control Program is responsible for the investigation and support for the prosecution of cases in which controlled substances such as OxyContin and other opioid pain medications (see Chapter 9) that are manufac- tured for legitimate medical use but diverted through illegal distribution channels. Nearly 600 diversion investigators are employed in seven regional offices in the United States.
58 ■ Part One The Challenge of Drugs in Our Society
however, the harsh realities of cocaine dependence were recognized. The very same celebrities, who had accepted cocaine into their lives, were now experiencing the conse- quences; many of them were in rehabilitation programs, and some had died from cocaine overdoses. To make mat- ters worse, in 1985, a new form of cocaine called “crack,” smokable and cheap, succeeded in extending the problems of cocaine dependence to the inner cities of the United States, to segments of American society that did not have the financial resources to afford cocaine itself. In the glare of intense media attention, crack dependence soon took on all the aspects of a national nightmare.
In the 1970s, there had been generally a lack of public interest and even some tolerance of drug use. As mentioned earlier, in several U.S. states there was even a trend toward deregulation. In the 1980s, however, the lack of public interest in drug use began to shift as grassroots groups began to demand that something be done about “America’s drug problem.” During the presidency of Ronald Reagan, drug abuse became a major political and social issue. President Reagan declared an all-out war on drugs, and First Lady Nancy Reagan launched her “Just Say No” campaign, which focused mostly on white middle-class children, who had not yet tried drugs. Reagan’s war on drugs focused on a policy of controlling the supply of drugs by increasing the budgets of drug enforcement agencies and providing foreign aid to such countries as Colombia, Peru, Bolivia, and Mexico. Demand was to be reduced by enacting laws that imposed some of the harshest penalties ever for drug- law violators.
With popular sentiment once again turned against drugs, Congress rewrote virtually all of the nation’s drug laws in record time. In 1984, Congress passed the Comprehensive Crime Control Act, which increased the penalties for violations of the Controlled Substances Act and expanded asset-forfeiture law, allowing both local and federal drug enforcement agencies to keep most of the money made from the sale of seized assets (see Chapter 7). Two years later, Congress passed the Anti-Drug Abuse Act of 1986, which placed mandatory minimum sentences for federal drug convictions, eliminating a judge’s discretion in pronouncing a sentence. Different mandatory minimum sentences were to be given for possession of powder and crack cocaine. The new law imposed a prison sentence of 5 to 40 years for possession of 500 grams of powder cocaine or 5 grams of crack cocaine. This mandatory sentence could not be suspended, nor could the offender be paroled or placed on probation. The Anti-Drug Abuse Act of 1986 also created a “kingpin” statute under which the heads of drug trafficking organizations could receive mandatory life imprisonment if convicted of operating a continuing crimi- nal enterprise.
One of the most important drug laws passed in the 1980s was the Anti-Drug Abuse Act of 1988. This legis- lation created a cabinet-level Director of National Drug Control Policy, often referred to in the media as the “Drug Czar,” whose job was to coordinate federal activities with
that drug abuse was here to stay and that the emphasis of government actions should be on containing rather than eliminating the problem. The administration also believed that some drugs were more dangerous than others and that anti-drug policies should be directed at controlling the sup- ply and demand of those drugs that posed the greatest threat to society.
President Jimmy Carter, elected in 1976, was more tol- erant toward drug use than Ford and even favored decrimi- nalization of the possession of small amounts of marijuana. President Carter stated: “Penalties against possession of a drug should not be more damaging to an individual than the use of the drug itself, and where they are, they should be changed. Nowhere is this more clear than in the laws against the possession of marijuana in private for per- sonal use.”28 By 1978, 11 states followed Carter’s lead and decriminalized small amounts of marijuana. California and Oregon made possession of one ounce or less of marijuana a citable misdemeanor with a maximum penalty of $1,000, and there were no increased penalties for repeat offend- ers.29 Relaxed attitudes toward drugs reached a peak in 1979, a year when an astounding 51 percent of high school seniors reported having smoked marijuana, and 28 percent reported using an illicit drug other than marijuana over the past 12 months, considerably higher levels than reported in 2013 (see Chapter 1).30
Renewed Efforts at Control, 1980–2000
With the decade of the 1980s came significant changes in the mood of the country in the form of a social and political reaction to earlier decades. If the media symbol formerly had been the “hippie,” now it was the “yuppie,” a young, upwardly mobile professional. The political cli- mate became more conservative in all age groups. With regard to drugs, the concern about heroin dependence was being overshadowed by a new fixation: cocaine. At first, cocaine took on an aura of glamor and (because it was so expensive) became a symbol of material success. The media spotlight shone on a steady stream of celebrities in entertainment and sports who used cocaine. Not long after,
Anti-Drug Abuse Act of 1988: Federal legislation creating a cabinet-level “Drug Czar” position to coordinate all federal drug-control activities.
Anti-Drug Abuse Act of 1986: Federal legislation establish- ing mandatory minimum sentences for federal drug convic- tions and creating special penalties for major leaders of drug trafficking organizations.
Comprehensive Crime Control Act of 1984: Federal legislation increasing penalties for drug possession and traf- ficking under the Controlled Substances Act and expanded laws regarding asset forfeiture of major drug traffickers.
Chapter 3 The History of Drug Use and Drug-Control Policy ■ 59
This provision later established the basis for drug testing in schools and in the workplace.
The wave of anti-drug legislation in the 1980s (Drugs … in Focus) profoundly changed America’s criminal justice sys- tem. Law enforcement budgets increased as more officers had to be hired to enforce drug laws. The number of drug violators increased to the highest level ever, and courts became back- logged with drug case after drug case. The number of inmates in U.S. prisons and jails rose nearly 100 percent from 1985 to 1996, and the budget for prisons increased by more than 160 percent.31 Prison building became one of the biggest pub- lic works projects in America; hundreds of new prisons sprang up across the country. Fortunately, by the end of the 1990s, the extent of crack abuse had greatly diminished, crime rates had begun to fall, and rates of illicit drug use began to decline. It is still being debated, however, whether these changes were due to the “get tough” policy on drugs.
respect to both drug supply and demand reduction. The first director was former Education Secretary William J. Bennett, who believed that individual users of drugs should accept moral responsibility for their behavior. Bennett believed that drug laws should be strict so that drug users would understand that involvement in the illegal drug trade has clear consequences. The law created harsher penal- ties for the possession of drugs; penalties for selling drugs to minors were enhanced; and the act reinstated the death penalty for anyone convicted as a “drug kingpin” or anyone convicted of a drug-related killing. The act also addressed alcohol use, especially the problem of drunk driving, by providing federal money to states that instituted tough pen- alties for drunk drivers. Lastly, the act addressed the issues of drug use in schools and in the workplace by requiring educational institutions and businesses to establish a system to ensure that students and workers remained drug free.
A History of American Drug-Control Legislation 1794 A federal tax on whiskey leads to the Whiskey
Rebellion in western Pennsylvania (see Chapter 15).
1868 The Pharmacy Act of 1868 requires registration of those individuals dispensing drugs.
1875 The Anti-Opium Smoking Act is passed in San Francisco.
1906 The Pure Food and Drug Act requires all packaged foods and drugs to list the ingredients on the label of the product.
1914 The Harrison Act is designed to regulate addiction and drug abuse through government taxation.
1919 Congress passes the Eighteenth Amendment, which outlaws the manufacture and sale of alcohol.
1933 Congress passes the Twenty-first Amendment, which repeals the Eighteenth Amendment.
1937 The Marijuana Tax Act places a tax on the manufac- ture and sale of marijuana.
1938 The Food, Drug, and Cosmetic Act requires all drugs and cosmetics are tested for safety (when used as directed) prior to being marketed. The U.S. Food and Drug Administration (FDA) is established to insure the safety of commercial drugs.
1962 The Kefauver-Harris Amendment extends the power of the FDA to ensure the effectiveness as well as safety of commercial drugs.
1970 Comprehensive Drug Abuse Prevention and Control Act, popularly known as the Controlled Substances Act, establishes five schedules for the classification of drugs based upon their approved medical uses, potential for abuse, and potential for producing dependence.
1984 The Comprehensive Crime Control Act enhances the penalties for violations of the Controlled Substances Act and expands asset-forfeiture law, allowing both local and federal drug enforcement agencies to keep the majority of the money made from the sale of seized assets.
1986 The Anti-Drug Abuse Act of 1986 establishes manda- tory sentences for federal drug convictions, eliminat- ing a judge’s discretion in pronouncing a sentence.
1988 The Anti-Drug Abuse Act of 1988 increases penalties for drug offenses involving children and creates a cabinet- level position of Director of National Drug Control Policy, often referred to in the media as “Drug Czar.”
1996 Arizona Proposition 200 and California Proposition 215 are passed, which legalize the use of marijuana for medicinal purposes within these two states (see Chapter 12).
1996 The Comprehensive Methamphetamine Control Act increases the penalties for trafficking and manufacture of methamphetamine and its precursor chemicals.
Drugs … in Focus
60 ■ Part One The Challenge of Drugs in Our Society
The 1990s can be characterized as a period of relatively little political interest in drug-abuse issues. During his first term in office from 1992 to 1996, President Bill Clinton reduced the staff of the Office of National Drug Control Policy by 83 percent, a move that he ascribed to keeping his campaign promise to reduce the White House staff by 25 percent. As the 1996 election approached and a rise in marijuana use among youth became publicized, Clinton was subject to the criticism that he had neglected America’s drug problem. In response, Clinton declared his own war on drugs and appointed a retired four-star military general, Barry McCaffrey, to be his “Drug Czar.” Clinton urged Congress to appropriate a $100 million increase in the bud- get for drug interdiction and increased foreign aid to stop the supply of drugs at their source. In addition, he signed the Comprehensive Methamphetamine Control Act into law in 1996. Designed to curb the use of methamphetamine, this act increased funding for identifying and dismantling small clandestine “meth labs” that were appearing across the country and increased restrictions on the sale of precursor chemicals used in the manufacture of methamphetamine (see Chapter 10).
Global Politics and National Security: 2001–Present
After the events of September 11, 2001, the war on ter- rorism became a dominating concern. As discussed in Chapter 2, President George W. Bush combined pro- grams aimed at drug-abuse control with programs aimed
2000 GHB (gamma-hydroxybutyrate) is added to the list of Schedule I controlled substances.
2003 The Illicit Drug Anti-Proliferation Act, aimed at the promoters of “raves,” holds persons more accountable for knowingly renting, leasing, or maintaining any place where drugs are distributed or manufactured.
2004 The Anabolic Steroid Control Act of 2004 adds sev- eral new steroids and steroid precursors to the list of controlled substances.
2004 The U.S. Food and Drug Administration (FDA) issues regulations prohibiting the sale of dietary supplements containing ephedrine.
2005 The Combat Methamphetamine Epidemic Act establishes nationwide sales restrictions on precursor chemicals and law enforcement initiatives for the sei- zure of domestic methamphetamine laboratories.
2009 The Tobacco Control Act gives the FDA authority to regulate the sale and manufacture of tobacco prod- ucts (see Chapter 16).
2012 The Synthetic Drug Abuse Prevention Act adds 26 chemicals to Schedule I controlled substances and extends authority of the DEA over the introduction of new synthetic drug formulations.
Quick Concept Check
Understanding the History of U.S. Drug-Control Legislation Test your understanding of American drug-control legislation by matching the statement on the left with the associated drug on the right. Note: An answer may be used more than once.
3.2
1. It has been suggested that, in order to get federal drug legislation passed in 1914, a propaganda campaign was launched that associated African Americans with this drug.
2. The opposition to this drug was intertwined with a negative reaction toward German, Italian, and Irish immigrants.
3. Legislation that made this drug an illegal substance in 1937 was linked to drug-taking behavior among Mexican migrant workers.
4. The Nixon administration initiated programs in the late 1960s that promoted this opiate drug as a thera- peutic strategy for treating individu- als dependent on heroin.
5. During Jimmy Carter’s presidency in the late 1970s, several states voted to decriminalize this drug.
6. Federal legislation passed in 1996 funds law enforcement efforts to close down small clandestine labo- ratories that were manufacturing this drug.
a. marijuana
b. methamphet- amine
c. cocaine
d. morphine
e. alcohol
f. heroin
g. methadone
Answers: 1. c. 2. e. 3. a. 4. g. 5. a. 6. b.
Comprehensive Methamphetamine Control Act of 1996: Federal legislation increasing penalties for methamphetamine trafficking and setting limits on the purchase of precursor materials for methamphetamine production.
Chapter 3 The History of Drug Use and Drug-Control Policy ■ 61
local law enforcement agencies in the investigation and prosecution of individuals committing methamphetamine offenses.
The Aims of Drug-Control Policy: Public Health and Public Safety
In general, societal problems associated with drug use and abuse can be broken down into two broad and somewhat overlapping areas of concern: public health and public safety.
Addressing public health concerns requires the efforts of psychiatrists, psychologists, drug-abuse counselors, and other health professionals, who focus on the effects of the use and abuse of a substance (or multiple substances) on one’s physi- cal health and psychological well-being. The decision to treat an individual with a drug problem is based on behavioral cri- teria. For example, an individual might have persistent inten- tions or make persistent efforts to cut down on drug-taking behavior, or fail on a recurring basis to meet major respon- sibilities at work, school, or home. While the treatment for these difficulties may be specifically tied to the type of drug that is involved, the diagnosis is based solely on the adverse behavioral consequences of drug use, not on the nature of the drug itself. Whether the drug is legal or illegal is not an issue. The strategy of health professions in addressing the public health concerns of drug-taking behavior will be examined in Chapter 4.
Addressing the public safety concerns, however, rests upon the efforts of governmental officials and professionals in the field of criminal justice. In this latter case, specific cat- egories of drugs have been established under the Controlled Substances Act of 1970, based upon accepted medical ben- efits and their potential for abuse. These categories represent the official stance of the U.S. government with regard to the degree to which public access to a specific drug should be
at enhancing national security. In effect, the war on drugs became intertwined with the war against terrorism in one all-encompassing policy. Foreign aid to Colombia was increased enormously, not only to fight drug trafficking but also to support Colombia’s domestic war against insurgent groups within the country.32
At the same time, as discussed in Chapter 2, efforts to control global drug trafficking have been complicated by economic and political aspects of U.S. foreign policy. Our relations with Mexico, for example, have been strained by the fact that Mexico continues to be not only a major traf- ficking route for cocaine from South America and heroin from Mexico itself but also a source of marijuana cultivation and a manufacturing source of methamphetamine and ille- gal medications. Efforts to reduce the cultivation of opium in the rugged, mountainous areas of Afghanistan have been intertwined with efforts to control the political influence of regional warlords, whether they have terrorist associations or not. The interconnected and sometimes opposing goals of America’s drug-control policy and global foreign policy continue to be a major challenge in the effort to regulate drug-taking behavior both in the United States and around the world.33
Domestic Drug Trafficking and National Security: 2001–Present
The connection between the war on drugs and the war on terrorism has been evident at the domestic level as well. The USA PATRIOT Act of 2001, enacted as a response to the September 11 attacks, increased the ability for federal author- ities to tap telephones and wireless devices, monitor Internet communications, and tighten the enforcement of money laundering activities, as well as protect U.S. borders. These powers were directed toward not only possible acts of terror- ism but also other criminal acts such as drug trafficking. The USA PATRIOT Improvement and Reauthorization Act of 2005 (often referred to as “PATRIOT II”) extended the original legislation, relaxing certain provisions that had been criticized as being restrictive of individual civil liberties, tight- ening other provisions regarding law enforcement powers, and closing some loopholes in the 2001 act with regard to terrorist financing.
Significantly, PATRIOT II contained a subsection called the Combat Methamphetamine Epidemic Act that restricted access to over-the-counter cold medications that could be used to manufacture methamphetamine (see Chapter 10). Limits on the amounts purchased were established, and consumers were required to provide photo identification and sign in a store log at the time of pur- chase. In addition, funding was authorized for the federal Meth Hot Spots program, intended to support state and
Combat Methamphetamine Epidemic Act of 2005: A portion of the USA PATRIOT Improvement and Reauthoriza- tion Act of 2005, setting limits on the sale of over-the-counter medications typically used as precursor materials for meth- amphetamine production and increasing support for law enforcement agencies involved in methamphetamine control operations.
USA PATRIoT Improvement and Reauthorization Act of 2005: Federal legislation modifying the USA Patriot Act of 2001, so as to satisfy certain civil liberty concerns and close certain loopholes in the previous law.
USA PATRIoT Act of 2001: Federal legislation authoriz- ing federal agents to carry on telephone and electronic surveillance in drug-control operations, increased money laundering enforcement, and expanded operations at the U.S. border.
62 ■ Part One The Challenge of Drugs in Our Society
allowed. Under this system, the guiding principle for view- ing drug-taking behavior from a criminal-justice perspective is that drugs with the fewest medical benefits and the great- est potential for abuse should be the drugs with the most stringently restricted availability to the public, as established by law. In addition, the possession and trafficking of these drugs should carry the most severe criminal penalties. The set of decisions as to which drugs are listed in a particular category is directly tied to the prevailing drug-control pol- icy at the time. As we will see in Chapter 12, a conflict has arisen between the U.S. federal government that has estab- lished marijuana as a Schedule I controlled substances and individual U.S. states that have legalized recreational mari- juana use.
It is clear that public health and public safety concerns frequently overlap when addressing the overall problems of drug use and abuse. In order to achieve the most produc- tive solutions to the drug problem in our society, health professionals and criminal-justice professionals coordinate their efforts as much as possible. A good example of this collaboration has been the creation of specialized drug courts for nonviolent drug-law offenders (Chapter 8).
Drug-Control Policy Today: Five Schedules of Controlled Substances
From the perspective of the U.S. federal government and criminal-justice professionals under federal jurisdic- tion, the legality of various forms of drug-taking behavior is defined along the five-category system created more than 40 years ago under the Controlled Substances Act. Each category or schedule defines a particular chemical substance in terms of its potential for medical use and its potential for abuse. The guiding principle is that those substances having the lowest potential for medical use and the highest potential for abuse (Schedule I controlled sub- stances) should be the substances whose availability to the public is most stringently restricted. In addition, the pos- session and trafficking of Schedule I controlled substances (with the exception of marijuana) carry the harshest crimi- nal penalties. Schedule II controlled substances are pre- scribed medications that are the most tightly regulated; no prescriptions for Schedule I controlled substances are permitted. Table 3.1 lists the major drugs under Schedules I through V. The specific criminal penalties for possession and trafficking of controlled substances will be outlined in Chapter 8.
TABLE 3.1
Summary of Controlled Substances Schedules under the Controlled Substances Act
SCHEDULE I:
Criteria: high potential for abuse; no accepted medical use
Restrictions: research use only; drugs must be stored in secure vaults
Examples: heroin, LSD, marijuana, MDMA (Ecstasy), mesca- line, mescaline, methqualone, methcathinone (khat), peyote, psilocybin
SCHEDULE II:
Criteria: high potential for abuse; some accepted medical use, though use may lead to severe physical or psychological dependence
Restrictions: no prescription renewals permitted; in cases of medical use, drugs must be stored in secure vaults
Examples: amphetamines (Dexedrine, Adderall), cocaine, coca leaves, codeine, hydrocodone (Vicodin)*, methadone, methamphetamine, methylphenidate (Ritalin), morphine, oxycodone (Percocet, OxyContin), phencyclidine (PCP)
SCHEDULE III:
Criteria: high potential for abuse; accepted medical use, though use may lead to low or moderate physical or psychological dependence
Restrictions: up to five prescription renewals permitted within six months
Examples: anabolic steroids and other testosterone-based compounds, ketamine
SCHEDULE IV:
Criteria: low potential for abuse; accepted medical use
Restrictions: up to five prescription renewals are permitted within six months.
Examples: antianxiety medications, antidepressant medica- tions, choral hydrate, phenobarbital, temazaepan (Restoril) triazolam (Halcion)
SCHEDULE V:
Criteria: minimal potential for abuse; widespread medical use
Restrictions: minimal controls for selling and dispensing
Examples: cough-control medications containing small amounts of codeine and diarrhea-control medications containing small amounts of opium or morphine
*As of 2014, hydrocodone (Vicodin) is now reclassified as a Schedule II controlled substance. Prior to 2014, it was classified under Schedule III. The reclassification was a result of concerns over widespread overprescriptions of hydrocodone and diversion of the drug to nonmedical recreational use.
Note: A full listing of drugs categorized as controlled substances in Schedules I through V can be found in publications of the Drug Enforcement Administration, http//www.justice.gov/dea.
Source: Based on data supplied by the Drug Enforcement Administration, U.S. Department of Justice, Washington, DC.
Chapter 3 The History of Drug Use and Drug-Control Policy ■ 63
Drugs in Early Times ●● Probably the earliest experiences with psychoactive drugs
came from tasting naturally growing plants. Individuals with knowledge about such plants were able to attain great power within their societies.
●● Ancient Egyptians and Babylonians, in particular, had extensive knowledge of both psychoactive and nonpsycho- active drugs. Some of these drugs had genuine beneficial effects, while others did not.
Drugs in the Nineteenth Century ●● Medical advances in the mid-1800s allowed isolation of
the active ingredients within many psychoactive sub- stances. For example, morphine was identified as the major active ingredient in opium.
●● During the nineteenth century, there was little regulation or control of drugs, and the U.S. government imposed no limitations on their distribution, sale, and promotion. The result was a century of widespread and uncontrolled medicinal and recreational drug use.
Drug Regulation in the Early Twentieth Century ●● The effects of drug dependence began to become a social
concern. The two most important factors that fueled the movement toward drug regulation in the beginning of the twentieth century were (1) the abuse of patent medicines and (2) the association of drug use with socially marginal- ized minority groups.
Drug Regulation, 1914–1937 ●● The Harrison Act of 1914 was the first of several legislative
efforts to impose criminal penalties on the use of opiates and cocaine.
●● Passage of the Eighteenth Amendment resulted in the national prohibition of alcohol in the United States from 1920 to 1933.
●● The Marijuana Tax Act of 1937 required that a tax stamp be issued to anyone selling marijuana. Tax stamps, how- ever, were rarely issued, making marijuana essentially illegal. The drug was prohibited in this way until the Controlled Substances Act of 1970.
Drugs and Society from 1945 to 1960 ●● During the 1940s and 1950s, the use of illicit drugs such
as heroin, cocaine, and marijuana was outside the main- stream of American life.
●● Legislation during the 1950s imposed increasingly severe penalties for drug violations.
Turbulence, Trafficking, and Treatment, 1960–1980 ●● In the 1960s and 1970s, the use of marijuana and hallucino-
genic drugs among young people spread across the nation, along with an increase in problems related to heroin.
●● President Richard Nixon declared a “total war on drugs,” directing the reduction in drug abuse as one of America’s top priorities. Two aspects of this initia- tive were the international pressure on specific foreign nations to reduce the source of illicit drugs entering the United States and the establishment of drug-abuse treat- ment programs.
●● The Controlled Substances Act of 1970 established a fed- eral drug-control system based upon a classification of drugs in five groups called schedules, I through V. Under this act, a drug is “scheduled” on the basis of its approved medical uses, potential for abuse, and potential for pro- ducing dependence.
●● By the end of the 1970s, drug-control policy in the United States shifted to a position of relative toler- ance with regard to drug-taking behavior. In some U.S. states, the possession of small amounts of marijuana was decriminalized.
Renewed Efforts at Control, 1980–2000 ●● A decline in heroin abuse in the 1980s was matched by an
increase in cocaine abuse and the emergence of crack as a cheap, smokable form of cocaine.
●● During the 1980s, a wave of federal drug legislation increased the penalties for the possession and trafficking of illicit drugs. As a result, the number of drug violators rose to record levels, and courts became backlogged with drug cases. The number of inmates in U.S. prisons and jails rose nearly 100 percent from 1985 to 1996.
Global Politics and National Security: 2001–Present
●● The 1990s and the beginning of the twenty-first century can be characterized by a general lack of political inter- est in drug abuse. After the events of September 11, 2001, however, the war on drugs became intertwined with the war on international and domestic terrorism.
●● The USA PATRIOT Act of 2001 was enacted as a response to the September 11 attacks, increasing the ability for federal authorities to monitor communications related to possible terrorist activities, tighten money laundering enforcement, and increase the protection of U.S. borders. These powers were directed toward other criminal acts, including drug trafficking.
Summary
64 ■ Part One The Challenge of Drugs in Our Society
●● The reauthorization of the PATRIOT Act legislation, known as PATRIOT II, included a program to restrict access to over-the-counter cold medications that could be used in the manufacture of methamphetamine.
●● The five-category classification of controlled substances established by the Controlled Substances Act remains the official stance of the federal government with regard
to the legal use of drugs. Substances in the first category, designated as having the lowest potential for medical use and the highest potential for abuse (Schedule I controlled substances) are those substances with the most restricted access to the public and carrying the harshest criminal penalties for their possession or trafficking.
Key Terms
Anti-Drug Abuse Act of 1986, p. 58
Anti-Drug Abuse Act of 1988, p. 58
Combat Methamphetamine Epidemic Act of 2005, p. 60
Comprehensive Crime Control Act of 1984, p. 58
Comprehensive Drug Abuse Prevention and Control
Act of 1970 (Controlled Substances Act), p. 56
Comprehensive Methamphet- amine Control Act of 1996, p. 61
Ebers Papyrus, p. 48 Federal Food, Drug, and
Cosmetic Act of 1938, p. 55
Harrison Act of 1914, p. 51
Kefauver-Harris Amendment of 1962, p. 55
laissez-faire, p. 49 Marijuana Tax Act of 1937,
p. 55 patent medicine, p.50 placebo effect, p. 48 Prohibition, p. 53 Pure Food and Drug Act of
1906, p. 50
shaman, p. 47 shamanism, p. 47 speakeasies, p. 53 temperance movement, p. 52 Volstead Act of 1919, p. 53 USA PATRIOT Act of 2001,
p. 61 USA PATRIOT Improvement
and Reauthorization Act of 2005, p. 61
1. Describe the public attitude and the official stance of the fed- eral government with respect to the use of opiate drugs prior to and subsequent to passage of the Harrison Act of 1914.
2. Discuss the positions for and against having a national prohibi- tion of alcohol in the United States. Provide some reasons why national prohibition failed.
3. Discuss the developments related to the “war on drugs” subse- quent to the events of September 11, 2001.
4. Describe the criteria for listing a particular drug in the five- category system of scheduled controlled substances under the Controlled Substances Act of 1970 and provide two examples of drugs that are listed in each of the five categories.
Review Questions
Given the relationship between prevalence rates for various illicit drugs and the perceived risk of harm in regular use in the Univer- sity of Michigan survey of high school seniors (Chapter 1), what advantages or disadvantages would there be in scaling back the
criminal penalties for possession of illicit drugs according to the extent to which the drugs are perceived as presenting relatively little risk of harm? How would this impact the existing system of schedul- ing drugs according to the Controlled Substances Act of 1970?
Critical Thinking: What Would You Do?
1. Caldwell, Anne E. (1970). Origins of psychopharmacology: From CPZ to LSD. Springfield, IL: C. C. Thomas, p. 3. Muir, Hazel (2003, December 20). Party animals. New Scientist, pp. 56–59.
2. De Foe, Vincenzo (2003). Ethnomedical field study in northern Peruvian Andes with particular reference to divina- tion practices. Journal of Ethnopharmacology, 85, 243–256. Del Castillo, Daniel (2002, November 22). Just what the
shaman ordered. The Chronicle of Higher Education, p. A72. Metzner, Ralph (1998). Hallucinogenic drugs and plants in psychotherapy and shamanism. Journal of Psychoactive Drugs, 30, 333–341.
3. Bryan, Cyril P. (1930). Ancient Egyptian medicine: The Papy- rus Ebers. Chicago: Ares Publishers. Inglis, Brian (1975). The forbidden game: A social history of drugs. New York: Scribners, pp. 11–36.
Endnotes
Chapter 3 The History of Drug Use and Drug-Control Policy ■ 65
4. Grilly, David; and Salamone, John D. (1998). Drugs, brain, and behavior (6th ed.). Boston: Pearson, p. 2.
5. Sneader, Walter (1985). Drug discovery: The evolution of modern medicines. New York: Wiley, pp. 15–47. Stearns, Peter N. (1998). Dope fiends and degenerates: The gendering of addiction in the early twentieth century. Journal of Social History, 31, 809–814.
6. Bugliosi, Vincent (1991). Drugs in America: The case for victory. New York: Knightsbridge Publishers, p. 215.
7. Freud, Sigmund (1884). Über coca (On ca). Centralblatt feur die gesammte therapie. Translated by S. Pollak (1884). St. Louis Medical and Surgical Journal, 47.
8. Brecher, Edward M. (1972). Licit and illicit drugs. Boston: Little, Brown, p. 3.
9. Musto, David F. (1999). The American disease: Origins of narcotics control (3rd ed.). New York: Oxford University Press, pp. 1–28.
10. Filler, Louis (1976). The muckrakers. Stanford, CA: Stanford University Press, p. 153. Young, James Harvey. (1961). The toad- stool millionaires: A social history of patent medicines in America before regulation. Princeton, NJ: Princeton University Press.
11. Goldberg, Jeff; and Latimer, Dean (2014). Flowers in the blood: The story of opium. New York: Skyhorse Publishing.
12. Helmer, John (1975). Drugs and minority oppression. New York: Seabury Press.
13. Cloyd, Jerald W. (1982). Drugs and information control: The role of men and manipulation in the control of drug trafficking. Westport, CT: Greenwood.
14. Musto, The American disease. Goldberg and Latimer, Flowers in the blood.
15. Goldberg and Latimer, Flowers in the blood. 16. Grimes, William (1993). Straight up or on the rocks: A cultural
history of American drink. New York: Simon and Schuster, p. 36. Lender, Mark E.; and Martin, James K. (1982). Drinking in America: A history. New York: Free Press, pp. 13–14. Musto, David F. (1996, April). Alcohol in American history. Scientific American, pp. 78–83.
17. First in war, peace—and hooch. By George! (2000, December 7). Newsday, p. A86. Grimes, Straight up, p. 51.
18. Lincoln, Abraham (1842/1989). Address to the Washingto- nian temperance society of Springfield, Illinois. Speeches and writings, 1832–1858. New York: Library of America, p. 84.
19. Quotation in Lender,. Drinking in America, p. 107. Okrent, Daniel (2010). Last call: The rise and fall of Prohibition. New York: Scribner.
20. Cashman, Sean D. (1981). Prohibition. New York: Free Press. Coffey, Thomas M. (1975). The long thirst: Prohibition
in America, 1920–1933. New York: Norton, pp. 196–198. Gusfield, Joseph R. (1963). The symbolic crusade: Status politics and the American temperance movement. Urbana, IL: University of Illinois Press. Sinclair, Andrew. (1962). The era of excess: A social history of the prohibition movement. Boston: Little, Brown.
21. Woodiwiss, Michael (1988). Crime, crusaders and corruption: Prohibition in the United States, 1900–1987. Totawa, NJ: Barnes and Noble.
22. Blocker, Jack S. (2006, February). Did Prohibition really work? Alcohol prohibition as a public health innovation. American Journal of Public Health, 233–243. Lerner, Michael A. (2007). Dry Manhattan. Cambridge, MA: Harvard University Press. Musto, Alcohol in American history. Sournia, Jean-Charles (1990). A history of alcoholism. Cambridge, MA: Basil Blackwell, p. 122.
23. Sinclair, The era of excess. 24. Musto, The American disease. 25. Helmer, Drugs and minority oppression. Schlosser, Eric (2003).
Reefer madness: Sex, drugs, and cheap labor in the American black market. Boston: Houghton Mifflin, p. 245.
26. Brecher, Licit and illicit drugs, p. 188. Musto, The American disease.
27. Marshall, Elliot (1971). Cold turkey: heroin. The source supply. New Republic, 165, 23–25.
28. Carter, James Earl, Jr. (1979). President’s message to the Congress on drug abuse. Federal Strategy for Drug Abuse and Drug Traffic Prevention, pp. 66–67.
29. Himmelstein, Jerome L. (1983). The strange career of marijuana: Politics and ideology of drug control in America. Westport, CT: Greenwood.
30. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; Schulenberg, John E.; and Miech, Richard A. (2014). Monitoring the Future: National survey results on drug use, 1975–2013, Vol. I: Secondary school students 2013. Ann Arbor, MI: Institute for Social Research, University of Michigan, Table 5-2.
31. Bureau of Justice Statistics (1998). U.S. Department of Justice sourcebook of criminal justice statistics. Washington, DC: Bureau of Justice Statistics.
32. Adam, Isacson (2003). Washington’s new war in Colombia: The war on drugs meets the war on terror. NACLA Report on the Americas, 36, pp. 5–11.
33. Lacey, Marc (2008, December 5). Hospitals now a theater in Mexico’s drug war. New York Times, pp. A1, A18. Shanker, Thom (2008, December 23). Obstacle in bid to curb Afghan trade in narcotics. New York Times, p. A6.
Fundamentals of Drug-Taking
Behavior
4 chapter
The sorrowful look on Carrie’s face was unmistakable as she returned
to the center that day. The drug rehabilitation counselor knew that
look all too well. It was clear that Carrie had relapsed. The process
of recovery needed to be started again.
Carrie was introduced to cocaine when she was 17 years old.
A boyfriend at the time thought it would be cool to try it, and she
joined him. He has since left town. No one knows whether he got
caught up in cocaine, but we do know that Carrie did.
Four years ago, Carrie entered drug rehab. It took her more
than a year of intense work, but she managed to get clean. Her life
began to improve. She met a man with no drug history, soon mar-
ried, and two months ago, she gave birth to a beautiful little boy.
At our urging, Carrie had made a complete break from her past.
She saw nothing of her “cocaine buddies,” avoided the old neigh-
borhood. Nothing to remind her of cocaine. She knew all about the
cocaine associations that would draw her back to substance abuse.
The cravings subsided, and all seemed to be going well.
After you have completed this chapter, you should have an understanding of the following:
●● The ways drugs enter the body
●● The ways drugs exit the body
●● Factors determining the behavioral impact of drugs
●● Psychological factors in drug-taking behavior
●● Physical and psychological dependence
●● Drug-taking behavior from a health professional perspec- tive: DSM-5
Chapter 4 Fundamentals of Drug-Taking Behavior ■ 67
Nonetheless, in order for drugs to affect the brain, they have to enter the body in some way. This is where we need to begin: How do drugs get into the body in the first place?
How Drugs Enter the Body
There are four principal routes through which drugs can be delivered into the body: oral administration, injection, inhala- tion, and absorption through the skin or membranes. In all of the four delivery methods, the goal is to get the drug absorbed into the bloodstream. In the case of psychoactive drugs, a drug effect depends not only on reaching the bloodstream but also on reaching the brain.
Oral Administration Ingesting a drug by mouth (later digesting it and absorbing it into the bloodstream through the gastrointestinal tract) is the oldest and easiest way of taking a drug. On the one hand, oral administration and reliance upon the digestive process for delivering a drug into the bloodstream provide a degree of safety. Many naturally growing poisons taste so vile that we normally spit them out before swallowing; others will cause us to be nauseous, causing the drug to be expelled through vomiting.
In the case of hazardous substances that are not spontaneously rejected, we can benefit from a relatively long absorption time for orally administered drugs. Most of the absorption process is accomplished between five and 30 minutes after ingestion, but absorption may not be com- plete for as long as six–eight hours. Therefore, there is at least a little time after accidental overdoses or suicide attempts to induce vomiting or pump the stomach.
On the other hand, the gastrointestinal tract contains a number of natural barriers that may prevent certain drugs that we want absorbed into the bloodstream from doing so. One determining factor is the degree of alkalinity or acidity in the drug, as measured by its pH value. The interior of the stom- ach is highly acidic, and the fate of a particular drug depends
A month ago, Carrie was changing her son’s
diaper. She stared at the baby powder and some-
thing clicked. Suddenly, the craving for cocaine
had returned. “I felt like Pavlov’s dog,” Carrie said.
“All of a sudden, I had to have cocaine.”
Up until now, issues surrounding drug-taking behavior have been addressed principally from a societal point of view. In this chapter, we will examine drug-taking behavior from a more personal perspective. What are the differences, for example, in the effects of a particular drug depending on how it has been introduced into the body? How does drug tolerance occur? Why would one person react quite differently than another person when both are admin- istered the same drug in the same way? What is the nature of drug dependence? Why are environmental cues so important in sustaining substance abuse? These are some of the ques- tions we will now address.
In the late 1980s, a public service announcement in a national anti-drug campaign aired on television. For those who saw it, few will forget it. The visual images were simple: an egg, a frying pan, and a fried egg. This was the message:
This is your brain (view of egg held in hand). This is drugs (view of sizzling frying pan). This is your brain on drugs (view of egg frying in pan). Any questions?1
Giving the viewer considerable “food for thought,” its impact was immediate and unmistakable: Don’t do drugs because they will fry your brain. The creators of this mes- sage were speaking metaphorically, of course. In effect, they were saying that there are certain classes of drugs that have a devastating impact on the human brain. Therefore, stay away from them.
Clearly, psychoactive drugs affect our behavior and experience through their effects on the functioning of the brain. Therefore, our knowledge about drugs and their effects is closely connected with the progress we have made in our understanding of the ways drugs work in the brain.
5–8 Number of seconds for nicotine in an inhaled cigarette to travel from the lungs to the brain 2,301,059 The estimated number of emergency department visits in 2011 due to an adverse reaction to prescription medicines,
over-the-counter drugs, or other types of pharmaceuticals. This represents just under half of all drug-related emergency department visits in the United States, as reported in the Drug Abuse Warning Network survey for that year.
105 Every day, the estimated number of people who die from a drug overdose in the United States.
Sources: Centers for Disease Control and Prevention (2013, September 9). Drug overdose in the United States: Fact Sheet. Atlanta, GA: Centers for Disease Control and Prevention. Center for Behavioral Health Statistics and Quality (2013). Drug Abuse Warning Network: National estimates of drug-related emergency department visits 2004–2011. Rockville, MD: Substance Abuse and Mental Health Services Administration.
Numbers Talk…
68 ■ Part One The Challenge of Drugs in Our Society
Injection A solution to the problems of oral administration is to bypass the digestive process entirely and deliver the drug directly into the bloodstream. One option is to inject the drug through a hypodermic syringe and needle.
The fastest means of injection is an intravenous (i.v.) injection, since the drug is delivered into a vein without any intermediary tissue. An intravenous injection of heroin in the forearm, for example, arrives at the brain in less than fifteen seconds. The effects of abused drugs delivered in this way, often called mainlining, are not only rapid but also extremely intense. In a medical setting, intravenous injections provide an extreme amount of control over dosage and the oppor- tunity to administer multiple drugs at the same time. The principal disadvantage, however, is that the effects of an intra- venous administration drugs are irreversible. In the event of a mistake or unexpected reaction, there is no turning back unless some other drug is available that can counteract the first one. In addition, repeated injections through a particular vein may cause the vein to collapse or develop a blood clot.
With intramuscular (i.m.) injections, the drug is deliv- ered into a large muscle (usually in the upper arm, thigh, or buttock) and is absorbed into the bloodstream through the capillaries serving the muscle. Intramuscular injections have slower absorption times than intravenous injections, but they can be administered more rapidly in emergency situations. Our exposure to intramuscular injections comes early in our lives when we receive the standard schedule of inoculations against diseases such as measles, diphtheria, and typhoid fever. Tetanus and flu shots are also administered in this way.
A third injection technique is the subcutaneous (s.c. or sub-Q) delivery, in which a needle is inserted into the tissue just underneath the skin. Because the skin has a less abundant blood supply relative to a muscle, a subcutaneous injection has the slowest absorption time of all the injection techniques. It is best suited for situations in which it is desirable to have a precise control over the dosage and a steady absorption into the blood- stream. The skin, however, may be easily irritated by this proce- dure. As a result, only relatively small amounts of a drug can be injected under the skin compared with the quantity that can be injected into a muscle or vein. When involved in drug abuse, subcutaneous injections are often referred to as skin-popping.
All injections require a needle to pierce the skin, so there is an inherent risk of bacterial or viral infection if the needle is not sterile. The practice of injecting heroin or cocaine with shared needles, for example, promotes the spread of infectious hepatitis and HIV. If administered orally, drugs do not have to be any more sterile than the foods we eat or the water we drink.
Inhalation Next to ingesting a drug by mouth, the simplest way of receiving its effects is to inhale it in some form of gaseous or vaporous state. The alveoli within the lungs can be imagined as a huge surface area with blood vessels lying immediately behind it. Our bodies are so dependent upon the oxygen in the air we breathe that we
upon how it reacts with that environment. Weakly acidic drugs such as aspirin are absorbed better in the stomach than highly alkaline drugs such as morphine, heroin, or cocaine. Insulin is destroyed by stomach acid, so it cannot be admin- istered orally, whereas a neutral substance such as alcohol is readily absorbed at all points in the gastrointestinal tract.
If it survives the stomach, the drug needs to proceed from the small intestine into the bloodstream. The membrane sepa- rating the intestinal wall from blood capillaries is made up of two layers of fat molecules, making it necessary for substances to be lipid-soluble, or soluble in fats, to pass through. Even after successful absorption into blood capillaries, however, substances still must pass through the liver for another “screen- ing” before being released into the general circulation. There are enzymes in the liver that destroy a drug by metabolizing (breaking down) its molecular structure prior to its excretion from the body. There is a further barrier separating the blood- stream (circulatory system) from brain tissue, called the blood- brain barrier, which determines a drug’s psychoactive effects.
As a result of all these natural barriers, orally adminis- tered drugs must be ingested at deliberately elevated dose levels to allow for the fact that some proportion of the drug will not make it through to the bloodstream. We can try to compensate for the loss of the drug during digestion, but even then we may be only making a good guess. The state of the gastrointestinal tract changes constantly over time, making it more or less likely that a drug will reach the cir- culatory system. The presence or absence of undigested food and whether the undigested food interacts with the chemical nature of the drug are examples of factors that make it diffi- cult to make exact predictions about the strength of the drug when it finally enters the bloodstream.
subcutaneous (s.c. or sub-Q): Underneath the skin.
Orally consumed drugs are absorbed into the brain relatively slowly, though for a liquid beverage containing alcohol, the opposite applies: It is easily absorbed.
intramuscular (i.m.): Into a muscle.
intravenous (i.v.): Into a vein.
Chapter 4 Fundamentals of Drug-Taking Behavior ■ 69
Absorption through the Skin or Membranes Drug users over the ages have been quite creative in finding other routes through which drugs can be administered. One way is to sniff or snort a drug in dust or powder form into the nose. Once inside the nose, it adheres to thin mucous membranes and dissolves through the membranes into the bloodstream. This technique, referred to as an intranasal administration, is commonly used in taking snuff tobacco or cocaine. Prescription medications are becoming increasingly available in nasal-spray formulations, avoiding the need for needle injections or difficult-to-swallow pills.
Snuff tobacco, chewing tobacco, and cocaine-containing coca leaves also can be chewed without swallowing over a period of time or simply placed in the inner surface of the cheek and slowly absorbed through the membranes of the mouth. Nicotine chewing gums, available for those individu- als who wish to quit tobacco smoking, work in a similar way. Nitroglycerin tablets for heart disease patients are typically administered sublingually, with the drug placed underneath the tongue and absorbed into the bloodstream.
At the opposite end of the body, medicines can be placed as a suppository into the rectum, where the supposi- tory gradually melts, and the medicine is absorbed through thin rectal membranes. This method is less reliable than an oral administration, but it may be necessary if the individual is vomiting or unconscious.
Another absorption technique involves a transdermal patch, which allows a drug to slowly diffuse through the skin without breaking the skin surface. Transdermal patches have been used for long-term administration of nitroglycerin, estrogen, motion-sickness medication, and more recently, nicotine. Newly developed procedures to enhance the pro- cess of skin penetration include the promising technique of administering low-frequency ultrasound, which allows large molecules such as insulin to pass through the skin. Insulin administration is an especially interesting applica- tion because, until now, the only effective way of getting it into the bloodstream has been through needle injection. Alternative methods under development include small sili- con chip patches containing a grid of microscopic needles that painlessly pierce the skin and allow the passage of large molecules into the bloodstream. Other future techniques may involve the application of ultrasound waves to increase skin permeability or the combining of medication with spe- cial compounds that help the medication slip through skin pores.2
The following Drugs . . . in Focus summarizes the vari- ous ways drugs can be administered into the body.
have evolved an extremely efficient system for getting oxygen to its destinations. As a consequence of this highly developed system, the psychoactive effect of an inhaled drug is even faster than a drug delivered through intravenous injection. Traveling from the lungs to the brain takes only five to eight seconds.
One way of delivering a drug through inhalation is to burn it and breathe in the smoke-borne particles in the air. Drugs administered through smoking include nicotine from cigarettes, opium, tetrahydrocannabinol (THC) from marijuana, free-base cocaine, crack cocaine, and crystallized forms of methamphetamine. Drugs such as paint thinners, gasoline, and glues also can be inhaled because they evap- orate easily and the vapors travel freely through the air. In medical settings, drugs that produce general anesthesia are administered through inhalation, since the concentration of the drug can be precisely controlled.
The principal disadvantage of inhaling smoked drugs, as you probably expect, arises from the long-term hazards of breathing particles in the air that contain not only the active drug but also tars and other substances produced by the burning process. Emphysema, asthma, and lung cancer can result from smoking in general (see Chapter 16). There is also the possibil- ity in any form of drug inhalation that the linings leading from the throat to the lungs will be severely irritated over time.
transdermal patch: A device attached to the skin that slowly delivers the drug through skin absorption.
sublingual: Applied under the tongue.
Drugs consumed by inhalation are absorbed extremely quickly, aided by a very efficient delivery system from lungs to brain.
intranasal: Applied to the mucous membranes of the nose.
70 ■ Part One The Challenge of Drugs in Our Society
metabolite (me-TAB-oh-lite): A by-product resulting from the biotransformation process.
The most common means of elimination is through excretion in the urine after a series of actions in the liver and kidneys. Additionally, elimination occurs through excretion in exhaled breath, feces, sweat, saliva, or (in the case of nursing mothers) breast milk.
The sequence of metabolic (chemical breakdown) events leading to urinary excretion begins with a process called biotransformation, chiefly through the action of specific enzymes in the liver. The end products of biotrans- formation, referred to as metabolites, are structurally modi- fied forms of the original drug. Generally speaking, if these metabolites are water-soluble, they are passed along to the
How Drugs Exit the Body
Having reviewed how a drug is absorbed into the bloodstream and, in the case of a psychoactive drug, into the brain, we now will consider the ways in which the body eliminates it.
Ways to Take Drugs: Routes of Administration Oral Administration (by Mouth) • Method: By swallowing or consuming with food or drink • Advantages: Slow absorption time; possibility of rejecting
poisons and overdoses • Disadvantages: Slow absorption time; no immediate effect • Examples: Medications in pill form, marijuana (baked in
food), amphetamine and methamphetamine, barbiturates, LSD (swallowed or licked off paper), PCP, opium, metha- done, codeine, caffeine, alcohol
Injection (by Hypodermic Syringe)
Intravenous Injection • Method: By needle positioned into a vein • Advantages: Very fast absorption time; immediate effects • Disadvantages: Cannot be undone; risks of allergic
reactions • Examples: PCP, methamphetamine, heroin, methadone,
morphine
Intramuscular Injection • Method: By needle positioned into a large muscle • Advantages: Quicker to administer than an intravenous
injection • Disadvantages: Somewhat slower absorption time than an
intravenous injection; risk of piercing a vein by accident • Examples: Vaccine inoculations
Subcutaneous Injection • Method: By needle positioned underneath the skin • Advantages: Easiest administration of all injection
techniques
• Disadvantages: Slower absorption time than an intramuscular injection; risk of skin irritation and deterioration
• Examples: Heroin and other opiates
Inhalation (by Breathing)
Smoking • Method: By burning the drug and inhaling smoke-borne
particles into the lungs • Advantages: Extremely fast absorption time • Disadvantages: Effect limited to time during which drug is
being inhaled; risk of emphysema, asthma, and lung cancer from inhaling tars and hydrocarbons in the smoke; lung and throat irritation on chronic use
• Examples: Nicotine (from tobacco), marijuana, hashish, methamphetamine, ice, free-base cocaine, crack cocaine, PCP, heroin, and opium
Vaporous Inhalation • Method: By breathing in vapors from drug • Advantages: Extremely fast absorption time • Disadvantages: Effect limited to time during which drug
is being inhaled; lung and throat irritation over chronic use
• Examples: Surgical and dental anesthetics, paint thinners, gasoline, cleaning fluid
Absorption (through Skin or Membranes) • Method: By positioning the drug against skin, inserting
it against rectal membranes, snorting it against mucous membranes of the nose, or placing it under the tongue or against the cheek so it diffuses across into bloodstream
• Advantages: Quick absorption time • Disadvantages: Irritation of skin or membranes • Examples: Cocaine, amphetamine, methamphetamine,
nicotine, snuff tobacco, coca leaves
Drugs … in Focus
biotransformation: The process of changing the molecu- lar structure of a drug into forms that make it easier to be excreted from the body.
Chapter 4 Fundamentals of Drug-Taking Behavior ■ 71
Finally, it is possible that two identical drugs taken by two individuals might have different effects by vir- tue of the characteristics of the drug user at the time of administration.
Timing All drugs, no matter how they are delivered, share some common features when we consider their effects over time. There is initially an interval (the latency period) during which the concentration of the drug is increasing in the blood but is not yet high enough for a drug effect to be detected. How long this latency period will last is related generally to the absorption time of the drug. As the concen- tration of the drug continues to rise, the effect will become stronger. A stage will be reached eventually when the effect attains a maximum strength, even though the concentration in the blood continues to rise. This point is unfortunately the point at which the drug may produce undesirable side effects. One solution to this problem is to administer the drug in a time-release form. In this approach, a large dose is given initially to enable the drug effect to be felt; then smaller doses are programmed to be released at specific intervals afterward to postpone, up to 12 hours or so, the decline in the drug’s concentration in the blood. The inten- tion is to keep the concentration of the drug in the blood within a “therapeutic window,” high enough for the drug to be effective while low enough to avoid any toxic effects. When drugs are administered repeatedly, there is a risk that the second dose will boost the concentration of the drug in the blood too high before the effect of the first dose has a chance to decline (Figure 4.1).
Drug Interactions Two basic types of interactions may occur when two drugs are mixed together. In the first type, two drugs in combina- tion may produce an acute effect that is greater than the effect of either drug administered separately. In some cases, the combination effect is purely additive. For example, if the effect of one drug alone is equivalent to a 4 and the effect of another drug is a 6, then the combined additive effect is equivalent to a value of 10. In other cases, however, the acute combination effect is hyperadditive, with the com- bined effect exceeding the sum of the individual drugs administered alone, as in the two drugs in the first example combining to a value of more than 10. Any hyperadditive effect produced by a combination of two or more drugs is
kidneys and eventually excreted with urine. If they are less water-soluble, then they are reabsorbed into the intestines and excreted with defecation. On rare occasions, a drug may pass through the liver without any biotransformation at all and be excreted intact. The hallucinogenic drug Amanita muscaria is an example of this kind of drug (see Chapter 11).
A number of factors influence the process of biotransfor- mation and urinary excretion and, in turn, the rate of elimina- tion from the body. For most drugs, biotransformation rates will increase as a function of the drug’s concentration in the blood- stream. In effect, the larger the quantity of a drug, the faster the body tries to get rid of it. An exception, however, is alcohol, for which the rate of biotransformation is constant no matter how much alcohol has been ingested (see Chapter 15).
The activity of enzymes required for biotransformation may be increased or decreased by the presence of other drugs in the body. As a result, the physiological effect of one drug may interact with the effect of another, creating a potentially dangerous combination. An individual’s age also can be a factor. Because enzyme activity in the liver decreases after the age of 40, older people eliminate drugs at a slower pace than do younger people. We will look at the consequences of drug interactions and individual differences in the next sec- tion of this chapter.
Finally, it is important to point out that drugs are gradu- ally eliminated from the body at different rates simply on the basis of their chemical properties. In general, if a drug is fat-soluble, the rate will be slower than if a drug is water- soluble. On average, we can look at the rate of elimination of a particular drug through an index called its elimination half-life, the amount of time it takes for the drug in the bloodstream to decline to 50 percent of its original equilib- rium level. Many drugs such as cocaine and nicotine have half-lives of only a few hours; marijuana and some prescrip- tion medications are examples of drugs with much longer half-lives.3 Understanding the variation in the elimination rates of drugs and their metabolites is extremely important in the development of drug-testing procedures to detect drug- taking behavior, a topic to be examined in Chapter 13.
Factors Determining the Behavioral Impact of Drugs
The type of delivery route into the bloodstream, as has already been discussed, places specific constraints upon the effect a drug may produce. Some drug effects are optimized, for example, by an oral administration, whereas others require more direct access to the bloodstream.
Other factors must be considered as well. If a drug is administered repeatedly, the timing of the administration plays an important role in determining the final result. If two drugs are administered close together in time, we also must consider how these drugs might interact with each other in terms of their acute effects. Repeated administrations of a drug may pro- duce a diminished physiological or psychological effect.
latency period: An interval of time during which the effect of a drug is not observed in the blood though the drug has been administered.
elimination half-life: The length of time it takes for a drug to be reduced to 50 percent of its equilibrium level in the bloodstream.
72 ■ Part One The Challenge of Drugs in Our Society
Tolerance Effects The concept of tolerance refers to the capacity of a drug dose to have a gradually diminished effect on the user as the drug is taken repeatedly. Another way of viewing tolerance is to say that, over repeated administrations, a drug dose needs to be increased to maintain an equivalent effect. A common illus- tration is the effect of caffeine in coffee. When you are first introduced to caffeine, the stimulant effect is usually quite pronounced; you might feel noticeably “wired” after a 5-ounce cup of coffee, containing approximately 100 mg of caffeine. After several days or perhaps a few weeks of coffee drinking, the effect is greatly diminished; you may need to be on the second or third cup by that time, consuming 200–300 mg of caffeine, to duplicate the earlier reaction. Some individuals who drink coffee regularly have developed such high levels of tolerance to caffeine that they are able to sleep comfortably even after several cups of coffee, whereas individuals with more infre- quent ingestions of caffeine end up remaining awake through the night after a single cup (Portrait on page 74).
Tolerance effects, in general, illustrate the need for us to look at the interaction between the actual amount of the drug taken and other factors involved in the drug-taking behavior. For example, as already noted, the number of previous times the drug has been used is crucial; repetition is what tolerance is all about. Another important factor, however, is the setting within which the drug-taking behavior occurs. There is strong evidence that tolerance is maximized when the drug-taking behavior occurs consistently in the same surroundings or under the same set of circumstances. We speak of this form of tolerance as behavioral tolerance.4
To have a clear idea of behavioral tolerance, we first have to understand the processes of Pavlovian conditioning, upon which behavioral tolerance is based. Suppose that you consistently heard a bell ring every time you had a headache. Previously, bells had never had any negative effect on you. The association between the ringing bell and the pain of the head- ache, however, would develop to such an extent that the mere ringing of a bell alone would now give you a headache, perhaps less painful than the ones you had originally but a headache nonetheless; this effect is Pavlovian conditioning at work.
Pioneering studies by the psychologist Shepard Siegel showed a similar phenomenon occurring with drug-taking behavior. In one experiment, one group of rats was injected with doses of morphine in a particular room over a series of days and later tested for tolerance to that dose in the same room. Predictably, they displayed a lessened analgesic effect as a sign of morphine tolerance. A second group was tested in a room other than the one in which the injections had been given. No tolerance developed at all. They reacted as if they had never been given morphine before, even though they had received the same number of repeated injections as the first group.
In a more extreme experiment, Siegel tested two groups of rats that were administered a series of heroin injections with increasingly higher dosages. Eventually, both groups were surviving a dosage level that would have been lethal to rats experiencing the drug for the first time. The difference
referred to as synergism. In some synergistic combinations, one drug may even double or triple the effect of the other. It is also possible that one drug might have no effect at all unless it is taken simultaneously with another. This special form of synergism is called potentiation; it is as though a drug with no effect at all by itself, but when combined with a drug having an effect of 6, produces a result equivalent to a 10. The danger of such interactions is that the combined effect of the drugs is so powerful that it can become toxic. In extreme cases, the toxicity can be lethal.
In the second type of interaction, two drugs can be antag- onistic if the acute effect of one drug is diminished to some degree when administered with another, a situation compa- rable to a drug with the effect of 6 and a drug with the effect of 4 combining to produce an effect of 3. Later chapters dis- cuss drugs that are totally antagonistic to each other, in that the second exactly cancels out, or neutralizes, the effect of the first. The following Help Line provides some examples of drug–drug combinations and food–drug combinations that can present significant problems.
0
0
1
2 4 6
B lo
od le
ve l
Hours
Therapeutic threshold
Toxic threshold
Therapeutic window
F IguRe 4 .1
The therapeutic window. Time-release drugs are formulated to administer the drug in small amounts over time to stay between the therapeutic level and the toxic level.
behavioral tolerance: The process of drug tolerance that is linked to drug-taking behavior occurring consistently in the same surroundings or under the same circumstances. Also known as conditioned tolerance.
tolerance: The capacity of a drug to produce a gradu- ally diminished physiological or psychological effect upon repeated administrations at the same dose level.
potentiation: The property of a synergistic drug interaction in which one drug combined with another drug produces an enhanced effect when one of the drugs alone would have had no effect.
synergism (SIN-er-jih-zum): The property of a drug interac- tion in which the combination effect of two drugs exceeds the effect of either drug administered alone.
Chapter 4 Fundamentals of Drug-Taking Behavior ■ 73
Help Line The Possibility of a Drug–Drug or Food–Drug Combination effect
It would be impossible to list every known drug–drug interac- tion or food–drug interaction. Nonetheless, here are some examples. Any adverse reaction to a combination of drugs or a combination of a drug with something eaten should be report- ed to your physician immediately. An awareness of adverse interactions is particularly important for elderly patients, who tend to be treated with multiple medications. The best advice is to ask your physician whether alcohol, specific foods, or other medications might either increase or decrease the effect of the medication that is being prescribed.
Hyperadditive effects Alcohol with barbiturate-related sleep medications, cardiovascular medications, insulin, anti-inflammatory medications, antihistamines, painkillers, antianxiety medications Septra, Bactrim, or related types of antibiotics with Coumadin (an anticoagulant) Tagamet (a heartburn and ulcer treatment medication) with Coumadin Aspirin, Aleve, Advil, Tylenol, or related painkillers with Coumadin Plendil (a blood pressure medication) and Procardia (an angina treatment), as well as Zocor, Lipitor, and Mevacor (all cholesterol-lowering medications), with grapefruit juice Lanoxin (a medication for heart problems) with licorice Lanoxin with bran, oatmeal, or other high-fiber foods
Antagonistic effects Morphine/heroin with naloxone or naltrexone Norpramin or related antidepressants with bran, oatmeal, or other high-fiber foods Soy products and certain vitamin K–rich vegetables such as broccoli, cabbage, and asparagus with Coumadin
Possible Toxic Reactions Internal bleeding by a combination of Parnate and Anafranil (two types of antidepressants)
Elevated body temperature by a combination of Nardil (an antidepressant) with Demerol (a painkiller) Excessive blood pressure or stroke by a combination of Parnate, Nardil, or other monoamine oxidase inhibitors (MAOIs) used to treat depression with cheddar cheese, pickled herring, or other foods high in tyramine Agitation or elevated body temperature by a combination of Paxil, Prozac, Zoloft, or related antidepressants with Parnate, Nardil, or other monoamine oxidase inhibitors (MAOIs) used to treat depression Irregular heartbeat, cardiac arrest, and sudden death by a combination of Hismanal or Seldane (two antihistamines) with Nizoral (an antifungal drug)
Note: The hyperadditive effects of grapefruit on certain medications can be dangerous or useful under certain circumstances. If grapefruit enhances the effect of the cholesterol-reducing medication Lipitor, for example, it is possible that drinking grapefruit juice might allow the patient to take less Lipitor (reducing costs and possible side effects) and still receive the same level of benefit. Combinations of this kind, however, should be administered only under the close supervision of one’s physician.
Where to go for assistance www.medscape/druginfo/druginterchecker
Register free and check out any combination of prescription or OTC drugs for potential adverse interactions.
Sources: Graedon, Joe; and Graedon, Teresa (2000, October 16). Say “aaah”: The people’s pharmacy; drugs and foods can interact adversely. Los Angeles Times, p. 2. Graedon, Joe; and Graedon, Teresa (1995). The people’s guide to deadly interactions. New York: St. Martin’s Press. Sørensen, Janina M. (2002). Herb–drug, food–drug, nutrient–drug, and drug–drug interactions: Mechanisms involved and their medical implications. Journal of Alternative and Complementary Medicine, 8, 293–308.
in the groups related to the environment in which these injections were given. One group received these injections in the colony room where they lived. When the second group was receiving the injections, they were in a room that looked quite different and were hearing 60-decibel “white noise.” Siegel then administered a single large dose of heroin, normally a level that should have killed them all. Instead, rats administered this extremely high dosage in the same room in which they had received the earlier heroin injection series showed only a 32 percent mortality rate. When the room was different, the mortality rate doubled (64%). In both groups, more rats survived than if they had
never received heroin in the first place, but the survival rate was influenced by the environment in which the heroin was originally administered.
Siegel explained the results of his studies by assuming that environmental cues in the room where the initial injec- tions were given elicited some form of effect opposite to the effect of the drug. In the case of heroin, these compensatory effects would partially counteract the analgesic effect of the drug and protect the animal against dying from potentially high dosage levels.
The phenomenon of behavioral tolerance, also referred to as conditioned tolerance because it is based on the principles of
74 ■ Part One The Challenge of Drugs in Our Society
PORTRAIT Mithridates VI of Pontus: Drug Tolerance and the Story of the Poison King
In the first century b.c., royal successions were anything but orderly and, more often than not, they were a matter of who could success- fully poison whom. In the land of Pontus, a region of modern-day Turkey, Mithri- dates (later to be known as King Mithri- dates VI of Pontus) had witnessed his own father (King Mithridates V) murdered by poison, and he knew a number of rulers (and potential rulers) who had died in the same way. He would later in his life use poison on a routine basis to do away with his rivals. Obviously, he was keenly aware of the possibility of himself being poisoned in retribution.
At one point, Mithridates arrived at a way of keeping himself out of
harm’s way. He regularly ingested sublethal doses of poison, increasing the dosage until he could survive even the most potent concoctions that were available at the time. In effect, he had built up a defense for life. It is the first recorded example of drug tolerance, and the phenomenon originally was known as mithridatism.
During his reign, King Mithridates’ ambitions for an empire that could dominate the entire region surround- ing Black Sea ran afoul of authorities in Rome who saw him as a threat to Roman
shipping and trade. When a protracted series of wars with Rome ended in his defeat, Mithridates had no choice but to commit suicide by poison. The problem was that no amount of poison was suf- ficient, and the grim task had to be com- pleted by the sword. According to one version of the story, the king ordered one of his guards to do the job.
Source: Lankester, Edwin Ray (1889). Mithridatism. Nature, 40, 149. Mayor, Adrienne (2010). The poison king: The life and legend of Mithridates, Rome’s deadliest enemy. Princeton, NJ: Princeton University Press.
A heroin abuser suffering from a possibly lethal heroin overdose immediately after the injection.
Quick Concept Check
Understanding Drug Interactions Check your understanding of drug interactions by assuming the following values to represent the effects of Drugs A, B, and C, when taken individually:
• Drug A 0 • Drug B 20 • Drug C 35
Identify the type of drug interaction when the following values represent the effect of two drugs in combination.
1. Drug A combined with Drug B 30
2. Drug B combined with Drug C 55
3. Drug A combined with Drug C 15
4. Drug B combined with Drug C 85
5. Drug B combined with Drug C 0
6. Drug A combined with Drug B 20
Answers: 1. potentiation 2. additive 3. antagonistic 4. synergistic (hyperadditive) 5. antagonistic 6. additive
4.1
Chapter 4 Fundamentals of Drug-Taking Behavior ■ 75
Cross-Tolerance If you were taking a barbiturate (a sedation-producing drug that acts to depress bodily functioning) for an extended length of time and you developed a tolerance for its effect, you also might have developed a tolerance for another depressant drug even though you have never taken the second one. In other words, it is possible that a tolerance effect for one drug might automatically induce a tolerance for another. This phenom- enon, referred to as cross-tolerance, is commonly observed in the physiological and psychological effects of alcohol, barbi- turates, and other depressants. As a result of cross-tolerance, an alcoholic will have already developed a tolerance for a bar- biturate, or a barbiturate abuser will need a greater amount of an anesthetic when undergoing surgery.
Individual Differences Some variations in drug effects may be related to an interac- tion between the drug itself and specific characteristics of the person taking the drug. One characteristic is an individual’s weight. In general, a heavier person will require a greater
Pavlovian conditioning, explains why a heroin addict may eas- ily suffer the adverse consequences of an overdose when the drug has been taken in a different environment from the one more frequently encountered or in a manner different from his or her ordinary routine.5 The range of tolerated doses of heroin can be enormous; amounts in the range of 200–500 mg may be lethal for a first-time heroin user, whereas amounts as high as 1800 mg may not even be sufficient to make a long- term heroin user sick.6 You can imagine how dangerous it would be if the conditioned compensatory responses a heroin abuser had built up over time were suddenly absent.
Behavioral tolerance also helps to explain why a formerly drug-dependent individual is strongly advised to avoid the sur- roundings associated with his or her past drug-taking behavior. If these surroundings provoked a physiological effect opposite to the effect of the drug through their association with prior drug-taking behavior, then a return to this environment might create internal changes that only drugs could reverse. In effect, environmentally induced withdrawal symptoms would increase the chances of a relapse. The fact that condition- ing effects have been demonstrated not only with respect to heroin but with alcohol, cocaine, nicotine, and other depen- dence-producing drugs as well makes it imperative that the phenomenon of behavioral tolerance be considered during the course of drug-abuse treatment and rehabilitation.
We do not have to be involved in drug dependence, however, to experience the effects of behavioral tolerance. (Drugs . . . in Focus).7
Conditioned Tolerance in Alcoholic Beverages: The Four-Loko effect When the beverage Four Loko was first introduced in 2005, the “Four” in its name referred to four primary ingredients: alcohol, caffeine, guarana, and taurine. In 2010, a number of college students were hospitalized for alcohol intoxication following consumption of Four Loko. Phusion Projects, the manufacturer of Four Loko, became the defendant in a number of unlawful death lawsuits. The argument was that caffeine (a stimulant) masked the intoxicating effects of alcohol (a depressant), leading to excess alcohol consumption and excessive intoxication. The research evidence that caffeine interacts with alcohol in such a way as to be responsible for excessive alcohol intoxication is not clear-cut. Nonetheless, as a response to the public outcry that caf- feine and alcohol was a dangerous combination, the FDA ruled that caffeine was an illegal additive to an alcoholic beverage and that manufacturers of alcohol and caffeine products must remove the caffeine or else be prosecuted. Phusion Projects complied, and hereafter Four Loko became essentially “Three Loko.”
Yet Four Loko remains a particularly intoxicating alco- holic beverage, and the question is, why? Shepard Siegel has argued that the culprit may not have been caffeine at all, but rather the fruit flavoring of the beverage. According to the principles of conditioned tolerance, a fruit flavoring allows alcohol consumption to occur in an unusual context. In effect, Four Loko delivers alcohol without the usual smells and tastes of typical alcoholic beverages. The individual who has experienced alcohol in the typical ways and has developed some level of tolerance to alcohol as a result now experi- ences (with Four Loko) alcohol with an entirely new set of associated cues. The expected tolerant response is not felt, and an increased level of intoxication (a hyperintoxicating effect) occurs. Essentially, people have become very drunk because they are now in a novel context for alcohol adminis- tration. Siegel has referred to the loss of drug tolerance as “the Four-Loko Effect.”
Source: Siegel, Shepard (2011). The Four-Loko Effect. Perspectives on Psychological Science, 6, 357–362.
Drugs … in Focus
cross-tolerance: A phenomenon in which the tolerance that results from the chronic use of one drug induces a tol- erance effect with regard to a second drug that has not been used before.
76 ■ Part One The Challenge of Drugs in Our Society
effects of alcohol consumption in terms of gender, we find that the lower water content (a factor that tends to dilute the alco- hol in the body) in women makes them feel more intoxicated than men, even if the same amount of alcohol is consumed.
Relative to men, women also have reduced levels of enzymes that break down alcohol in the liver, resulting in higher alcohol levels in the blood and a higher level of intoxi- cation.8 We suspect that the lower level of alcohol biotrans- formation may be related to an increased level of estrogen and progesterone in women. Whether gender differences exist with regard to drugs other than alcohol is presently unknown.
Another individual characteristic that influences the ways certain drugs affect the body is ethnic background. About 50 percent of all people of Asian descent, for example, have lower than average levels of one of the enzymes that normally breaks down alcohol in the liver shortly before it is excreted. With this particular deficiency, alcohol metabolites tend to build up in the blood, producing a faster heart rate, facial flushing, and nausea.9 As a result, many Asians find drinking to be quite unpleasant.
Ethnic variability can be seen in terms of other drug effects as well. It has been found that Caucasians have a faster rate of biotransformation of antipsychotic and antianxiety medications than Asians and, as a result, end up with relatively lower concentrations of drugs in the blood. One consequence of this difference is in the area of psychiatric treatment. Asian schizophrenic patients require significantly lower doses of antipsychotic medication for their symptoms to improve, and they experience medication side effects at much lower doses than do Caucasian patients. Since other possible factors such as diet, life-style, and environment do not account for these differences, we can speculate that these differences have a genetic basis.10
In some cases, differences in the physiological response to a particular drug can explain differential patterns of drug-taking behavior. For example, researchers have found recently that African Americans have a slower rate of nicotine metabolism following the smoking of cigarettes relative to whites. This finding might be the reason why African Americans, on aver- age, report smoking fewer cigarettes per day than whites. If we assume that an equivalent level of nicotine needs to be maintained in both populations, fewer cigarettes smoked but a higher level of nicotine absorbed per cigarette will produce the same effect as a greater number of cigarettes smoked but a lower nicotine level absorbed per cigarette. Consequently, African American smokers may be taking in and retaining relatively more nicotine per cigarette and, as a result, not having to smoke as many cigarettes per day.11
Psychological Factors in Drug-Taking Behavior
It is clear that certain physiological factors such as weight, gender, and race must be taken into account to predict particular drug effects. Yet, even if we controlled these factors
amount of a drug than a lighter person to receive an equiva- lent drug effect, all other things being equal. It is for this rea- son that drug dosages are expressed as a ratio of drug amount to body weight. This ratio is expressed in metric terms, as mil- ligrams per kilogram (mg/kg).
Another characteristic is gender. Even if a man and a woman are exactly the same weight, differences in drug effects still can result on the basis of gender differences in body com- position and sex hormones. Women have, on average, a higher proportion of fat, due to a greater fat-to-muscle ratio, and a lower proportion of water than men. When we look at the
Quick Concept Check
Understanding Behavioral Tolerance through Conditioning Check your understanding of behavioral tolerance as proposed by Shepard Siegel by answering the following questions.
1. Suppose that you have a rat that has been placed in an environment where it had been repeatedly injected with morphine. You now inject a saline solution (a substance that has no physiological effect) to that rat. Assuming that morphine will make a person less sensitive to pain, how will this animal react to the saline injection? Will the rat be less sensitive to pain, more sensitive to pain, or will there be no effect? Explain your answer.
2. If King Mithridates VI (see Portrait) had changed palaces from time to time during his reign, what would have been the effect on his eventual level of drug tolerance to poison when he chose to attempt suicide?
3. Suppose King Mithridates VI had two palaces. Palace 1 was the place where he lived most of the time, with Palace 2 (a very different looking palace than Palace 1) being the place where he lived only in dire circumstances. He rarely used Palace 2 during his life. If we assume that the king was hiding out in Palace 2 at the end of his reign, would the circumstances have been better for a successful suicide by poisoning?
Answers: 1. The rat will now be more sensitive to pain. The exposure to an environment associated with morphine injections will have induced a conditioned compensatory effect: a heightened sensitivity to pain. The saline injection produces no physiological effect of its own; however, because it is given in that same environment where the morphine was adminis- tered, the conditioned effect will remain, and the rat’s reaction will be hyperalgesia. (The experiment has been performed, by the way, and this predicted outcome does occur.)
2. Most likely, the king would have died. He would not have been able to develop a sufficient level of drug tolerance to protect himself from succeeding in his suicide attempt.
3. Yes. The change in the environment, from Palace 1 to Palace 2, would have reduced (or eliminated) the drug tolerance that the king had built up during his life.
4.2
Chapter 4 Fundamentals of Drug-Taking Behavior ■ 77
Unfortunately, we cannot predict with certainty whether a person will react strongly or weakly to a placebo. We do know, however, that the enthusiasm or lack of enthusiasm of the prescribing physician can play a major role. In one study that varied the attitude of the physician toward a par- ticular medication, negative attitudes toward the medica- tion resulted in the least benefits, whereas positive attitudes resulted in the most.15
It is not at all clear how the placebo effect is accom- plished. In the case of pain relief, there is evidence that we have the natural ability to increase the levels of endor- phins (internally produced opiates) in the bloodstream and the brain from one moment to the next, but the nature of our ability to alter other important substances in our bod- ies is virtually unknown. Recent studies have documented a 33 percent increase in lung capacity among asthmatic children who inhaled a bronchodilator containing a pla- cebo instead of medication and the development of skin rashes in people who have been exposed to fake poison ivy, to name a few examples of placebo-induced physiologi- cal reactions. Placebo research forces us to acknowledge the potential for psychological control over physiological processes in our bodies.16
Drug Research Methodology Given the power of the placebo effect in drug-taking behavior, it is necessary to be very careful when carrying out drug research. For a drug to be deemed truly effective, it must be shown to be better not only in comparison to a no-treatment condition (a difference that could conceiv- ably be due to a placebo effect) but also in comparison to an identical-looking drug that lacks the active ingredi- ents of the drug being evaluated. For example, if the drug under study is in the shape of a round red pill, another round red pill without the active ingredients of the drug (called the active placebo) also must be administered for comparison purposes.
The procedures of these studies also have to be carefully executed. Neither the individual administering the drug or placebo nor the individual receiving the drug or placebo should know which substance is which. Such precautions, referred to as double-blind procedures, represent the mini- mal standards for separating the pharmacological effects of a drug from the effects that arise from one’s expectations and beliefs.17 We will return to the issue of interactions between drug effects and expectations when we consider alcohol intoxication in Chapter 13.
completely, we would still frequently find a drug effect in an individual person to be different from time to time, place to place, and situation to situation. Predictions about how a per- son might react would be far from perfect.
In general, a good way of thinking about an individual’s response to a particular drug is to view the drug effect as the product of three factors: (1) the drug’s pharmacological properties (the biochemical nature of the substance), (2) the individual taking the drug (set), and (3) the immediate environment within which drug-taking behavior is occurring (setting). It is the three-way interaction of these factors that determines the final outcome.
Whether one or more of these factors dominate in the final analysis seems to depend upon the dosage level. Generally speaking, the higher the drug dose, the greater the contribution made by the pharmacology of the drug itself; the lower the dose, the greater the contribution of individual char- acteristics of the drug-taker or environmental conditions.12
Expectation Effects One of the most uncontrollable factors in drug-taking behav- ior is the set of expectations a person may have about what the drug will do. If you believe that a drug will make you drunk or feel sexy, the chances are increased that it will do so; if you believe that a marijuana cigarette will make you high, the chances are increased that it will. You can consider the impact of negative expectations in the same way; when the feelings are strong that a drug will have no effect on you, the chances are lessened that you will react to it. In the most extreme case, you might experience a drug effect even when the substance you ingested was completely inert—that is, pharmacologi- cally ineffective. Any inert (inactive) substance is referred to as a placebo (from the Latin, “I will please”), and the physical reaction to it is referred to as the placebo effect.
The concept of a placebo goes back to the earliest days of pharmacology. The bizarre ingredients prescribed in ancient times to treat various diseases were effective to the extent that people believed that they were effective, not from any known therapeutic property of these ingredients. No doubt, the pla- cebo effect was strong enough for physical symptoms to dimin- ish. During the Middle Ages, in one of the more bizarre cases of the placebo effect, Pope Boniface VIII reportedly was cured of kidney pains when his personal physician hung a gold seal bearing the image of a lion around the pope’s thigh.13
It would be a mistake to think of the placebo effect as involving totally imaginary symptoms or totally imaginary reac- tions. Physical symptoms, involving specific bodily changes, can occur on the basis of placebo effects alone. How likely is it that a person will react to a placebo? The probability will vary from drug to drug, but in the case of morphine, the data are very clear. In 1959, a review of studies in which morphine or a placebo was administered in clinical studies of pain concluded that a placebo-induced reduction in pain occurred 35 percent of the time. Considering that morphine itself had a positive result in only 75 percent of the cases, the placebo effect is a very strong one.14
double-blind: A procedure in drug research in which nei- ther the individual administering nor the individual receiving a chemical substance knows whether the substance is the drug being evaluated or an active placebo.
placebo (pla-See-bo): Latin term translated “I will please.” Any inert substance that produces a psychological or physi- ological reaction.
78 ■ Part One The Challenge of Drugs in Our Society
Psychological Dependence The most important implication of the model of physical dependence, as distinct from psychological dependence, is that individuals involved in drug abuse continue the drug-taking behavior, at least in part, to avoid the feared consequences of withdrawal. This idea can form the basis for a general model of drug dependence only if physical withdrawal symptoms appear consistently for every drug considered as a drug of abuse. It turns out, however, that a number of abused drugs (cocaine, hallucinogens, and mar- ijuana, for example) do not produce physical withdrawal symptoms, and the effects of heroin withdrawal are more variable than we would expect if physical dependence alone were at work.
It is possible that drug abusers continue to take the drug not because they want to avoid the symptoms of withdrawal but because they crave the pleasurable effects of the drug itself. They may even feel that they need the drug to func- tion at all.19
Many heroin abusers (between 56 and 77 percent in one major study) who complete the withdrawal process after abstaining from the drug have a relapse.20 If physical depen- dence were the whole story, these phenomena would not exist. The withdrawal symptoms would have been gone by that time, and any physical need that might have been evi- dent before would no longer be present.
When we speak of psychological dependence, we are offering an explanation of drug abuse based not upon the attempt of abusers to avoid unpleasant withdrawal symp- toms but upon their continued desire to obtain pleasurable effects from the drug. Unfortunately, we are faced here with a major conceptual problem: The explanation by itself is circular and tells us basically nothing. If I were to say, for example, that I was taking cocaine because I was psychologi- cally dependent upon it, then I could just as easily say that I was psychologically dependent upon cocaine because I was abusing it. Without some independent justification, the only explanation for the concept of psychological dependence would be the behavior that the concept was supposed to explain!
Fortunately, there is independent evidence for the con- cept of psychological dependence, founded chiefly upon studies showing that animals are as capable of self-admin- istering drugs of abuse as humans are. Using techniques developed in the late 1950s, researchers have been able to insert a catheter into the vein of a freely moving laboratory animal and arrange the equipment so that the animal can self-administer a drug intravenously whenever it presses a lever (Figure 4.2). It had been well known that animals would engage in specific behaviors to secure rewards such as food, water, or even electrical stimulation of certain regions of the brain. These objectives were defined as positive rein- forcers because animals would learn to work to secure them. The question at the time was whether animals would self- administer drugs in a similar way. Could drugs be positive reinforcers as well?
Physical and Psychological Dependence
When we refer to the idea of dependence in drug abuse, we are dealing with the fact that a person has a strong compul- sion to continue taking a particular drug. Two possible mod- els or explanations for why drug dependence occurs can be considered. The first is referred to as physical dependence, and the second is referred to as psychological dependence. The two models are not mutually exclusive; the abuse of some drugs can be a result of both physical and psychological dependence, whereas the abuse of others can be a result of psychological dependence alone.
Physical Dependence The concept of physical dependence originates from obser- vations of heroin abusers, as well as of those who abuse other opiate drugs, who developed strong physical symptoms fol- lowing heroin withdrawal: a runny nose, chills and fever, inability to sleep, and hypersensitivity to pain. For barbitu- rate abusers in a comparable situation, symptoms include anxiety, inability to sleep, and sometimes lethal convulsions. For chronic alcohol abusers, abstention can produce trem- ors, nausea, weakness, and tachycardia (a fast heart rate). If severe, symptoms may include delirium, seizures, and hallucinations.18
Although the actual symptoms vary with the drug being withdrawn, the fact that we observe physical symptoms at all suggests strongly that some kind of physical need, perhaps as far down as the cellular level, develops over the course of drug abuse. It is as though the drug, previously a foreign sub- stance, has become a normal part of the nervous system, and its removal and absence become abnormal.
From this point of view, it is predictable that the with- drawal symptoms would involve symptoms that are opposite to effects the drug originally had on the body. For example, heroin can be extremely constipating, but eventually the body compensates for heroin’s intestinal effects. Abrupt abstinence from heroin leaves the processes that have been counteracting the constipation with nothing to counteract, so the result of withdrawal is diarrhea. You may notice a strong resemblance between the action–counteraction phenomena of withdrawal and the processes Siegel has hypothesized as the basis for behavioral tolerance.
psychological dependence: A model of drug depen- dence based on the idea that the drug abuser is motivated by a craving for the pleasurable effects of the drug.
physical dependence: A model of drug dependence based on the idea that the drug abuser continues the drug- taking behavior to avoid the consequences of physical withdrawal symptoms.
Chapter 4 Fundamentals of Drug-Taking Behavior ■ 79
all. Body weight dropped by 47 percent, their normal groom- ing behavior ended, and there was steady deterioration in their physical health. Thirty days later, 90 percent of the rats were dead.24 In the final analysis, from the standpoint of treat- ing individuals who abuse drugs, however, it can be argued that it does not matter whether there is physical dependence or psychological dependence going on. According to many experts in the field, the distinction between physical and psychological dependence has outgrown its usefulness in explaining the motivation behind drug abuse. Whether the discontinuation of an abused drug does induce major physi- cal withdrawal symptoms (as in the case of heroin, alcohol, and barbiturates) or does not (as in the case of cocaine, amphetamines, and nicotine), the patterns of compulsive drug-taking behavior are remarkably similar. If the pattern of behavior is similar, then there can be common strategies for treatment (see Chapter 17).25
Drug-Taking Behavior and Treatment: The Health Professional Perspective
For any treatment program to be effective, whether the problems are drug-related or not, a system of guidelines must be in place to establish an appropriate diagnosis. Treatment for ulcerative colitis, for example, requires the presentation of specific bodily symptoms (among them, diarrhea, abdominal pain). Once a diagnosis of ulcerative colitis is made, treatment can begin. In the case of drug- related problems, health professionals in the United States use a set of specific behavioral circumstances that serve as criteria for a diagnosis, just as symptoms serve as criteria for a physical disease.
From the perspective of a health professional, the goal is to reduce the incidence of drug-related problems in an individual’s life through a therapeutic intervention (see Chapter 17). The emphasis in making a diagnosis is on the adverse impact of drug-taking behavior on his or her life, independent of any possible illegality in the behavior itself (see Chapter 1).
The Diagnostic and Statistical Manual of Mental Disorders (referred to as the “DSM”), issued under the auspices of the American Psychiatric Association, has been the official standard for defining and diagnosing a wide range of psychological disorders, including those related to drug-taking behavior. The fifth edition of the manual (referred to as DSM-5), issued in 2013, estab- lishes a diagnosis of substance use disorder on the basis
The experiments showed clearly that animals would self- administer drugs such as cocaine and other stimulants despite the fact that these drugs would not ordinarily produce physi- cal symptoms during withdrawal. In one study, rats pressed the lever as many as 6,400 times for one administration of cocaine; others were nearly as eager for administrations of amphetamines.21 Interestingly, a number of other drugs were aversive, judging from the reluctance of animals to work for them. Hallucinogens such as LSD, antipsychotic drugs, and antidepressant drugs were examples of drugs that animals clearly did not like.22
By connecting the concept of psychological dependence to general principles of reinforcement, it is possible for us to appreciate the powerful effects of abused drugs. When an ani- mal is presented with a choice of pressing a lever for food or pressing a lever for cocaine, cocaine wins hands down—even to the point of the animal starving to death.23
When the effects of heroin are compared with those of cocaine, the differences are dramatic. Rats self-administering heroin eventually established a stable pattern of use. They maintained their body weight, continued to groom them- selves as before. For a while, they appeared to be in good health, although about a third of them died in a month’s time. Rats self-administering cocaine, however, showed a more erratic pattern of use. There would be binge-like epi- sodes of heavy use alternating with brief periods of no use at
substance use disorder: A diagnostic term in DSM-5 (issued in 2013) identifying an individual with varying degrees of behavioral difficulties that are related to some form of drug- taking behavior.
Pump
Programming equipment
Catheter
Lever
Drug
F IguRe 4 .2
A simplified rendering of how drugs are self-administered in rats. The rat’s pressure on a lever causes the pump to inject a drug through a catheter implanted into its vein.
80 ■ Part One The Challenge of Drugs in Our Society
hallucinogen use (see Chapter 11) or inhalant use (see Chapter 14), Criterion 11 is not considered in arriving at a diagnosis.
According to the DSM-5, the severity of substance use disor- der is defined in terms of the number of criteria an individual meets. The presence of two or three criteria indicates a mild level of substance use disorder; the presence of four to five criteria indicates a moderate level; and the presence of six or more criteria indicates a severe condition.
Four major points should be made with respect to the terminology used in the DSM-5 system.
●■ First, the phrase “substance use” is used throughout rather than “drug use” since it is acknowledged that confusion often exists in the public mind about what is defined as a drug-taking behavior and what is not— particularly in the consumption of alcohol or tobacco products (see Chapter 1).
●■ Second, the word “addiction” is not used in any diagnos- tic classification or criteria. Even though it is commonly used to describe a severe problem related to compul- sive or habitual behavior, the word is considered to be difficult to define, and the negative connotation of the word might cause its use to be an obstacle to successful treatment.
●■ Third, separate diagnoses for substance abuse and sub- stance dependence, which had been identified in an earlier edition of the DSM (specifically DSM-IV-TR), have been eliminated in DSM-5. With minor exceptions, the four criteria previously listed for the diagnosis of sub- stance abuse and the seven criteria previously listed for the diagnosis of substance dependence have been combined into one set of 11 criteria for the diagnosis of substance use disorder. It has been felt that the clinical treatment of drug-related problems is more easily carried out with a sin- gular diagnosis and a scale of severity-of-symptoms. While they continue to be helpful as concepts in understanding the problems associated with drug-taking behavior (see Chapter 1), substance abuse and substance dependence are not diagnoses in the DSM-5 system. Nonetheless, as a rough approximation, fulfilling six or more criteria for substance use disorder (establishing a diagnosis of severe substance use disorder) can be considered equivalent to the diagnosis of substance dependence.
●■ Fourth, when a single drug is involved, the diagnosis of substance use disorder is identified in the context of that drug. As examples, the DSM-5 establishes separate diagno- ses of opioid use disorder (when heroin is involved), stimu- lant use disorder, hallucinogen use disorder, cannabis use disorder, or alcohol use disorder. With exception of those cases in which Criterion 11 is not considered (see above), the same behavioral criteria are used, no matter what drug is involved.26
of 11 possible behavioral circumstances (or criteria). As we will see, a minimum number of criteria must be met for this diagnosis.
The possible criteria for substance use disorder can be viewed in terms of four groupings of dysfunctional behavior:
●■ Impaired control: A substance may be taken in larger amounts or over a longer period of time than the indi- vidual originally intended (Criterion 1). There may be a persistent desire to cut down or regulate substance use or there may be multiple unsuccessful attempts to cut down or discontinue substance use (Criterion 2). A great deal of time may be spent obtaining the substance, using it, or recovering its effects (Criterion 3). There may be intense urges or cravings to engage in substance use or times in which the individual cannot think of anything else (Criterion 4).
●■ Social impairment: There may be a failure in fulfill- ing a major role obligation at work, at school, or at home as a consequence of substance use (Criterion 5). Substance use may be continued despite the persistence or recurrence of social or interpersonal problems associ- ated with use (Criterion 6). An individual may withdraw from, reduce, or give up on important social, occupa- tional, or recreational activities because of substance use (Criterion 7).
●■ Risky use: There may be multiple times when substance use has occurred in a physically hazardous situation (Criterion 8). Substance use may continue despite the knowledge that it is likely to cause or exacerbate a physical or psychological problem. In other words, there is a failure to abstain from using the substance even though the indi- vidual recognizes the problems substance use is causing (Criterion 9).
●■ Pharmacological effects: Over time, there may be a development of tolerance to the effects of the sub- stance being used (Criterion 10). For those substances for which significant withdrawal symptoms have been documented in humans (e.g., alcohol, opiate-related drugs, sedative-hypnotics, and antianxiety medications), withdrawal symptoms may be observed (Criterion 11). However, in cases in which withdrawal symptoms are not documented to occur in humans, such as with
substance dependence: Prior to 2013, a diagnostic term in DSM-IV-TR identifying an individual with significant signs of a dependent relationship upon a psychoactive drug.
substance abuse: Prior to 2013, a diagnostic term in DSM-IV-TR identifying an individual who continues to take a psychoactive drug despite the fact that the drug-taking behavior creates specific problems for that individual.
Chapter 4 Fundamentals of Drug-Taking Behavior ■ 81
How Drugs enter the Body ●● There are four basic ways to administer drugs into the
body: oral administration, injection, inhalation, and absorption through the skin or membranes. Each of these presents constraints on which kinds of drugs will be effec- tively delivered into the bloodstream.
How Drugs exit the Body ●● Most drugs are eliminated from the body with urinary
excretion. Drugs are broken down for elimination by the action of enzymes in the liver. An index of how long this process takes is called the elimination half-life.
Factors Determining the Behavioral Impact of Drugs ●● The physiological effect of a drug can vary as a factor of
the time elapsed since its administration, the possible combination of its administration with other drugs, and finally the personal characteristics of the individual con- suming the drug.
●● Some characteristics that can play a definite role in the effect of a drug include the individual’s weight, gender, and racial or ethnic background.
●● Two important issues need to be understood in looking at the physiological effect of drugs: the extent to which drugs pass into the bloodstream and from the bloodstream to the brain and the extent to which tolerance effects occur over repeated administrations of a given drug.
Psychological Factors in Drug-Taking Behavior ●● Although the physiological actions of psychoactive
drugs are becoming increasingly well understood, great variability in the effect of these drugs remains, largely because of psychological factors.
●● The most prominent psychological factor is the influence of personal expectations on the part of the individual con- suming the drug. The impact of expectations on one’s reaction to a drug, a phenomenon called the placebo effect, is an important consideration in drug evaluation and research.
Physical and Psychological Dependence ●● Drugs can be viewed in terms of a physical dependence
model, in which the compulsive drug-taking behavior is tied to an avoidance of withdrawal symptoms, or a psy- chological dependence model, in which the drug-taking behavior is tied to a genuine craving for the drug and highly reinforcing effects of the drug on the user’s body and mind.
Drug-Taking Behavior and Treatment: The Health Professional Perspective
●● For health professionals, the Diagnostic and Statistical Manual of Mental Disorders (referred to as “DSM”), issued by the American Psychiatric Association, has been the official standard for defining and diagnos- ing a wide range of psychological problems, includ- ing problems related to drug-taking behavior. The fifth edition (DSM-5), issued in 2013, identifies the diagnosis of substance use disorder, based upon meeting a mini- mum number of behavioral circumstances (criteria). A severity-of-symptoms scale identifies a mild, moderate, or severe level of substance use disorder, based upon the number of criteria met.
Summary
Key Terms
behavioral tolerance, p. 72 biotransformation, p. 70 cross-tolerance, p. 75 double-blind, p. 77 elimination half-life, p. 71 intramuscular, p. 68
intranasal, p. 69 intravenous, p. 68 latency period, p. 71 metabolite, p. 70 physical dependence, p. 78 placebo, p. 77
potentiation, p. 72 psychological dependence,
p. 78 subcutaneous, p. 68 sublingual, p. 69 substance abuse, p. 80
substance dependence, 80 substance use disorder,
p. 79 synergism, p. 72 tolerance, p. 72 transdermal patch, p. 69
1. Discuss the oral, injection, inhalation, and absorption routes of drug administration. Rank the four administrations roughly in terms of the speed by which a drug enters the bloodstream.
2. Compare and contrast the major forms of drug interactions. 3. Define drug tolerance and describe the circumstances under
which environmental and contextual cues play a role in the development of behavioral (conditioned) tolerance.
4. Describe the drug research methodology that is necessary to eliminate the possibility that a drug effect may be due to the expectation of the user rather than the physical properties of the drug itself.
5. Contrast the concepts of physical dependence and psychologi- cal dependence.
6. Describe the 11 behavioral criteria in the diagnosis of sub- stance use disorder in DSM-5.
Review Questions
82 ■ Part One The Challenge of Drugs in Our Society
Suppose you are a drug-abuse professional treating a young man who has a history of relapse, despite repeated attempts to end a life of drugs and the destructive consequences on his life. At this point, it appears that the client has succeeded in ending his current pattern of drug abuse. He has recently established a relationship
with a woman with a history of drug abuse and is also at the end of a successful treatment program. They have decided to move together to another city. What recommendations would you give to your client (and the woman) as they enter into a new phase of their lives?
Critical Thinking: What Would You Do?
1. Public-service message (1987). Frying Pan. New York: Partners for a Drug-free America.
2. Karande, Pankaj; and Mitragotri, Samir (2009). Enhancement of transdermal drug delivery via synergistic action of chemi- cals. Biomembranes, 1788(11), 2362–2373. Mitragotri, Samir (2005). Healing sound: The use of ultrasound in drug delivery and other therapeutic applications. Nature Reviews: Drug Discovery, 4, 255–260. Whitten, Lori (2009, November). Nal- trexone via skin patch technology proves effectiveness of new technology. NIDA Notes, 22(3), 13, 16.
3. Hawks, Richard L.; and Chiang, C. Nora (1986). Examples of specific drug assays. In Richard L. Hawks and C. Nora Chi- ang (Eds.), Urine testing for drugs of abuse (NIDA Research Monograph 73). Rockville, MD: National Institute on Drug Abuse, pp. 84–112. Julien, Robert M. (2001). A primer of drug action (9th ed.). New York: Worth, pp. 27–31. McKim, William A. (2000). Drugs and behavior: An introduction to behavioral pharmacology (4th ed.). Upper Saddle River, NJ: Prentice-Hall, pp. 1–25.
4. Siegel, Shepard (1990). Drug anticipation and the treatment of dependence. In Barbara A. Ray (Ed.), Learning factors in sub- stance abuse (NIDA Research Monograph 84). Rockville, MD: National Institute on Drug Abuse, pp. 1–24.
5. Gerevich, Jóseph; Bácskai, Erika; Farkas, Lajos; and Danics, Zoltán (2005, July 25). A case report: Pavlovian conditioning as a risk factor of heroin “overdose” death. Harm Reduction Jour- nal, 2(11) (online publication). Siegel, Shepard (1975). Evi- dence from rats that morphine tolerance is a learned response. Journal of Comparative and Physiological Psychology, 89, 489– 506. Siegel, Shepard; Hinson, Riley E.; Krank, Marvin D.; and McCully, Jane (1982). Heroin “overdose” death: Contribution of drug-associated environmental cues. Science, 216, 436–437.
6. Brecher, Edward M., and the editors of Consumer Reports. (1972). Licit and illicit drugs. Mount Vernon, NY: Consumers Union.
7. Siegel, Shepard (1999). Drug anticipation and drug addiction. The 1998 H. David Archibald Lecture. Addiction, 94, 1 113–1124.
8. Frezza, Mario; DiPadova, Carlo; Pozzato, Gabrielle; Terpin, Maddalena; Baraona, Enrique; and Lieber, Charles S. (1990). High blood alcohol levels in women: The role of decreased gastric alcohol dehydrogenase activity and first-pass metabo- lism. New England Journal of Medicine, 322, 95–99.
9. Nakawatase, Tomoko V.; Yamamoto, Joe; and Sasao, Toshiaki (1993). The association between fast-flushing response and alcohol use among Japanese Americans. Journal of Studies on Alcohol, 54, 48–53.
10. Goodman, Deborah (1992, January–February). NIMH grantee finds drug responses differ among ethnic groups. ADAMHA News, pp. 5, 15. Johnson, Ronald C.; Nagoshi, Sylvia Y.; Schwit-
ters, Kirk S.; Bowman, Frank M., et al. (1984). Further investiga- tion of racial/ethnic differences and of familial resemblances in flushing in response to alcohol. Behavior Genetics, 14, 171–178.
11. Perez-Stable, Eliseo J.; Herrera, Brenda; Jacob III, Peyton; and Benowita, Neal L. (1998). Nicotine metabolism and intake in black and white smokers. Journal of the American Medical Association, 280, 152–156.
12. Goode, Erich (1999). Drugs in American society (5th ed.). New York: McGraw-Hill College, p. 9.
13. Kornetsky, Conan (1976). Pharmacology: Drugs affecting behavior. New York: Wiley, p. 23. Morris, David B. (1999). Placebo, pain, and belief: A biocultural model. In Anne Har- rington (Ed.), The placebo effect: An interdisciplinary explora- tion. Cambridge, MA: Harvard University Press, pp. 187–207. Shapiro, Arthur K.; and Shapiro, Elaine (1997). The powerful placebo: From ancient priest to modern physician. Baltimore: Johns Hopkins University Press.
14. Beecher, Henry K. (1959). Measurement of subjective responses: Quantitative effects of drugs. New York: Oxford University Press. Waber, Rebecca L.; Shiv, Baba; Cannon, Ziv; and Ariely, Dan (2008). Commercial features of placebo and therapeutic efficacy. Journal of the American Medical Association, 299(10), 1016–1017.
15. Benedetti, Fabrizio (2002). How the doctor’s words affect the patient’s brain. Evaluation and the Health Professions, 25, 369–386.
16. De la Fuente-Fernández, R; and Stoessl, A. J. (2002). The bio- chemical bases for reward: Implications for the placebo effect. Evaluation and the Health Professions, 25, 387–398. Flaten, Magne Arve; Simonsen, Terje; and Olsen, Harald (1999). Drug- related information generates placebo and nocebo responses that modify the drug response. Psychosomatic Medicine, 61, 250–255. Levinthal, Charles F. (1988). Messengers of paradise: Opiates and the brain. New York: Anchor Press/Doubleday. Talbot, Margaret (2000, January 9). The placebo prescription. New York Times Magazine, pp. 34–39, 44, 58–60. Wager, Tor D. (2005). The neural basis of placebo effects in pain. Current Directions in Psychological Science, 14, 175–179.
17. Quitkin, Frederic M. (1999). Placebos, drug effects, and study design: A clinician’s guide. American Journal of Psychiatry, 156, 829–836.
18. Blum, Kenneth (1991). Alcohol and the addictive brain. New York: Free Press, p. 17.
19. Pinel, John P. J. (2003). Biopsychology (5th ed.). Boston: Allyn and Bacon, p. 398.
20. Simpson, D. Dwayne; and Marsh, Kerry L. (1986). Relapse and recovery among opioid addicts 12 years after treatment. In Frank M. Tims and Carl G. Leukefeld (Eds.), Relapse and recovery in drug abuse (NIDA Research Monograph 72). Rockville, MD: National Institute on Drug Abuse, pp. 86–103.
Endnotes
Chapter 4 Fundamentals of Drug-Taking Behavior ■ 83
Pharmacology, effects, and treatment of abuse. Rockville, MD: National Institute on Drug Abuse, pp. 54–71.
24. Bozarth, Michael A.; and Wise, Roy A. (1985). Toxicity associated with long-term intravenous heroin and cocaine self-administration in the rat. Journal of the American Medical Association, 254, 81–83.
25. Stewart, Jane; De Wit, Harriet; and Eikelboom, Roelof (1984). Role of unconditioned and conditioned drug effects in the self- administration of opiates and stimulants. Psychological Review, 91, 251–268.
26. American Psychiatric Association (2000). Diagnostic and statis- tical manual. Text Revision (4th ed.). Washington, DC: Ameri- can Psychiatric Publishing, pp. 191, 197, and 199. American Psychiatric Association (2013). Diagnostic and statistical man- ual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing, pp. 483–490.
21. Halikas, James A. (1997). Craving. In Joyce H. Lowinson; Pedro Ruiz; Robert B. Millman; and John G. Langrod (Eds.), Substance abuse: A comprehensive textbook (3rd ed.). Balti- more: Williams and Wilkins, pp. 85–90. Pickens, Roy; and Thompson, Travis (1968). Cocaine-reinforced behavior in rats: Effects of reinforcement magnitude and fixed-ratio size. Journal of Pharmacology and Experimental Therapeutics, 161, 122–129.
22. Hoffmeister, F. H.; and Wuttke, W. (1975). Psychotropic drugs as negative reinforcers. Pharmacological Reviews, 27, 419–428. Yokel, R. A. (1987). Intravenous self-administration: Response rates, the effect of pharmacological challenges and drug prefer- ences. In Michael A. Bozarth (Ed.), Methods of assessing the reinforcing properties of abused drugs. New York: Springer- Verlag, pp. 1–34.
23. Johanson, Chris E. (1984). Assessment of the abuse potential of cocaine in animals. In John Grabowski (Ed.), Cocaine:
After you have completed this chapter, you should have an understanding of the following:
●● Biological perspectives on drug use and abuse
●● Psychological perspectives on drug and abuse
●● Sociological perspectives on drug and abuse
●● The biopsychosocial model of drug and abuse
●● Risk factors and protective fac- tors for drug use and abuse
Theoretical Perspectives on Drug
Use and Abuse
5
Joe sat down with me to tell his story. He wanted to make sure every-
thing he said would be strictly confidential. I promised that I would
never use his real name. His name isn’t really Joe.
“Yeah. I used to smoke weed a lot when I was younger. It was
the thing to do,” he said.
“But after I got married and had kids, I knew things had to
change. I wanted to quit smoking weed. I stopped smoking for
two weeks and didn’t have any withdrawal symptoms like the
shakes or anything, but sometimes certain things would make
me want to smoke again. Like if I heard an old Dead song or saw
someone I used to get high with, I kind of had an urge to light up
a joint. And every time I got drunk, I wanted to end the night with
a bong hit. Like the old days. Never did, of course. I would have
gotten caught on that one. I still get high sometimes if I go out with
some of my old friends, but I never tell my wife. She would kick me
out of the house.”
Joe said with a laugh, “Maybe I should get me some new
friends. Yeah, that might do it.”
PA r t t W O
Drugs, Crime, and Criminal Justice
chapter
Chapter 5 Theoretical Perspectives on Drug Use and Abuse ■ 85
alcohol abuse) is the result of personal choice, and the violator of drunk driving laws should be punished.2
Biological Perspectives on Drug Abuse
When we theorize about the origins of drug abuse from a biological perspective, we are referring to specific physical mechanisms in specific individuals that influence the initial experience with drugs or an engagement in drug abuse over a period of time. Biological theories have focused primarily on genetic factors, physiological factors, and neurochemical systems in the brain.
Genetic Factors As genetic research has advanced over the years, particularly since the completion of the mapping of the human genome in 2000, a great deal of attention has focused on the contribution that certain genetic traits make toward the abuse of a range of drugs. Environmental factors are also undoubtedly important. Recent studies have shown, however, that genetic factors play an equal or greater role. Studies of different strains of mice and rats, for example, have found that some have a genetic propensity to become dependent upon cocaine, whereas other strains are more susceptible to the dependence-producing effects of opiates.3
Why do people take drugs? We all take drugs, of course, for genuine therapeutic reasons, to relieve ourselves of pain or symptoms that arise from a range of physical or psychological disorders. But why do people take drugs on a purely recreational basis? Is it for sheer pleasure, to escape from a life of boredom, to suppress feelings of sorrow and depression, to fit in with a group of friends, to relieve stress? Or is there some propensity toward drug-taking behavior that is rooted in the neurochemistry of the brain? Chapter 1 iden- tified a biopsychosocial model as a way of understanding the interplay of biological, psychological, and sociological fac- tors. In this chapter, the three perspectives on drug-taking behavior will form the basis for an examination of a variety of explanatory theories.1
The oldest theory of drug abuse, and arguably the old- est theory to explain disapproved behavior in general, has its origin in demonology. Why would you do something bad? Answer: “Because the devil made you do it.”
We have certainly moved away from believing that an evil spirit (or anything outside our experience) invokes bad behavior, but, strangely enough, a modern version of this belief continues to influence the way people might think about drug abuse. To some, a drug abuser is an individual who is morally deficient, who, because of personal inadequa- cies, overindulgence, a weakness of will, or other character flaw, has succumbed to a pattern of drug-taking behavior that has taken over his or her life and those around him or her.
A nonreligious version of this point of view is referred to as the moral model of drug abuse. According to the moral model, drug-taking behavior is simply a matter of personal choice that we have made in our lives, and not a conse- quence of a biological defect, a psychological dysfunction, or sociological circumstances.
The implications can be profound with respect to the ways in which drug abusers are held responsible for their actions and the way the criminal justice system views drug-taking behavior in general. In 1988, the U.S. Supreme Court ruled that crimes committed by an alcoholic were willful misconduct, and not a consequence of a disease. Essentially, excessive alcohol use (no matter whether the individual has a pattern of chronic
moral model: An explanation for drug abuse in which drug-taking behavior is attributed to personal inadequacies, overindulgence, a weakness of will, or other serious character flaw.
biopsychosocial model: A theoretical perspective on drug abuse that recognizes the biological, psychological, and sociological factors underlying drug-taking behavior and encourages an integrated approach toward drug-abuse treatment.
100 billion Estimated number of neurons in the human brain 10–100 trillion Estimated number of synapses in the human brain 7.1 times The degree of increase in the likelihood of using marijuana among youths (aged 12–17) having a history of
getting into a serious fight at school or at work, relative to youths having no history of getting into a serious fight at school or at work
Sources: Drachman, D. (2005). Do we have brain to spare? Neurology, 64, 2004–2005. Wright, Douglas, and Pemberton, Michael (2004). Risk and protective factors for adolescent drug use: Findings from the 1999 National Household Survey on Drug Abuse. Rockville, MD: Substance Abuse and Mental Health Services Administration, Chapter 3 and Appendix A. Thompson, R. F. (1993). The brain: A neuroscience primer (2nd ed.). New York: Freeman, pp. 75, 299.
Numbers Talk…
86 ■ Part Two Drugs, Crime, and Criminal Justice
are speaking of a predisposition toward a lcoholism, which can increase the probability of alcoholism.6
Physiological Factors One physiological factor hypothesized to be involved in drug abuse has to do with metabolic processes in the body. In other words, people might differ in the extent to which chemicals in the body are broken down or changed in some way to allow us to function normally. For example, it has been proposed that chronic heroin abuse might be due to a metabolic defect in the bodies of heroin abusers. Just as Type 1 diabetics have an insufficient level of insulin that prevents them from process- ing glucose in a normal fashion, heroin abusers may have an inborn deficiency with respect to natural opiate-like chemicals produced by the brain itself, and, as a result, they feel com- pelled to seek out heroin and other opiate drugs from the envi- ronment to make up for that deficiency. From this perspective, heroin abusers are “normalizing” their body by indulging in heroin abuse. A specific dysfunctional system in the body of a heroin abuser, however, is yet to be discovered. At present, the evidence of a metabolic defect is only circumstantial. In other words, heroin-dependent individuals appear to behave as if they have a metabolic imbalance with respect to opioids (opiate-related drugs) in general.7
Most studies concerning genetic factors in humans have focused on alcoholic individuals, and a growing research literature indicates that alcoholism has a genetic component (see Chapter 15). Family studies have shown that children of alcoholics are four times more likely than other children to become alcoholics (Figure 5.1). Identical twins (those who have identical genetic compositions) are more likely to have a similar risk for alcoholism than fra- ternal twins, who share only half their genetic traits with each other. In addition, children who have at least one alcoholic biological parent and were adopted by nonalco- holic parents are three times more likely to have a problem with alcohol, even when they have been raised in a low-risk environment.4
We have yet to identify the single gene or complete set of genes responsible for the emergence of alcoholism, much less the interaction of gene expression that increases the like- lihood of alcoholic behavior. Like cancer and heart disease, alcoholism is considered to be genetically complex, distin- guishing it from diseases such as cystic fibrosis, which results from the mutation of a single gene. In the case of alcohol- ism, genes are likely to be associated with liver enzymes that metabolize (break down) alcohol as well as specific patterns of brain chemistry.5 Even so, we are not speaking of genetic factors producing these effects in a deterministic manner. We
• Heavy alcohol user • Binge drinker • Tobacco chewer and
heavy smoker
• Heavy smoker • Died of lung
cancer
• Illicit substance abuser • Died of overdose
• Social drinker • Moderate smoker
• Alcohol abuser
• Alcohol abuser
Harold Gladys
• Heavy drinker • Car accident death
while drinking • Heavy smoker
Ike Lorraine
Brad
• Alcohol abuser • Closet drinker • Heavy smoker
Jane KarenWilliam
Sandy
Pam
F igure 5 .1
The genogram of two alcohol abusers, Pam and Sandy, reveals that alcohol and other substances have been abused for four generations, causing family problems and death throughout the family’s history.
Source: Based on data from Stevens, Patricia; and Smith, Robert L. (2005). Substance abuse counseling: Theory and practice (3rd ed.). Boston: Allyn and Bacon, p. 94.
Chapter 5 Theoretical Perspectives on Drug Use and Abuse ■ 87
Neurochemical Systems in the Brain Amphetamines, cocaine, heroin, alcohol, and nicotine may be very different from a pharmacological standpoint, but the way people and animals react to them are remarkably similar. Use of these substances results in a pattern of com- pulsive behavior that is based on an intense drive to repeat the experience. We cannot determine whether animals are “craving” these substances, but we certainly recognize feelings of craving in humans. In general, the similarities among all of these drugs and across species are numer- ous enough to entertain the idea that there exists a com- mon neurochemical system in the brain that links them all together (Drugs … in Focus).
There are two key elements in understanding the intensely rewarding effect of certain psychoactive drugs. The first of these is the existence of brain chemicals called
neurotransmitters, which allow neurons (brain cells) to com- municate with each other. A specific neurotransmitter of interest with respect to drug abuse is dopamine. The second is the existence of a group of neurons in the brain called the nucleus accumbens.
understanding the Biochemistry of Psychoactive Drugs Neurons are specialized cells, designed to receive and transmit information. There are an estimated 100 billion neurons in the brain, making the brain arguably the most complex organ of the body. Importantly, neurons are interconnected with other neurons, providing the basis for communication of information within the nervous system.
The transfer of information from neuron to neuron is con- trolled by the activity of chemical molecules called neurotrans- mitters. Specifically, neuron A communicates with neuron B at thousands of juncture points referred to as synapses. Essen- tially, information travels from the cell body of the neuron A to synaptic knobs, at the end of the axon. Neurotransmitters are released from these synaptic knobs and “delivered” across the synapse to the dendrites of neuron B. Special receptor sites embedded in neuron B receive the neurotransmitters that have been released. When the neurotransmitter molecules have successfully locked into the receptor sites (an event called receptor binding), the communication between neurons A and B has been accomplished.
Here is a partial list of neurotransmitters that play a role in the effects of alcohol and other drugs: • Acetylcholine influences heart rate, learning, and memory. • Dopamine affects motor control, mood, and feelings of
euphoria. Dopamine plays a major role in producing feelings of craving that encourage a continuing pattern of compulsive drug-taking behavior.
• Serotonin affects sensory perception, sleep, mood, and body temperature. Alterations in serotonin have been related to hallucinatory effects of such drugs as LSD and psilocybin.
Abnormal levels of serotonin have been associated with depression and other mood disorders.
• Endorphins are natural pain killers produced by the brain and bear a remarkable resemblance to morphine.
• Norepinephrine influences sleep, blood pressure, heart rate, and memory. Along with serotonin, norepinephrine has been associated with the regulation of mood.
• Gamma-aminobutyric acid (GABA) influences levels of anxiety and general excitation in the brain. Antianxiety medications, often referred to as tranquilizers, stimulate GABA-releasing neurons, providing a reduction in feelings of stress and fear.
• Glutamate is the basis for the effects of PCP (angel dust) and ketamine. It is also involved in drug craving and the likelihood of drug-abuse relapse.
Drugs … in Focus
Axon
Cell body
Dendrites
Synaptic knobs
nucleus accumbens (NeW-clee-us ac-CuM-buns): A region of the brain considered to be responsible for the reinforcing effects of several drugs of abuse.
dopamine (DOPe-ah-meen): A neurotransmitter in the brain whose chemical activity is related to emotionality and motor control.
neurotransmitter: A chemical that makes it possible for neurons (brain cells) to communicate with each other in nor- mal brain functioning. Some examples of neurotransmitters are dopamine, serotonin, GABA, and endorphins.
88 ■ Part Two Drugs, Crime, and Criminal Justice
in the nucleus accumbens. Administration of any substance that interferes with dopamine activity in this region eliminates the desire of animals to work for the self- administration of these abused drugs. Considering the evidence now in hand, a persuasive argument can be made that dopamine-related processes in the nucleus accumbens underlie the reinforcing effects of many abused drugs (Portrait). Research also shows an involvement of the nucleus accumbens in compulsive gambling and eating disorders as well.8
Research on the influence of dopamine in drug depen- dence can help us understand why some individuals may be more susceptible than others to drug-taking behavior. In one study, for example, 23 drug-free men with no history of drug abuse were given doses of methylphenidate (brand name: Ritalin), a psychoactive stimulant when ingested by adults. Twelve of the men experienced a pleasant feeling, nine felt annoyed or distrustful, and two felt nothing at all. Measurements of dopamine receptors in the brains of these subjects showed a consistent pattern. The men with the least concentration of dopamine receptors were the ones experiencing pleasant effects.9 It is reasonable to hypothesize that those individuals with the fewest dopamine receptors might be the most vulnerable to drug abuse. The understanding we now have about the neu- rochemical processes underlying dependence has significant implications for drug-abuse treatment (see Chapter 17).
The significance of the nucleus accumbens is that ani- mals will work hard to produce an increase in its activity. As with animal experiments involving self-administration of drugs (see Figure 4.2 ), researchers have been able to conduct studies in which the pressing of a lever causes electrical brain stimulation in a localized fashion. We cannot say how animals are feeling at the time, but their behavior indicates that they are intensely motivated toward “turning on” this region of their brains. Their compulsive efforts to receive this stimula- tion are unmistakable. Since self-administration behavior in animals closely parallels the pattern of human behavior that characterizes psychological dependence (see Chapter 4), stud- ies of this kind can be used to understand the neural changes that occur as a consequence of drug abuse.
In other words, it is reasonable to assume a connection to the human experience: the craving, the intense “rush,” and compulsive drug-taking behavior associated with heroin, cocaine, amphetamines, or a host of other dependence- producing drugs. When laboratory animals are administered amphetamines, heroin, cocaine, alcohol, or nicotine, for exam- ple, there is a rapid increase in the level of dopamine activity
dopamine receptors: Specialized areas of neurons that enable dopamine to change the neuron’s functioning.
POrtrAit Dr Nora D. Volkow—Imaging the Face of Addiction in the Brain
It is one thing to speculate about the effects of drug dependence on the brain, to assert that the transition from initially being a voluntary drug user to becoming a compulsive drug user is a matter of subtle but significant brain changes. It is quite another thing to show the effects themselves at a neurochemi- cal level. But that is precisely what Nora D. Volkow and her associates have done. Using a brain scanning technique called positron emission tomography (PET), neural activity in the human brain can be captured in graphic detail.
As a result of Volkow’s studies, the process of drug dependence is becoming understood. As expected, the critical area in the brain is the nucleus accumbens, and the critical neurotransmitter is dopa- mine. However, the real key is a subset of dopamine receptors (referred to as D2 receptors) and their change over time. All dependence-producing drugs that pro- duce a “high” cause a very rapid increase in D2 receptor activity in the nucleus accumbens. Conventional wisdom has
held that drug dependence is a result of a sensitization of D2 receptors, but just the opposite appears to be the case. Drug- dependent individuals show a significant decline in D2 receptor activity over time, with a loss of about 20 percent of the receptors themselves. Volkow has esti- mated that a comparable decline in dopa- mine receptors would take at least 40 years to accomplish in a drug-free brain. In the case of chronic cocaine abusers, these changes result in a somewhat ironic situ- ation: They no longer feel that they enjoy the cocaine, but, at the same time, the craving for it is so strong that they feel compelled to seek it out.
Why the compulsive nature of drug dependence? Volkow’s research has shown that ordinarily D2 receptor activ- ity causes a stimulation of the prefrontal cortex of the brain, which is responsible for normal inhibitory control. (Think of the prefrontal cortex as being a “no-go” mechanism in our lives.)
Evidently, without signals from the nucleus accumbens in chronic drug
abuse, the prefrontal cortex is itself inhibited—the result being compulsive behavior, essentially an “inhibition of inhibition.”
In 2003, Nora D. Volkow was appointed director of the National Institute on Drug Abuse (NIDA), the lead federal agency for research into drug abuse and dependence. Her extraordinary program of neurochemical research continues.
Sources: National Institute on Drug Abuse (2003, January 23). Press release: Dr. Nora D. Volkow named new director of NIDA. Rockville, MD: National Institute on Drug Abuse. Volkow, Nora D.; Wang, Gene-Jack; Tomasi, Dardo; and Baler, Ruben D. (2013). Unbalanced neuronal circuits in addic- tion. Current Opinion in Neurobiology, 23, 639–648. Volkow, Nora D.; Wang, Gene- Jack; Fowler, Joanna S.; Logan, Jean; Gatley, Samuel J.; Hitzemann, Robert; Chen, A. D.; and Pappas, Naomi (1997). Decrease in stria- tal dopaminergic responsiveness in detoxified cocaine-dependent subjects. Nature, 386, 830–833.
Chapter 5 Theoretical Perspectives on Drug Use and Abuse ■ 89
the sense that the drug abuser is striving for superiority over others. According to this point of view, they are attempting to “rise above” a self-deprecating sense of self. Other theo- rists view drug dependence in terms of an unconscious death wish, the ultimate form of self-loathing. The self-destructive lifestyle of drug abuse is viewed as a failure of ego functioning that, under normal and healthier circumstances, should have promoted self-care, self-protection, and self-esteem.11
Nonpsychoanalytic Personality Theories Psychological explanations of drug abuse can also emphasize a constellation of personality traits that distinguish drug abusers from nonabusers, without reference to psychoana- lytic concepts. A general theme is that antisocial personality disorder, anxiety, and depression are more common among drug abusers. Individuals with antisocial personality disorder are typically impulsive, sensation seeking, and immature. Individuals displaying these traits may be more prone to abuse drugs because of their increased need for stimula- tion, excitement, and immediate gratification. Sensation- seeking people are essentially risk takers (“edgewalkers”), and drug use epitomizes risk-taking behavior, particularly in adolescence.12
Interestingly, as pointed out in Chapter 4, in the natu- ral world, all forms of drug-taking behavior are not equally desirable. Our attraction to the use of hallucinogens such as LSD (see Chapter 11) as a means for altering one’s conscious experience, for example, is not commonly shared by animals. While animals may self-administer drugs such as cocaine and other stimulants with a level of compulsiveness that matches the human experience, a number of other drugs are not attractive at all, judging from the animals’ reluctance to work for their administration. Hallucinogens, in particular, are examples of drugs that animals clearly prefer to leave alone.13
Drug abusers typically demonstrate poor judgment, have difficulty learning from their mistakes, are emotionally insensi- tive to others, and are unable to form long-lasting relationships with other people. It is believed that anxiety and depression are immediate precursors to drug abuse, in that drugs elevate one’s mood and relieve feelings of stress. In effect, individuals suffering from anxiety and depression are engaging in a pat- tern of self-medication. It is well known, however, that patterns of drug abuse can actually induce anxiety and depression or make matters worse.
While psychologists have studied specific personal- ity traits that are more frequently observed in drug abusers than in the general population, they have not been able to
Psychological Perspectives on Drug Abuse
Psychological perspectives on drug abuse typically draw on one of three theoretical orientations: (1) psychoanalytic theories of personality, (2) nonpsychoanalytic theories of personality, or (3) behavioral accounts of human learning.
Psychoanalytic Theories Psychoanalytic theories of drug abuse are derived from the work of Sigmund Freud (1856–1939), the founder of psycho- analysis, as well as the work of other psychologists who have expanded on Freud’s basic principles of human behavior. In general, psychoanalytic explanations of drug abuse focus on internal psychological disturbances that begin in early child- hood. According to Freud, one’s personality consists of three fundamental systems: the id, the ego, and the superego. The id, present at birth, consists of instinctual animal impulses or drives, such as hunger and sex. On an unconscious level, the id continually seeks pleasure, is self-serving, and disregards others who get in the way. At the time of birth and imme- diately thereafter, humans are essentially “all id.” The ego, however, is the part of the personality that becomes conscious and rational. The ego develops when a child begins to rec- ognize that he or she cannot “get away with everything,” that his or her actions have specific consequences, and that instinctual needs should and eventually will be satisfied in an appropriate context of socially approved behavior. The development of the superego represents the internalization of societal norms and serves as one’s social conscience. As a person develops a superego, feelings of guilt and shame arise when social norms are violated.
Psychoanalytic theory asserts that a strong and healthy ego is ultimately the product of a delicate psychological balancing act in which everyday decisions are maintained in such a way as to minimize excessive out-of-control pres- sures from the id, on the one hand, and excessive pressures of guilt and anxiety from the superego, on the other. You might notice a connection between the psychoanalytic viewpoint and the basic tenets of the moral model, discussed earlier.
Another psychoanalytic concept that helps to explain drug abuse is the idea that most of us pass through (and advance beyond) an oral and narcissistic stage of develop- ment in infancy, a time when our basic needs of food, water, and feelings of security are satisfied orally. Drug abusers, however, have not advanced beyond the oral stage. They are thought to be fixated (stuck) in the oral stage well past infancy. Psychoanalyst Otto Fenichel theorized that individuals engage in drug abuse to satisfy an archaic oral longing, a sexual long- ing, a need for security, and a need for the maintenance of self-esteem. All of these needs, he argued, exist in the earliest years of life and, in drug abusers, continue to exert influence, resulting in an orally based pattern of drug-taking behavior.10
Some psychoanalytic theorists focus on the symbolism of “getting high,” representing an expression of power in
psychoanalytic theories: Theoretical explanations based upon the writings of Sigmund Freud and those influenced by him. In terms of drug use and abuse, psychoanalytic concepts include subconscious processes that develop in early childhood, a fixation on the oral stage of development, expressions of power, and self-loathing.
90 ■ Part Two Drugs, Crime, and Criminal Justice
conventionality is no longer possible. In Chapter 9, we will examine studies of heroin abusers (called “chippers”), who are classified as maintainers rather than euphoria seekers. Clearly, their lives are extremely precarious—a testament to the reinforcing power of heroin.16
Behavioral theorists also assert that specific cues or situations have the capability of stimulating powerful drug cravings brought on by memories of past pleasurable (reinforcing) experiences. Through a process of Pavlovian conditioning (discussed in the context of behavioral tolerance in Chapter 4), drug users associate drug use with certain visual cues, specific friends and situations, or even a song. Cigarette smokers, for example, commonly report that it is difficult to abstain from smoking when drinking alcohol, talking on the phone, or driving a car if these circumstances have been closely associated with smoking behavior. Some marijuana users report cravings after see- ing paraphernalia used in smoking marijuana, such as a bong or pipe, while heroin injectors may crave heroin after viewing a hypodermic needle.
Conditioned cues are very difficult to break and can pres- ent major obstacles to overcome on the path to drug-abuse recovery. Drug-abuse treatment efforts are often cut short by the appearance of cues that have played an important part in previous drug-taking behavior. Counseling professionals believe that it is essential that individuals break both their phar- macological and their psychological (behavioral) dependence on drugs to return to and maintain a drug-free life.
Sociological Perspectives on Drug Abuse
For sociologists, environmental and societal factors play an especially important role in drug use and abuse. The focus of sociological theories is quite different from the focus of theories associated with either a biological or psychological
identify a unique set of personality traits for such individuals. For example, alcohol abusers tend to be more independent, nonconformist, and impulsive, but these same traits are also found in successful athletes.14
Behavioral Theories In contrast to psychoanalytic theories that emphasize inter- nal struggles of human personality or primitive impulses and drives, behavioral theories emphasize the role of learn- ing through the principle of reinforcement. According to the behavioral point of view, practically all of human behavior is learned. In other words, drug-taking behavior leading to drug abuse and dependence is a consequence of having modified one’s behaviors in specific ways as a result of being rewarded.
The overarching principle of behavioral theory is that any behavior that is followed by a reward (reinforcement) is more likely to be repeated in the future. Repeated rewards will result in a continuing pattern of behavior that can be weakened only when these reinforcers are removed (a process called extinc- tion) or other behaviors are now reinforced (a process called counterconditioning). Individuals using a drug with a high reinforcement potential typically report that they care more about obtaining and using the drug than just about anything else in their life. In this case, reinforcers related to drug-taking behavior exceed or overcome competing reinforcers, such as the benefits derived from a job, financial security, or satisfying relationships with friends and family.
While behavior theorists make the distinction between positive reinforcement (gained through the attainment of a pleasurable circumstance) and negative reinforcement (gained through the reduction of a painful or uncomfortable circumstance), the principle of reinforcement remains the same. The reinforcement of heroin abuse, for example, can focus either on the reexperiencing of the euphoric feelings associated with heroin or on the relief from uncomfortable feelings associated with heroin withdrawal.
Which aspect of reinforcement is emphasized among drug abusers in general can determine the pattern of drug- taking behavior. Those guided by the positive reinforcement of the drug experience are often referred to as euphoria seekers, and those guided by the negative reinforcement of withdrawal relief are referred to as maintainers. Euphoria seekers typically display a compulsive pattern of drug-taking behavior.15
In the case of heroin abuse, maintainers tend to consume just enough heroin to avoid the withdrawal symptoms that would occur if their pattern of heroin abuse were to cease. They try to stay within the conventionality of their social community as they “nurse” their habit along. Euphoria seek- ers, however, are inclined to be so heavily into the pleasur- able aspects of heroin that their lives spiral out of control. They descend into a lifestyle dominated by the drug. Social
behavioral theories: Theoretical explanations of behavior based upon the effect of reinforcement on learned responses to one’s environment.
A visual image of white powder, resembling lines of cocaine, along with a razor blade, tends to elicit powerful feelings of craving among individuals with earlier experiences of cocaine abuse.
Chapter 5 Theoretical Perspectives on Drug Use and Abuse ■ 91
Anomie/Strain Theory In 1893, sociologist Emile Durkheim used the term anomie to describe the feelings of frustration and alienation that exist among individuals who see themselves as not being able to meet the demands of society.19 Durkheim studied the effects of anomie as they pertained to suicide, while sociologist Robert Merton in 1968 applied the concept to other forms of deviant behavior, such as drug use. Merton believed that every society includes a set of cultural goals and means to achieve them (norms). In most cases, members of society can reach these cultural goals, or at least have some hope of reach- ing them, by following certain socially defined means. In the United States and other economically developed nations of the world, the primary cultural goal is economic success, and individuals aspire to reach this goal through the accept- able social norm of hard work. When someone is unable to obtain economic success, the result is a feeling of frustration and anomie. This sense of anomie or strain (hence the terms “anomie theory” or “strain theory”) is highest among disad- vantaged segments of the population, who experience high rates of crime and drug use in their everyday lives.20
Merton classified five possible adaptations or responses to anomie when someone is unable to achieve cultural goals through acceptable means. The five adaptations (confor- mity, innovation, ritualism, retreatism, and rebellion) will be reviewed in the context of drug use and abuse.21
●■ In the first adaptation, conformity, individuals accept both culturally defined goals and the prescribed means for achieving them. They may find it necessary to scale down their aspirations, work hard, and save money, while con- tinuing to follow legitimate paths. In this sense, confor- mity is not deviant behavior but rather an adjustment in their lives. It is also the most common mode of response when contending with anomie. This type of adaptation would lead to a decision not to use or abuse drugs that are outside the mainstream of our culture. It would not, how- ever, discourage the use of alcohol or nicotine if drink- ing and tobacco smoking were acceptable drug-taking behaviors.
●■ In the second adaptation, innovation, individuals retain the dominant cultural goal of monetary success but choose to reject legitimate avenues of goal attainment. Unlike con- formity, innovation involves illegal behavior. Aspiring to be a drug dealer in order to achieve economic success is an example of innovation.
●■ In the third adaptation, ritualism, individuals reject the goal of economic success (considering it unattainable) but continue to accept the means of working in legiti- mate areas of life. An example is the burnt-out factory
perspective. The emphasis is not on the individual alone, but the individual embedded in social situations, social relationships, and social structures.17
During the Vietnam War, for example, a large propor- tion of American troops used and abused heroin, which was available in Vietnam at extraordinarily high levels of purity. It is reasonable to assume that easy access to heroin in the context of being in a strange and dangerous environment encouraged them to turn to heroin for escape and relief (see Chapter 9). However, only one in eight soldiers continued to use heroin after returning home to a “normal” life. Evidently, the social context of their drug-taking behavior was a crucial factor in allowing them to make this shift.18
Sociological perspectives on drug use and abuse will be represented by five major theories: (1) anomie or strain theory, (2) social control or bonding theory, (3) differential association theory, (4) subcultural recruitment and socialization theory, and (5) labeling theory.
Quick Concept Check
Understanding Biological and Psychological Perspectives on Drug Use and Abuse Check your understanding of biological and psychological perspectives on drug use and abuse by matching the statement (on the left) with appropriate factor or theoretical orientation within these perspectives (on the right).
5.1
1. Identical twins are more likely than fraternal twins to develop alcoholism later in life.
2. Animals will work hard to self-stimulate in order to release dopamine in the nucleus accumbens in their brains.
3. Drug-taking behavior is strength- ened through positive outcomes (rewards) and negative outcomes (punishments).
4. Sensation-seeking individuals are more likely to experiment with drugs, particularly in adolescence.
5. Drug abuse and drug addiction arise from unconscious internal forces exerted by the id, ego, or superego.
6. Heroin-dependent individuals may have a metabolic imbalance that heroin appears to correct.
a. Behavioral factor
b. Psychoanalytic orientation
c. Nonpsychoana- lytic orientation of personality
d. Neurochemical factor
e. Physiological factor
f. Genetic factor
Answers: 1. f 2. d 3. a 4. c 5. b 6. e
anomie (AN-eh-Mee): In sociological terms, feelings of frus- tration and alienation when individuals see themselves as not being able to meet the demands of society. Anomie theory is sometimes referred to as strain theory.
92 ■ Part Two Drugs, Crime, and Criminal Justice
one person chooses to be a ritualist, for instance, whereas another becomes an innovator. Finally, anomie theory disregards the potential impact of interpersonal relation- ships, such as peer group association, differential access to drugs, and the degree of attachment to one’s community and family.
Social Control/Bonding Theory A second major sociological perspective on drug use and abuse is social control theory. According to social control theorists, all human beings are, by nature, rule breakers. The bonds that people have to society and its moral code are what keep them from breaking the law and remaining socially con- trolled (hence the terms “social control theory” or “bonding theory”). When an individual is strongly bonded to his or her family, religious affiliation, school, or community, that indi- vidual is less likely to engage in delinquent behavior. When these bonds become weakened, deviant behavior, such as drug use, results.
Social control theorists identify four social bonds that promote conformity: attachment, commitment, involvement, and belief.23 Attachment refers to one’s closeness to significant others, such as parents, peers, and teachers. Individuals will conform to social norms and refrain from drug use because they seek the approval of these significant individuals. Commitment refers to an individual’s investment and pursuit in reaching conventional goals, such as the attainment of a good education and a satisfying job. Involvement refers to the extent to which one is associated with conventional activities within a school, community, or religious affiliation. Belief refers to how well an individual has internalized the moral values of society, such as honesty, perseverance, and respect for authority. Attention to social bonds is important in the design of effective prevention and treatment programs (see Chapter 17).
Empirical tests of predictions made by social control theory with regard to drug use are mixed. Several studies
worker who uses illicit drugs to get through the day with- out “making waves” and then goes home to get drunk or “stoned.”
●■ In the fourth adaptation, retreatism, individuals reject both the goal of economic success and the means of hard work. They have, in effect, given up. Members belonging to this category include individuals who have developed a depen- dence on alcohol or other drugs. Retreatists can be viewed as double failures. First, they have been unable to find success through conformity. Second, they have not been able to find success as an innovator through criminal activ- ity. Ironically, drug-dependent individuals retreat in this way with the expectation that they are entering a seem- ingly undemanding world. The harsh reality, however, is that drug dependence itself sets off a never-ending series of brutal demands, on both physical and psychological levels. Perhaps, only in the case of a Chinese opium smoker (see Chapter 9) would a retreatist adaptation approach the fantasy of a completely undemanding existence.
●■ In the fifth adaptation, rebellion, individuals not only reject both the goal of economic success and the means of work- ing but also seek to overturn the social system and replace it with an alternate set of values. These individuals are the radicals and revolutionaries of society, who break the law in an attempt to change it. An example is the rebellious youth of the “hippie” subculture of the 1960s. Their association with marijuana and LSD use and their involvement with a wide range of psychoactive substances were components of a political act of rebellion. The popular slogan of the time, “sex, drugs, and rock and roll,” represented their rebellious response to the anomie they felt at the time.
It is conceivable that someone’s personal adaptation to feel- ings of anomie could be a combination of any of the above possibilities.
A survey of more than 9,000 high school students in 1990 found that feelings of anomie or strain were important predic- tors of drug use. Students who have a negative response to questions such as, “When you are older, do you expect to own more possessions than your parents do now?” or to the state- ment, “My life is in my hands, and I am in control of it.” were more likely to engage in drug-taking behavior.22
Anomie theory, however, does tend to oversimplify a complex problem. We know that people who have attained economic success have, at the same time, become depen- dent on drugs and alcohol. Rock stars and celebrities of all kinds, for example, have become dependent on drugs such as cocaine, heroin, alcohol, and prescription medica- tion. In fact, celebrity status in our society encourages such involvement. Moreover, anomie theory fails to explain why
social control theory: A sociological theory of drug use based on weakened social bonds between an individual and social entities such as family, religious affiliation, school, and community. Social control theory is sometimes referred to as bonding theory.
Treatment for drug-related problems is optimized when there is positive involvement from the family and the social bond of attach- ment is strengthened.
Chapter 5 Theoretical Perspectives on Drug Use and Abuse ■ 93
subcultural recruitment and socialization theory: A theoretical perspective on drug abuse that focuses on specific relationships that drug abusers have with respect to each other within a cohesive subculture and the changes that occur in this subculture over time.
subculture: A subdivision within a dominant culture that has its own norms, beliefs, and values. An example is a drug subculture that provides the social bonding for continued drug use and abuse.
take part in a drug subculture that plays a pivotal role in teaching them about illicit drugs. A subculture is a subdivision within a dominant culture that has its own norms, beliefs, and values. It exists within the larger soci- ety, not apart from it. Several important American drug subcultures include the “hippie” subculture of the 1960s that promoted the use of marijuana and LSD or the rave subculture that has promoted the use of Ecstasy. Drug subcultures not only teach young users about the skills for successfully using drugs but also point out the way to obtain drugs, how to avoid getting “ripped off,” and some- times how to manufacture the drugs themselves. A strong sense of social bonding within a drug subculture, usually with its own subculture language, provides the motivation for continued drug use (Drugs … in Focus).
Subcultural Recruitment and Socialization Theory The fourth major sociological perspective draws on the assumptions of differential reinforcement theory but focuses more directly on the dynamic relationships that drug abusers have with respect to each other. According to proponents of subcultural recruitment and socialization theory, such as Erich Goode and Bruce Johnson, a selec- tive interaction exists in which individuals are drawn to drug users because they recognize a compatibility of social values.27
The social bonding of individuals in the subculture increases as a direct function of drug-taking behavior becom- ing more and more a central focus of their social interactions. The dominant influence of peers, however, applies primar- ily to adolescent drug abuse. In later stages of drug abuse, when the drugs of choice change from a concentration on beer, wine, cigarettes, liquor, and marijuana to drugs such as cocaine and heroin, drug abusers tend to break away from a tightly focused subcultural group and move toward a set of less intimate relationships. At this point, there is typically a close relationship with only one drug-abusing friend, an indi- vidual who shares the same social attitudes, behaviors, and problems.28
have found that variables such as parental attachment and school attachment are related to lower rates of drug use among youths, whereas other studies have found that rela- tionships with peers act as a more important predictor of drug use than attachment to one’s family or school. In fact, the primary weakness of social control theory is that it under- estimates the importance of the role of delinquent friends, while overestimating the importance of involvement in con- ventional social activities. Studies have consistently found that patterns of adolescent alcohol and drug use are strongly related to drug abusers having friends who also engage in this behavior. Yet, there is no explanatory role for peers in social control theory.24
Differential Association Theory The third major sociological perspective is differential asso- ciation theory. Originally proposed by sociologist Edwin Sutherland in 1939 as a general theory of deviance, differ- ential association theory has served in recent years as a theo- retical foundation for some of the most important research on illicit drug use. The basic premise of the theory is that deviant behavior such as drug use is learned in interactions and communications with other individuals. This learning takes place within relatively intimate groups, such as family and friends. Significant others (parents and friends) often communicate pro-drug or anti-drug messages. When one’s attitudes and beliefs favoring drug use exceed one’s attitudes and beliefs against it, the likelihood of drug use increases. In other words, if an adolescent has a greater number of friends who encourage and use drugs than friends who discourage and do not use drugs, he or she is more likely to engage in that behavior.25
From a differential association perspective, the process of learning to use drugs also involves learning the tech- niques to use drugs and learning how to enjoy the experi- ence. First-time marijuana users, for example, must learn how to roll a “joint” and how to hold the marijuana smoke in their lungs for a period of time to obtain the drug’s full effects (see Chapter 12). First-time heroin users must learn how to “cook” or prepare the heroin for intravenous injec- tions by placing the drug in a spoon with water, then heating the substance with a lighter or match to liquify the heroin. Heroin users also must learn the correct method of inject- ing the drug without damaging their veins (see Chapter 9). Individuals who use LSD or MDMA (Ecstasy) for the first time may be frightened. Users may experience social with- drawal, anxiety, and paranoia (Chapter 11). Peers often play an important role in calming novice users and in teaching them to focus on the positive aspects of the drug experience rather than the negative ones. These techniques are typically demonstrated in small, intimate groups. In fact, very few, if any, adolescents begin using drugs alone or with strangers present at the time.26
Identifying oneself as a drug user typically emerges from being immersed in a social network of friends who share a similar outlook in life. Some drug-using youths
differential association theory: A sociological theory of drug use based upon the premise that drug-taking behavior is learned in interactions and communications with other individuals.
94 ■ Part Two Drugs, Crime, and Criminal Justice
the Private Language of a Drug Subculture A powerful bond within a subculture is a common language that makes sense only for people within it and is virtually unintel- ligible to people on the outside. This communication system is largely hidden from the mainstream culture of the society at large. In the case of a marijuana drug subculture in New York City, a personal language provides a socially constructed way of talking, expressing, and interacting among marijuana users and distributors.
Sociologist Bruce Johnson and his associates have examined the importance of “argot” (invented slang) on maintaining the identity of the subculture, as well as establishing boundaries with subcultures defined by other types of drugs. They can be standard words with special meanings or completely new words. Here are some examples: • Bambu—marijuana rolling papers • One and a Dutch—a single tobacco cigarette and a blunt
(marijuana in a Dutch Master cigar shell) • Kind—good-quality marijuana, shortened form for kind bud,
shortened further to kb
• Crunked—under the influence of marijuana and alcohol • Beastin’—rushing the process of smoking; not willing to wait
one’s turn and thus rushing everyone around them • Puff-puff-pass—promoting equality among smokers in group
settings, meaning each person takes two inhalations and then passes the marijuana to the next person, until everyone has smoked or the marijuana joint is finished
A private language is a characteristic feature of any deviant subculture, whether the focus is a particular illicit drug such as heroin, cocaine, or Ecstasy or a specialized illicit activity such as computer hacking.
Sources: Holt, Thomas (2007). Subcultural evolution? Examining the influence of on- and off-line experiences on deviant sub- cultures. Deviant Behavior, 28, 171–198. Furst, R. Terry; Johnson, Bruce D.; Dunlap, Eloise; and Curtis, Richard (1999). The stigma- tized image of the “crack head”: A sociocultural exploration of a barrier to cocaine smoking among a cohort of youth in New York City. Deviant Behavior, 20, 153–181. Johnson, Bruce D.; Bardhi, Flu- tura; Sifraneck, Stephen J.; and Dunlap, Eloise (2006). Marijuana argot as subculture threads: Social constructions by users in New York City. British Journal of Criminology, 46, 46–77.
Drugs … in Focus
secondary deviance: Persistent nonconformist behavior by an individual who has been labeled as deviant and whose deviant behavior (e.g., drug use) is based upon expecta- tions of others.
Labeling Theory The fifth major sociological perspective is labeling theory. Labeling theorists argue that virtually everyone has experimented with drugs at some time in his or her life. This experimentation is referred to as primary deviance, nonconformity that is temporary, exploratory, and easily concealed. Primary deviant acts, such as drug experimen- tation, often go unnoticed, and individuals who commit these acts do not generally regard themselves as deviants and are not labeled as such by others. Once the drug use is
discovered and made public by others, however, the situa- tion changes. At this point, drug users are labeled as devi- ant, and they are often seen in a new light by others as a “stoner” or “dope head.” It becomes difficult for users to shed this new status.
Eventually, users begin to internalize the newly acquired label and continue to use drugs because others expect them to do so. In other words, the individual changes his or her self-perception to fit the expectations of others. Behavior now continues as secondary deviance, in the form of a persistent pattern of nonconformity by the individual who has been labeled as deviant. Drug users who do not wish to be labeled as deviant may choose to keep their drug use covert or, in time, may become a member of a drug subculture.
According to labeling theorists, social class distinctions play a major role in determining whether an individual might be labeled in a negative manner. A businessman who drinks three vodka martinis at lunch, for example, is much less likely to be labeled as deviant than a factory worker who drinks three beers at lunch. As discussed in Chapter 3, policy decisions regarding which drugs to outlaw and which to legitimize have often been associated with an underlying fear of a minority group whose drug use has become labeled as socially deviant.29
primary deviance: Nonconformist behavior associated with drug experimentation. It is temporary, exploratory, and easily concealed from others.
labeling theory: A sociological theory of drug use that emphasizes the process by which a drug user internalizes a newly acquired label of deviance and continues a pattern of drug-taking behavior that is based on the expectations of others.
Chapter 5 Theoretical Perspectives on Drug Use and Abuse ■ 95
of alcohol consumption over that period of time. In other words, the incidence of alcohol use has declined, but the reasons for drinking in general have remained the same. Likewise, the percentages of high school seniors giving these reasons for marijuana use are similar to that found in sur- veys from 1976 to 2005, despite the “roller-coaster” trends in marijuana prevalence rates over that period of time (see Chapter 1).
These studies are interesting not only for the insights they have provided but also for the way they have been carried out. There was no theoretical perspective behind the question. In other words, the research was not theory driven.
A large literature has accumulated that deals with the statistical relationships between a given variable (pertaining to an individual’s lifestyle, family makeup, environmental condition, etc.) and the likelihood that drug use will occur, without assuming a particular theoretical explanation. Through studies of this kind, we can gain an understanding of the degree of vulnerability each individual may have with respect to drug-taking behavior.
An individual’s vulnerability toward drug-taking behav- ior is conceptualized as being shaped by two separate groups of factors in that individual’s life. The first are risk factors, which make it more likely that a person will be involved with
Integrating Theoretical Perspectives on Drug Abuse
Success in drug-abuse treatment rests upon the recognition that there are multiple pathways to drug abuse. For each individual, a specific combination of biological, psychologi- cal, and sociological factors play a role in getting that person to the point at which treatment is necessary. This inte- grated, combinational approach to treatment (Figure 5.2) reflects the biopsychosocial model of drug-taking behavior in general.30
Risk Factors and Protective Factors
In a direct and straightforward manner, researchers have for decades asked high school seniors to report their personal reasons for taking drugs.31 In a survey of seniors in the Class of 1983 and 1984, the most frequently given responses were “to have a good time with my friends” (65%), “to experiment or see what it’s like” (54%), “to feel good or get high” (49%), and “to relax or relieve tension” (41%). The Class of 1976 had responded in a very similar way, as had the Classes of 2001 through 2005. Interestingly, the percentages of high school seniors giving these reasons for alcohol use are similar to that found in surveys from 1976 to 2005, despite a decline of 18 percent that took place in the annual prevalence rate
Genetic predisposition Abnormal
neurotransmitter functioning
Biological Factors
Poor self-esteem Peer influences
Expectancies toward abusive
behavior
Sensitivity to environmental cues
for drug abuse Psychological Factors
Dysfunctional family system
Community-based expectations
Sociological Factors
F igure 5 .2
The biopsychosocial model with respect to effective drug-abuse treatment.
Source: Modified from Margolis, Robert D.; and Zweben, Joan E. (1998). Treating patients with alcohol and other drug problems: An integrated approach. Washington, DC: American Psychological Association, pp. 76–87.
risk factors: Factors in an individual’s life that increase the likelihood of involvement with drugs.
96 ■ Part Two Drugs, Crime, and Criminal Justice
Specific Risk Factors Certain factors that may appear to be strong risk factors for drug- taking behavior in general (socioeconomic status, for example) turn out to have an association that is far from simple and may depend upon the particular drug under discussion. The most reliable set of risk factors consists of psychosocial characteris- tics that reflect a tendency toward nonconformity within soci- ety. Young people who take drugs are more inclined to attend school irregularly, have poor relationships with their parents, or get into trouble in general. As discussed earlier, sociologists refer to such individuals as members of a deviant subculture.32
The effects of participating in a socially deviant sub- culture are highlighted by the increased probability that an individual will display some level of drug-taking behavior. For example, the odds of youths aged 12–17 using marijuana during the past year are more than six times (6.25 times, to be precise) greater among those who had at least a few close friends who tried or used marijuana than among those who did not have such friends (the second listed risk factor in Table 5.1). To put this risk factor in perspective, the “odds ratio” is considerably lower than the 27 times greater like- lihood of developing lung cancer after decades of smoking more than a pack of cigarettes each day (vs. never smoking at all). Therefore, we are more likely to be wrong in predict- ing marijuana use on the basis of one’s association with close friends who use marijuana than in predicting lung cancer on the basis of years of cigarette smoking. Nonetheless, studies of risk factors are important elements in our overall under- standing of the complexities of drug-taking behavior.33
The leading risk factors for marijuana use include the perceived prevalence of marijuana use by friends in and out of school and the perceived prevalence of use in the community. Individual attitudes toward marijuana smoking and, in particu- lar, the attitude of friends toward marijuana smoking are also significant risk factors. The most significant risk factor, however, is the inclination toward delinquent (antisocial) behavior. By contrast, economic deprivation as measured by a low household income fails to be a risk factor for marijuana use.34
Specific Protective Factors Protective factors provide the basis for someone to have stron- ger resistance against the temptations of drugs, to have a degree of resilience against engaging in a drug-taking lifestyle, despite the presence of risk factors in that person’s life.35 It is impor- tant that we not see these protective factors, however, as simply the inverted image, or the negation, of opposing risk factors. Rather, each group of factors operates independently of the other. One way of thinking about protective factors is to view them as a kind of “insurance policy” against the occurrence of some future event that you hope to avoid. For example, the third protective factor listed in Table 5.2 shows an odds ratio of 0.45, indicating that youths aged 12–17 who answer “yes” to the question “Do you like going to school?” are about one-half (0.45 to be precise) as likely to have tried or used marijuana during the past year than youths who answer “no.”36
drugs; the second are protective factors, which make it less likely that a person will be involved with drugs. Together, risk factors and protective factors combine to give us some idea about the likelihood that drug-taking behavior will occur. The emphasis, however, should be on the phrase “some idea.” We still cannot know for certain which individuals would use drugs and which ones would not. Any predictions about drug use would be probabilistic, not deterministic.
Nonetheless, an understanding of risk factors and protec- tive factors in general and knowledge about which factors apply to a given individual are useful pieces of information in the development of effective drug prevention programs. Identifying the population with the highest risk toward drug use is the first step toward allocating the necessary time, effort, and money to lower the chances that drug-related problems will occur.
protective factors: Factors in an individual’s life that decrease the likelihood of involvement with drugs and reduce the impact that any risk factor might have.
Quick Concept Check
Understanding Sociological Perspectives on Drug Use and Abuse Check your understanding of sociological perspectives on drug use and abuse by matching the statement (on the left) with appropriate sociological theory (on the right).
5.2
1. Virtually everyone has experimented with drugs at some time in their life. However, when this drug use is discovered, users may be stigmatized and labeled as deviant by others.
2. People denied access to societal goals will suffer from strain and respond by conforming, rebelling, illegally innovating, or retreating. According to this theory, most drug users are retreatists.
3. Deviant behavior such as drug use is learned in interaction and communication with other persons.
4. It is the bond to society and its moral orders that keeps individuals from breaking the law.
5. Adolescent drug abuse is character- ized by a tightly focused subcultural group based on intimate relation- ships among group members.
a. Social control theory
b. Differential association theory
c. Anomie theory
d. Labeling theory
e. Social recruitment and socialization theory
Answers: 1. d 2. c 3. b 4. a 5. e
Chapter 5 Theoretical Perspectives on Drug Use and Abuse ■ 97
tABLe 5.1
Major risk factors: Odds ratios for marijuana use over the past year among youths aged 12–17 as related to specific questions
riSk FACtOr rePreSeNtAtive QueStiON ODDS rAtiO
Antisocial behavior “How many times have you gotten into a serious fight at school or at work?”
7.10
Friends’ marijuana use “How many friends would you say use marijuana?” 6.25
Perceived prevalence of marijuana use in school
“How many of the students in your grade in school would you say use marijuana?”
4.78
Individual attitudes toward marijuana use “How would you feel [positively] about someone your age trying marijuana?”
4.47
Friends’ attitudes toward marijuana use “How do you think your close friends would feel [positively] about your trying marijuana?”
4.37
Marijuana use in community “How many adults who you know personally would you say used marijuana?”
4.14
Perceived risk of marijuana use “How [little] do you think people risk harming themselves physically and in other ways when they smoke marijuana?”
3.48
Marijuana available in community “How easy would it be to get some marijuana, if you wanted some?”
2.72
Lack of parental monitoring “How [seldom] have your parents checked on whether you did your homework?”
2.60
Note: By definition (see text), risk factors have odds ratios greater than 1. Behavior is more likely to occur if a risk factor is present, through a multiplier designated by the odds ratio. The higher the odds ratio, the stronger the risk factor.
Source: Based on information from Wright, Douglas; and Pemberton, Michael (2004). Risk and protective factors for adolescent drug use: Findings from the 1999 National Household Survey on Drug Use. Rockville, MD: Substance Abuse and Mental Health Services Administration, Chapter 3 and Appendix A.
tABLe 5.2
Major protective factors: Odds ratios for marijuana use over the past year among youths aged 12–17 as related to specific questions
PrOteCtive FACtOr rePreSeNtAtive QueStiON ODDS rAtiO
Sanctions against substance use in school “How much trouble do you think a student in your grade would be in if he or she got caught using an illegal drug?”
0.28
Parents as sources of social support “Would you select your mother or father as a source of social support?”
0.40
Commitment to school “Do you like going to school?” 0.45
Religiosity “How many times did you attend religious services?” 0.47
Extracurricular activities “Have you participated in at least two extracurricular activities in or out of school?”
0.52
Parental encouragement “How often did your parents let you know that you’d done a good job?”
0.59
Exposure to prevention messages in school “Have you had a special class or some information in your school about drugs or alcohol?”
0.63
Exposure to prevention messages in the media
“Have you seen or heard any alcohol or drug prevention messages outside of school?”
0.70
Note: By definition (see text), protective factors have odds ratios less than 1. The lower the odds ratio, the stronger the protective factor through a multiplier designated by the odds ratio.
Source: Based on information from Wright, Douglas, and Pemberton, Michael (2004). Risk and protective factors for adolescent drug use: Findings from the 1999 National Household Survey on Drug Use. Rockville, MD: Substance Abuse and Mental Health Services Administration, Chapter 3 and Appendix A.
98 ■ Part Two Drugs, Crime, and Criminal Justice
Harm reduction: A Strategy for Controlling undesirable Behavior If we were to use a metaphor of warfare in looking at the drug control policy in America and the structure of present-day drug enforcement, we would recognize that there is an acknowledged enemy (drug misuse and abuse), that there are victims or casu- alties (us), that there are resources at our disposal to fight the necessary battles (federal and state governments, communities, parents, etc.), and, finally, that there is a high price to pay (bil- lions of dollars of federal funds each year, uncounted numbers of lives lost or diminished).
Continuing the metaphor, we can ask about what our strat- egy should be. Do we want total victory and complete annihi- lation of the enemy? Or do we want some kind of negotiated settlement, some type of “truce” that gives us some semblance of peace and tranquility? If it is the former, then we have set a standard of “zero tolerance.” In other words, we would not be satisfied until there is a total elimination of abusive drug-taking behavior in America (a tall order, to say the least). If it is the lat- ter, then we have set a much lower standard for ourselves. In that case, we aim for only a reduction in the harmful consequences
of abusive drug-taking behavior. The approach is referred to as the strategy of harm reduction.
Whichever strategy we adopt has profound implications for drug enforcement. It is evident that drug-taking behavior does indeed harm other people. The question, according to those advocating a harm-reduction strategy, is to look for law enforce- ment efforts that reduce the harm that drugs do, both directly to the drug user and indirectly to others.
A number of harm reduction tactics are controversial. They include needle-exchange programs to lower the incidence of HIV infection among intravenous drug abusers (Chapter 4), methadone maintenance programs for the treatment of heroin abusers (Chapter 9), efforts to reduce the incidence of driv- ing while under the influence of alcohol (Chapter 15), and the use of nicotine patches or e-cigarettes to avoid the effects of cigarette smoking such as emphysema and lung cancer (Chapter 16). Probably the most controversial tactic would be to reduce the level of illicit drug use down from a heavy level of consumption to a level of occasional use. However, it is acknowledged that any level of use involving some types of illicit drugs would present a significant amount of harm to the user.
Drug Enforcement … in Focus
Peer influence is a major factor in predicting the extent of drug- taking behavior during adolescence. It can represent either a risk factor or a protective factor for drug abuse.
one thousand high-risk male and female adolescents in the seventh and eighth grades, and information was collected on their drug use later in high school. As the number of pro- tective factors increased, the resistance of these students to drug use increased as well. With six or more such factors in their lives, as many as 56 percent of the high-risk adolescents showed a resistance to drug use three years later. In contrast, only 20 percent of the youths with three or fewer factors, were drug free.37
In research by the Search Institute in Minneapolis, as many as 40 protective factors have been identified, referred to collectively as developmental assets.38 These developmen- tal assets have been found to increase resistance not only to drug-taking behavior (such as problem alcohol use and illicit drug use) but to other high-risk behaviors (such as sexual activity and violence) as well (Drug Enforcement … in Focus).
Ultimately, the enhancement of protective factors in an individual’s life can prove beneficial in reducing the likelihood of drug-related problems, even if there are significant risk factors that are present. In doing so, there will be a degree of resilience with regard to the develop- ment of a pattern of drug abuse. Chapter 17 will examine the importance of resilience in light of drug-abuse preven- tion programs.
Protective factors can serve as a buffering element among even high-risk adolescents, allowing them to have a greater degree of resilience against drug-taking behavior and a higher resistance to drug use than they would have had oth- erwise. In one study, protective factors were examined in
Chapter 5 Theoretical Perspectives on Drug Use and Abuse ■ 99
With regard to cigarette smoking and marijuana use, there is an indication that some teenagers may already be “harm reduc- ing.” In the University of Michigan survey (Chapter 1), high school seniors engaging in occasional marijuana smoking and occasional cigarette smoking indicated a higher perceived risk of “regular substance use” than did high school seniors engaging in heavy use, even though there was no difference in the perceived risk of “occasional substance use.” In other words, occasional users may have been moderating their behavior to minimize the harmful effects they associated with heavy drug-taking behavior. Whether a prevention program that emphasizes the risks of heavy drug use, as opposed to emphasizing the risks of any level
of use, is the more successful strategy in reducing significant levels of drug-taking behavior is a question that advocates of the harm reduction approach will be investigating in the future with great interest.
Sources: Denning, Patt (2003). Over the influence: The harm reduction guide for managing drugs and alcohol. New York: Guilford Press. Levinthal, Charles F. (2003). Question: Should harm reduction be our overall goal in fighting drug abuse? Point/ Counterpoint: Opposing perspectives on issues of drug policy. Boston: Allyn and Bacon, pp. 70–73. Marlatt, G. Alan (Ed.) (2002). Harm reduction: Pragmatic strategies for managing high-risk behaviors. New York: Guilford Press.
Biological Perspectives on Drug Abuse ●● Biological perspectives on drug abuse refer to specific
physical mechanisms in specific individuals that influence the initial experience with drugs or an engagement with drug abuse over a period of time. Theories from this per- spective have focused on genetic factors, physiological fac- tors, and neurochemical systems in the brain.
●● Research on genetic factors has concentrated primarily on explanations for alcohol abuse and alcoholism. The con- sensus in this literature is that there is a genetic predisposi- tion toward alcoholism.
●● Physiological factors include metabolic deficiencies that set the stage for individuals to seek out drugs to “normal- ize” their bodies. A metabolic-defect concept has been applied to the study of heroin abuse.
●● Research on the role of neurochemical systems in drug abuse has concentrated on the functioning of dopamine in the nucleus accumbens. Drug-taking behavior has been hypothesized to be a compensation for an inadequate number of dopamine receptors necessary to experience pleasurable feelings without drugs.
Psychological Perspectives on Drug Abuse ●● Psychological perspectives on drug abuse draw on either
theories of personality or the behavioral processes of human learning.
●● Psychoanalytic theories of personality, derived from the writings of Sigmund Freud, focus on psychological distur- bances that have their origin in early childhood. Concepts include the competition of id and superego processes for dominance in ego functioning, oral fixation in develop- ment, and self-destructive behavior as an expression of self-loathing.
●● Behavioral theories emphasize the pivotal role of rein- forcement in the learning of drug-taking behaviors. Behavioral theorists have studied the influence of posi- tively reinforcing experiences inherent in the drug experi- ence itself as opposed to negatively reinforcing experience
of gaining relief from uncomfortable withdrawal symp- toms in predicting the manner in which heroin is abused.
●● Nonpsychoanalytic personality theories consider the per- sonality traits that distinguish drug abusers from nonabusers, without reference to psychoanalytic concepts. A central theme in these theories is the role of sensation-seeking among individuals as a predisposing characteristic for drug experimentation and abuse.
Sociological Perspectives on Drug Abuse ●● Sociological perspectives emphasize the important role of
environmental and social factors in drug use and abuse. Theories generated from a sociological perspective include anomie/strain theory, social control/bonding theory, dif- ferential association theory, subcultural recruitment and socialization theory, and labeling theory.
●● Anomie/strain theorists assert that drug use and abuse result from feelings of frustration and alienation existing in individuals who see themselves as not being able to meet the demands of society. Adaptations to feelings of anomie include conformity, innovation, ritualism, retreatism, and rebellion.
●● Social control/bonding theory identifies attachment, commitment, involvement, and belief as four social bonds that promote conformity and the disinclination to be a drug user.
●● The basic premise of differential association theory is that drug use is learned in interactions and communications with significant others such as parents and friends.
●● In subcultural recruitment and socialization theory, the focus is on the dynamic relationships among drug abusers as a cohesive group. In adolescent patterns of drug abuse, peer influence is the dominant factor in maintaining the subculture; in later stages, drug abusers tend to break away from a tightly focused subcultural group and move toward a set of less intimate relationships.
●● Labeling theory emphasizes the process through which individuals continue to use drugs because others expect
Summary
100 ■ Part Two Drugs, Crime, and Criminal Justice
family makeup, environmental condition, etc.) and the likelihood that drug use will occur.
●● Risk factors for drug-taking behavior in adolescence include a tendency toward nonconformity within society and the influence of drug-using peers.
●● Protective factors for drug-taking behavior include an intact home environment, a positive educational experi- ence, and conventional peer relationships.
them to do so. Drug users who are labeled as devi- ant may “find comfort” in being a member of a drug subculture.
risk Factors and Protective Factors ●● Investigations of risk factors and protective factors in drug-
taking behavior are not theory driven. A relationship is sought between a given variable (an individual’s lifestyle,
Key Terms
anomie, p. 91 behavioral theories, p. 90 differential association theory,
p. 93 dopamine, p. 87
dopamine receptors, p. 88 labeling theory, p. 94 moral model, p. 85 neurotransmitters, p. 87 nucleus accumbens, p. 87
primary deviance, p. 94 protective factors, p. 96 psychoanalytic theories, p. 89 risk factors, p. 95 secondary deviance, p. 94
social control theory, p. 92 subcultural recruitment and
socialization theory, p. 93
subculture, p. 93
1. Briefly discuss some evidence in favor of viewing drug-taking behavior in terms of genetic, physiological, and neurochemi- cal factors.
2. Compare and contrast the psychoanalytic perspective and the behavioral perspective in terms of the inclination to engage in a pattern of drug-taking behavior.
3. Describe in a few words the main tenets of strain theory, social control/bonding theory, differential association theory,
subcultural recruitment and socialization theory, and labeling theory in regard to drug-taking behavior.
4. In what way is a study of risk factors and protective factors an “atheoretical” approach to examining drug-taking behavior?
5. Describe the top three risk factors and top three protective fac- tors for adolescent drug use, according to the study of Wright and Pemberton (2004).
Review Questions
Suppose you are a drug rehabilitation counselor at a local high school and you are acquainted with two students, named Tara and Debbie.
Tara, 17 years old, is an active substance abuser. Previous interviews with Tara indicate that there have been many instances in which she has gotten into a serious fight at school, and she knows several students her age who use marijuana and other drugs. What strategies could be encouraged during counseling with Tara that would provide a greater number of protective factors in her life?
Debbie, 17 years old, is not an active substance abuser. Previ- ous interviews with Debbie indicate that she also has gotten into serious fights at school and knows several students her age who use marijuana and other drugs. What factors might be present in Debbie’s life that could be responsible for her resistance to drug- related problem? Could your experience with the case of Debbie be useful in counseling Tara? Explain.
Critical Thinking: What Would You Do?
1. Goode, Erich (2013). Drugs in American society (8th ed.). New York: McGraw-Hill Higher Education, pp. 142–172.
2. Fisher, Gary L.; and Harrison, Thomas C. (2000). Substance abuse: Information for school counselors, social workers, therapists, and counselors. Boston: Allyn and Bacon. Miller, William R.; and Hester, Reid K. (1995). Treatment for alcohol problems: Toward an informed eclecticism. In William R. Miller and Reid K. Hester (Eds.), Handbook of alcoholism treatment approaches (2nd ed.). Boston: Allyn and Bacon, pp. 1–11.
3. George, Frank R.; and Goldberg, Steven R. (1989). Genetic approaches to the analysis of addictive processes. Trends in Pharmacologial Science, 10, 78–83. LeGrand, Lisa N.; Iacono, William G.; and McGue, Matt (2005, March–April). Predict- ing addiction. American Scientist, pp. 140–147.
4. Sher, Kenneth J. (1991). Children of alcoholics: A critical appraisal of theory and research. Chicago: University of Chicago Press.
5. Herman, Aryeh I.; Philbeck, John W.; Vasilopoulos, Nicholas L.; and DePetrillo, Paolo B. (2003). Serotonin transport promoter
Endnotes
Chapter 5 Theoretical Perspectives on Drug Use and Abuse ■ 101
polymorphism and differences in alcohol consumption behavior in a college study population. Alcohol and Alcoholism, 38, 446–449. National Institute on Alcohol Abuse and Alcoholism (2003). Is there a genetic relationship between alcoholism and depression? Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism. Nurnberger, John I.; and Bierut, Laura J. (2007, April). Seeking the connections: Alcoholism and our genes. Scientific American, pp. 46–53.
6. Goode, Drugs in American society, p. 145. 7. Goode, Drugs in American society, pp. 145–146. Myerson,
David J. (1969). Methadone treatment of addicts. New Eng- land Journal of Medicine, 281, 380. Prendergast, Michael L.; and Podus, Deborah (1999, May 10). Methadone debate reflects deep-rooted conflicts in field. Alcoholism and Drug Abuse Weekly, p. 5.
8. Heidbreder, Christian A.; and Hagan, Jim J. (2005). Novel pharmacotherapeutic approaches to the treat- ment of drug addiction and craving. Current Opinion in Pharmacology, 5, 107–108. Nestler, Eric J.; and Malenka, Robert C. (2004, March). The addicted brain. Scientific Ameri- can, pp. 78–85. Phillips, Paul E. M.; Stuber, Garret D.; Hei- en, Michael L, A. V.; Wightman, R. Mark; and Carelli, Regina M. (2003). Subsecond dopamine release promotes cocaine seeking. Nature, 422, 614–618. Weiss, Freidbert (2005). Neu- robiology of craving, conditioned reward, and relapse. Current Opinion in Pharmacology, 5, 9–19.
9. Volkow, Nora D.; Wang, Gene-Jack; Fowler, Joanna S.; Logan, Jean; Gatley, Samuel J.; Gifford, Andrew; Hitzemann, Robert; Ding, Yu-Shin; and Pappas, Naomi (1999). Prediction of reinforcing responses to psychostimulants in humans by brain dopamine D2 receptor levels. American Journal of Psychiatry, 156, 1440–1443.
10. Fenichel, Otto (1945). The psychoanalytic theory of neurosis. New York: Norton. Fields, Richard (2004). Drugs in perspective (5th ed.). New York: McGraw-Hill Higher Education.
11. Fields, Drugs in perspective. Gottheil, Edward (Ed.) (1983). Etiological aspects of alcohol/drug abuse. Springfield, IL: Charles C. Thomas. Stanton, M. Duncan; and Todd, Thomas C. (Eds.) (1982). The family therapy of drug abuse and addic- tion. New York: Guilford Press.
12. Cristie, Kimberly A.; Burke, Jack; Regier, Darrel A.; Rae, Donald S.; Boyd, Jeffrey H.; and Locke, Ben Z. (1988). Epidemiological evidence for early onset of mental disorders and higher risk of drug abuse in young adults. American Journal of Psychiatry, 145, 971–975. Fields, Drugs in perspective, p. 8. Lewis, C. E. (1984). Alcoholism, antisocial personality, narcotic addiction: An integrative approach. Psychiatric Developments, 3, 22–35. Shedler, Jonathan; and Block, Jack (1990). Adolescent drug users and psychological health: A longitudinal inquiry. American Psychologist, 45, 612–630.
13. Yokel, Robert A. (1987). Intravenous self-administration: Response rates, the effect of pharmacological challenges and drug preferences. In Michael A. Bozarth (Ed.), Methods of assessing the reinforcing properties of abused drugs. New York: Springer-Verlag, pp. 1–34.
14. Kerr, John S. (1996). Two myths of addiction: The addictive personality and the issues of free choice. Human psychophar- macology, 11, 39–45. Ross, Helen E.; Glaser, Frederick B.; and Germanson, Teresa (1988). The prevalence of psychiatric disorders in patients with alcohol and other drug problems. Archives of General Psychiatry, 45, 1023–1031.
15. Goode, Drugs in American society, pp. 146–149.
16. Hser, Yih-Ing; Hoffman, Valerie; Grella, Christine; and Anglin, M. Douglas (2001). A 33-year follow-up of narcotics addicts. Archives of General Psychiatry, 58, 503–508. Zinberg, Norman E. (1984). Drugs, set, and setting: The basis for controlled intoxi- cant use. New Haven, CT: Yale University Press, pp. 46–81.
17. Goode, Drugs in American society, pp. 151–152. 18. Robins, Lee N. (1974). The Vietnam drug user returns. Special
Action Office for Drug Abuse Prevention Monograph Series A, No. 2, Contract HSM-42–72–75.
19. Durkheim, Emile (1951). Suicide (translated by John Spauld- ing and George Simpson). New York: Free Press.
20. Agnew, Robert (1992). Foundation for a general strain theory of crime and delinquency. Criminology, 30, 47–87. Merton, Robert K. (1968). Social theory and social structure. New York: Free Press.
21. Merton, Social theory and social structure. 22. Lorch, Barbara D. (1990). Social class and its relationship to
youth substance use and other delinquent behaviors. Social Work Research Abstracts, 26, 25–34.
23. Akers, Ronald L. (1992). Drugs, alcohol, and society: Social structure, process, and policy. Belmont CA: Wadsworth, pp. 8–9. Hirschi, Travis (1969). Causes of delinquency. Los Angeles: University of California Press.
24. Burkett, Steven R.; and Warren, Bruce O. (1987). Religiosity, peer associations, and adolescent marijuana use: A panel study of underlying causal structures. Criminology, 25, 109–131. Durkin, Keith F.; Wolf, Timothy W.; and Clark, Gregory (1999). Social bond theory and binge drinking among col- lege students: A multivariate analysis. College Student Journal, 33, 450–462. Durkin, Keith F.; Wolfe, Timothy; and Clark, Gregory A. (2005). College students and binge drinking: An evaluation of social learning theory. Sociological Spectrum, 25, 255–272. Guo, Jie; Hill, Karl J.; Hawkins, David; Catalano, Richard F.; and Abbott, Robert D. (2002). A developmental analysis of sociodemographic, family, and peer effects on ado- lescent illicit drug initiation. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 838–846.
25. Sutherland, Edwin H. (1939). Principles of criminology (3rd ed.). Philadelphia: Lippincott.
26. Becker, Howard S. (1953). Becoming a marijuana user. American Journal of Sociology, 59, 235–242. Faupel, Charles E. (1991). Shooting dope: Career contingencies of hard-core heroin users. Hirsch, Michael L.; Conforti, Randall W.; and Graney, Carolyn, J. (2001). The use of marijuana for pleasure: A repli- cation of Howard S. Becker’s study of marijuana use. Journal of Social Behavior and Personality, 5, 497–510.
27. Goode, Drugs in American society, pp. 159–163. Johnson, Bruce (1973). Marijuana users and drug subcultures. New York: Wiley-Interscience. Johnson, Bruce (1980). Toward a theory of drug subcultures. In Dan J. Lettieri; et al. (Eds.), Theories on drug abuse, pp. 110–119.
28. Kandel, Denise B. (1973). Adolescent marijuana use: Role of parents and peers. Science, 181, 1067–1070. Kandel, Denise B. (1980). Developmental stages in adolescent drug involve- ment. In Dan J. Lettieri; et al. (Eds.), Theories on drug abuse, pp. 120–127. Kandel, Denise B.; and Mark Davies (1991). Friendship networks, intimacy, and drug use in young adult- hood: A comparison of two competing theories. Criminology, 29, 441–467.
29. Becker, Howard S. (1963). Outsiders: Studies in the sociology of deviance. New York: Free Press. Erickson, K. (1962). Notes on the sociology of deviance. Social Problems, 9, 397–414.
102 ■ Part Two Drugs, Crime, and Criminal Justice
34. Wright, Douglas; and Pemberton, Michael (2004). Risk and protective factors for adolescent drug use: Findings from the 1999 National Household Survey on Drug Abuse. Rockville, MD: Substance Abuse and Mental Health Services Administration, Chapter 3 and Appendix A.
35. Scheier, Lawrence M.; Botvin, Gilbert J.; and Baker, Eli (1997). Risk and protective factors as predictors of adoles- cent alcohol involvement and transitions in alcohol use: A prospective analysis. Journal of Studies in Alcohol, 58, 652–667. Scheier, Lawrence M.; Newcomb, Michael D.; and Skager, Rodney (1994). Risk, protection, and vulnerability to adolescent drug use: Latent-variable models of three age groups. Journal of Drug Education, 24, 49–82.
36. Wright and Pemberton, Risk and protective factors for adoles- cent drug use, Chapters 3 and Appendix A.
37. Smith, Carolyn; Lizotte, Alan J.; Thornberry, Terence P.; and Krohn, Marvin D. (1995). Resilient youth: Identifying factors that prevent high-risk youth from engaging in delinquency and drug use. In J. Hagan (Ed.), Delinquency and disrepute in the life course. Greenwich, CT: JAI Press, pp. 217–247.
38. Scales, Peter C.; and Leffert, Nancy (1999). Developmental assets: A synthesis of the scientific research on adolescent development. Minneapolis: Search Institute. Search Institute (2001, February). Profiles of student life: Attitudes and behavior. Minneapolis: Search Institute.
Lemert, Edwin M. (1951). Social pathology. New York: McGraw-Hill.
30. Margolin, Robert D.; and Zweben, Joan E. (1998). Treating patients with alcohol and other drug problems: An integrated approach. Washington DC: American Psychological Associa- tion, pp. 76–87.
31. Johnston, Lloyd D.; and O’Malley, Patrick M. (1986). Why do the nation’s students use drugs and alcohol? Self-reported reasons from nine national surveys. The Journal of Drug Issues, 16, 29–66. Terry-McElrath, Yvonne M.; O’Malley, Patrick M.; and Johnston, Lloyd D. (2009, Summer). Reasons for drug use among American youth by consumption level, gender, and race/ethnicity: 1976–2005. Journal of Drug Issues, 677–713.
32. Goode, Drugs in American society, pp. 159–162. 33. Substance Abuse and Mental Health Services Administra-
tion (2001). Risk and protective factors for adolescent drug use: Findings from the 1997 National Household Survey on Drug Abuse. Rockville, MD: Substance Abuse and Mental Health Services Administration, pp. 27–42. Watts, W. David; and Wright, Loyd S. (1990). The drug use–violent delinquency link among adolescent Mexican-Americans. In Mario De la Rosa; Elizabeth Y. Lambert; and Bernard Gropper (Eds.), Drugs and violence: Causes, correlates, and consequences (NIDA Research Monograph 103). Rockville, MD: National Institute on Drug Abuse.
Drugs and Crime 6chapter
On the streets of south side Chicago, Shayne had never been a model
citizen, but he wasn’t a born killer either. At the age of 56, Shayne had
a long rap sheet but only served time once, back when he was in his
thirties, according to police records. Lately, Shayne would hang out in
the neighborhood with guys half his age; some of them had criminal
records that matched or exceeded his own.
Intermittently, they were a bunch of guys that got along. But
more often than not, they would give Shayne a really hard time.
They would taunt him with threats of killing him, often for no reason
at all. People would say that, even though he was a lot older
than the other guys, Shayne was the whipping boy for the group,
whenever they felt like it.
Then last year, something snapped. Out of the blue, one guy
turned to Shayne and slapped him. It seemed to be the final straw.
Shayne went to his place got his handgun, and opened fire.
Following his arrest, Shayne was tested for ten illicit drugs that
may have been in his system. Results were negative for them
all. Shayne was later convicted of second-degree murder and
sentenced to 15 years in a downstate correctional facility. During
his trial, Shayne made no comment as to the motive for his crime.
But bystanders knew that it had been only a matter of time.
After you have completed this chapter, you should have an understanding of the following:
●● The difference between drug-defined crime and drug- related crime
●● The drug–crime connection in juveniles
●● The drug–crime connection in adult offenders
●● Psychopharmacological circumstances in drug-related crime
●● Economically compulsive circumstances in drug-related crime
●● Systemic circumstances in drug-related crime
●● Social structures in illicit drug trafficking
●● Gangs and drug-related crime
●● Money laundering and drug- related crime
104 ■ Part Two Drugs, Crime, and Criminal Justice
law. The possession of cocaine or heroin, the manufacture of LSD or other hallucinogens, the sale of methamphetamine are all examples of drug-defined offenses, though the sever- ity of the offenses and the penalties imposed vary widely (see Chapter 8). Naturally, offenses involving Schedule I con- trolled substances, which are regarded as having the greatest potential for abuse and with no accepted medical use, carry the most severe penalties.
For the most part, drug-control laws are uniform across jurisdictions in the United States, allowing us to speak of a drug-defined crime in the same way no matter where we are in the country. But in a few instances, federal authorities and state authorities may have different positions on whether a certain form of drug-taking behavior is a drug-defined crime. The nonmedical use of marijuana, for example, qualifies as a drug-defined crime on a federal level and in all U.S. states other than those that have legalized marijuana possession. One U.S. state may classify a particular drug under a dif- ferent schedule of controlled substances than another U.S. state. The issues surrounding medical marijuana and non- medical use of marijuana will be examined in Chapter 12.
The impact of drug-defined crimes on the criminal justice system and on society at large is immense. Consider these statistics:
●■ In 2013, approximately 1.5 million arrests in the United States, about one in eight arrests for any reason whatsoever, were made for a drug-defined criminal offense.
●■ Roughly 82 percent of drug-defined criminal offenses in 2013 were for possession of a controlled substance. Of these offenses, approximately 49 percent involved marijuana; 20 percent involved heroin, cocaine, or their derivatives; 5 percent involved synthetic or manufactured drugs; and 26 percent involved other controlled substances.
●■ One-half of the approximately 194,000 individuals pres- ently incarcerated in federal prisons in 2013 were serving time for a drug-defined offense.2
For law enforcement officers and other criminal justice professionals who contend with drugs and crime on a daily basis, the drug–crime connection is all too real and an inarguable fact of contemporary society. For the general public, the news headlines about “drive-by shootings” and “neighborhoods under siege” reinforce the common assump- tion that drugs and crime are inextricably bound together.
There is also no dispute among researchers in criminal justice that a drug–crime connection exists. But how does this connection come about? Three sets of fundamental questions can be asked about the drug–crime connection: (1) Are there circumstances under which drug use leads to criminal behav- ior? Does drug use cause crime? (2) Are there circumstances under which criminal behavior leads to drug use, instead of the other way around? Does crime cause drug use? (3) Are there circumstances under which a third variable is involved? Is the connection between criminal behavior and drug use a result of a third factor or set of factors in an individual’s life?1
Defining the Terms
In order to understand the complexities of the drug–crime connection, it is important to differentiate two general categories of criminal behavior: (1) drug-defined crimes and (2) drug-related crimes.
Drug-defined crimes are offenses in violation of laws prohibiting the possession, distribution, or manufacture of specific drugs or specific quantities of drugs. The drugs in question have been identified as controlled substances under the federal Controlled Substances Act (see Chapter 3) or state
1545 Number of armed pharmacy robberies in the United States in 2013 and 2014. One out of six robberies in the two years occurred in Indiana or Arizona.
1 out of 8 The number of people in the United States arrested in 2013 for a drug-law violation offense out of the total number of people arrested for any reason.
22 Percentage of youths in grades 9–12 in the United States who reported in 2013 being either offered, sold, or given an illicit drug by someone on school property.
Sources: Information courtesy of the Office of Diversion Control, Drug Enforcement Administration, U.S. Department of Justice, Wash- ington, DC. Kann, Laura; Kinchen, Steve; Shanklin Shari L.; Flint, Katherine H.; Hawkins Joseph; et al. (2014, June 13). Youth risk behavior surveillance—United States, 2013. Morbidity and Mortality Weekly Report. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. U.S. Department of Justice (2014). Estimated number of arrests. United States. 2013. Crime in the United States 2013. Washington, DC: Federal Bureau of Investigation, U.S. Department of Justice, Table 29.
Numbers Talk…
drug-defined crime: A violation of laws that prohibit the possession, use, distribution, and manufacture of illegal drugs.
Chapter 6 Drugs and Crime ■ 105
regard, prostitution could be a drug-related crime in this category. These circumstances are collectively referred to as economically compulsive crime.
●■ In the third category, the drug-related crime is committed on the basis of participation in the business of drug traffick- ing (see Chapter 2) or in a subculture with involvement in an ongoing pattern of drug-taking behavior. Associated activities in this category of drug-related crimes could be money laundering and acts of political corruption (bribery or extortion). These circumstances are collectively referred to as systemic crime (Figure 6.1).3
In many cases, drug-related crimes are violent in nature, but there are exceptions. The embezzlement of funds in a company in order to support the expenses of chronic cocaine abuse, for example, would seldom involve violent behavior, even though it would qualify as economically compulsive crime. Likewise, the money laundering of funds acquired through drug trafficking transactions would be not necessar- ily involve violent behavior but would qualify as a systemic crime. In some unusual cases, the categories may not be mutually exclusive. Imagine that a drug user’s withdrawal symptoms are so severe and money is so scarce that the drug user commits a robbery of a drug dealer in order to secure more drugs. All three categories would apply in this instance.
While the Goldstein model is not perfect, its significance lies in the fact that it has enabled criminal justice profes- sionals and drug-control policy makers to make a clear distinction between drug-related crimes caused directly by drug use (psychopharmacological) and drug-related crimes driven by money (economically compulsive and systemic). Unfortunately, it is impossible to arrive at an overall pro- portion of drug-related crimes in each category, since there are so many variables to consider, such as the abused drug in question, the historical period being examined, and the society in which these crimes are committed. Nonetheless, there is no question that the share of criminal activity in eco- nomically compulsive and systemic categories far exceeds the share that is psychopharmacological. In other words,
Drug-related crimes, on the other hand, are offenses that do not involve a violation of a drug law per se, but rather involve a violation of a law of some other type. The crimi- nal act is, in some way, associated with illicit drug-taking behavior.
In 1986, Paul J. Goldstein introduced a conceptual framework for understanding the connection between drugs and criminal behavior, identifying three basic categories of circumstances under which a drug-related crime may occur (Figure 6.1).
●■ In the first category, the drug-related crime is committed as a result of being under the influence of the drug itself at the time of a criminal act. It is possible that withdrawal symptoms are the instigating factor in drug-related crimes, as long as the symptoms have a direct influence on the behavior at the time. The assumption is that the intoxica- tion (or withdrawal from it) reduces the customary inhibi- tion we have over our actions and, as a result, we become aggressive and violent. These circumstances are collec- tively referred to as psychopharmacological crime.
●■ In the second category, the drug-related crime is commit- ted on the basis of the need on the part of the drug user to gain money to purchase the drug. While property crime (robbery and burglary) most often comes to mind in this
The drug–violence
connection
Pharmacological violence
Ingestion of drug causing individuals to become excitable, irrational, or inclined to exhibit violent behavior
Economically compulsive violence
Need for money to buy drugs as the primary motivation for violence
Systemic violence
• Disputes over territory between rival drug dealers • Violent acts committed to enforce discipline • Elimination of police informants • Punishment for selling adulterated drugs • Punishment for defrauding the drug dealer
F igure 6 .1
The Goldstein tripartite model of drugs and violence, showing the importance of distinguishing three major types of drug-related violence.
Source: Based on Goldstein, Paul (1985, Fall). The drug-violence nexus: A tripartite framework. Journal of Drug Issues, 493–506.
systemic crime: A drug-related crime in which the criminal act is committed as part of a pattern of violent behavior existing in an organization involved in illicit drug trafficking and distribution.
economically compulsive crime: A drug-related crime in which the criminal act is committed in order to obtain money to buy drugs.
psychopharmacological crime: A drug-related crime in which the criminal act is committed while the perpetrator is under the influence of a particular psychoactive substance, with the implication that the drug itself caused the drug- related crime to occur by altering one’s mental state.
drug-related crime: An offense in which a drug contributes to the commission of a crime, either by virtue of the drug’s psychopharmacological effects, the economic need to secure the drug, or drug trafficking.
106 ■ Part Two Drugs, Crime, and Criminal Justice
Collecting the Statistics on Drugs and Crime
In order to arrive at evidence-based conclusions about the relationship between drugs and crime, it is important to ana- lyze the best available statistical data on this question. We will examine two sources of information: (1) information about adolescent drug use and juvenile delinquency and (2) infor- mation about adult drug use and criminal offenses.
Drugs and Delinquency On odd-numbered years, the Centers for Disease Control and Prevention, an agency of the U.S. Department of Health and Human Services, conducts a nationwide survey of more than 15,000 students in grades 9 through 12 through the Youth Risk Behavior Surveillance (YRBS) program. Behaviors assessed in the YRBS include alcohol, tobacco, and illicit drug use and sexual risk behaviors associated with unin- tended pregnancy or sexually transmitted diseases, as well as delinquent behaviors such as carrying a weapon or being in a physical fight.6 Table 6.1 shows the prevalence rates of drug use and delinquent behaviors in 2009, 2011, and 2013.
Drawing upon responses in the 2007 YRBS survey, researchers found a strong relationship between drug use and delinquency. Twice as many students who reported consum- ing five or more drinks in a row within a few hours on at least one day (the criterion for binge drinking, see Chapter 15), using marijuana one or more times, or even using cocaine one or more times also reported carrying a weapon or engag- ing in a fight on at least one day in the past year, when com- pared to students who consumed fewer than five drinks, did not use marijuana, or did not use cocaine. While there have been changes in prevalence rates and delinquent behaviors among adolescents sampled in the YRBS program in succeed- ing years (see Table 6.1), it is not unreasonable to assume that the relationship between drug use and delinquent behaviors has remained basically the same.7
Drugs and Adult Crime A federal data collection program called the Arrestee Drug Abuse Monitoring (ADAM II) survey provides information about drug use among men who have been arrested for any criminal offense. Under this program, all males arrested in five selected U.S cities are required to report prior use of 10 illicit drugs and submit to urinalysis tests (see Chapter 13) within 48 hours of their arrest. Figure 6.2 shows the percent- age testing positive for four major illicit drugs (marijuana, cocaine, heroin, and methamphetamine), multiple drugs, and any of the 10 drugs being investigated.
ADAM II statistics indicate that drug use among an arrestee population is much higher than in the general U.S. population (see Chapter 1). In 2013, at least two-thirds of the arrestees tested positive for at least one illicit drug, with the percentage varying from 63 percent in Atlanta, Georgia, to
drug-related crime can be viewed more as a matter of drug marketing and drug buying than as a matter of drug use per se.4
The images of violence associated with drug-related crimes that are psychopharmacological or economically compulsive in nature (sexual assaults while under the influ- ence of a drug, armed robberies carried out in order to gain drug money) are the images that most often come to mind, but it can be argued that violence associated under systemic circumstances have the potential for being the most intense and socially far-reaching. The social violence associated with gangsters involved in liquor trafficking during the Prohibition era in the 1920s and the violent urban lifestyle of individu- als in drug trafficking at the height of the crack cocaine epi- demic in the late 1980s (Chapters 3 and 10) are two examples from the past. Of course, a prime example is the culture of violence associated with the present-day global illicit drug trade. As we saw in Chapter 2, systemic violence has been carried out in order to settle territorial disputes among rival drug-trafficking groups, to impose punishments for defraud- ing a drug dealer or being a police informant, to intimidate public officials, or simply to assert the authority of the leader of the group over its members. Later in the chapter, we will examine the culture of violence in certain types of gangs and the forms of drug-related crime that occur in the context of a deviant subculture.
Perspectives on Drug Use and Crime
Historically, the process by which there is a connection between drug use and crime has been explored through three major perspectives. The first perspective is called the enslavement model, also referred to as the “medical model.” It asserts that individuals become forced into a life of crime and drug abuse either as a result of social situations such as pov- erty or from a personal condition such as a physical disorder. In other words, criminal activity and drug use or abuse exist together, arising from a common adverse set of circumstances in one’s life. The predisposition model, also referred to as the “criminal model,” asserts that drug abusers are far from law- abiding citizens in the first place and that they have already been involved in criminal activity prior to initial drug use. A predisposition toward criminal activity is increased by the fact that criminals exist in social subcultures in which drug use is readily accepted and encouraged. The intensification model, essentially a combination of the previous perspectives, asserts that drug use tends to perpetuate a life of crime. In essence, according to this perspective, criminal careers have already begun in the life of the individual, but the degree of criminality is intensified by one’s involvement with drug use. The intensification model is able to account for two basic conclusions in the drug–crime research literature: (1) criminal careers typically begin prior to drug use and (2) criminal activity declines substantially during times of drug abstinence.5
Chapter 6 Drugs and Crime ■ 107
National Crime Victimization Survey (NCVS), conducted in 2008, has addressed the extent to which the victim of a violent crime believed that the perpetrator was under the influence of alcohol or other drugs. As shown in Figure 6.3, nearly half of the victims (47%) were unable to say whether the perpetra- tor was under the influence of alcohol or drugs, but for those who had an opinion, approximately one-half of these victims felt that the perpetrator was either under the influence of alcohol, or drugs, or a combination of alcohol and drugs. In 14 percent of the cases, the perpetrator was identified as being specifically under the influence of alcohol, but in about three out of ten cases the victim reported that the perpetrator was not under the influence of alcohol or drugs at the time of the crime. Surveys of victims of rape or sexual assault have indicated a similar pattern regarding the victim’s perception of the perpetrator at the time of the crime (see Chapter 14).10
83 percent in Chicago and Sacramento, California. From 12 to 50 percent of arrestees (depending upon the city where an arrest was made) tested positive for more than one drug.8
Another survey examines drug use among criminal offenders at a later stage in the criminal justice process. In this program, prison inmates are interviewed to check the pattern of illegal drug use prior to their incarceration. In 2002, one- half of them reported symptoms of a substance use disorder involving an illicit drug at a previous time and two-thirds had received drug treatment of some sort. The prevalence rate of severe substance use disorder (see Chapter 4) were especially high for property crimes, with the prevalence rate as high as 74 percent for those serving time for burglary.9
A more direct examination of the connection between drug use and adult crime, however, can be made through information provided by the victim of a criminal act. The
0 20 40 60 80 100
Atlanta, GA
Chicago, IL
Denver, CO
New York, NY
Sacramento, CA
63
83
74
73
83
Percentage Testing Positive for Any of Ten Drugs Marijuana Cocaine Heroin Methamphetamine
34
52
48
44
60
33
24
20
32
7
6
14
8
8
18
<1
<1
16
0
51
12
20
27
23
50
Multiple Drugs Percentage Testing Positive
F igure 6 .2
Urinalysis results for illicit drug use among male adult arrestees in 5 U.S. cities in 2013. The most common substances identified during testing were, in descending order: marijuana, cocaine, heroin, and methamphetamine, though distinct regional differ- ences can be noted. Methamphetamine use was identified with arrestees primarily in the western regions of the United States.
Source: Based on data from the Office of National Drug Control Policy (2014, January) ADAM II:2013 Annual report. Arrestee Drug Abuse Monitoring Program II. Washington, DC: Office of National Drug Control Policy, Executive Office of the President, Tables 3.3–3.8.
TAble 6.1
Prevalence rates for alcohol use, marijuana use, cocaine use, and selected risk behaviors among students in the youth risk behavior surveillance (YRBS) surveys in 2009, 2011, and 2013
2009 (%) 2011 (%) 2013 (%)
Had five or more drinks of alcohol in a row within a couple of hours on at least one day
24 22 21
Used marijuana one or more times in the past 30 days 21 23 23
Ever used any form of cocaine one or more times 6 7 6
Engaged in a fight on one or more days in the past 30 days 32 33 25
Carried a weapon on at least one day 18 17 18
Sources: Eaton, Danice K.; Kann, Laura; Kinchen, Steve; Shanklin, Shari L.; Ross, James; Hawkins, Joseph; et al. (2010, June 4). Youth risk behavior surveillance—United States, 2009. Morbidity and Mortality Weekly Report. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Eaton, Danice K.; et al. (2012, June 8). Youth risk behavior surveillance— United States, 2011. Morbidity and Mortality Weekly Report. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Kann, Laura; Kinchen, Steve; Shanklin Shari L.; Flint, Katherine H.; Hawkins Joseph; et al. (2014, June 13). Youth risk behavior surveillance—United States, 2013. Morbidity and Mortality Weekly Report. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.
108 ■ Part Two Drugs, Crime, and Criminal Justice
Despite the limitations, statistical information about drug-related crime allows us some insight into the nature of drugs and crime. In particular, we can examine the important features of three specific forms of drug-related crime.
Regarding Psychopharmacological Crime The ADAM II surveys have the potential for gaining an insight into a causal relationship (in this case, a psychopharmaco- logical relationship) between drug use and crime, but even here, the presence of a drug in the bloodstream of an arrestee after a interval up to 48 hours following the arrest does not necessarily indicate that the arrestee was under the influence of the drug at the time of the crime. The main criticism of pharmacological explanations from the standpoint of ADAM II data rests on the fact that traces of a drug (referred to as metabolites) can be detected in a standard urinalysis drug test for a period of time after the user no longer feels intoxicated by the drug. This length of time can range from a matter of days to two months in the case of marijuana (see Table 13.3). Therefore, testing positive for a drug only indicates that the individual might have committed the crime while under the influence of the drug, if indeed that drug has the potential for inciting criminal behavior in the first place.
If we are speaking of a violent crime, it is important to recognize the degree to which specific drugs might be capable of inciting violent behavior. In some instances, the physiological nature of the drug itself makes the possibility of violence quite unlikely. A prominent effect of marijuana, for example, is that it makes you more lethargic than active, in effect quite mellow in circumstances in which there may be some interpersonal conflict. A study of 559 males in Philadelphia, for example, found that 96 percent of those who used marijuana said that they “never” or “almost never” felt an urge to hurt someone while under the influence of the drug. An overwhelming majority of the respondents said that marijuana made them feel more peaceful and passive than before its use.12 Yet, the Philadelphia study did find that indi- viduals who used marijuana were significantly more likely
Surveys bearing on the chronological sequence of drug- taking behavior and adult crime, however, make it difficult to see the drug–crime connection as a clear directional pro- cess. Several studies of drug users in Miami, conducted dur- ing the 1970s and 1990s, found that the only drug use that preceded the first crime they committed was the use of alco- hol and marijuana. Use of more expensive drugs, such as heroin and cocaine, usually did not begin until two to four years after their first crime. A survey of inmates in Michigan, California, and Texas prisons found that only 20 percent of those who used drugs reported that their drug use began prior to their first crime, and more than 52 percent reported that they began using drugs and committing crimes at about the same time. The National Youth Survey Family Study, con- ducted by the University of Colorado, found that the initial involvement in criminal activity often preceded drug use. In a 10-year survey of more than 1700 youths aged 11–17 years old, the first criminal offense preceded their first alcohol use in 63 percent of cases, and their first criminal offense pre- ceded their first marijuana use in 93 percent of cases.11
What the Statistics Tell Us and What They Do Not
Undoubtedly, the statistics in the surveys confirm the open- ing supposition that drugs and crime are linked together, but, as persuasive as they may be, most of them establish only a correlation between drugs and crime, not a causal relation- ship between drugs and crime. And correlation does not imply causation. In other words, if we observe that when drug use increases, criminal activity increases as well, we can con- clude that the two behaviors are correlated. Yet we cannot say necessarily that there is a directional cause-and-effect rela- tionship going on. If there is a cause-and-effect relationship between a third variable and drug use and, at the same time, a cause-and-effect relationship between that variable and crimi- nal activity, then it is likely that there will be a correlation between drug use and criminality activity as a result.
47%
29%
14%
5%
4%
1%
Perceived to be under influence of alcohol
Perceived to be under the influence of alcohol and drugs Perceived to be under the influence but not sure if alcohol or drugs
Perceived to be under influence of drugs
Don’t know or not ascertained Not on alcohol or drugs
F igure 6 .3
Perceptions of victims of a violent crime with regard to alcohol and/or drug use by the perpetrator at the time of the crime.
Source: Based on data from the Bureau of Justice Statistics (2011, May) Criminal victimization in the United States, 2008. Statistical tables. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice, Table 32.
Chapter 6 Drugs and Crime ■ 109
In terms of its psychopharmacological effect, heroin pro- duces a passive state of mind (hence the expression, “being on the nod”), thus reducing the inclination toward violent behavior. In fact, as rates of heroin abuse rise, the incidence of crimes against individuals (as opposed to crimes against property) declines.14
In contrast, psychoactive stimulants such as metham- phetamine and cocaine or the hallucinogen PCP (known
than nonusers to have committed multiple criminal offenses. The results of this study show that marijuana use on its own may not have caused crime per se, but may have been part of a lifestyle of people who commit crime. The relationship may be due to the fact that the same types of people who are most likely to commit crime—young males of lower socio- economic status—are also the same types of people who are most likely to use drugs (Drugs . . . in Focus).13
From Heroingen and Crackgen to bluntgen: The rise and Fall of Drugs and Violence From a sociological point of view, the impact of drug use on vio- lent crime over the last 40 years or so can be examined in terms of the dominant drug of abuse at a particular time. Sociologists Bruce D. Johnson, Andrew Golub, and Eloise Dunlap have divided the drug scene in inner-city New York City into three distinct eras, each defined by a specific drug subculture and set of shared social norms. Each subculture has been guided by a set of expected behaviors that have dictated what subculture par- ticipants must do, what they must refrain from doing, and what the consequences are for noncompliance. An agreed-upon set of norms defining their conduct allows participants to function as if on “automatic pilot.”
The Heroingen According to their analysis, the period 1960–1973 was the era of heroin injection and a subculture of heroin-abusing participants (the heroin-injection generation, or HeroinGen for short). In the peak year of 1968, the HeroinGen members were between 15 and 25 years old. Quite often, they had grown up in a subculture of alcohol abuse, with their parents being heavy alcohol con- sumers. In mid-adolescence, HeroinGen members were turned on to marijuana, but by 1964–1965, heroin had hit the New York streets in a major way. The promise was that heroin would give them a better high than marijuana or alcohol, and a process of introduction into heroin use began. A dominant feature of the subculture was the act of robbery. Handguns were rarely carried or used; instead, knives and blunt instruments were the weapons of choice.
The Crackgen Crack cocaine became available around 1984 in New York City and other metropolitan communities. Subculture members, born between 1955 and 1969, came of age during the height of the cocaine/crack era (1985–1989). For these individuals, called the Crack Generation or CrackGen, conduct norms were quite different from those of the HeroinGen. Crack use was carried out in intensive binges. Hyperactivity, rapid cycling between euphoria and dysphoria, and paranoia dominated their behavior.
Sales of crack became so profitable that the entire illicit drug industry revolved around it. Vicious competition between crack dealers ensued. The key factor was “keeping the money and product straight.” At this point, handguns became common- place. There were 218 recorded drug-related homicides in New York in 1988 alone, as well as other forms of systemic violence.
The bluntgen By the 1990s, remaining members of the CrackGen were in their thirties and increasingly isolated as they continued their compulsive drug-taking behavior. In their place were members of the Marijuana/Blunt subculture (BluntGen, for short). Born in the 1970s, the BluntGen smoked marijuana as a cigar. They would combine funds in a peer group to buy marijuana, occa- sionally committing a crime to get money for their purchases. They saw no need for handguns.
Evidence shows that members of the BluntGen viewed the ravages of the lives of HeroinGen and CrackGen members as a reason to limit their pursuit of drug-taking behavior to the use of marijuana and alcohol. The subculture of assault and disregard for human life had been transformed into a subculture of “stay safe, stay alive.” Rates of violence and nondrug-related criminal- ity, relative to that of an earlier era, declined sharply.
Conduct norms of the BluntGen have impacted on alcohol abuse in a positive way, and there are indications that patterns of drug-taking behavior may have changed. From studies in California and other U.S. states that have legalized medical marijuana in recent years, marijuana has become a substitute for alcohol for young people, reducing the problems typically associated with alcohol. Technically, marijuana in these states is legal only for medical use, but it is nonetheless widely available. Information about a possible decline in alcohol abuse in U.S. states, where marijuana is legal for either medical or nonmedical use, is not yet available.
Sources: Johnson, Bruce D.; Golub, Andrew; and Dunlap, Eloise (2006). The rise and decline of hard drugs, drug markets, and violence in inner-city New York. In Alfred Blumstein and Joel Wallman (Eds.), The crime drop in America. New York: Cambridge University Press, pp. 164–206. Quotations on pages 173, 178, 180, and 186. Nagourney, Adam; and Lyman, Rick (2013, October 27). Few problems with cannabis for California. New York Times, pp. A1, A19.
Drugs … in Focus
110 ■ Part Two Drugs, Crime, and Criminal Justice
Whether or not alcohol or other drugs have a direct bear- ing on the committing of a criminal offense, their psycho- pharmacological effects may be sought after and experienced in conjunction with criminal activity. Drugs may be used before a criminal offense to bolster courage in the planning of criminal activity or afterward to celebrate success. Prostitutes may turn to alcohol and drugs as a method of coping with the stresses of their way of life. In these cases, psychopharmaco- logical factors in drug-taking behavior are intertwined with a criminal lifestyle rather than a critical element in the instiga- tion of a specific crime.
Regarding Economically Compulsive Crime The evidence bearing on economically compulsive crime in the late 1980s and 1990s is overwhelming and from today’s perspective quite frightening. A 1990 study of 611 adoles- cent (principally crack cocaine) users in Miami, Florida, for example, showed that 59 percent participated in 6,669 rob- beries over a 12-month period, averaging 31 robberies per individual. While most of these robberies were carried out to obtain drugs, they were not always break-ins and holdups. Sometimes the crime involved the theft of drugs from drug dealers or other users.17 Nonetheless, a large proportion of the crimes committed to obtain drug money involved vio- lent acts directed against individuals within the community. Particular targets included storekeepers, children, and the elderly. In a later study, reported in 1998, interviews with 699 crack and cocaine users in Miami regarding the number of crimes and arrests during the previous 90 days revealed that more than 1,700,000 offenses had been committed, roughly 28 per person each day! However, offenses included procur- ing drugs, drug sales, prostitution, and gambling—all activi- ties that could occur multiple times in a 24-hour period. Nonetheless, there were nearly 5,000 offenses involving rob- beries and assaults. Roughly seven crimes of this sort were committed per person over the 90-day period. Yet, less than 1 percent of the offenses resulted in arrest.18
While the prevalence rate for drug-related crime is lower than it was during the 1990s and the percentage of arrests per drug-related offense is considerably higher, the incidence of economically compulsive crime is still high. According to a 2004 study of state prison inmates, 30 percent of all property- crime offenders admitted that they committed their current offense in order to get money to buy drugs.19
If economically compulsive crimes are indeed eco- nomically driven, to what extent are they related to “market conditions” (that is, the price of the drug at the time)? The dynamic features of economically compulsive crimes are important elements in public policy decisions about drug use. For example, if we artificially reduced the price of her- oin (by providing a greater amount of heroin on the street), could we reduce economically compulsive crimes among heroin users?
In the early 1970s, when heroin abuse was particularly problematic, it was found that elevations in heroin prices
as “angel dust”) produce an on-edge frame of mind and a social paranoia that can potentially lead to violent behavior (see Chapters 10 and 11). In the case of crack cocaine, crack smokers have the reputation of being irritable, paranoid, and inclined to lash out at another person at the slightest prov- ocation. Yet, even in these cases, we need to be careful in interpreting statistical data linking violence with the abuse of these drugs. For example, in a study conducted at an Atlanta medical center, more than half of all patients being treated for acute cocaine intoxication were reported to be aggressive, agitated, and paranoid just prior to and at the time of hos- pital admission. It is impossible to determine whether these patients were mentally unstable prior to their taking cocaine. People who have long-standing psychological disorders may be overrepresented in any population of cocaine abusers.15
Of all the psychoactive drugs that we could consider in the context of psychopharmacological violence, the one with the widely reported links to violent behavior toward individu- als is alcohol. Of course, millions of people drink alcohol and never become violent, but the chances that violence will occur are increased when people are drinking. In such cases, the violence is clearly pharmacological because the effects of being drunk from the ingestion of alcohol are apparent almost immediately. There is a very short lag time between alcohol consumption and behavioral consequences, and there is little doubt that a causal relationship is operating.
On a domestic level, males involved in violent spousal abuse commonly report having been drinking or having been drunk during the times that abuse has occurred. Moreover, violent crime outside the home is strongly related to alcohol intoxication. The more violent the crime, the greater is the probability that the perpetrator of the crime was drunk while committing it.
On the one hand, from the statistical evidence, it is clear that more crime and violence is alcohol related than is related to all forms of illicit drugs combined. Perhaps, this is because so many people consume alcohol so often in their lives. In other words, it may be that the preeminence of alcohol in psychopharmacological crime is simply due to the fact that the hours of alcohol intoxication exceeds the hours of intoxi- cation from the entire range of all illicit drugs. But alcohol is also the champion in terms of violent acts per hour of intoxi- cation, far ahead of marijuana, which is the most prevalent of illicit drugs. Therefore, it is not the overall availability of alcohol in our society nor the number of people involved in alcohol consumption that is of issue here.
On the other hand, for any psychoactive substance that we may consume—licit or illicit, dependence or nondepen- dence producing, alcoholic or nonalcoholic—the majority of occasions of chemical intoxication in our lives do not moti- vate us to commit a crime. As discussed earlier, victimiza- tion surveys have shown that, from the victim’s perspective, alcohol intoxication on the part of the offender accounts for only 14 percent of instances in which a violent crime has occurred. On the other side of the coin, 76 percent of these instances do not involve alcohol intoxication (or at least the victim is not aware of the offender being drunk).16
Chapter 6 Drugs and Crime ■ 111
and resulted in dramatically higher methamphetamine prices. Higher prices led to a general reduction in metham- phetamine-related property crimes as well as a decline in methamphetamine use, particularly among light users. Since methamphetamine abuse was a relatively new phenomenon at the time, the preponderance of methamphetamine users were in a “light user” category. Evidently, fewer property crimes were committed because there were fewer light meth- amphetamine users to commit them. Heavy methamphet- amine users showed less of a change in their drug usage or criminal behavior.21
The way in which property crime rates respond to higher drug prices, therefore, may depend on the character of the drug user population. Property crimes may be more likely to be reduced as drug prices increase when the popu- lation in question is comprised of significant numbers of newly initiated drug users. For these individuals, the level
(caused by reducing its availability) coincided with a higher level of property crime; when heroin prices were low, the crime level decreased. The implication was that heroin abus- ers committed property crimes in order to maintain a stable consumption of heroin. Therefore, the deliberate elevation of heroin prices tended to increase the incidence of property crime among heroin users. But price increases for heroin had no impact on the incidence of other forms of criminal behavior among heroin users nor did they reduce the number of heroin users themselves.20
Does the heroin price–property crime relationship, as noted in the 1970s, hold for other historical periods or other drugs of abuse? In the case of methamphetamine abuse dur- ing the 1990s, the picture appears to have been somewhat different. The passage of federal legislation beginning in 1996 greatly restricted public access to ingredients used in the manufacture of methamphetamine (see Chapter 10)
PorTrAiT David Laffer—Pharmacy Robber and Killer of Four
Arguably the most famous bank robber in American history, Willie Sutton, was once asked by a reporter in an interview why, over a 40-year criminal career, he robbed banks. “Because that’s where the money is,” he explained. It has become a famous quote, and probably the most well-known quote by a lifelong criminal.
Today, it is not the banks that are being robbed but the local pharmacies. Why pharmacies? To update Willie Sut- ton’s explanation: “Because that’s where the drugs are.” To be more specific: “That’s where the OxyContin is.” From a law enforcement standpoint, phar- macy robberies have gotten totally out of control, in practically every region in America, in states as disparate as Okla- homa, Ohio, California, and Oregon. The Drug Enforcement Administration (DEA) reported more than 700 drug- related pharmacy robberies in 2013. And it has gotten deadly. In 2011, four people were killed during a suburban pharmacy robbery on Long Island, New York. The killer, David Laffer, had acquired nearly 12,000 opioid pain medication pills in the four years leading to the robbery. Lives have been lost in similar armed robberies in 2012 and 2013 as well.
From a street sale alone, the 80 mg dosage of OxyContin has become a prime target for theft. A single pill at this dos- age goes for $80 on the street, so a heist
of even a few bottles can add up to real money. Meanwhile, pharmacists
have had to contend with some difficult choices. Do they suspend all sales of Oxy- Contin, depriving the many patients with genuine pain-control issues? Do they institute security measures such as those instituted by banks? Do they hire guards around the clock to protect themselves?
Some pharmacies (particularly those that are independently owned) have upgraded their surveillance cameras, have installed bulletproof glass-enclosed counters, and have installed buzzers at the door for customers. Time-release locks on the safes used to store narcotics are now in place to reduce the number of burglaries. In one counter-move, a pharmacist in Maine took to attaching a tracking device on specific bottles of OxyContin, reserved for a potential pharmacy robber, which successfully led to the location of the perpetrator. Some pharmacists have greatly restricted their stock supplies of Oxycodone or OxyCon- tin products and have no regrets in tell- ing this to their customers.
Several U.S. states are increasing the minimum jail time for second-degree robbery, when a pharmacist may be threatened but no weapon is shown (a typical scenario in pharmacy robberies), from three months to three years. As a county prosecutor in Washington State has put it, “Word travels fast on the street
about what an easy target the pharmacies are and how much profit can be made and what small punishment is attached.”
While the incidences of armed rob- bery in a pharmacy receive most of the media attention, a five-year analysis report of pharmacy experiences nation- wide issued in 2013 by the Pharmacists Mutual Insurance Company concluded that break-ins are far more common, representing about 80 percent of phar- macy theft cases. A national pharmacy crime database, called RxPatrol, has been established to monitor pharmacy theft, in cooperation with the DEA. No matter how the pharmacy industry deals with this problem, the crisis in prescription drug abuse is bound to continue. It is dif- ficult to battle an increasing trend in the number of opioid pain prescriptions that are being filled throughout the nation.
Sources: Brown, J. (2011, June 23). The oxycodone curse. Newsday, p. A8. Good- nough, A. (2011, February 7). Pharmacies under siege from robbers seeking drugs. New York Times, p. A14. Peddie, S.; Van Sant, W.; and Lewis, R. (2012, January 8). The fear in the pharmacies. Newsday, pp. A3, A4. Pharmacists Mutual Companies (2013, January). 5 year analysis of pharmacy burglary and robbery experience, Algona, IA. Information courtesy of the Drug Enforcement Administration, U.S. Depart- ment of Justice, Washington, DC.
112 ■ Part Two Drugs, Crime, and Criminal Justice
factors provide the necessary ingredients for a thriving system of systemic crime.
In the world of systemic crime, it is difficult to separate criminality from drug use, in that the business of drug dis- tribution is built upon drug use and the subculture of drug dealers is defined by criminality. A substantial number of drug users may become involved in drug distribution as their drug- using careers progress and hence become part of a criminal subculture that uses violence to maintain control over its operations. In general, there may not be a direct relationship between drug use and crime but rather an indirect relation- ship that has been called by the U.S. Department of Justice interactional circumstances.
The prominence of systemic violence associated with crack cocaine abuse during the 1980s was particularly strik- ing in the lives of young urban males. For those living in socioeconomic circumstances that offered few opportu- nities for future advancement, the enticement of acquir- ing great wealth, beyond anything that could be attained through legitimate means, was a strong factor in their par- ticipation in drug distribution operations. It was common for successful drug dealers to keep large stores of illicit drugs to show off their wealth and success; they were, in effect, role models in their society. Individuals recruited into crack cocaine distribution would become more likely to be involved in drug use, despite the warning that, as a drug seller, they should not be “their own best customer.” Drug use would be an intrinsic part of an overall criminal lifestyle within a deviant subculture, in line with the sub- cultural recruitment and socialization theory of drug-taking behavior (Chapter 5).
As the involvement of a youth in crack distribution increased, it was more likely that the person would become involved in violent crime. The enormous value of the drug itself relative to its quantity (the contents of a plastic sandwich bag often being worth thousands of dollars) was a major factor in increasing the intensity of interpersonal relationships. Transactions were conducted under great uncertainty as the other party could be a law enforcement informant.
In addition, the subculture was characterized by the most violent drug users being the people most highly regarded by young people. Many adolescents living in communities dominated by the crack cocaine market felt the need to prove that they could be brutal in order to avoid being harassed by their peers. It can be argued that the pressure to be an accepted member of such a community was more responsi- ble for a drug abuser’s committing frequent violent acts than the effects of the drugs themselves or the need for money to buy drugs.
It is impossible to know how much of the violence among drug dealers during this era, or any period since then, can be attributed to the nature of illicit drug distribution opera- tions or the inclination of individuals prior to their involve- ment. Particularly in the 1980s, violent drug dealers tended to live and carry out their operations in poor, inner-city neighborhoods, where violence was a common occurrence,
of drug usage would be relatively low, and they would be the ones who were inclined to give up the drug (perhaps switching to other forms of drug use) when the metham- phetamine costs rise. The population of heroin users in the 1970s was comprised of fewer individuals of this type. Long- standing heroin users, less inclined to relinquish their drug of choice, would engage in greater levels of property crime as costs rise.
Whether or not criminal behavior increases or decreases as a result of drug prices, the specific economically com- pulsive crime a drug user commits can be differentiated on the basis of gender. Males are more likely to commit crimes against persons (muggings), property (burglary and car theft), or drug laws (distribution and trafficking), whereas females are more likely to commit crimes against the public order, such as prostitution. One study, for example, found that 64 percent of female crack users exchanged sex for money to buy drugs and that 24 percent reported trading sex for drugs. In “crack houses,” women and young girls often bartered sex for crack cocaine. Many of these women remained in the crack houses for extended periods of time, providing sexual favors to multiple customers in order to acquire a continuous sup- ply of the drug.22
While the literature of economically compulsive crime has traditionally focused on heroin and cocaine use, it is important to point out that, in recent years, a new cat- egory of economically compulsive crime has emerged, in the form of pharmacy robberies carried out for the purpose of securing prescription pain medications, predominantly OxyContin.
A growing number of pharmacy robberies occur each year; more than 700 pharmacy robberies occurred in 2012 alone. They represent the clearest evidence of a causal rela- tionship between drug use and criminal activity in that the robbery is expressly directed toward getting a supply of these medications. This chapter’s Portrait depicts a particularly deadly incident among pharmacy robberies in 2011.23
Regarding Systemic Crime The vast majority of drug-related crime in the United States stems from essentially three expensive illicit drugs: heroin, cocaine/crack cocaine, and methamphetamine. It has been estimated that these drugs represent 80 percent of all reve- nues in the black market of illicit drugs. It is no surprise that a combination of the costliness of compulsive drug-taking behavior and the limited incomes (at least from legitimate sources) of drug users would lead to drug-related crime.24 Added to this situation is the dynamic pattern of supply and demand that gives, as we know, the upper hand to the drug supplier over the drug customer (Chapter 2). All of these
interactional circumstances: The idea that there may not be a direct relationship between drug use and crime but rather an indirect relationship.
Chapter 6 Drugs and Crime ■ 113
Does Crime Cause Drug Use? ●■ Persons who are predisposed to commit crimes also use
drugs. Therefore, it is likely that an individual involved in criminality will be in a position to become involved in drugs. See pages 112–113.
●■ Despite the frequently observed developmental pattern of “crime first” and “drug use second,” however, it is uncer- tain whether there is a causal relationship in this regard. See page 108.
Do Drug Use and Crime Share Common Causes?
●■ A strong case can be made for drug-related crime to be caused by a third factor or set of factors. In other words, social risk factors lead to deviant behavior, and deviant behavior includes both drug abuse and criminal behavior. See page 112.
●■ Frequently, for example, individuals with a greater chance of abusing drugs have a number of socioeconomic disad- vantages, such as a low level of education, a broken family, little or no social supervision, and low social status, which also produce a greater chance of criminal behavior.28 See pages 112–113.
●■ While the effects of marijuana may not directly motivate a user to commit crime, both marijuana use and crime may be common characteristics of an overall deviant lifestyle.29 In short, the type of person who is a heavy drug user also could be the type of person who is likely to have short-term goals supported by illegal activities and is more likely to be exposed to situations and persons that encourage criminal behavior.30 See pages 112–113.
Social Structures in Illicit Drug Trafficking
In Chapter 2, the aggregate impact of the global illicit drug trade was examined in detail. In this section, we will address the inner workings of an individual drug trafficking operation.
As with other businesses, the operational design of an illicit drug business can be divided into various “stages” of production and distribution that include (1) cultivation and manufacturing, (2) importation, (3) wholesale distribution, and (4) retail distribution. For drugs such as cocaine and heroin, peasant farmers living in remote locations in the world carry out the actual cultivation and initial processing. Growers then sell the drugs to importers or drug traffickers who smuggle large quantities into the United States and other worldwide markets. Once inside the United States, the drugs are sold to wholesalers who later sell smaller quantities to lower-level retail sellers or street dealers, often in adulter- ated forms.
independent of the illicit drug business. In other words, vio- lent behavior might have been a “job description” in drug dealing markets. In a perverse example of natural selection, dealers who were dead or arrested and imprisoned over time made way for dealers who were better able to employ vio- lence, intimation, and manipulation by corruption for the purposes of maintaining their status and livelihood. The prominence of guns, particularly handguns, in this subcul- ture tended to increase the lethality of the violence, and this element of the subculture continues today.25
Not surprisingly, when street sales of crack cocaine declined in the 1990s, there was an accompanying decline in homicide rates and violent crime in areas where crack sales had been dominant. When community policing pro- cedures succeeded in breaking up drug gangs and large street-level drug markets, the result was a change in the pattern of drug buying and selling.26 As drug distribution operations moved indoors from the streets, territoriality battles were unnecessary. A drug business could hire fewer numbers of people, relying more on trusted friends than easily replaceable (and potentially unpredictable) workers. As a result, there was less conflict among people in a par- ticular drug-selling operation. There were fewer robberies by drug users since drug sales could be limited to known “customers.”27
The Three Fundamental Questions about Drugs and Crime
We can arrive at some tentative conclusions, based upon research, about the process by which drugs and crime are bound together. As stated earlier, it comes down to answer- ing three fundamental questions. References to pages in the chapter that bear upon these conclusions are included.
Does Drug Use Cause Crime? ●■ Of all psychoactive drugs, licit or illicit, the drug with the
highest potential for causing aggressive and violent behav- ior is alcohol. The circumstances tend to be psychophar- macological. From the perspective of victims, however, the prominence of alcohol as a drug intoxicant in the execu- tion of a criminal act is moderate at best. See page 110.
●■ Most of the criminal offenses that are associated with illicit drugs are related to either cocaine (or crack cocaine), heroin, or methamphetamine. The circumstances tend to be economically compulsive, but the incidence varies by the specific drug involved, the drug user population, and the environment under which drug use is occurring. See pages 110–112.
●■ Marijuana use has only a minor direct effect on drug- related crime, other than it represents a drug-defined crime in jurisdictions defining it as such. See pages 104 and 108–109.
114 ■ Part Two Drugs, Crime, and Criminal Justice
the drugs, and the price of a drug is negotiated at the time of the buy. Dealers may have many different buyers, some of whom they never see again after a given transaction is completed. If transactions occur successfully, dealers and buyers may negoti- ate similar arrangements on a more regular basis, but there is no expectation that they will cooperate in the future.
The freelance model typically is associated with the street sale of marijuana and hallucinogens such as LSD and MDMA (Ecstasy). Marijuana sellers are more likely to oper- ate independently than as part of an organized operation, and marijuana often is sold through acquaintance or referral networks. LSD and MDMA are sold principally at concerts, nightclubs, and raves, where sellers and buyers do not know each other, providing a level of anonymity combined with a sense of being part of a common subculture.
In the early years of crack cocaine abuse, from 1984 to 1987, the freelance model dominated as the means by which crack was sold and distributed. The principal drug dealer was a “juggler” who would buy a supply of 10–20 vials of crack and sell them at a standard retail price, approximately twice the initial cost. When the supply was sold, the juggler would “re-up” by obtaining a new supply that would then be sold. Through several cycles, a freelance seller could make up to 50 deals a day. Since most of these freelancers used their product themselves, however, the quantity of sales did not produce substantial incomes. Less than 10 percent of dealers during this period had lengthy drug-dealing careers.32
In contrast, the business model of street dealing is organized as a “business” in a hierarchical fashion with numerous individuals occupying a range of roles. At the center of the business model is the crew boss who receives a supply of drugs from the wholesaler. Drugs are “fronted” at each level of the organization. The wholesaler fronts the drugs to the crew boss, who then divides the drugs and fronts them to street dealers, often called “runners.” Runners most often are young (aged 14–23) males recruited from inner-city neighborhoods. Each crew boss may have as many as 20 run- ners working under his direction. Runners are assigned to work at a particular street location, sell only at a given price, and then hand over all of the money to the crew boss. As the drugs are sold, the money flows up the chain, from runners, to crew boss, and back to the wholesaler. Prices are agreed upon before the drugs are fronted. At the end of the day, each runner is paid in money or drugs for his or her work. To avoid rip-offs and robberies, each crew is guarded by an armed lieutenant who supervises several street sellers.
Crack cocaine (crack, for short) dealing organizations, located in urban neighborhoods, best exemplify the business model of street dealing. In contrast to the freelance dealer, business model dealers and crew bosses who managed to limit their personal use of crack would soon make more than 1,000 dollars per day. Competition among crack dealers would necessitate “protectors,” whose worth was often mea- sured by their violent inclinations and ability to instill fear in others. Thus, the subculture of crack abuse would become enmeshed in an environment of systemic violence.33
In general, drug dealers at the retail (“street”) level follow two types of drug distribution models: (1) the freelance model and (2) the business model.31 As we will see, the first model can evolve into the second, as the character of drug dealing matures from an informal style of interaction to a more formal one.
Independent individuals working together without a pre- viously established relationship characterize the freelance model of retail drug distribution. These dealers and buyers are not part of any large-scale drug organization. It is a “cash only” business, in that the buyer must pay for the drugs at the time of purchase. Both wholesalers and retailers usually do not “front”
business model: A model of retail drug distribution in which drug transactions are conducted within a hierarchically structured organization.
Quick Concept Check
Understanding the Drug–Crime Connection Check your understanding of the drug–crime connection by matching one of the three aspects of this relationship (on the right) with the following drug situations (on the left).
Note: Some of the answers may be used more than once.
6.1
1. A teenager suddenly behaves in a violent man- ner toward a classmate and pulls out a knife after ingesting a drug.
2. A drug dealer kills a subor- dinate for stealing money gained from a street deal.
3. A woman engages in pros- titution in order to gain money to buy drugs.
4. A man robs a store in order to get money for heroin.
5. One drug dealer is killed for encroaching on another drug dealer’s territory.
6. A man who is intoxicated with alcohol rapes a woman.
a. Psychopharmacological crime
b. Economically compulsive crime
c. Systemic crime
Answers: 1. a 2. c 3. b 4. b 5. c 6. a
freelance model: A model of retail drug distribution in which dealers and buyers transact their business with relative anonymity, outside of the structure of a large-scale drug organization.
Chapter 6 Drugs and Crime ■ 115
Street Gangs The association between street gangs and drug selling became particularly striking in the 1980s during the height of crack cocaine abuse in inner-city neighborhoods. In contrast to outlaw motorcycle gangs, the largest proportion of street gangs involved in drug sales during this time com- prised of individuals between 15 and 16 years of age. The prevalence of gang members aged 18 years or older increased when drug sales reached higher levels. White and Hispanic/ Latino gang members tended to be more prevalent in neigh- borhoods where drug involvement was relatively low, and African American gang members tended to be more preva- lent in neighborhoods where drug involvement was high. The extreme levels of systemic violence during this period were attributed in large part to the drug distribution activities of street gang members and their leaders.37
On the other hand, gang members during this period were not dealing drugs in an organized and structured way, and in an analysis of drug dealing in San Francisco, the types of drugs and style of dealing varied across the demographic characteristics. African American gangs sold crack cocaine near housing proj- ects and small corner stores; Latino gang sold crack cocaine, marijuana, and heroin along major roads, often blending in with shoppers and passengers waiting for public buses. Asian gangs stayed out of public places, restricting drug sales, primar- ily powder cocaine, to private transactions by phone or pager.38
In 1995, the National Youth Gang Center was estab- lished as a federal center for statistically tracking and moni- toring gang activity. In light of National Youth Gang Surveys conducted annually since then and other studies, a general picture of American street gangs over a period from 1996 to 2009 has emerged that relates to the issue of drug-related crime in this subculture.
First of all, tracking studies show that gang problems in the United States declined substantially between 1996 and 2001 but increased steadily between 2001 and 2009. While large cities consistently have the highest prevalence rate for gang activity (86 percent of law enforcement agencies report- ing gang problems), there has been significant gang activity in suburban counties (52 percent reporting gang problems) and smaller cities (33 percent reporting gang problems).39
Second, there continues to be a high prevalence rate for violent crime among gang members and drug traffickers. In a recent study of gangs in two locations of Arizona, the majority of gang members reported engaging in violent acts, with 80 percent reporting that they had jumped or attacked people and 51 percent reported killing a person. Drug traf- ficking consisted primarily of sales of marijuana (80%), crack cocaine (51%), and powder cocaine (48%). Drug sales were highly correlated with violent offenses.40
Third, street gangs in western and southwestern U.S. states have strong working relationships with Mexico-based and Central America-based drug trafficking cartels. Gangs had traditionally been the primary organized retail or mid-level distributors of drugs, but now are purchasing drugs directly from the cartels, eliminating the mid-level wholesale dealer.41
Gangs and Drug-Related Crime
The association between drug trafficking activity, gang membership, and violent crime is well documented. Gang members who sell drugs are significantly more violent than gang members who do not sell drugs and are more violent than drug sellers who do not belong to gangs. In a study conducted among gang members in Rochester, New York, for example, 30 percent of youth who participated in gangs committed more than two-thirds of property and violent offenses throughout adolescence and 86 percent of all seri- ous crimes.34
In order to understand the details of this association, however, we need to distinguish between two fundamentally different types of gang organizations: (1) outlaw motorcycle gangs primarily in western U.S. states, notably the Hell’s Angels, the Outlaws, the Bandidos, and the Pagans and (2) street gangs in urban communities, such as the Crips and the Bloods in Los Angeles. Since the late 1980s, law enforce- ment authorities as well as researchers have recognized both organizations as having become the “new faces of orga- nized crime” in America.35 The question is the relationship between the criminal activity in general and drug-related crime in particular. The two types of gang organizations have their unique history and present-day involvement in drug-related crime.
Outlaw Motorcycle Gangs Motorcycle clubs can be divided into either conventional or deviant categories. By far the greatest proportion of clubs are of the conventional type, comprised of men and women who join together based on a common interest in motorcycles, riding together for pleasure and companion- ship, behaving in accordance with the norms of society. A very small percentage of clubs are of the deviant type, comprised of individuals who engage in unconventional, often criminal, behavior. In essence, these “clubs” func- tion as outlaw gangs and their behavior is characteristic of a deviant subculture (see Chapter 5). In contrast to the popular image of mythic figures rebelling against the norms of society or misunderstood social misfits, members of outlaw motorcycle gangs typically have a history of vio- lent behavior and criminal records that include offenses such as drug trafficking, racketeering, brawling, weapons possession, and homicide. Dating back to 1970s and 1980s, outlaw motorcycle gangs have been principal dealers and traffickers of methamphetamine, and their association with this drug continues today. As mentioned in Chapter 2, the name, crank, for methamphetamine originated from the practice of concealing the drug in the crankshaft of motor- cycles. Their association with methamphetamine contin- ues today, but the trafficking of methamphetamine has since been taken over by Mexican drug trafficking organi- zations and outlaw motorcycle gangs play an increasingly minor role.36
116 ■ Part Two Drugs, Crime, and Criminal Justice
convert bulk amounts of drug profits into legitimate revenue. Money laundering refers to the process where illegal sources of income are disguised to make them appear legitimate. Money laundering conceals the illegal sources of money and gives the money a legitimate history.
One of the simplest methods of money laundering is called “smurfing,” by which a number of persons, or “smurfs,” deposit random amounts of less than $10,000 into variously named accounts at many different banks. Using 20 smurfs, for example, each depositing $9,000 in cash, a trafficker could launder as much as $180,000 in less than an hour and circum- vent the regulations of the Bank Secrecy Act. After the money is deposited, it can be withdrawn by the trafficker to purchase money orders in U.S. funds, which are sent out of the country to purchase more drugs or for safekeeping. It can be a quite successful technique, except for the fact that traffickers have to give each of their smurfs a cut of their profits. Therefore, smurf- ing is not the most profitable method of money laundering.
A second technique of money laundering is for traffick- ers to ship the money abroad and deposit it in banks located in countries that have few, if any, money laundering regula- tions. Commonly called “offshore banks,” unregulated banks in the Caribbean nations that were formerly British colonies, such as the Cayman Islands, have become favorite laun- dering havens. With the seventh largest deposit base in the world, the Cayman Islands have more than 550 banks, only 17 of which have a physical presence, operating operate with- out any requirement to report transactions. Typically, these offshore banking havens have very strict policies with regard to nondisclosure, effectively shielding foreign investors from investigations and prosecutions from their home countries.42
One of the oldest methods of money laundering is for drug traffickers to operate a cash-based retail service business such as laundromats, car washes, vending-machine routes, video rentals, or bars and restaurants, mixing the illegal and legal cash and reporting the total as the earnings of the cover business. In fact, the term “money laundering” is said to origi- nate from Mafia ownership of laundromats in the United States during Prohibition. Bootleggers needed to show a legit- imate source for their monies, and laundromats were chosen because they were cash transaction businesses. Later, in the 1970s, the Mafia used pizza parlors to launder money made from the sale of heroin. Acquiring a legitimate business to launder money serves to provide drug traffickers with a report- able income for tax purposes.
Profits in the global illicit drug trade have grown to such immense levels that ordinary businesses have become inad- equate in handling the funds for money laundering purposes. Money laundering has included bribing employees of financial institutions, acquiring financial institutions themselves, as well as conducting large business loans and real estate transactions. The globalization of financial markets through the growth of international trade and the expansion of international corpora- tions have provided a range of opportunities for the conversion of illegal proceeds into what appear to be legitimate funds.43
The combination of globalization and Internet technol- ogy has raised concerns about money laundering to new levels
Money Laundering in Drug-Related Crime
Because practically all transactions in the illicit drug business are conducted in cash, a conspicuously large number of small bills can render drug traffickers vulnerable to law enforce- ment interdiction. Drug traffickers cannot simply deposit their profits into a local bank. The Bank Secrecy Act of 1970 requires that financial institutions in the United States report cash transactions of $10,000 or more to the Internal Revenue Service (IRS), and these institutions must identify the deposi- tors and the sources of the money. Drug traffickers, there- fore, must rely on a variety of money laundering methods to
money laundering: The process where illegal sources of income are concealed or disguised to make the sources appear legitimate.
Quick Concept Check
Understanding Gangs and Social Structures in Illicit Drug Trafficking Check your understanding of gangs and other social structures in illicit drug trafficking by matching each drug situation given on the left with a term or name on the right.
Note: Some of the answers may be used more than once or not at all.
6.2
1. The drug dealers and buyers are not part of any large-scale drug organization.
2. Hell’s Angels, the Outlaws, the Bandidos, and the Pagans are examples.
3. Urban groups in western and southwestern U.S. states work closely with Mexico-based or Central American-based drug cartels.
4. Street drug dealing is organized in a hierarchical structure of drug distribution.
5. The model of crack cocaine deal- ing was dominant in the early years of crack cocaine abuse, 1984–1987.
6. The Crips and the Bloods are examples.
a. Freelance model
b. Business model
c. Outlaw motorcycle gangs
d. Motorcycle clubs
e. Street gangs
Answers: 1. a 2. c 3. e 4. b 5. a 6. e
Chapter 6 Drugs and Crime ■ 117
money laundering. Since then, however, a series of legislative actions have strengthened the regulatory controls over this practice. Considering the globalization of illicit drugs, money laundering controls have been instituted around the world, and the U.S. Department of State has responsibility over issues related to international money laundering, through the Bureau for International Narcotics and Law Enforcement Affairs. Each year, an International Narcotics Control Strategy Report on Money Laundering and Financial Crimes is issued, listing regulatory controls in more than 200 nations and jurisdictions. It is important to note that the financial suc- cess of a modern-day drug trafficking organization is based not only on its ability to produce, distribute, and sell drugs but also on its ability to launder the money made from the illicit drug business.44
of complexity. In recent years, Internet providers, known as digital currency exchange (DCE) services, allow individuals to exchange legal tender (U.S. dollars, for example) into a form of electronic currency or exchange one form of elec- tronic currency for another. The DCE transactions are made through Web sites rather than any physical location, and the process is independent of traditional banking or money trans- fer systems. Since the DCE is made anonymously, it has been a convenient vehicle for money laundering of funds acquired through the illicit drug trade or other illegal enterprises (Drug Enforcement . . . in Focus).
Until the Money Laundering Control Act of 1986 offi- cially criminalized money laundering, the practice was not technically illegal. Federal drug-control authorities had to prosecute drug dealers on the basis of activities outside of
understanding Drug use and Crime ●● Empirical studies on the relationship between alcohol
and drug use and the commission of crime are unani- mous in their findings: Crime and drug use are strongly correlated. Individuals who drink alcohol and/or use drugs are significantly more likely to commit crimes
than are individuals who neither drink nor use illegal drugs. Jail and prison inmates in the United States have much higher rates of drug use relative to the general population. The principal question is whether drug use and criminal behavior have a cause-and-effect relationship.
Summary
The New Money laundering: Digital Currency exchanges In May of 2013, Liberty Reserve, one of the world’s largest DCE companies, and seven principal employees of the company were indicted for conducting an international money laundering operation. The investigation and takedown involved law enforce- ment action in 17 countries. Liberty Reserve was alleged to have had more than 1 million users worldwide (more than 200,000 in the United States alone) who had conducted since its found- ing in 2006 approximately 55 million anonymous transactions, worth more than 6 billion dollars.
According to indictment records, Liberty Reserve allowed users to open accounts without validation of their identities. The Liberty Reserve Web site offered a “shopping cart inter- face” that “merchant” Web sites could use to accept currency transfers as a form of payment. The “merchants” included illicit drug trade organizations as well as traffickers of stolen credit cards, and personal activities proceeded without registration with the U.S. Department of Treasury. As Preet Bharara, Manhattan District Attorney, said at the time of the indictment:
“. . . the only liberty that Liberty Reserve gave many of its users was the freedom to commit crimes… and it became a
popular hub for fraudsters, hackers, and traffickers. The global enforcement action . . . is an important step toward reining in the ‘Wild West’ of illicit Internet banking.”
Whether or not the indictment of Liberty Reserve will lead to prosecutions of other digital currency firms remains to be seen. One prominent digital currency in circulation, Bitcoins, operates with greater transparency, but there are Web sites (some of them suspiciously with names like Bitlaundry and Bitcoinlaundery!) that evidently use Bitcoins in their transactions. Needless to say, they will be subject to intense scrutiny, as law enforcement authorities continue to grapple with this new form of financial crime.
Sources: Manhattan U.S. Attorney announces charges against Liberty Reserve, one of the world’s largest digital currency com- panies, and seven of its principals and employees for allegedly running a $6 billion money laundering scheme. Press release of Manhattan District Attorney’s Office, New York, U.S. Department of Justice, May 28, 2013. Quotation of Preet Bharara, U.S. District Attorney. Perlroth, Nicole (2013, May 29). Unlike Liberty Reserve, Bitcoin is not anonymous—yet. New York Times, Bits. http://bits. blogs.nytimes/com.
Drug Enforcement … in Focus
118 ■ Part Two Drugs, Crime, and Criminal Justice
gangs and Drug-related Crime ●● The association between drug trafficking activity, gang
membership, and violent crime is well documented. Gang members who sell drugs are significantly more violent than gang members who do not sell drugs and are more violent than drug sellers who do not belong to gangs.
●● Two fundamentally different types of gang organizations are involved in drug trafficking and distribution: (1) out- law motorcycle gangs primarily in western U.S. states and (2) street gangs in urban communities, such as the Crips and the Bloods in Los Angeles. Since the late 1980s, law enforcement authorities as well as researchers have recog- nized both organizations as having become the “new faces of organized crime” in America.
Money laundering in Drug-related Crime ●● To escape the attention of law enforcement agencies, the
enormous amount of income gained from “cash only” drug distribution and sales must be converted into legiti- mate revenue in a process called money laundering.
●● One method of money laundering, called “smurfing,” is to enlist a number of individuals to deposit random amounts of less than $10,000 into accounts at many different banks. A second method is to ship the money abroad and deposit it into banks located in countries with few, if any, banking regulations. A third method is to operate cash-based retail service businesses that serve as “fronts” for illegal drug distribution activities. A fourth method is to employ digital currency exchange services on the Internet, where transactions can be carried out anonymously
●● Psychopharmacological crime refers to the possible effects of a drug on an offender committing a crime, that is, the drug in question is assumed to cause violent or criminal behavior while the drug is actually present in the individ- ual’s system. Alcohol is regarded as the psychoactive drug with the greatest potential for psychopharmacological vio- lence or crime.
●● Economically compulsive crime refers to circumstances in which drug use may lead users to commit crimes to obtain money to buy drugs or to support some form of drug-taking behavior. Several studies have shown that economically compulsive crime is a major component of the link between drugs and crime. Whether drug prices coincide with increases or decreases in crimes of this type appears to depend upon the historical period examined and the specific drug of abuse.
●● Systemic crime refers to drug use and crime being inter- twined in the lifestyle of a deviant subculture or an organi- zation involved in illicit drug trafficking and distribution.
The Social Structure of the illicit Drug Dealing ●● The illicit drug business can be divided into the follow-
ing “stages” of production and distribution:(1) cultiva- tion and manufacturing, (2) importation, (3) wholesale distribution, and (4) retail distribution. In this sense, the illicit drug business is no different from that of a foreign or domestic commodity on the legitimate market.
●● At the retail level, drug dealers follow either the freelance model in which dealers and buyers transact their business with relative anonymity or the business model in which drug transactions are conducted within a hierarchically structured organization.
Key Terms
business model, p. 114 drug-defined crime, p. 104 drug-related crime, p. 105
economically compulsive crime, p. 105
freelance model, p. 114
money laundering, p. 116 psychopharmacological crime,
p. 105
systemic crime, p. 105 interactional circumstances,
p. 112
1. Describe the difference between drug-law crime and drug-related crime.
2. Describe the following three types of drug-related crimes, as established in the Goldstein model: psychopharmacological crime, economically compulsive crime, and systemic crime. Give one example of a criminal act in each of these categories.
3. Why do the characteristics of the user population matter when explaining the relationship between the price of illicit drugs and illicit drug use?
4. For each of the three explanations for the drug–crime connec- tion, describe the findings of one research study that support that explanation.
5. Distinguish between the features of the freelance model and business model of retail drug distribution.
6. Distinguish between outlaw motorcycle gangs and street gangs with respect to their history and present-day involvement with drug trafficking.
7. Describe the operations of DCEs in terms of their money laun- dering of funds from illegal criminal activity, including drug trafficking.
Review Questions
Chapter 6 Drugs and Crime ■ 119
Suppose you were in a position to reduce the prevalence of heroin abuse in your community by manipulating the price of heroin, either making it more or less available or artificially increasing or decreasing its street value. Would you decide to make heroin
cheaper or more expensive? Describe your policy decision. How do you justify your decision? Discuss what ramifications you believe your policy might have not only on future heroin use but also on future use of other illicit drugs.
Critical Thinking: What Would You Do?
1. International Association of Chiefs of Police (2001, December 28). Violent crime in America: Summit recommendations. Alex- andria, VA: International Association of Chiefs of Police. Office of Justice Programs (2003). Toward a drugs and crime research agenda for the 21st century. Washington, DC: National Insti- tute of Justice, U.S. Department of Justice.
2. Carson, E. Ann (2014, September). Prisoners in 2013. Bureau of Justice Statistics Bulletin. Washington, DC: U.S. Department of Justice, Tables 14 and 15. Federal Bureau of Investigation (2014). Crime in the United States 2013. Washington, DC: U.S. Department of Justice, Arrests for Drug Abuse Violations and Table 29.
3. Goldstein, Paul J. (1985, Fall). The drugs/violence nexus: A tri- partite conceptual framework. Journal of Drug Issues, 493–506.
4. Caulkins, Jonathan P.; and Kleiman, Mark A. R. (2011). Drugs and crime. In Michael Tonry (Ed.), Crime and criminal justice. New York: Oxford University of Press.
5. Goode, Drugs in American Society, pp. 335–337. Inciardi, James A. (1992). The war on drugs II: The continuing epic of heroin, cocaine, crack, AIDS, and public policy. Mountain View, CA: Mayfield.
6. Centers for Disease Control and Prevention (2013). Youth risk behavior surveillance system: 2011 National overview. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Depart- ment of Health and Human Services.
7. Eaton, Danice K.; Kann, Laura; Kinchen, Steve; Shanklin, Shari; Ross, James; Hawkins, Joseph; et al. (2008, June 6). Youth risk behavior surveillance—United States, 2007. Mor- bidity and Mortality Weekly Report. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Eaton, Denice K; et al. (2010, June 4). Youth risk behavior surveillance—United States, 2009. Mor- bidity and Mortality Weekly Report. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Eaton, Denice K.; et al. (2012, June 8). Youth risk behavior surveillance—United States, 2011. Mor- bidity and Mortality Weekly Report. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.
8. Office of National Drug Control Policy (2014, January). ADAM II: 2013 Annual report. Arrestee Drug Abuse Monitoring Program II. Washington, DC: Office of National Drug Control Policy, Executive Office of the President, Tables 3.3– 3.8.
9. Karberg, Jennifer C.; and Doris, J. James (2005). Substance abuse, dependence, and treatment of jail inmates. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice.
10. Bureau of Justice Statistics (2013, May). Criminal victimization in the United States, 2012, Statistical tables. Washington, DC: U.S. Department of Justice, Table 32.
11. Elliot, Delbert S.; Huizinga, David; and Menard, Scott (1989). Multiple problem youth: Delinquency, substance use and
mental health problems. New York: Springer-Verlag. Inciardi, James A. (1979). Heroin use and street crime. Crime and Delinquency, 25, 335–346. Inciardi, James A.; and Pottieger, Anne E. (1994). Crack-cocaine and street crime. Journal of Drug Issues, 24, 273–292. Inciardi, James A.; Horowitz, Robert; and Pottieger, Anne E. (1993). Street kids, street drugs, street crime. Belmont, CA: Wadsworth.
12. Goode, Erich (1972). Excerpts from marijuana use and crime. In National Commission of Marijuana and Drug Abuse, Mari- juana: A signal of misunderstanding, Appendix, Vol. 1. Wash- ington, DC: U.S. Government Printing Office, pp. 447–453.
13. Goode, Erich (2005). Drugs in American society (6th ed.). New York: McGraw-Hill, pp. 329–350.
14. De La Rosa, Mario; Lambert, Elizabeth Y.; and Gropper, Bernard (Eds.), (1990). Introduction: Exploring the substance abuse-violence connection. In Drugs and violence: Causes, correlates, and consequences (NIDA Research Monograph 103). Rockville, MD: National Institute on Drug Abuse, pp. 1–7.
15. Roth, Jeffrey A. (1994, February). Psychoactive substances and violence: Research brief. Washington, DC: National Institute of Justice. Tyner, Elizabeth A.; and Fremouw, William J. (2008). The relation of methamphetamine use and violence: A critical review. Aggression and Violent Behavior, 13, 285–297.
16. Boyum, David A.; Caulkins, Jonathan P.; and Kleiman, Mark A. R. (2011). Drugs, crime, and public policy. In James Q. Wil- son and Joan Petervilia (Eds.), Crime and public policy. New York: Oxford University Press, pp. 368–410. Bureau of Justice Statistics, Criminal victimization, Table 32. Bushman, Brad J. (1993, October). Human aggression while under the influence of alcohol and other drugs: An integrative research review. Cur- rent Directions in Psychological Science, 2, 148–152. Caulkins and Kleiman, Drugs and Crime. Collins, James J.; and Mess- erschmidt, Pamela M. (1993). Epidemiology of alcohol-related violence. Alcohol Health and Research World, 17, 93–100. Foran, Heather M.; and O’Leary, K. Daniel (2008). Alcohol and intimate partner violence: A meta-analytic review. Clinical Psychology Review, 28, 1222–1234. Goode, Drugs in American society, pp. 343–346. Kuhns, Joseph B.; and Clodfelter, Tam- matha A. (2009). Illicit drug-related psychopharmacological violence: The current understanding within a causal context. Aggression and Violent Behavior, 14, 69–78.
17. Inciardi, James A. (1990). The crack–violence connection within a population of hard-core adolescent offenders. In Marion De La Rosa; Elizabeth Y. Lambert; and Bernard Gropper (Eds.), Drugs and violence: Causes, correlates, and consequences (NIDA Research Monograph 103). Rockville, MD: National Institute on Drug Abuse, pp. 92–111.
18. Inciardi, Jamees A.; and Pottieger, Anne E. (1998). Drug use and street crime in Miami: An (almost) twenty-year retrospec- tive. Substance Use and Misuse, 33, 1839–1870.
Endnotes
120 ■ Part Two Drugs, Crime, and Criminal Justice
33. Johnson; Golub; and Dunlap (2006). The rise and decline of hard drugs, pp. 164–206. Office of National Drug Control Policy (2002, April). Pulse check: Trends in drug abuse. Office of National Drug Control Policy (2004, January). Pulse check. Vannostrand, Lise-Marie; and Tewksbury, Richard (1999). The motives and mechanics of operating an illegal drug enterprise. Deviant Behavior, 20, 57–83.
34. Maxson, Cheryl (2011). Street gangs. In James Q. Wilson and Joan Petersilla (Eds.), Crime and public policy. New York: Oxford University Press, pp. 158–182.
35. Barker, Thomas; and Human, Kelly M. (2009). Crimes of the Big Four motorcycle gangs. Journal of Criminal Justice, 37, 174–179. Bellair, Paul E.; and McNulty, Thomas L. (2009). Gang membership, drug selling, and violence in neighborhood context. Justice Quarterly, 26, 644–669. Howell, James C.; and Decker, Scott H. (1999, January). The youth gangs, drugs, and violence connection. OJJDP Juvenile Justice Bulletin. Wash- ington DC: Office of Juvenile Justice and Delinquency Pre- vention, U.S. Department of Justice. McDermott, Edward J. (2006, Winter). Motorcycle gangs: The new face of organized crime. Journal of Gang Research, 13, 27–36.
36. McDermott, Motorcycle gangs. 37. Bellair and McNulty, Gang membership drug selling, and
violence in neighborhood context. Howell, James C.; and Gleason, Debra K. (1999, December). Youth gang drug traf- ficking. OJJDP Juvenile Justice Bulletin. Washington DC: Office of Juvenile Justice and Delinquency Prevention, U.S. Department of Justice. Decker, Scott; Katz, Charles M.; and Webb, Vincent J. (2008). Understanding the black box of gang organization: Implications for involvement in violent crime, drug sales, and violent victimization. Crime and Delinquency, 54, 153–172.
38. Joe-Laidler, Karen; and Hunt, Geoffrey P. (2012) Moving beyond the gang-drug-violence connection. Drug: Education, Prevention and Policy, 19, 442–452.
39. Howell, James C.; Egley, Arlen; Tita, George E.; and Griffiths, Elizabeth (2014). In Cheryl L. Maxson; Arlen Egley; Jody Miller; and Malcolm W. Klein (Eds.), The modern gang reader. New York: Oxford University Press, pp. 55–60.
40. Decker, Scott H.; Katz, Charles M.; and Webb, Vincent J. (2014). In In Cheryl L. Maxson; Arlen Egley; Jody Miller; and Malcolm W. Klein (Eds.), The modern gang reader. New York: Oxford University Press, pp. 166–178.
41. National Gang Intelligence Center (2011). 2011 National Gang Threat Assessment: Emerging Trends. Tallahassee, FL: National Gang Intelligence Center.
42. Mark, Clayton. (1995, September). Where the world’s crooks go to do their dirty laundry. Christian Science Monitor, p. 1.
43. Motivans, Mark. (2003, July). Money laundering offenders, 1994–2001. Washington, DC: U.S. Department of Justice. Office of National Drug Control Policy (2002, January). ONCP fact sheet: International money laundering and asset forfeiture. Washington, DC: Office of National Drug Control Policy. Wankel, Harold D. (1996, February 28). DEA congres- sional testimony: Money laundering by drug trafficking organi- zations. Washington, DC: U.S. Department of Justice.
44. Bureau for International Narcotics and Law Enforcement Affairs (2013, March). International Narcotics Control Strategy Report. Vol. II: Money laundering and financial crimes. Wash- ington DC: U.S. Department of State.
19. Caulkins and Kleiman, Drugs and crime. Mumola, Christo- pher; and Karberg, Jennifer C. (2006). Drug use and depen- dence, state and federal prisoners, 2004. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice.
20. Silverman, Lester P.; and Spruill, Nancy L. (1977). Urban crime and the price of heroin. Journal of Urban Economics, 4, 80–103.
21. Rafert, Greg (2007, October 23). Illicit drug policy in the United States: Will increased drug prices reduce use and drug-related crime? Presentation at the Crime and Population Dynamics 2007 Summer Workshop, Berkeley, CA. Rhodes, William; Johnston, Patrick; Han, Song; McMullen, Quentin; and Hozik, Lynne (2002, January). Illicit drugs: Price elastic- ity of demand and supply. Report to the National Institute of Justice, U.S. Department of Justice, Washington, DC.
22. Inciardi, J. A. (1995). Crack, crack house sex, and HIV risk. Archives of Sexual Behavior, 24, 249–269. McCoy, Virginia H.; Inciardi, James A.; Metsch, Lisa R.; Pottieger, Anne.; and Saum, Christine A. (1995). Women, crack and crime: Gender comparisons of criminal activity among crack cocaine users. Contemporary Drug Problems, 22(3), 435–452.
23. Information courtesy of the Drug Enforcement Administration, U.S. Department of Justice, Washington, DC.
24. Caulkins and Kleiman, Drugs and crime. 25. Boyum; Caulkins; and Kleiman, Drugs, crime, and public
policy. 26. Blumstein, Alfred; and Rosenfeld, Richard (1998, October).
Assessing the recent ups and downs in U.S. homicide rates. National Institute of Justice Journal, 237, 9–11. Curtis, Richard (1998, October). The improbable transformation of inner-city neighborhoods: Crime, violence, drugs, and youths in the 1990s. National Institute of Justice Journal, 16–17. Reuter, Peter (2009). Systemic violence in drug markets. Crime, Law, and Social Change, 52, 275–284.
27. Harris, Jonathan (1991). Drugged America. New York: Four Winds Press, p. 117.
28. Ibid., p. 112. 29. Bureau of Justice Statistics (1992). Drugs, crime, and the justice
system: A national report from the Bureau of justice statistics. Washington, DC: U.S. Department of Justice.
30. White, Jason (1991). Drug dependence. Englewood Cliffs, NJ: Prentice Hall, p. 200.
31. Alder, P. (1985). Wheeling and dealing. New York: Colom- bia University Press. Hamid, Ansely. (1990). The political economy of crack-related violence. Contemporary Drug Prob- lems, 17(1), 31–78. Johnson, Bruce D.; Hamid, Ansely; and Sanabria, Harry (1992). Emerging models of crack distribu- tion. In Thomas Mieczkowski (Ed.), Drugs, crime and social policy: Research, issues, and concerns. Boston: Allyn and Bacon. Preble, Edward.; and Casey, J. (1969). Taking care of business: The heroin user’s life on the streets. International Journal of Addictions, 4, 1–24.
32. Johnson, Bruce D.; Golub, Andrew; and Dunlap, Eloise (2006). The rise and decline of hard drugs, drug markets, and violence in inner-city New York. In Alfred Blumstein and Joel Wall- man (Eds.), The crime drop in America. New York: Cambridge University Press, pp. 164–206. Office of National Drug Control Policy (2004, January). Pulse check: Trends in drug abuse, drug markets and chronic users in 25 of America’s largest cities. Wash- ington, DC: Office of National Drug Control Policy.
Drugs and Law Enforcement
7chapter
“I was on the upper level of a municipal garage looking down over a
housing development playground in a less desirable part of the city,”
Sgt. Ramos said to me with a smile as he told me his favorite story.
“Not surprisingly, there weren’t any children in the playground. The
only people there were five or six young males just standing around,
doing a whole lot of nothing. To the experienced eye, it was obvious
that a ‘crew’ had taken over the playground, doing a brisk business
in broad daylight. Evidently, they had no fear of the residents of the
development, and no one knew that police were around.”
“It was easy to get those guys. The ‘buy-walk’ operation was
completed in a matter of minutes (though it had been planned
well in advance). Meanwhile, it was a hot summer day, and many
of the windows in the 15-story building were open. Mothers and
grandmothers sunned themselves by these open windows.”
“As we led those guys off, we all heard a sound usually reserved
for a baseball game. All those mothers and grandmothers were
giving us a loud round of applause, heckling and cat-calling the
men now in cuffs. They were showing their appreciation for us giv-
ing back the playground that had been built for their children and
grandchildren. This gave us more satisfaction and pride in our job
than any grand jury could have.”
After you have completed this chapter, you should have an understanding of the following:
●● Efforts to control the production and/or cultivation of illicit drugs
●● The role of law enforcement in illicit drug interdiction
●● Street-level drug enforcement operations
●● Asset forfeiture and the federal RICO statute
122 ■ Part Two Drugs, Crime, and Criminal Justice
drug-law offenders after they are apprehended and arrested by law enforcement officers.
Domestic and international law enforcement has always been, and remains, the predominant method of waging the “war on drugs” at the federal, state, and local levels in the United States. Of the more than $25.5 billion in the 2015 federal drug-control budget, most of the funding (57%) was allocated to domestic law enforcement, drug interdiction, or international control programs (Figure 7.1). Together, these efforts represent the “supply reduction” side of the drug- control equation, with the remaining “demand reduction” portion (43%) devoted to drug treatment and prevention. In 2015, there was a significantly greater emphasis on demand reduction efforts, judging from 2011 budget allocations where the supply-to-demand reduction ratio was approxi- mately 63-to-37.1
In general, drug-law enforcement programs are divided into three major areas: (1) source control, (2) drug interdic- tion, and (3) street-level enforcement.
Source Control
Source control programs are aimed at limiting the cultivation and production of illicit drugs. There are four approaches in source control: (1) crop eradication, (2) control of refining agents for the processing of plant-based illicit drugs, (3) con- trol of precursor chemicals for the manufacture of illicit
The criminal justice system in the United States is responsible for protecting the public from individuals and groups that are deemed harmful to social order in our communities. In the context of drug-taking behavior, the crimi- nal justice system is designed to respond to the social problems of drug abuse by fulfilling a threefold mission: (1) the enforce- ment of drug-defined and drug-related laws, (2) the adjudica- tion through a court system of individuals who have violated these laws, and (3) the implementation of penalties for those convicted of drug-defined and drug-related offenses through a correctional system.
This chapter will focus on the operations of criminal jus- tice professionals, both domestic and international, who are responsible for the enforcement of drug laws. The specific law enforcement objectives include crop eradication, the control of refining agents and solvents used in the processing of plant-based material into illicit drugs, the control of precur- sor chemicals used in the manufacture of illegal drugs, the interdiction of illicit drugs at our borders, the arrest of crimi- nal offenders in violation of drug laws, and the use of asset forfeiture and other means to reduce the financial gains of those involved in illicit drug trafficking. Chapter 8 will focus on the court systems and correctional systems that deal with
source control: Law enforcement actions that reduce or eliminate the cultivation and production of illicit drugs in foreign countries.
$22.2 billion Value of assets and drugs seized from drug trafficking organizations by the Drug Enforcement Administration between 2005 and 2013
30,688 Number of domestic drug-law violation arrests made by the Drug Enforcement Administration in 2013
Source: Drug Enforcement Administration, U.S. Department of Justice, Washington, DC.
Numbers Talk…
Prevention and Treatment
$10.9 billion
Domestic Law Enforcement $9.2 billion
Interdiction $3.9 billion
International Control $1.5 billion
F igure 7 .1
Allocations of the U.S. federal drug-control budget for fiscal year 2015.
Source: Based on information from the Office of National Drug Control Policy (2014, July). National drug control strategy FY 2015 budget summary. Washington DC: Office of National Drug Control Policy, p. 7.
Chapter 7 Drugs and Law Enforcement ■ 123
On the other hand, opponents have argued that it is highly questionable whether crop eradication can ever be successful in reducing the supply of illicit drugs. The avail- able evidence has shown that, on a global level, there has rarely been more than a 10 percent decrease in the worldwide cultivation of any one type of illicit crop in any given year, despite massive crop eradication efforts. Even when there is a reduction in the cultivation of a particular crop, such as opium poppies or coca, in one part of the world, there is typically an increase in the cultivation in a neighboring coun- try or another part of the world. This phenomenon is often likened to a continuing game of “whack-a-mole.”
In addition, opponents argue that crop eradication is not cost-effective in terms of work-hours that are required to do the job. Manual removal of coca plants, for example, involves more than 20 work-hours of effort in order to get rid of one hectare (about 2.5 acres) of coca. Aerial fumigation is obviously more cost-effective, but it is not permitted in some countries; and where it is permitted, there are adverse environmental effects. Herbicides have produced irreversible contamination of local water supplies, and the relocation of planting fields to previously uncultivated land has resulted in extensive deforestation and a reduction in valuable rain forest resources.3
While the debate continues, there has been no argu- ment that in many impoverished regions of the world, crop eradication programs have had serious economic and politi- cal consequences. For many poor farmers, the cultivation of opium poppies or coca represents their only source of signifi- cant income. Even when governments have promoted alter- native crops such as corn, banana trees, and rubber, as has been done in Peru, Afghanistan, and other nations, farmers have resisted because these alternatives are far less profitable for them and their families.4 It has been acknowledged by some U.S. officials that opium poppy eradication programs in Afghanistan may have encouraged many poor Afghan farm- ers to align themselves with insurgents and other groups in opposition to the central Afghan government.5
Chemical Controls There are two opportunities to exert chemical control over the availability of illicit drugs. The first is the monitoring and con- trol over refining agents and solvents that are required for the processing of plant-based materials such as coca and opium poppies into cocaine and heroin. For example, acetic anhy- dride is an essential chemical for converting opium into her- oin (see Chapter 9), and control over this chemical, which has no legitimate use, has been central to efforts to reduce heroin production in Afghanistan. Similarly, potassium permanga- nate is an essential oxidizing agent for converting coca into
drugs, and (4) the U.S. certification process. In most cases, source control involves operations in foreign countries (such as the eradication of opium poppy fields in Afghanistan), but there are instances in which source control involves domestic locations as well. The dismantling of methamphetamine lab- oratories in a rural county of Missouri would be an example of source control within our own country.2
Crop Eradication Crop eradication is the strategy of reducing the availability of illicit drugs through the destruction of opium poppies, coca plants, and marijuana plants in their countries of origin, or the elimination of the means by which they are cultivated. Crops are eradicated by manual or mechanical removal of the plants themselves or by fumigation with herbicides (chemicals that kill plants) that are either sprayed or dropped from the air as pellets that melt into the soil when it rains. Eradication programs are driven by the premise that decreas- ing marijuana cultivation and opium and coca cultivation for the production of heroin and cocaine, respectively, makes these drugs more expensive and less available to drug users. Chapter 6 dealt with the question of whether a reduced availability of illicit drugs results in a significant decrease in drug use or drug-related crime.
There is a continuing controversy over the benefits of crop eradication as a component of U.S. drug policy. On the one hand, proponents have argued that crop control is cost- effective in reducing the supply of illicit drugs because the drugs (specifically heroin and cocaine) cannot enter the illicit drug market if the plants by which they are derived (opium poppies and coca) have not been cultivated and harvested. Ideally, there would be no further need for drug interdiction or domestic law enforcement. Another argument in favor of crop eradication is that it is easier to locate and destroy opium poppies and coca than it is to confront the supplies of illicit drugs later on, either in transit through drug trafficking routes or at the street level where they are sold.
crop eradication: Programs in which opium poppies, coca plants, and marijuana plants are destroyed in their countries of origin, prior to transport overseas.
Coca plants are destroyed in a crop eradication program in Colombia. These efforts have been financed, in large part, by the U.S. Department of State through the Andean Counterdrug Initiative.
124 ■ Part Two Drugs, Crime, and Criminal Justice
Obviously, decertification can have significant adverse consequences for the economy as well as the political stability of a nation, but it is rare that decertification is fully imple- mented. Under the law, the president has the option of waiv- ing the removal of foreign aid from a decertified nation if it is determined that continued assistance is vital to U.S. national interests. In 2013, 22 nations were identified as “drug majors” and therefore eligible for decertification, but only three received official decertification: Burma (Myanmar), Bolivia, and Venezuela. However, it was determined not to suspend aid to these three nations because such action would jeopar- dize vital U.S. interests.
Opponents of U.S. certification have argued that decer- tification serves merely as an international “score card” with little or no impact on the worldwide illicit drug supply or the global illicit drug trade. Nonetheless, the U.S. certification has been useful to exert pressure on certain nations to be more aggressive in their drug-control policies.8
Drug Interdiction
Denying drug traffickers the use of air, land, and maritime routes into the United States in order to prevent illicit drugs from being smuggled across our borders is a strategy known
cocaine (see Chapter 10). However, in the case of potassium permanganate, there are legitimate environmental benefits in its use, such as in the disinfecting of waste water.
The DEA maintains programs to regularly monitor and track large shipments of acetic anhydride and potassium permanganate entering the United States and provides assis- tance to other countries in their internal monitoring and control. But many nations lack the capacity to determine whether the import or export of chemicals is related to illicit drug production or else they fail to meet goals for reducing the availability of these chemicals because of internal politi- cal pressures. The problem has been complicated by the fact that acetic anhydride and potassium permanganate are often transshipped through third-party countries to disguise their purpose or destination.6
The second opportunity for chemical control is the mon- itoring and control of precursor chemicals and other sub- stances used in the manufacture of illicit drugs. For example, ephedrine and pseudoephedrine (a common ingredient in cough-and-cold remedies) are essential for the manufacture of methamphetamine (see Chapter 10). As a result of the Combat Methamphetamine Epidemic Act of 2005, substan- tial limitations in the availability of pseudoephedrine have been imposed in the United States, but serious problems remain with the continuing export levels of ephedrine and pseudoephedrine elsewhere in the world. Table 7.1 lists the top five exporting countries of ephedrine and pseudoephed- rine, compared to the United States.7
U.S. Certification The United States attempts to control the production of illicit drugs in foreign countries through a diplomatic program, referred to as certification. Enacted by Congress in 1986, certi- fication is a process in which the U.S. government evaluates the cooperation of foreign countries in counterdrug efforts. Each year, the president is required to compile a list of countries that have been determined to be major illicit producing and/or drug transit countries (referred to as “drug majors”). Countries on this list are then divided into two categories: (1) those that are fully compliant with U.S. counterdrug efforts (“certified”) and (2) those not compliant with U.S. efforts (“decertified”). If a country is decertified, U.S. law requires that all foreign aid be withheld until the president determines whether the country should be certified. In addition, U.S. representatives to multi- national banks such as the World Bank and the International Monetary Fund are required to vote against any loans or grants to a decertified country.
TAble 7.1
Top five exporting countries and the United States—ephedrine and pseudoephedrine, 2011
ePHeDriNe
APPrOXiMATeD QuANTiTieS iN KilOgrAMS
India 95,000
Germany 63,000
Singapore 10,000
Poland 8,000
United Kingdom 5,000
Top five total 181,000
United States 163
certification: The process by which the United States has the option of withholding foreign aid to a country if that country is judged to be noncompliant with U.S. counter- drug efforts, by virtue of its participation in major illicit drug production and/or trafficking.
PSeuDOePHeDriNe
APPrOXiMATe QuANTiTieS iN KilOgrAMS
India 1,658,000
Germany 475,000
Taiwan 70,000
China 65,000
Switzerland 49,000
Top five total 2,317,000
United States 13,000
Note: One kilogram equals 2.2 pounds.
Source: Based on data from Bureau for International Narcotics and Law Enforcement Affairs (2013, March). International Narcotics Control Strategy Report, Vol. I: Chemical controls. Washington DC: U.S. Department of State.
precursor chemicals: Substances required for the produc- tion of illicit drugs. Examples are acetic anhydride and pseu- doephedrine for the production of methamphetamine.
Chapter 7 Drugs and Law Enforcement ■ 125
Federal Agencies Involved in Drug Interdiction The primary federal agencies involved in drug interdic- tion include the DEA, the U.S. Immigration and Customs Enforcement (ICE) agency, the U.S. Customs and Border Protection agency, the U.S. Coast Guard, and the U.S. mili- tary. Of these agencies, only the DEA has drug-law enforce- ment as its sole responsibility. Employing more than 4,000 officers with the authority to make arrests and carry firearms, the DEA investigates major drug-law violators, enforces reg- ulations governing the manufacture and dispensing of con- trolled substances, and performs various other functions to prevent and control drug trafficking. DEA agents also work overseas, where they engage in undercover operations in foreign countries, work in cooperation with foreign govern- ments to apprehend major drug traffickers, help to train for- eign law enforcement officials, and collect intelligence about general trends in drug trafficking, drug production (illicit
as drug interdiction. It is a lofty goal, but consider the fol- lowing difficulties: The entirety of our international border with Mexico and Canada extends nearly 7,000 miles. Each year, according to the U.S. Customs and Border Protection agency, 60 million people enter the United States on more than 675,000 commercial and private flights, while another 6 million arrive by sea and 370 million by land. More than 116 million land vehicles cross our borders with Canada and Mexico. More than 90,000 merchant and passenger ships dock at U.S. ports, off-loading in excess of 9 million shipping containers and 400 million tons of cargo. More than 150,000 pleasure boats and other vessels visit U.S. coastal towns on a regular basis. Any one of these planes, land vehicles, or marine vessels could carry contraband cargo.9
An additional challenge comes from drug traffickers, who come up with increasingly bizarre ways to circumvent standard interdiction controls; customs officials must leave no stone unturned. A shipment of boa constrictors from Colombia was once confiscated with their intestines stuffed with condoms full of cocaine.10 In 1994, federal agents at JFK international airport in New York noticed an emaciated and ailing sheepdog on a flight from Bogota, Colombia. X-rays and surgery revealed that five pounds of cocaine in ten rub- ber balloons had been surgically implanted in the dog’s abdo- men. New York Police Department detectives later arrested a 22-year-old man from New Jersey when he came to claim the animal. The dog survived the surgery to remove the condoms and was taken to the Canine Enforcement Training Center in Virginia, where its handlers named it, appropriately enough, “Cokie.”11
With tightened security after September 11, 2001, the use of air cargo as a method of smuggling drugs into the United States led to an extreme alternative. Drug traffickers resorted to using women from Colombia and other Andean nations as well as other regions of the Caribbean as drug “mules.” The women would swallow as many as 50 condoms filled with cocaine or heroin and then board a flight on a commercial airline. They were given a topical anesthetic to deaden the throat before ingesting the condoms and then told to use laxatives to help them “retrieve” the condoms after reaching their destination. Unfortunately, these condoms would sometimes break and leak into the stomach, causing a drug overdose and death. Most of these “mules” were women who were desperate for money and entered the business will- ingly, but there were an increasing number of women who were forced into the drug trade. The traffickers were known to kidnap a woman’s children or other family members and threaten to kill the hostages unless the woman successfully smuggled drugs into the United States.12
In recent years, changes in airport security have caused traffickers to scale back their smuggling of drugs through airports entirely and instead direct their drug shipments over land routes. Most of this smuggling occurs at the U.S.- Mexico border, where drug traffickers use various strategies ranging from concealed compartments in cars, minivans, and commercial trucks to clandestine underground tunnels (see Chapter 2).13
drug interdiction: Efforts to prevent illicit drugs from being transported across the U.S. border.
A police officer collects heroin capsules after displaying them during a news conference in Panama in 2004. A police opera- tion uncovered some 15 kilograms of heroin, one of the largest confiscations in Panama, from a group of five Colombians.
126 ■ Part Two Drugs, Crime, and Criminal Justice
capable of carrying up to 12 metric tons of cargo. As a response to the Coast Guard’s tactic of using snipers in helicopters to shoot out engines on drug traffickers’ speedboats, these new vessels are especially designed with engines beneath water level. In 2008, a major Coast Guard interdiction operation succeeded in the capture of one of these semi-subs off the coast of Guatemala and seized approximately 7 metric tons of Colombian cocaine (see photo on page 34).16
The U.S. military supports the drug interdiction efforts of federal and state drug enforcement agencies by providing air and ground observation and reconnaissance, environmental assessments, intelligence analysts and linguists, and transpor- tation and engineering support. Military training teams also teach civilian law enforcement officers such skills as combat lifesaving, surveillance techniques, and advanced and tactical military operations that can be used in counterdrug opera- tions. Military personnel can support counterdrug efforts, but they cannot search or arrest drug traffickers. Law enforcement agencies and the military both benefit from this relationship. Police are able to use military resources, and service members are able to practice their military skills in real-world situations.
farming operations and laboratories), and criminal organiza- tions operating in the illicit drug trade.
As a result of the creation of the U.S. Department of Homeland Security in 2003, two major federal agencies were formed: U.S. Customs and Border Protection (CBP) and U.S. Immigration and Customs Enforcement (ICE).
CBP agents are responsible for patrolling all land and coastal borders as well as ports of entry into the United States, detecting and arresting immigrants attempting to cross U.S. borders illegally, and controlling any form of contraband (including illicit drugs) from entering the country. More than 17,000 CBP officers screen incoming travelers, conveyances, and cargo at more than 300 ports of entry across the United States, often working with drug detection dogs. Special agents within the CBP are responsible for conducting investigations of drug trafficking and money laundering activities. The Marine Branch of the CBP is responsible for interdicting drugs in near- shore waters by stopping and searching incoming vessels that behave suspiciously, especially small boats with large engines commonly referred to as “go-fast boats.” The Air Branch is responsible for interdicting suspicious aircraft, such as small low-flying aircraft operating at night. Once a suspicious aircraft has been detected, it is normally tracked and forced down by high-speed chase planes and then searched. CBP inspectors are not hampered by constitutional protections that typically limit the power of other law enforcement agencies; they can search a person, vehicle, or container at ports of entry or near to a U.S. shoreline without probable cause.
ICE agents are responsible for enforcing immigration laws not only at U.S. borders but in all 50 U.S. states. ICE has the authority to cooperate with state and local law enforce- ment agencies in the identification, processing, and depor- tation of illegal immigrants and to assist in investigations of human trafficking, drug trafficking, and money laundering. Like CBP agents, ICE agents do not need probable cause or warrants for operations at port of entry, only a degree of suspi- cion that there is an occurrence of wrongdoing. The primary responsibility of ICE is to prevent illegal entry into the United States, but ICE agents often work closely with DEA and CBP agents (see Drugs…in Focus) when cross-border individuals are involved in drug trafficking.14
The U.S. Coast Guard is the lead federal agency for maritime drug interdiction and shares responsibility for air interdiction with the Air Branch of the CBP. The Coast Guard is a key player in combating the flow of illegal drugs to the United States by denying smugglers the use of mari- time routes in the “transit zone,” a 6-million-square-mile area including the Caribbean, the Gulf of Mexico, and the Eastern Pacific. Coast Guard ships can stop and board any maritime vessel operating within a 12-mile radius of U.S. shoreline. Like CBP and ICE inspectors, Coast Guard per- sonnel do not have to establish probable cause before board- ing and searching a vessel at sea.15
In recent years, Coast Guard agents have had to contend with drug traffickers using semi-immersible submarinelike boats as the means for transport. These semi-subs are either self-propelled vessels or towed by other vessels, and they are
Members of the U.S. Coast Guard law enforcement team gather in Miami around more than 5,000 pounds of cocaine seized from a Honduran fishing boat off the coast of Colombia. The drugs were discovered hidden in compartments within the fuel tank, and eight Colombians were arrested. The 110-foot boat was later towed to Miami and confiscated.
Chapter 7 Drugs and Law Enforcement ■ 127
Profiling and Drug-Law Enforcement
Over the years, drug-law enforcement agents have often developed “drug courier profiles” to help in the identifica- tion of potential drug traffickers. In United States v. Sokolow (1989), the U.S. Supreme Court ruled that drug courier pro- files at airports could be used as a legitimate law enforcement tool, the Fourth Amendment to the U.S. Constitution not- withstanding. In this case, Andrew Sokolow, a young African American male dressed in a black jumpsuit with gold jewelry, purchased two airline tickets in Miami with $1,200 in cash. Sokolow flew from Honolulu to Miami, planning to return
The U.S. military is also active in drug interdiction by working with military units in foreign countries and inter- national law enforcement agencies. Intelligence, strategic planning, and training are provided for anti-drug operations in several Latin American countries, such as Colombia, Mexico, Peru, and Bolivia. A key element of the military’s anti-drug program in Latin America is its Tactical Analysis Teams (TATs), made up of a small number of U.S. Special Forces and military intelligence personnel. These teams gather intelligence and plan operations that are carried out by host nations and DEA agents.17
Military Operations and Domestic Law Enforcement
Technically speaking, the Posse Comitatus Act of 1878 for- bids the military to be used as a law enforcement agency within the borders of the United States. The law was designed originally to bar federal troops from policing southern states after the Civil War and to protect Americans against abuses by their own military by dictating that federal troops could not enter private land or dwellings and could not detain or search civilians. In 1988, however, Congress expanded the National Guard’s role in drug interdiction and allowed the guard to be actively involved in drug-law enforcement. In 2010, President Obama ordered up to 1,200 additional National Guard troops to be stationed in the Southwest, join- ing a few hundred Guard members previously assigned to help local law enforcement officials in reducing drug smug- gling along the U.S.-Mexico border.
How did the National Guard operation manage to cir- cumvent the Posse Comitatus Act? The key to National Guard involvement in drug operations is the word “fed- eral” in the language of Posse Comitatus Act. Since 1912, the National Guard has had a two-tier mission to serve both the state and federal governments. Guard units involved in anti-drug operations typically work for the state government under the supervision of a state governor. Therefore, while the soldiers’ salary and other benefits were paid by the fed- eral government, it was argued that they were not bound by the Posse Comitatus Act. Since the U.S. Coast Guard is a military unit within the Department of Homeland Security, it has been authorized to operate outside the restrictions of the Posse Comitatus Act as well.
According to legal experts, the National Defense Authorization Act of 2011 essentially repealed the Posse Comitatus Act, leaving open the opportunity for all branches of the U.S. military to be involved in law enforcement, when authorized by the president. This development greatly con- cerned libertarians who viewed the Posse Comitatus Act as a long-standing protection against the development of a milita- rized police state. Others have argued, however, that the issue had for several years been a moot point, since state and local police forces have gained the weapons and tactical equip- ment that allow them to operate in a militarized fashion.18
Quick Concept Check
Understanding Law Enforcement Agencies in Drug Control Check your understanding of drug-law enforcement agencies involved in domestic and international drug control by match- ing the activity/responsibilities on the left with the agency, organization, or individual on the right. Note: Some of the answers may be used more than once.
7.1
1. Monitoring and tracking large shipments of acetic anhydride and potassium permanganate into the country
2. Drawing up a list of nations that do not comply with U.S. counterdrug efforts
3. Enforcing laws regarding noncitizen individuals at U.S. borders and in all 50 U.S. states
4. Stopping and boarding suspi- cious maritime vessels within a 12-mile radius of U.S. shoreline
5. Possible engagement to supplement security and law enforcement policing along the U.S.-Mexico border
6. Drug-law enforcement as its sole responsibility
7. Operating in anti-drug programs in Latin America through Tactical Analysis Teams (TATs)
8. Patrolling all land and coastal borders as well as ports of entry into the United States
a. The president
b. Drug Enforcement Administration (DEA)
c. U.S. Customs and Border Protection (CBP)
d. U.S. Immigra- tion and Customs Enforcement (ICE)
e. U.S. Coast Guard
f. National Guard
g. U.S. Special Forces
Answers: 1. b 2. a 3. d 4. e 5. f 6. b 7. g 8. c
128 ■ Part Two Drugs, Crime, and Criminal Justice
those searched. Studies in other U.S. states also have found that police regularly engage in racial profiling.21
While there are those who believe that African Americans, Latinos, Asians, and other minorities are more likely to carry drugs than their white counterparts, several studies suggest that this is not the case. One study of motorists on an interstate highway in Maryland found that 28 percent of African American drivers and passengers who were searched were found with contraband compared with 29 percent of white drivers.22 In New York in 1988 and 1989, 13 percent of whites were arrested for possessing illicit drugs compared with 11 percent of African Americans and 11 percent of Latinos.23 A study of drug interdiction at major U.S. airports found that African Americans (6%) and Latinos (3%) were less likely to possess illicit contraband than whites (7%). In 2003, under a Justice Department directive, racial and ethnic profiling was officially banned at all federal agen- cies with law enforcement powers, the only exception being investigations involving terrorism and national security. In 2006, the International Association of Chiefs of Police issued an extensive training guide for state and local authorities to implement a commitment to bias-free policing (Drug Enforcement … in Focus).24
Street-Level Drug-Law Enforcement
As the third area of drug-law enforcement, street-level opera- tions are the responsibility of federal agencies, state agencies, or local sheriffs’ and police departments. Increasingly, these different agencies are joining forces and working together to form multijurisdictional drug task forces. Most of these task forces are coalitions of five or more local and state agencies that work closely with federal law enforcement agencies. Multijurisdictional task forces allow agencies at different lev- els of government to share funds, personnel, and intelligence and allow drug agents to track drug traffickers across many different jurisdictions. At the local level, a majority of local police departments and more than 70 percent of sheriffs’ offices serving 25,000 or more residents have officers assigned to a multiagency drug task force. In recent years, large ship- ments of heroin and other illicit drugs have been seized, prior to their distribution to substance abusers.25
Undercover Operations in Drug Enforcement For street-level enforcement of drug laws, police departments employ a variety of undercover and nonundercover operations. Undercover operations include (1) the reverse sting, (2) the controlled buy, (3) the buy-bust, and (4) the buy-walk.
●■ The reverse sting is a drug-law enforcement opera- tion in which undercover agents pose as drug dealers and sell a controlled substance or imitation version of
to Hawaii 48 hours later. He also was traveling under a false name, did not check any luggage, and appeared very nervous. Drug agents stopped him at the Honolulu airport and used a drug-sniffing dog, which led them to 1,063 grams of cocaine in his carry-on luggage. Chief Justice William H. Rehnquist stated, “While a trip from Honolulu to Miami, standing alone, is not a cause for any sort of suspicion, here there was more: Surely few residents of Honolulu travel from that city for 20 hours to spend 48 hours in Miami during the month of July.” In a seven-to-two decision, the Court ruled that the drug courier profile could provide a “reasonable basis” for officials to suspect that a person is transporting drugs.
The most significant criticism of drug courier profiling is that some law enforcement authorities or individual law enforcement officers have created their own profiles based solely on race, ethnicity, or national origin rather than on the behavior of an individual, a practice that has become known as racial profiling. In the late 1990s, racial profil- ing became a major topic of controversy. National and local media reports often proclaimed that racial profiling was a significant social problem, and national surveys confirmed that most Americans agreed. In a 1999 Gallup Poll, more than half the Americans polled believed that police actively engaged in the practice of racial profiling, and 81 percent said that they disapproved of the practice. When responses to survey questions were broken down by race, 56 percent of whites and 77 percent of African Americans believed that racial profiling was a pervasive problem.19
One of the most common complaints about racial profiling was the claim that police were stopping vehicles simply because the race of the driver did not appear to “match” the type of automobile he or she was driving. In a widely publicized case, Dr. Elmo Randolph, a 42-year-old African American dentist, was stopped more than 50 times over an eight-year span while driving a BMW car to his office near Newark. New Jersey state troopers, believing that Dr. Randolph was “driving the wrong car,” would pull Dr. Randolph over, check his license, and ask him if he had any drugs or weapons in his car. Randolph claims that he did not drive at excessive speeds and that he had never been issued a ticket.20
A study was conducted by the New Jersey State Police in 1999 on the question of race and ethnicity of persons stopped by state troopers. It was found that New Jersey state troopers had indeed engaged in racial profiling along the New Jersey Turnpike. Although individuals of color comprised 13.5 percent of the New Jersey Turnpike population, they represented 41 percent of those stopped on the turnpike and 77 percent of
reverse sting: A law enforcement operation in which an undercover agent posing as a drug dealer sells a controlled substance, or an imitation of it, to a buyer.
racial profiling: A practice of arresting or detaining an indi- vidual for possible drug violations, based on race, ethnicity, or national origin rather than on the individual’s behavior.
Chapter 7 Drugs and Law Enforcement ■ 129
in which the buy is to take place, he or she is usually searched to insure that there are no drugs on his or her person before conducting the buy. After the buy has been made, the informant is again searched and asked to turn over the drugs bought in the transaction. To pro- tect the identity of the informant, arrests are usually not made at the time of the buy. Warrants are obtained and later executed within 10 days.
●■ In a buy-bust operation, an undercover agent makes a buy, and immediately thereafter, the seller is arrested for the drug sale. During a buy-bust, an undercover agent sets up a drug deal for a specified time and location. A cover
a controlled substance to buyers. Community polic- ing programs have made reverse stings popular because such operations can be used as a method of “cleaning up” a neighborhood. The reverse sting operation also makes money for law enforcement because asset for- feiture laws allow agencies to keep at least part of the proceeds made in these operations. The logistical plan- ning of a reverse sting operation is described in Drug Enforcement … in Focus on page 130.
●■ In the controlled buy operation, an undercover infor- mant buys the drug under the supervision of the police. The informant may be a paid informant or a person who has been convinced by agents to “roll over” on other traffickers because they themselves have been charged with the possession or trafficking of an illicit drug. In the latter case, criminal charges against the informant may be either reduced or dropped for their participation in the operation. After agents have gained confidence in the informant, the informant is allowed to set up a con- trolled buy. Before the informant enters the dwelling
updating Police behavior During Traffic and Street Stops In 2011, almost 63 million U.S. residents, aged 16 or older (one-fourth of the population), had one or more contacts with police, either in traffic or on the street, during the past 12 months. One-half of these contacts were involuntary or police initiated. A survey conducted by the Bureau of Justice Statistics in the U.S. Department of Justice came to the following conclusions with regard to racial or ethnic disparities in the conduct of the police or the frequency of an individual being stopped.
Traffic Stops • A greater percentage of African American drivers (7%) and
Latino drivers (6%) were ticketed in a traffic stop than white drivers (5%). A greater percentage of African American drivers (2%) were stopped and allowed to proceed with no enforcement action than white (1%) or Latino drivers (1%).
• There was no statistical difference in the percentage of white drivers (50%) and African American drivers (55%) who were stopped and given a ticket, although Latino drivers (60%) were more likely to be ticketed than white drivers.
• About 84 percent of white drivers believed that there was a legitimate reason for a traffic stop, compared to 67 percent of African American drivers and 74 percent of Latino drivers.
• A greater percentage of white drivers (89%) in a traffic stop believed the police acted properly than did African
American drivers (83%). There was no statistical difference in this regard between white drivers and Latino drivers (87%).
• It was more likely that the police acted properly if the race or ethnicity of the police officer matched that of the driver (83%) than if the race or ethnicity did not match (74%).
Street Stops • About 62 percent of individuals stopped on the street by
police were white, 12 percent were African American, and 15 percent were Latino. The demographic profile of the population in this age range is 69 percent white, 11 percent African American, and 13 percent Latino.
• A greater percentage of those stopped on the street by police and believed the police acted properly were white (77%) than were African American (38%) or Latino (63%).
• Among individuals stopped on the street because the police suspected them of something, 62 percent believed that the reason for the stop was legitimate. No demo- graphic breakdown on this statistic was available on this question.
Source: Bureau of Justice Statistics (2013, September). Special Report: Police behavior during traffic and street stops, 2011. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice.
Drug Enforcement … in Focus
buy-bust: A law enforcement operation in which an under- cover agent makes a buy, and immediately thereafter, the seller is arrested for the drug sale.
controlled buy: A law enforcement operation in which an undercover informant buys an illicit drug under the supervision of the police.
130 ■ Part Two Drugs, Crime, and Criminal Justice
The Anatomy of a reverse Sting Operation A reverse sting is a complex undercover operation, typically requiring 20 or more police officers in order for the operation to be executed safely and efficiently. Typically seven police vehicles are involved. The following diagram shows an example of the overall logistical arrangement: • Vehicle 1 (an inconspicuous panel van without rear or side
windows, for example) accommodates the officers making the arrest. Three officers employ weapons during the arrest; two others search and handcuff the arrestee or arrestees.
• Vehicles 2 and 3 (unmarked cars, for example) accom- modate two officers. Vehicles should park on each side of Vehicle 1 if needed to block the suspect’s vehicle at the time of takedown.
• Vehicle 4 is used for surveillance. • Vehicles 5 and 6 are marked police cars each with two
uniformed police officers inside. These vehicles in the perimeter of the takedown area and are available to provide coverage in case the suspect or suspects flee the area.
• A prisoner transportation van is nearby to make sure the arrestee or arrestees are taken to the police station for booking.
Source: Lyman, Michael D. (2007). Practical drug enforcement (3rd ed.). Boca Raton, FL: CRC Press, pp. 248–253. Drawing on page 250.
Drug Enforcement … in Focus
buy-walk: A law enforcement operation in which an undercover agent buys drugs but does not arrest the dealer at the time of the deal. The drug deal is used to obtain a warrant for the dealer that is served at a later time.
Survelliance Van
Takedown Van Primary undercover officer
4
3
5
1
2 6
Vehicles 2 & 3 = Blockade Vehicles
Vehicles 5 & 6 = Backup Officers
Undercover Officers
ANATOMY OF A STING OPERATION
team monitors the transaction via surveillance equipment, which is either hidden on the agent or in the room. After a “bust signal” is given by the undercover agent, a cover team rapidly moves in to make the arrest. Generally, the undercover agent is also “arrested” to protect his or her identity.
●■ In a buy-walk operation, an undercover agent buys drugs but does not arrest the dealer at the time of the deal. The drug deal is used to obtain a warrant for the dealer that is served at a later time. The advantage of this operation is that it protects the identity of the undercover agent while
Police officers arrest drug offenders in a drug bust in Tampa, Florida.
at the same time ensuring his or her immediate safety during the time of the operation. Buy-walk operations are often used when a drug deal takes place at the residence of a drug dealer and officer safety is a concern.
Chapter 7 Drugs and Law Enforcement ■ 131
were being treated for substance abuse. According to court tes- timony, in the course of their hospital stay when it was appar- ent that they were having a hard time, the informant asked Sherman where he could get some drugs. The informant acted as though he was suffering from withdrawal and continually pressed Sherman to do something about it. Finally, Sherman was persuaded to get drugs from his supplier and gave them to the informant. The prosecution in Sherman’s trial argued that a conviction was justified because Sherman’s past drug use predisposed him to commit the crime. The Court ruled that a prior history of criminality was not sufficient to establish a predisposition, and Sherman was cleared of charges.27
In Jacobson v. United States (1992), the U.S. Supreme Court ruled on a reverse-sting operation specifically related to a pornography investigation but applicable to drug cases as well. In their decision, the government was guilty of repeat- edly inducing Jacobson to order pornographic material. The Court ruled that “…in their zeal to enforce the law…govern- ment agents may not originate a criminal design, implant in an innocent person’s mind the disposition to commit a crimi- nal act so that the government may prosecute.”28
Undercover Operations and the Issue of Entrapment In order for an arrest of an individual for a drug-law violation such as small-scale drug trafficking to lead to a conviction, the case has to be presented that the police agent acting under- cover had not induced the arrestee to commit a crime that was not contemplated beforehand. Otherwise, a defendant can claim that he or she has been a victim of entrapment.
The concept of an entrapment defense was first estab- lished in a Prohibition Era decision of the U.S. Supreme Court, Sorrells v. United States (1932). In this case, a federal agent in North Carolina had been informed that a local fac- tory worker named Sorrells was a “rum-runner” in violation of the Volstead Act prohibiting the sale of liquor (see Chapter 3). According to court testimony, the agent posing as a tour- ist visited Sorrell’s home and began a lengthy conversation, reminiscing about stories of their time in World War I. After being asked three times whether he could get some liquor and claiming that he “did not fool with whiskey,” Sorrells left his home and returned with a half gallon, which he sold the agent for $5. Sorrells was immediately arrested, but later he appealed his case. The court ruled that the investigation was a “gross abuse of authority” and that “the agent had lured the defendant, otherwise innocent, to [committing the crime] by repeated and persistent solicitation.” In an unanimous deci- sion, the Court reversed Sorrells’ conviction.26
In a later case, Sherman v. United States (1958), an infor- mant and a man named Sherman met in a hospital where they
POrTrAiT Commissioner William J. Bratton—New York’s Top Cop Second Time Around
In 2014, William J. Bratton became New York City’s police commissioner for the second time, resuming his leadership in a 35,000-member department, the larg- est in the nation. When he was police commissioner between 1994 and 1996, he was widely credited for reducing crime in the city, instituting a computer- ized crime-tracking system to monitor criminal activity and the police response to it, and cracking down on corruption in local precincts. By emphasizing the policy of “community policing,” Brat- ton put more police officers on patrol in city neighborhoods and held police commanders accountable for crime in their precincts. The focus was on what has been called the “broken window theory” of policing, emphasizing smaller but highly visible crimes of disorder. As a result, the number of police stops increased. Police officers were more
actively searching out and confront- ing individuals who showed some
level of suspicious behavior. The “stop and frisk” strategy would later become a highly controversial issue under Bratton’s predecessor, Raymond Kelly. The racial disparity among individuals stopped by police on a daily basis was widely criticized.
At the news conference announcing his reappointment in December 2013, Bratton made it clear that there was a need to “bring police and community back together.” “What we want to create is an environment where stop-and-frisk as we knew it ends.” The newly elected New York City mayor, Bill de Blasio, who campaigned against the abuses of stop-and-frisk policing, quickly added that Bratton meant “the overuse of stop- and-frisk, the unconstitutional use of stop-and-frisk, the targeting of young men of color regardless of whether
they’d done anything wrong. That’s going to end.”
The return to community policing with the support of the community behind those who are responsible for protecting them was Bratton’s goal at the second term of being commissioner. As he put it, “In this city, I want every New Yorker to talk about ‘their police. . . ,’ ‘my police.’”
Sources: DeStefano, Anthony M. (2013, December 15). Kelly on his NYPD years: We protected the city. Newsday, pp. A30–A31. Goodman, David J. (2013, December 6). Bratton to lead New York police for second time. New York Times, pp. A1, A30. Rashbaum, William K.; and Goldstein, Joseph (2013, December 6). Bratton is expected to alter policy to rebuild connec- tions with public. New York Times, p. A30. Quotations of William J. Bratton and Bill de Blasio from the appointment news confer- ence, New York City, December 5, 2013.
entrapment: Actions by undercover police agents that are intended to induce an individual to commit a crime that was not contemplated beforehand. In order to argue against the charge of entrapment, it must be demonstrated that the idea of committing the crime came from the defendant rather than the police agent.
132 ■ Part Two Drugs, Crime, and Criminal Justice
Under present-day guidelines, police agents engaging in a form of undercover operation must show clearly that coer- cive or persuasive tactics were not used. It must also be dem- onstrated that the idea of committing the crime came from the defendant rather than the police agent (Portrait).29
A Nonundercover Operation: Knock and Talk The knock and talk is an operation that is used when officials receive information that an individual is dealing drugs but do not have probable cause to seek a search warrant. In this case, agents arrive at a suspect’s residence, knock on the door, iden- tify themselves as police officers, and ask permission to enter the residence. Once inside, agents ask the suspect if anyone in the residence is producing or dealing drugs. After the sus- pect responds to the allegations, agents ask for permission to search the residence for illicit drugs.
The element of surprise obviously is an important factor in the success of the knock and talk. If there has been no prior warning, suspects do not expect law enforcement officers to knock on their door and confront them with an allegation. To “confuse” suspects, agents often make misleading allegations. To find evidence against a marijuana dealer, agents may state that they believe the suspect is producing methamphetamine at his residence. Knowing that such charges are ridiculous, even though they are dealing in marijuana, suspects usu- ally allow a consent search. Agents state that approximately 75–85 percent of drug dealers waive their constitutional right to privacy and consent to a search. When later asked why they consent to such a search, dealers often state, “I thought I would have been in worse trouble if I didn’t let you search” or “I didn’t know I had the right to refuse.” Once evidence of illicit drug trafficking is found, agents typically make an arrest or return with a search warrant.30
Quick Concept Check
Understanding Drug-Law Enforcement Operations Check your understanding of drug-law enforcement operations by matching the descriptions on the left with the types of operations on the right.
Note: Some of the answers may be used more than once or not at all.
7.2
relation-back doctrine: The principle behind the authority for asset forfeiture, in which the government asserts that it has the right to illicit proceeds relating back to the time they were generated.
1. An undercover informant makes a drug buy under the supervision of the police.
2. Undercover agents pose as drug dealers and sell a controlled substance or imitation controlled substance to buyers.
3. A police officer, posing as a drug abuser, buys illicit drugs from a suspected drug dealer. The dealer is later arrested for drug trafficking.
4. Agents use “drug courier profiles” and identify at an airport an indi- vidual bringing cocaine into the United States.
5. Colombian drug-control officials spray herbicides on fields of coca.
6. Drug traffickers are apprehended outside Miami, and their “go-fast” boat is confiscated by authorities.
a. the knock and talk
b. the undercover buy
c. the controlled buy
d. the reverse sting
e. interdiction
f. crop eradication
Answers: 1. c 2. d 3. b 4. e 5. f 6. e
Asset Forfeiture and the RICO Statute
Asset forfeiture refers to the seizure by the government of cash, cars, homes, and other property that the government claims are the result of criminal activity. Authorization for this strategy in law enforcement was created as part of the Organized Crime Control Act of 1970. A section of this leg- islation, known as the Racketeer Influenced and Corrupt Organization (RICO) statute (or simply, RICO), pertained to the prevention of criminal infiltration of legitimate businesses. It was a response to the practice of funneling profits from crim- inal activity, whether drug related or not, into financial deal- ings of an unrelated commercial enterprise. This had been for many years a popular strategy of criminal organizations to circumvent detection by law enforcement (Chapter 6).
The principle of asset forfeiture, known as the relation- back doctrine, is that “because the government’s right to
riCO statute: The Racketeer Influenced and Corrupt Orga- nization (RICO) statute, pertaining to the prevention of crimi- nal infiltration of legitimate businesses. It was enacted as a section of the Organized Crime Control Act of 1970.
asset forfeiture: A process used in drug-law enforcement in which cash, automobiles, homes, and other property are seized if these items have been acquired or used as a result of criminal activity.
search warrant: A court-ordered document providing law enforcement agents the right to search a residence or vehicle for illicit drugs.
consent search: A procedure in which law enforcement agents ask and receive permission from a suspect to inspect a residence or vehicle for illicit drugs.
knock and talk: A law enforcement operation in which agents ask for permission to search a residence for illicit drugs after asking the suspect whether anyone in the resi- dence has been engaged in drug production or dealing.
Chapter 7 Drugs and Law Enforcement ■ 133
Civil forfeitures, on the other hand, are in rem actions based upon the unlawful use of property, irrespective of its owner’s culpability. Traditionally, civil forfeiture has oper- ated on the premise that the property itself is the guilty party, and the fact that the forfeiture of the property affects an indi- vidual’s property rights is not considered. With civil forfeiture, the offender does not need to be convicted or even charged with a crime because it is contended that the property “itself” is guilty. The property owner’s guilt or innocence is therefore irrelevant, and civil forfeiture proceedings can be pursued independently or in lieu of a criminal trial.
Forfeitures have existed for thousands of years and are traceable to biblical and pre-Judeo-Christian times. Early English law recognized a kind of forfeiture known as “deodand,” which required forfeiture of the instrument of a person’s death. The principle was based on the legal fic- tion that the instrument causing death was deemed “guilty property” capable of doing further harm. For example, if a domesticated animal killed a person, it would be forfeited, usually to the king, whether or not its owner was responsible. The original purpose for creating this legal fiction was to sat- isfy the superstition that a dead person would not lie in tran- quility unless the “evil property” was confiscated and viewed by the deceased’s family as the object of their retribution. The king often used forfeiture to enhance royal revenues, and this corrupt practice led to the statutory abolishment of deodand in England in 1846.33
The Confiscation Act of 1862, passed during the Civil War, authorized the use of in rem civil procedures against southern rebels and their sympathizers who possessed prop- erty in the North. The law stated that the properties seized were to be used for supporting the Union cause in waging its war. The federal government at the time was responding to a Confederate law that confiscated the southern properties belonging to supporters of the Union. It was not until the late twentieth century, however, that civil forfeiture was “rediscov- ered” to address a pressing social concern: the war on drugs. The justification for extending forfeiture into the realm of illicit drug control was one of deterrence. Legislators believed that imprisonment of drug traffickers often was treated by criminal organizations as a mere cost of business, and therefore, forfeiture could be used to attempt to reduce their profits, in effect striking where it would really hurt.
The 1970 Controlled Substances Act provided, in part, for the forfeiture of property used in connection with con- trolled substances. In 1978, the law was expanded to include all profits from drug trafficking and all assets purchased with drug profits as items subject to forfeiture. The scope of the statute was further amended in 1984 to include all property that was used, or intended to be used, in a drug offense, and every drug offense, from simple possession to mass distri- bution, could trigger forfeiture. In recent years, civil asset forfeiture has become the weapon of choice in combating illicit drug trafficking and distribution in America. Law enforcement officials argue that civil forfeiture allows them to combat drug crime by attacking the economic viability of drug trafficking organizations while at the same time raising
illicit proceeds relates back to the time they are generated, anything acquired through the expenditure of those proceeds also belongs to the government.”31 In 1978, asset forfeiture was authorized to be used in the federal prosecution of con- trolled substance trafficking cases. Since then, many states have passed legislation authorizing their own asset forfeiture procedures when dealing with the violation of state drug laws. Forfeiture is particularly useful in drug-law enforcement because it reduces the financial incentive to reap the often enormous profits that are involved in drug trafficking and dis- rupts a drug-trafficking organization by seizing any vehicles, boats, planes, or property used to transport or produce illicit drugs. As shown in Table 7.2, the DEA made 15,613 domes- tic seizures of nondrug property and cash, valued at approxi- mately $722 million in 2013 as a result of drug investigations. Currently, the U.S. Marshals Service is assigned to the man- agement and care of more than $1.7 billion worth of property seized through the federal asset forfeiture program.32
There are two types of forfeitures: criminal (in personam) forfeitures and civil (in rem) forfeitures. The distinction between criminal and civil forfeitures is based upon whether the penalty pertains to a person or a thing. Criminal forfei- tures are primarily against a specific person and result after a conviction for a crime to which the forfeited property is related. This can occur upon showing during the course of sentencing or plea bargaining that the property is contra- band (illegally obtained through the profit of a crime). Such criminal forfeitures are subject to all the constitutional and statutory procedural safeguards available under criminal law, and both the forfeiture case and the criminal case are tried together. Forfeiture must be included in the indictment of the defendant, which means that the grand jury must find a basis for the forfeiture as well as punishment for the criminal offense itself.
TAble 7.2
Major DEA asset seizures in 2013
TyPe OF SeizeD ASSeT
NuMber OF SeizureS
APPrOXiMATe SeizeD ASSeT VAlue
Cash 9,133 $410,970,000
Firearms 605 $19,000
Real property 291 $33,853,000
Vehicles 3,813 $52,192,000
Vessels 45 $1,794,000
Aircraft 26 $2.525,000
Financial accounts 978 $213,853,000
Jewelry/precious items
256 $4,065,000
Total 15,613 $722,126,000
Note: Total assets seized in 2011 and 2012 were valued at $770,786,000 and $833,737,000, respectively.
Source: Information courtesy of the Drug Enforcement Administration, U.S. Department of Justice, 2014.
134 ■ Part Two Drugs, Crime, and Criminal Justice
A series of U.S. Supreme Court decisions in the 1990s have established the constitutionality of asset forfeiture actions, while setting certain limits on its use. In United States v. 92 Buena Vista Avenue (1993), the Court ruled that the government was prohibited from seizing assets that were gained through a drug transaction if those assets were later obtained by a new and innocent owner. On the other hand, in Bennis v. Michigan (1996), it was decided that property (in this case, a car) could be seized if it was used in the com- mission of a crime, even though it might have been owned by an individual not involved in the crime. The Court also ruled in United States v. Ursery (1996) that forfeiture stat- utes did not violate the double jeopardy clause of the U.S. Constitution.36
In 2000, the Civil Asset Forfeiture Reform Act was enacted to meet objections that in some cases asset forfeiture proceedings placed too great a burden on individuals who eventually were found innocent. At the time, it was reported that 80 percent of individuals who had their property seized by federal authorities as a result of a drug-law violation arrest were never formally charged with a crime. Yet, in some cases, the seized property had been destroyed so it could not be recovered. The law now requires a stricter burden-of-proof standard with regard to the involvement of the property in the crime before it is seized. If found innocent, defendants have five years to make a claim on the seized property after it has been confiscated by the government.37
money for future law enforcement operations. Critics argue that forfeiture laws distort law enforcement priorities. In many states, local, state, and federal agencies have pooled personnel and resources to form multiagency drug task forces. Many of these task forces finance themselves, at least in part, through asset forfeiture. By allowing such agencies to rely on asset forfeiture as a source of revenue, critics claim, the law enforcement priorities are shifted from efforts toward crime control to “funding raids.”
While it is claimed that forfeiture promotes the accomplishment of law enforcement goals, it turns out that 80 percent of seizures are unaccompanied by any criminal prosecution.34 This may stem from the fact that, for many law enforcement agencies, civil forfeiture creates a temptation to depart from legitimate law enforcement goals in order to max- imize funding. Some police departments now prefer to arrest drug buyers rather than drug sellers by employing a “reverse sting,” the chief attraction being the confiscation of a buyer’s cash rather than a seller’s drugs.
Supporters of asset forfeiture claim that the lack of crimi- nal prosecutions in such a large number of forfeiture cases is attributed to the need for police and prosecuting attorneys to offer a substantial bargaining chip in plea-bargaining negotia- tions. Defendants may be given the choice of not fighting the civil forfeiture procedure in exchange for avoiding criminal prosecution. This type of arrangement would benefit both the prosecutor and the prosecuted. The government would be able to “punish” defendants in legally weak cases that involve inadmissible or insufficient evidence, and the defendant would escape the monetary and social costs of a criminal con- viction. Advocates of forfeiture also argue that forfeiture is an effective tool because it deters criminal activity, saves taxpay- ers’ money by allowing law enforcement to self-fund many of their operations, and increases police officer morale.35
Civil Asset Forfeiture reform Act: A law enacted in 2000 to insure that individuals involved in asset forfeiture proceedings were not jeopardized if they were eventually found innocent.
●● More than $25 billion is spent annually on the federal drug-control budget. The greatest proportion of the money (approximately 57%) is spent on drug-law enforcement.
●● There are four general areas of present-day drug-law enforcement: (1) source control, (2) interdiction, (3) street- level enforcement, and (4) the correctional system.
Source Control ●● Source control involves actions focusing on reducing
the cultivation and production of illicit drugs. The four approaches to source control are crop eradication, control of agents used in the processing of illicit drugs, control of precursor chemicals for illicit drug manufacture, and the U.S. certification program.
●● Crop eradication programs involve the destruction of opium poppies, coca plants, and marijuana plants in their countries of origin. Crops are eradicated both manually
and with herbicides. Critics point out that these programs have been responsible for causing environmental damage and disrupting the local economy of many rural regions of the world.
●● Agents of the U.S. Drug Enforcement Administration (DEA) regularly monitor and track large shipments of pre- cursor chemicals to prevent them from reaching the pro- ducers of illicit drugs, as well as specific refining agents used to convert coca to cocaine and opium to heroin.
●● “Certification” is a procedure by which the U.S. govern- ment evaluates the cooperation of foreign countries in counterdrug efforts.
interdiction ●● Interdiction programs are designed to prevent illicit drugs
from being smuggled across the U.S. border by denying drug traffickers the use of air, land, and maritime routes.
Summary
Chapter 7 Drugs and Law Enforcement ■ 135
●● Asset forfeiture is the process by which the government seizes cash, cars, homes, and other property that it claims has been involved in or associated with criminal activity.
Asset Forfeiture and the riCO Statute ●● Criminal forfeitures result after a conviction for a crime to
which the forfeited property is related. Civil forfeitures are based upon the unlawful use of property, irrespective of its owner’s culpability. With civil forfeiture, the offender does not need to be convicted or even charged with a crime, since the contention is that the property “itself” is guilty.
●● Authority for asset forfeiture in law enforcement was cre- ated as part of the Organized Crime Control Act of 1970. A section of this legislation, known as the Racketeer Influenced and Corrupt Organization (RICO) statute, pertained to the prevention of criminal infiltration of legitimate businesses.
●● A number of U.S. Supreme Court decisions in the 1990s confirmed the legitimacy of asset forfeiture as a tool in drug-law enforcement and established guidelines to avoid abuses of the practice.
In recent years, a prime avenue for drug trafficking has occurred in the Southwest United States, along the border with Mexico. The primary agencies involved in drug inter- diction include the DEA, U.S. Immigration and Customs Enforcement (ICE), U.S. Customs and Border Protection (CBP), the U.S. Coast Guard, and the U.S. military. The DEA is the only federal agency that has drug-law enforce- ment as its only responsibility.
●● Over the years, drug-law enforcement agents have devel- oped “drug-courier profiles” to help in the identification of potential drug smugglers. Law enforcement authorizes have been criticized for developing profiles based solely on race, a practice known as racial profiling.
Street-level Drug-law enforcement ●● There are four basic types of undercover drug-law enforce-
ment operations: (1) the reverse sting, (2) the controlled buy, (3) the buy-bust, and (4) the buy-walk. An important legal issue with respect to undercover operations is the pos- sibility of entrapment. Law enforcement officers design their undercover operations in order to avoid this possibility.
1. Describe the four programs in drug-law enforcement that relate to source control. For each of these programs, discuss a specific difficulty that limits their effectiveness as a means for illicit drug control.
2. Discuss the recent trend toward overland drug trafficking routes along the border of the United States and Mexico. What are the challenges in securing borders from drug trafficking operations?
3. Discuss the need for drug trafficking profiles in effective drug- law enforcement. In what ways can racial profiling be avoided?
4. Compare and contrast the four undercover operations in the street-level drug-law enforcement. What would be the common procedures to avoid accusations of entrapment?
5. Contrast criminal forfeitures and civil forfeitures under the RICO statute. What are the general powers that law enforcement authorities have with respect to asset forfeiture? What protections have been put in place to limit the asset forfeiture approach in drug-law enforcement?
Review Questions
Suppose you were in charge of undercover drug-law enforcement operations at the street level in a major metropolitan police depart- ment. What undercover procedures would put you and your police
officers in jeopardy with respect to accusations of entrapment? What specific procedures would you put into place that would effectively avoid such accusations?
Critical Thinking: What Would You Do?
Key Terms
asset forfeiture, p. 132 buy-bust, p. 129 buy-walk, p. 130 certification, p. 124 Civil Asset Forfeiture Reform
Act, p. 134
consent search, p. 132 controlled buy, p. 129 crop eradication, p. 123 entrapment, p. 131 drug interdiction, p. 125
knock and talk, p. 132 precursor chemicals, p. 124 racial profiling, p. 128 relation-back doctrine, p. 132
reverse sting, p. 128 RICO statute, p. 132 search warrant, p. 132 source control, p. 122
136 ■ Part Two Drugs, Crime, and Criminal Justice
1. Office of National Drug Control Policy (2014, July). National drug control budget: FY2015 funding highlights. Washington, DC: Office of National Drug Control Policy.
2. Lyman, Michael D. (2007). Practical drug enforcement. Boca Raton, FL: CRC Press, pp. 193–209. Marshall, Elliot (1971, July 27). Cold turkey: Heroin: The source supply. New Republic, 165(4), 23–25. Office of National Drug Control Policy (2011, August). National drug threat assessment 2011. Washington DC: U.S. Department of Justice.
3. Vargas, Ricardo (2002). The anti-drug policy, aerial spraying of illicit crops and their social, environmental and political impacts on Colombia. Journal of Drug Issues, 32, 11–61. Wyler, Liana S. (2013, August 13). International drug control policy: Background and U.S. responses. Washington, DC: Report for Congress, Congressional Research Service, pp. 26–28.
4. Editorial: Afghanistan’s unending addiction (2014, October 27). New York Times, p. A26. Farrell, Graham (1998). A global empirical review of drug crop eradication and United Nations crop substitution and alternative development strategies. Journal of Drug Issues, 28, 395–437. Lama-Tierramrica, Abraham (2002, November 18). Peru: Cash for farmers who destroy their coca crops. Global Information Network, p. 1. Matheson, Mary (1996, August 12). Colombian leader tries to please U.S. on drugs, but ignites peasant revolt. Christian Science Monitor, 88, 7–8.
5. Wyler, International drug control policy, p. 27. 6. Bureau for International Narcotics and Law Enforcement
Affairs (2012, March). 2013 International narcotics control strategy report, Vol. 1: Drug and chemical control. Washington DC: U.S. Department of State.
7. Ibid. Lyman, Practical drug enforcement, pp. 206–209. 8. Presidential Memorandum—Presidential determination on the
annual Presidential determination on major illicit drug transit and drug producing countries. The White House, Washington, DC, September 14, 2012. U.S. Department of State (2003, January 31). The certification process: Fact sheet released by the Bureau of International Narcotics and Law Enforcement Affaires. Washington DC: U.S. Department of State. Wyler, International drug control policy, pp. 36–40.
9. U.S. Customs and Border Protection, U.S. Department of Homeland Security, Washington, DC.
10. Miller, D. W. (1994, December 19). Canine carrier. U.S. News and World Report, 117, 14.
11. Ibid. 12. McCleland, Susan (2003, July 28). Drug mules. Maclean’s,
116, 25–31. Philbert, James (2009, November 9). Don’t be drug mules…Top cop advises women. The Trinidad Guardian. http://guardian.co.tt.
13. Drug Enforcement Administration (2003). Drug intelligence brief: Common vehicle concealment methods. Washington DC: Drug Enforcement Administration.
14. U.S. Customs and Border Protection, Department of Homeland Security. U.S. Immigration and Customs Enforcement, Department of Homeland Security, Washington, DC.
15. Office of National Drug Control Policy (2003, March). Drug data summary fact sheet. Washington DC: Office of National Drug Control Policy. Office of National Drug Control Policy (2002, September 5). ONDCP fact sheet: Interdiction
operations. Washington DC: Office of National Drug Control Policy. Information Courtesy of U.S. Coast Guard.
16. http://www.news.navy.mil, The official web site for the U.S. Navy.
17. Peters, Katherine M. (2003, April). Troops on the beat. Government Executive, 35, 56. Shanker, Thom (2008, December 23). Obstacle seen in bid to curb Afghan trade in narcotics. New York Times, p. A6. Zirnite, Peter (1998, April). The militarization of the drug war. Current History, 97, 166–186.
18. Archibold, Randal C. (2010, May 26). National Guard will be deployed to aid at border. New York Times, pp. A1, A3. Baker, Al. (2011, December 4). When the police go military. New York Times, Sunday Review, p. 6. Sen. Rand Paul fights against martial law legislation. http://www.louisville.com. November 30, 2011. Vaughn, Ed (1992, December). National Guard involvement in the drug war. Justicia, the Newsletter of the Judicial Process Commission, p. 1.
19. Gallup Poll Organization (1999, December 9). Racial profiling is seen as widespread, particularly among young black men. Princeton, NJ: Gallup Poll Organization. Lyman, Practical drug enforcement, pp. 182–185. United States v. Sokolow, 490 U.S. 1 (1989).
20. Hosenball, Mark (1999, May 17). It is not the act of a few bad apples: Lawsuit shines the spotlight on allegations of racial profiling by New Jersey state troopers. Newsweek, pp. 34–35.
21. Verniero, Peter; and Zoubek, Paul (1999, April 20). New Jersey Attorney General’s interim report of the state police review team regarding allegations of racial profiling. Trenton, NJ: Office of the New Jersey Attorney General.
22. Lamberth, John (1999, April 16). Driving while black: A stat- istician proves that prejudice still rules the road. Washington Post, p. C1.
23. New York Attorney General (1999, December 1). New York City Police, “stop and frisk” practices: A report to the people of New York from the Office of the Attorney General. New York: New York Office of the Attorney General.
24. Bureau of Justice Statistics (2013, September). Special Report: Police behavior during traffic and street stops, 2011. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice. International Association of Chiefs of Police (2006, September). Addressing racial profiling: Creating a comprehensive commit- ment to bias-free policing. Protecting civil rights: A leadership guide for state, local, and tribal law enforcement. Washington, DC: International Association of Chiefs of Police, pp. 153–191. U.S. Customs Service (1998). Personal searches of air passengers results: Positive and negative. Washington DC: U.S. Customs Service.
25. Bureau of Justice Statistics (2008). Local police. Census of state and local law enforcement agency. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice. Bureau of Justice Statistics (2012, December). Sheriffs’ offices 2007—Statisti- cal Tables. Washington DC: Bureau of Justice Statistics, U.S. Department of Justice. Deutsch, Kevin (2014, April 17). Feds seize hidden heroin. Newsday, p. A3. Lyman, Practical drug enforcement, pp. 1–12.
26. Sorrells v. United States, 287, U.S 435 (1932). 27. Sherman v. United States, 356, U.S. 369 (1958).
Endnotes
Chapter 7 Drugs and Law Enforcement ■ 137
28. Jacobson v. United States, 503, U.S.540 (1992). 29. Lyman, Practical Drug Enforcement, pp. 12–46, 255–278.
Council of the Inspectors General on Integrity and Efficiency (2010, June). Guidelines on undercover operations. Washington, DC: Council of the Inspectors General on Integrity and Efficiency (CIGIE).
30. Paterline, Brent (2003). Drug identification and investigation for law enforcement. Temecula, CA: Staggs Publishing.
31. Schmalleger, Frank (2009). Criminal justice today: An introductory text for the 21st century. Upper Saddle River, NJ: Pearson Prentice Hall, p. 604.
32. Drug Enforcement Administration (2013). DOJ computerized asset program. Washington DC: Drug Enforcement Adminis- tration, U.S. Department of Justice. Information courtesy of the United States Marshals Service, U.S Department of Justice.
33. Finkelstein Jacob J. (1973). The goring ox: Some historical perspectives on deodands, forfeitures, wrongful death and the Western notion of sovereignty. Temple Law Quarterly, 46, 169–290.
34. Maguire, Kathleen; and Pastore, Anne L. (Eds.) (1995). Sourcebook of criminal justice statistics 1994. Washington DC: Bureau of Justice Statistics, U.S. Department of Justice.
35. Hawkins, C. W., Jr.; and Payne, T. E. (1999). Civil forfeiture in law enforcement: An effective tool or cash register justice? In J. D. Sewall (Ed.), Controversial issues in policing. Boston: Allyn and Bacon, pp. 23–34.
36. Bennis v. Michigan, 417, U.S. 1163 (1996). United States v. Ursery, 518, U.S. 267 (1996). United States v. 92 Buena Vista Avenue, 507, U.S. 111 (1993).
37. Schmalleger, Criminal justice today, pp. 604–605.
8 Drugs, Courts, and
Correctional Systems
chapter
“Hell, I saw it a whole lot different a year ago,” Charlie told me.
“First off, I couldn’t believe the D.A. when she told me that I
had a chance not to go to jail. But then, I thought, maybe this
drug court thing was just going to get in the way of getting back to
using. I really felt that it wasn’t a good idea.”
“Yeah, I was pretty stupid then. Now, I know that if drug court
didn’t happened, I would never have went to Stevan House, never
got me a program, never got me in line for getting sober. ’Course,
like all the other guys and gals going through it like me, I didn’t
want to be here. For weeks, I couldn’t help thinking about getting
back on the street and doin’ my thing. But at the same time now
that it’s almost over, I’m kind of thankful for it, ’cause I probably
wouldn’t have no way stopped or even wanted to. You know?”
“So I’m grateful for drug court. I wish some of my buddies had
the chance I had. ’Course most of them are in jail now. A couple
of them are dead.”
As he turned to leave the room, Charlie started to smile. “Look
at me, I’m smiling. I haven’t smiled in years.”
After you have completed this chapter, you should have an understanding of the following:
●● The principal phases of judicial events in the criminal justice system
●● Federal and state penalties for drug trafficking and simple possession
●● Present-day sentencing guidelines
●● The role of drug courts in the criminal justice system
●● Correctional systems for drug-law offenders
●● Drug-abuse treatment programs in correctional facilities
Chapter 8 Drugs, Courts, and Correctional Systems ■ 139
requirement that the offender pay compensation (referred to as restitution) to the victim or victims.
●■ In cases in which a fine is imposed, arrangement must be made for the fine to be paid. In cases in which a sentence involves incarceration, the offender “serves time” gener- ally in a local jail (if the sentence is less than one year) or a state prison (if the sentence is more than a year). If sentenced under federal charges, incarceration is carried out in a federal correctional facility. At a later time, if eli- gible for parole, a prisoner receives a conditional release prior to serving the full term. In that case, the individual is required to be supervised on a regular basis by a parole officer in the community for the balance of the unexpired sentence. Violation of parole can be the basis for returning to prison.2
It should be noted that juvenile offenders (defined as individuals either 16, 17, or 18 years old or younger, de- pending on the U.S. state having jurisdiction) can be pros- ecuted and tried as adults under certain circumstances, but in the vast majority of cases juvenile offenders enter into an alternative juvenile justice system (see Figure 8.1) that has distinct differences from adult criminal proceedings. First of all, referrals can be made not only by law enforcement
Each year, more than 11 million individuals in the United States are arrested on criminal charges by state or local law enforcement agencies. In doing so, they enter into the criminal justice system.1 For adult offenders following their arrest, an extended sequence of judicial events begins (Figure 8.1). These events are comprised of four phases: (1) prosecution and pretrial services, (2) adjudication in an arraignment and trial, and pending conviction of the criminal charges, (3) sentencing and sanctions, and (4) imposition of a fine and/or incarceration in a correctional facility. At multi- ple points in each phase, judicial mechanisms are in place to protect innocent individuals from being unjustly prosecuted. In such circumstances, individuals who have been accused of a crime will exit the system entirely (that is, they will be set free). The basic features of each phase are as follows:
●■ During the prosecution and pretrial services phase, law enforcement officers involved in the arrest present infor- mation about the case to the prosecutor, who decides if formal charges are to be filed. If charged with a crime, the suspect must appear before a judge without unneces- sary delay, and if he or she has not yet been represented by counsel, a state-appointed defense attorney is provided. The judge sets the conditions of pretrial release and bail if circumstances warrant them, and determines in a pretrial hearing whether there is probable cause to believe that the accused has committed a specific crime within the jurisdiction of the court. If the judge so rules, the case proceeds to trial.
●■ During the adjudication phase, a formal indictment is filed in the trial court, leading to arraignment. At arraign- ment, the accused is informed of the charge or charges, advised as to the rights of a criminal defendant, and required to enter a plea of guilty or not guilty. A trial pro- ceeding takes places, leading to acquittal or conviction by a judge or jury.
●■ During the sentencing and sanctions phase, assuming a conviction judgment has been reached, a sentence is im- posed by the judge or (in capital cases) the jury. Possible sentences include one or more of the following: death penalty, a specific term to be spent confined in a prison, jail or other correctional facility, probation, fines, or a
5 The percentage of the population of the United States, relative to the total population of the world. 67 The percentage of illicit drug consumption in the United States relative to the total world consumption of illicit drugs. 25 The percentage of prisoners in the United States, relative to the total prison population in the world.
Source: The National Center on Addiction and Substance Abuse at Columbia University (2010, February). Behind bars II: Substance abuse and America’s prison population. New York: The National Center on Addiction and Substance Abuse, p. i.
Numbers Talk…
parole: A conditional release from prison prior to serving the full term of one’s sentence.
incarceration: The fourth phase of the criminal justice sys- tem in which a convicted defendant, if sentenced to impris- onment, enters a correctional facility.
sentencing and sanctions: The third phase of the criminal justice system in which a defendant, if convicted, receives a sentence and/or sanctions judgment by a judge or jury.
adjudication: The second phase of the criminal justice system in which an individual is formally indicted and ar- raigned. A plea of guilty or not guilty is entered, and a trial proceeding takes place.
prosecution and pretrial services: The first phase of the criminal justice system in which an individual is formally charged of a crime, receives defense counsel, and (after a ruling by a judge) proceeds to trial.
140 ■ Part Two Drugs, Crime, and Criminal Justice
Entry into the system
Reported and observed crime
Unsolved or not arrested
Released without prosecution
Released without prosecution
Charges dropped or dismissed
Charges dropped or dismissed
Refusal to indict
Grand jury
Information
Information
Arrest Charges filed
Initial appearance
Preliminary hearing
Prosecution as a
juvenile
Police juvenile unit
Intake hearing
Waived to criminal court
Unsuccessful diversion
Diversion by law enforcement, prosecutor, or court
Formal juvenile or youthful offender court processing
Informal processing diversionNonpolice referrals
Released or diverted
Released or diverted
Bail or detention hearing
Investi- gation
Prosecution and pretrial services
Juvenile offenders
Crime
Felonies
Misdemeanors
F igure 8 .1
A flowchart of the phases of judicial events in the criminal justice system, as depicted on pages 140 and 141.
Note: Procedures vary among jurisdictions. The weights of the lines are not intended to reflect the relative size of caseloads in each phase.
Source: Bureau of Justice Statistics (2013, November). Criminal justice system flowchart. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice.
officers, but also by school officials, social service agencies, neighbors, or parents who have determined that specific behaviors of the juvenile require intervention by a formal judicial process. Second, juvenile justice decisions often divert the case out of a judicial system to alternatives such as counseling, educational, or recreational programs. In some cases, however, courts may order juveniles removed from their homes to foster homes or treatment facilities. Following release from a treatment facility, there is typi- cally a period of aftercare, similar to parole supervision for adult offenders.
Drug-Law Violators in the Criminal Justice System
In the United States, about 1.5 million arrests were made in 2013 for a drug-law violation of some kind. To put it in per- spective, compare this statistic to the number of arrests made for other categories of crime:
●■ 480,000—Major violent crime (murder, manslaughter, forc- ible rape, robbery, or aggravated assault)
Chapter 8 Drugs, Courts, and Correctional Systems ■ 141
Released
Adjudication
Out of system
Arraignment Trial
Trial
Convicted
Convicted
Sentencing
Sentencing
Appeal
Acquitted Charge dismissed
Arraignment
AcquittedCharge dismissed
Reduction of charge
Guilty plea
Guilty plea
Disposition
Aftercare
Revocation
Revocation Residential placement
Probation or other nonresidential disposition
Probation
Revocation
Jail
Revocation Out of system
Out of system (registration, notification)
Intermediate sanctions
Probation
Prison
Parole
Revocation
Habeas corpus
Pardon and clemency
Out of system
Out of system
Capital punishment
Adjudication Sentencing and sanctions Corrections
●■ 1,549,000—Major property crime (burglary, larceny-theft, or motor vehicle theft)
●■ 1,610,000—Driving under the influence (DUI), or drunkenness3
It can be seen that there are more than three times as many drug-law arrests as there are for all types of major violent crime, about the same number as for all major prop- erty crimes, and about the same number as for all crimes relating to excessive or inappropriate alcohol consumption. Figure 8.2 shows the distribution of drug-law arrests according to either the sale/manufacturing or possession of a controlled substance. Possession of marijuana accounted for 49 percent
of all possession arrests and 41 percent of all drug-law arrests in 2013.4
When you consider the percentage of state and federal prison inmates in the United States who are presently in- carcerated as a result of a drug-law conviction, the impact of drug-law enforcement on the criminal justice system becomes particularly striking. In 2013, about 51 percent of the approximately 194,000 inmates in federal prisons and about 16 percent of approximately 1.3 million inmates in state prisons were being incarcerated solely for a drug-law violation. Overall, there were approximately 308,000 drug- law offenders in U.S. prisons, about one in five prisoners of the total prison population.5
142 ■ Part Two Drugs, Crime, and Criminal Justice
Sale/Manufacturing
Heroin or cocaine and
their derivatives
Marijuana
Synthetic or manufactured
drugs
Other controlled substances
10%
24%
32%
34%
F igure 8 .2
Drug-law arrests in 2013 according to the type of violation and the controlled substance involved.
Note: Arrests for sale/manufacturing accounted for 18% and arrests for possestion accounted for 82% of all drug-law arrests in 2013.
Source: Federal Bureau of Investigation (2014, November). Crime in the United States 2013. Washington, DC: Federal Bureau of Investigation, U.S. Department of Justice, page 2.
Possession
Heroin or cocaine and
their derivatives
Marijuana
Synthetic or manufactured
drugs
Other controlled substances
20%
49%
6%
25%
simple possession: Having on one’s person any illicit or nonprescribed controlled substance for one’s own use.
drug trafficking: The unauthorized manufacture of any controlled substance, its distribution by sale or gift, or possession of such a substance with intent to distribute it.
The preponderance of drug-law offenders in America’s prison system has long been a subject of great concern and the impetus, as we will see, for reforms in the ways that drug-law violators are dealt with in the criminal justice system. What are the penalties that have been imposed on these individuals? The current status of criminal penalties for drug-law offenses, at the federal and state level, will be the topic of the next section.
Criminal Penalties for Drug-Law Offenses
Criminal drug-law offenses and their respective penalties fall into two broad categories. In the first category, referred to as drug trafficking, the offense is defined as the unauthorized manufacture, distribution by sale or gift, or possession with in- tent to distribute any controlled substance. In the second cat- egory, referred to as simple possession, the offense is defined as having a controlled substance on one’s person or under one’s control without intention to engage in sale or distribution. Cases of simple possession require that the amount of drug that is seized is small enough for the purpose of personal use only, and that there were no large amounts of cash, baggies, or other items that would indicate the intention to sell or distribute.
Federal Penalties for Drug Trafficking The current federal law with regard to drug trafficking is a re- sult of statutes originating in the Controlled Substances Act of 1970 and subsequently revised in 1986, 1988, and 2010. As mentioned in Chapter 3, penalties for drug trafficking are most severe for Schedule I and II controlled substances (Table 8.1). Federal penalties for drug trafficking in marijuana, while offi- cially a Schedule I controlled substance, are treated separately (Table 8.2). As a result of the Anti-Drug-Abuse Acts of 1986 and 1988, a number of special circumstances are considered in arriving at the penalty that is imposed:
●■ Penalties are doubled for first-offense trafficking of Schedule I or II controlled substances if death or bodily injury results from the use of such substances.
●■ Penalties for the sale of drugs by a person over 21 years of age to someone under the age of 18 are increased to up to double those imposed for sale to an adult.
●■ Penalties for the sale of drugs within 1,000 feet of an ele- mentary or secondary school are increased to up to double those imposed when the sale is made elsewhere.
●■ Fines for companies or business associations are generally 2.5 times greater than for individuals. In either case, penalties include the forfeiture of cars, boats, or planes that have been used in the illegal conveyance of controlled substances.6
Federal Penalties for Simple Possession of Controlled Substances Federal penalties for simple possession of a controlled substance in any of the five schedules are much simpler. First-time offenders for simple possession face a maximum
Chapter 8 Drugs, Courts, and Correctional Systems ■ 143
and 8.2), the offenses are, by definition, considered felonies. Offenses that carry a penalty of up to one year incarcera- tion and fine or a fine alone are considered, by definition, misdemeanors.
of one year imprisonment and a fine of between $1,000 and $5,000. Second-time offenders face a maximum of two years and a fine of up to $10,000.7
Felonies, Misdemeanors, and State Drug Laws Since all federal penalties for drug trafficking, whatever the circumstances or the category of controlled substance, carry a minimum of one year incarceration and fine (see Tables 8.1
misdemeanor: A criminal offense for which a sentence carries an incarceration of up to one year and a fine or a fine alone.
felony: A criminal offense for which a sentence carries a minimum of one year incarceration and a fine.
TAble 8.1
Federal trafficking penalties for Schedules I, II, III, IV, and V controlled substances (except marijuana and hashish)
Schedule SubSTAnce/QuAnTiTy PenAlTy SubSTAnce/QuAnTiTy PenAlTy
II Cocaine 500–4,999 grams mixture
First Offense: Not less than 5 years and not more than 40 years. If death or serious bodily injury, not less than 20 years or more than life. Fine of not more than $5 million if an individual, $25 million if not an individual.
Second Offense: Not less than 10 years and not more than life. If death or serious bodily injury, life imprisonment. Fine of not more than $8 million if an individual, $50 million if not an individual.
Cocaine 5 kilograms or more mixture
First Offense: Not less than 10 years and not more than life. If death or serious bodily injury, not less than 20 years or more than life. Fine of not more than $10 million if an individual, $50 million if not an individual.
Second Offense: Not less than 20 years, and not more than life. If death or serious bodily injury, life imprisonment. Fine of not more than $20 million if an individual, $75 million if not an individual.
2 or More Prior Offenses: Life imprisonment. Fine of not more than $20 million if an individual, $75 million if not an individual.
II Crack cocaine 28–279 grams mixture
Cocaine Base 280 grams or more mixture
IV Fentanyl 40–399 grams mixture
Fentanyl 400 grams or more mixture
I Fentanyl Analogue 10–99 grams mixture
Fentanyl Analogue 100 grams or more mixture
I Heroin 100–999 grams mixture
Heroin 1 kilogram or more mixture
I LSD 1–9 grams mixture LSD 10 grams or more mixture
II Methamphetamine 5–49 grams pure or 50–499 grams mixture
Methamphetamine 50 grams or more pure or 500 grams or more mixture
II PCP 10–99 grams pure or 100–999 grams mixture
PCP 100 grams or more pure or 1 kilogram or more mixture
SubSTAnce/QuAnTiTy PenAlTy
Any amount of other schedule I and II substances
First Offense: Not more than 20 years. If death or serious bodily injury, not less than 20 years or more than Life. Fine $1 million if an individual, $5 million if not an individual.
Second Offense: Not more than 30 years. If death or serious bodily injury, life imprisonment. Fine $2 million if an individual, $10 million if not an individual.
Any drug product containing gamma-hydroxybutyric acid
Flunitrazepam (schedule IV) 1 gram
Any amount of other schedule Ill drugs
First Offense: Not more than 10 years. If death or serious bodily injury, not more than 15 years. Fine not more than $500,000 if an individual, $2.5 million if not an individual.
Second Offense: Not more than 20 years. If death or serious injury, not more than 30 years. Fine not more than $1 million if an individual, $5 million if not an individual.
Any amount of all other schedule IV drugs (other than one gram or more of flunitrazepam)
First Offense: Not more than 5 years. Fine not more than $250,000 if an individual, $1 million if not an individual.
Second Offense: Not more than 10 years. Fine not more than $500,000 if an individual, $2 million if other than an individual.
Any amount of all schedule V drugs
First Offense: Not more than 1 year. Fine not more than $100,000 if an individual, $250,000 if not an individual.
Second Offense: Not more than 4 years. Fine not more than $200,000 if an individual, $500,000 if not an individual.
144 ■ Part Two Drugs, Crime, and Criminal Justice
drug paraphernalia: Products that are considered to be used to administer, prepare, package, or store illicit drugs.
TAble 8.2
Federal trafficking penalties for marijuana, hashish, and hashish oil Schedule I controlled substances
Marijuana 1,000 kilograms or more marijuana mixture or 1,000 or more marijuana plants
First Offense: Not less than 10 years or more than life. If death or serious bodily injury, not less than 20 years, or more than life. Fine not more than $10 million if an individual, $50 million if other than an individual.
Second Offense: Not less than 20 years or more than life. If death or serious bodily injury, life imprisonment Fine not more than $20 million if an individual, $75 million if other than an individual.
Marijuana 100–999 kilograms marijuana mixture or 100–999 marijuana plants
First Offense: Not less than 5 years or more than 40 years. If death or serious bodily injury, not less than 20 years or more than life. Fine not more than $5 million if an individual, $25 million if other than an individual.
Second Offense: Not less than 10 years or more than life. If death or serious bodily injury, life imprisonment. Fine not more than $8 million if an individual, $50 million if other than an individual.
Marijuana 50–99 kilograms marijuana mixture, 50–99 marijuana plants
First Offense: Not more than 20 years. If death or serious bodily injury, not less than 20 years or more than life. Fine $1 million if an individual, $5 million if other than an individual.
Second Offense: Not more than 30 years. If death or serious bodily injury, life imprisonment. Fine $2 million if an individual, $10 million if other than an individual.Hashish
More than 10 kilograms
Hashish Oil More than 1kilogram
Marijuana less than 50 kilograms marijuana (but does not include 50 or more marijuana plants regardless of weight)
1–49 marijuana plants
First Offense: Not more than 5 years. Fine not more than $250,000, $1 million if other than an individual.
Second Offense: Not more than 10 years. Fine $500,000 if an individual, $2 million if other than individual.
Hashish 10 kilograms or less
Hashish Oil 1 kilogram or less
Source for Tables 8.1 and 8.2: Drug Enforcement Administration, U.S. Department of Justice, Washington, DC.
Federal penalties set the standard for the punishment of drug offenses in the United States, but most drug-related offenses are prosecuted at the state level rather than the fed- eral level, and state regulations for drug trafficking and simple possession can vary greatly. In case of simple possession of a controlled substance, penalties depend on the drug involved and the statutes of the particular U.S. state where the viola- tion has occurred. An offense might be a misdemeanor in one state and a felony in another. Detailed information regard- ing penalties for simple possession is available through state- specific Web sites. Obviously, from the standpoint of a drug- law offender, the degree of variation in drug-law statutes from state to state can have an enormous impact on his or her life.
Drug Paraphernalia Certain other aspects of drug-taking behavior, such as the day-to-day regulation of alcohol sales and distribution, are
regulated primarily by state and local municipalities, unless interstate commerce is involved. U.S. states and local munici- palities have also taken on regulatory authority with regard to drug paraphernalia, products whose predominant use is to administer, prepare, package, or store illicit drugs. Nearly all U.S. states have statutes making it unlawful to sell these items to minors, unless they are accompanied by a parent or legal guardian. In addition, the importation, exportation, and advertising of drug paraphernalia are prohibited.8
Rethinking Drug-Law Penalties: 1970s–Present
Prevailing attitude toward crime and punishment in the 1970s and 1980s, particularly with respect to drug-law violations, were quite different than they are today. Public outcry over dramatic increases in drug use and criminal behavior asso- ciated with it during this time resulted in a criminal-justice system that emphasized deterrence, incarceration, and gen- eral retribution toward drug-law offenders. Official statements
Chapter 8 Drugs, Courts, and Correctional Systems ■ 145
enacted. Under this legislation, among other provisions, a mandatory minimum sentence of 15 years to life imprison- ment was established as the penalty for simple possession of more than four ounces (112 grams) of heroin, cocaine, or any other “narcotic” drug. This criminal penalty at the time was equivalent to the penalty for second-degree murder.
For many years, the Rockefeller Drug Laws represented the harsh and inflexible policies toward drug-law violations that were being enacted across the nation. While the penal- ties for marijuana possession in New York State were relaxed in 1979, the overall effect of the 1973 legislation on the crimi- nal justice system, particularly with respect to nonviolent vio- lators, was devastating. Drug offenders as a percentage of the prison population in New York tripled from 1973 to 1994. Similar statutes stipulating mandatory minimum sentencing for drug offenders produced similar effects in other U.S. states as well. Arguably, no other legislative policy had contributed more to the increase in the number of drug offenders in U.S. prisons than the policy of mandatory minimum sentencing.10
Essentially, mandatory minimum sentencing required a judge to impose a fixed minimal term in prison for individuals convicted of certain crimes, regardless of the individual’s role in the crime or other mitigating circumstances. Guidelines for sentences were based on the type of drug, the weight of the drug, and the number of prior convictions; offenders were required to serve their entire sentence (or in some states a minimum of 85%) without parole. Under federal law, for example, anyone convicted of selling 500 grams of powder cocaine received a minimum prison sentence of five years. A judge could issue a sentence shorter than the mandatory minimum only if the defendant provided “substantial assis- tance” or cooperation in the prosecution of another offender. This meant that if the defendant implicated someone else in a crime (rightly or wrongly), he or she could possibly escape a mandatory sentence. Even then, however, the prosecutor, not the judge, had the power to decide whether this “assistance” was valuable enough to warrant a reduction in sentence.
Proponents of mandatory sentencing believed that the policy was an effective deterrent to drug use and drug traf- ficking because it enhanced awareness of the consequences of breaking the law and kept drug offenders off the streets. Supporters of tough sentences for drug crimes claimed that the “drug epidemic” had a devastating effect on many com- munities, and the law was needed to protect these vulner- able communities by keeping drug offenders in prison. It was argued that mandatory sentences made the task of judges easier by allowing each offender to be sentenced equally under the law. Judges no longer had to weigh conflicting evi- dence in the course of deciding how much time a convicted offender would spend in jail or prison. In addition, mandatory
of the Office of National Drug Control Policy, such as the fol- lowing issued in 1989, summarized the punitive stance:
To prevent people from using drugs, drug enforcement activities must make it increasingly difficult to engage in any drug activity with impunity…we need a national drug law enforcement strategy that casts a wide net and seeks to ensure that all drug users—whatever its scale— face the risk of criminal sanctions.9
In light of the social mood toward drug-taking behavior in general and the criminal activity associated with crack cocaine abuse in particular (see Chapter 6), new laws were enacted that required the imposition of severe criminal penalties for drug-law offenses. The result was a policy that established mandatory minimum sentences.
The Issue of Mandatory Minimum Sentencing In 1973, the so-called Rockefeller Drug Laws, named for former New York Governor Nelson A. Rockefeller, were
mandatory minimum sentencing: A policy that requires a judge to impose a fixed minimal term in prison for individuals convicted of certain crimes, regardless of the individual’s role in the crime or other mitigating circumstances.
Quick Concept Check
Understanding the Criminal Justice System Check your understanding of the fundamental aspects of the criminal justice system by matching the terms/events on the left with the identifications/definitions on the right.
8.1
1. Misdemeanor penalty
2. Felony penalty
3. Federal penalty for simple possession (first offense)
4. Judges determine whether there is probable cause that a crime has been committed
5. Drug paraphernalia
6. Parole
7. Arraignment
a. Part of the adjudication phase
b. Part of the prosecution and pretrial services phase
c. Conditional release from imprisonment prior to serving the full term of the sentence
d. Imprisonment for a minimum of one year and a fine
e. Maximum of one year imprisonment and a $1,000–5,000 fine
f. Up to one year imprisonment and a fine or a fine alone
g. Regulated primar- ily by state and local municipalities
Answers: 1. f 2. d 3. e 4. b 5. g 6. c 7. a
146 ■ Part Two Drugs, Crime, and Criminal Justice
sentences aided prosecutors and law enforcement authorities because the prospect of sentences tended to persuade lower- level drug dealers to testify against upper-level ones (Drug Enforcement … in Focus).
Critics of mandatory minimum sentencing maintained that these inflexible penalty sentences filled American prisons with minor players, such as drug abusers, rather than major drug traffickers. They argued that as federal and state govern- ments continued to spend billions of dollars on the operation of existing prisons and the construction of new ones, they ne- glected other social needs, such as drug-abuse prevention and education. It had not been uncommon for some U.S. states to have faster-growing prison budgets over the years than drug- abuse treatment and education budgets, a particularly disturb- ing trend given the potential for effective drug-abuse treat- ment programs to be available. The practice of making false accusations against innocent parties by defendants in a desper- ate effort to reduce their sentence times became rampant.11
Penalties for crack versus Penalties for cocaine: correcting an injustice Under the 1986 Anti-Drug Abuse Act, the penalties for posses- sion of crack (the smokable form of cocaine) were much more severe than those for possession of cocaine itself (the powder form). A mandatory minimum prison sentence of five years was imposed upon conviction of possessing more than 500 grams of powder forms of cocaine, whereas the possession of as little as 5 grams of crack could result in the same penalty. This became known as the “100-to-1” rule, referring to the threshold in the drug quantity for an equivalent prison sentence. In addition, in 1988, the federal penalty for possession of more than 5 grams of cocaine powder was set at a minimum of one year imprison- ment; the penalty for possessing an equivalent amount of crack was set at a minimum of five years.
This disparity, according to critics of this policy, had resulted in far more African Americans in prison for five years or more than white drug offenders. Why? Statistics showed that whites were more likely to snort or inject cocaine, whereas African Americans were more likely to smoke cocaine in its cheaper crack form. The differential effects of drug-law enforcement for the two forms of cocaine were reflected in a drug offense inmate population that became divided along racial lines. On the one hand, 90 percent of crack cocaine convictions involved African Americans; on the other, nearly two-thirds of powder cocaine abusers in the United States were white. Moreover, it was more common for offenses relating to the possession of powder co- caine to be prosecuted under state regulations, under which mandatory minimum sentences frequently did not apply.
In 2007, the United States Sentencing Commission, the agency that establishes guidelines for federal prison sentences, unanimously voted to lighten punishments retroactively for some crimes related to crack cocaine possession. As a result, the stark disparity that had existed for more than 20 years in penal- ties for powder cocaine and crack cocaine was narrowed, and more than 19,000 prisoners became eligible for early release. As many as 17,000 others incarcerated for a crack-related offense, however, could not benefit from the change. These prisoners had been given the absolute minimum term in the first place or were arrested with huge amounts of crack cocaine.
In 2010, the Fair Sentencing Act was signed into law, narrowing the gap between penalties involving crack cocaine and powder cocaine. Under the new regulations, the amount of crack cocaine subject to the five year minimum sentence was increased from 5 to 28 grams. The former “100-to-1 rule” (500 versus 5) was changed to the “18-to-1 rule” (500 versus 28). In addition, the Sentencing Commission was directed to review and amend its guidelines to increase penalties for persons convicted of using violence while trafficking in illicit drugs. Table 8.1 reflects the current penalties for the two forms of cocaine.
Sources: Hatsukami, Dorothy K.; and Fischman, Marian W. (1996). Crack cocaine and cocaine hydrochloride: Are the differences myth or reality? Journal of the American Medical Association, 276, 1580–1588. Stout, David (2007, December 12). Retroactively, panel reduces drug sentences. New York Times, pp. A1, A31. Weinreb, Arthur (2010, August 4). Obama signs fair sentencing act into law. http://news.suite101.com. Wren, Christopher S. (1997, July 22). Reno and top drug official urge smaller gap in cocaine sen- tences. The New York Times, pp. A1, A12.
Drug Enforcement … in Focus
Since 1992, however, sentencing reforms have caught hold with the American people and, more specifically, state legislators. State laws regarding mandatory sentencing have been modified or rescinded, largely through the lobbying of such organizations as the Families Against Mandatory Minimums (FAMM), the U.S. Sentencing Commission, the American Psychological Association, the National Association of Criminal Defense Lawyers, and the American Bar Association. At one time, in Michigan, possession with intent to deliver more than 650 grams of heroin or cocaine once carried a mandatory life sentence with no chance of pa- role. This law now has been changed to 20 years to life, with the possibility of parole after 15 years. In Mississippi, sentenc- ing laws that had required drug offenders, even those con- victed of simple possession of a controlled substance, to serve 85 percent of their sentence, no matter the circumstances of their incarceration, now have reduced the maximum sentence to less than 25 percent. As of 2009, judges in New
Chapter 8 Drugs, Courts, and Correctional Systems ■ 147
a “tug-of-war” in deciding how drug-law offenders should be handled. The introduction of drug courts in prosecuting nonviolent drug offenders was essentially a compromise, combining the potential effectiveness of drug treatment programs with the structured features of proceedings within the criminal justice system.13 As one researcher expressed it,
Proponents of “tough on crime” approaches to drug problems were able to support drug courts and maintain face, as drug courts closely supervise and hold offenders accountable. Supports of rehabilitation and pragmatists were able to support drug courts, as they use treatment programs demonstrated to be effective outside of the drug court context.14
Drug courts are specialized courts designed to handle adult, nonviolent offenders with substance abuse problems, incor- porating an intensely supervised drug treatment program as an alternative to standard sentencing. The goals are to reduce
York who had previously had been permitted no discretion in sentencing now have leeway in deciding whether a drug offender should be sent to a substance abuse treatment center instead of prison. Changes in New York State law permitted thousands of inmates convicted of nonviolent drug offenses to apply for reduced sentences or to have sentences set aside. At the federal level, a major U.S. Supreme Court decision in 2007 ruled that federal district judges had broad discre- tion to impose what would be, in their judgment, reasonable sentences in criminal proceedings, even if federal guidelines were more stringent (Portrait).12
Meanwhile, as sentencing reforms were being made within the traditional criminal justice system, a new approach was being advanced that would represent a radical change in the overall strategy for handling the adjudication of drug-law offenders.
The Advent of Drug Courts At the time when courts and correctional systems were inclined to pursue a punitive strategy in dealing with drug-law offenders, research in drug treatment strategies had begun to demonstrate their effectiveness in dealing with drug-taking behavior. The two opposing orientations of criminal justice professionals and public health professionals had produced
POrTrAiT State Senator John R. Dunne—Drug Warrior/ Drug-War Reformer
In 1973, John R. Dunne, Republican state senator of New York, was leading the charge for legislation that became known as the Rockefeller Drug Laws. It was a time of public panic. New York and other states around the country were contending with dramatic increases in illicit drug use (specifically heroin) and suffering its criminal and social consequences. Harsh mandatory minimum sentencing seemed to be the answer.
A quarter-century later, it was clear that the laws had done more harm than good. By 2001, Dunne himself was fully convinced that reform was more than overdue. The laws, according to Dunne, did nothing to reduce the drug trade, instead “The only thing they’ve done is to fill the prisons.” Case in point: Daniel Boyd (not his real name), 46-year-old father of four with no criminal record, serving time in maximum security for 15 years to life after signing for a FedEx package delivered to his uncle’s house that turned out to contain cocaine.
Records would show that while most drug users and drug traffickers were
white, 94 percent of New York’s inmates convicted of drug-law offenses were ei- ther African American or Latino.
Prompted by his conscience, Dunne became the leading advocate for drug- law reform in New York. He appeared in emotional television commercials alongside an African American grand- mother from upstate New York whose family had been destroyed by the policy of mandatory minimum sentencing. The appeals that Dunne had made and the connections to former colleagues in the State Senate were powerful, but the move to reform was frustratingly slow. It was difficult to dislodge conservative legislators from their tough-on-drugs stance. Some legislators saw the reforms as jeopardizing local economies that were dependent upon the operation of state prisons and the people who worked there. In 2002, reform legislation was stalled.
It was not until 2009, under New York State Governor David A. Patterson,
that legislators reached an agreement. Mandatory prison sentences were elimi- nated for most drug offenses. Judges were given more leeway in sentencing deci- sions, drug courts and other alternatives to incarceration were expanded, drug-law penalties were reduced, and, importantly, about 1,500 people incarcerated at the time under the old drug laws were al- lowed retroactive resentencing. John R. Dunne and fellow reformers had finally succeeded in writing a new chapter in the history of drug legislation in the state.
Sources: New York’s Rockefeller Drug Laws: Explaining the reforms of 2009. www. drugpolicy.org. Perlman, Ellen (2000, April). Public safety and justice: Terms of impris- onment. www.governing.com. Goldberg, Michelle (2002, August 5). Reforming Rockefeller drug laws. www.alternet.org. Peters, Jeremy W. (2009, March 26). Albany reaches deal to repeal ‘70s drug laws. New York Times. www.nytimes.com. The John R. Dunne Fund of the New York Bar Foundation. www.tnybf.org.
drug courts: Specialized court systems that handle adult, nonviolent offenders of drug laws, incorporating a supervised drug treatment program as an alternative to standard criminal sentencing.
148 ■ Part Two Drugs, Crime, and Criminal Justice
Specialty courts in Today’s criminal Justice System Since the establishment of the first Drug Court in Miami- Dade County, Florida in 1989, a number of specialty courts have appeared throughout the United States and its territories that focus on specific problem-solving strategies for drug-law offenders or individuals with offenses that stem from a pattern of substance abuse. In some cases, specialty courts involve individuals at a postincarceration point in their lives. Following are examples of specialty courts, all based upon the philosophy of dealing with nonviolent offenders in a judicial process that leads to successful substance abuse treatment. The numbers in parentheses refer to the number of courts in each category, as of June, 2012.
Adult Drug Court (1,438, of which 401 are hybrid DWI/ Drug Courts): A specially designed court, aimed at a reduc- tion in recidivism and substance abuse in nonviolent drug- law offenders and an increase in their successful treatment and recovery. DWI Court (208): A specially designed court for repeat offenders arrested for Driving While Impaired (DWI), aimed at changing the behavior of individuals with alcohol or other drug-abuse problems. Like drug courts, DWI courts involve extensive interactions between offenders and the judge and offenders so as to insure their compliance with court, supervision, and treatment conditions. Family Dependency Treatment Court (344): A juvenile or family court for cases of child abuse or neglect in which sub- stance abuse of one or both parents is a contributing factor. In some cases, child protection services provide safe and nur- turing alterative homes, while parents are provided necessary support services for substance abuse treatment. These courts promote establishment of long-term recovery and increase the possibility of family reunification. Juvenile Drug Court (458): A specialty docket within the juvenile or family court system, where selected juveniles charged with delinquency are referred to for handling by a designated judge with jurisdiction over youths who are identi- fied as having serious problems with alcohol and/or other drugs.
Campus Drug Court (5): Modeled after adult drug courts but targeted specifically to college students whose alcohol and other drug-abuse issues have created serious problems for themselves and others and have jeopardized their ability to complete their college education. Tribal Healing to Wellness Court (89): A component of the tribal justice system for the Native American com- munity, aimed at addressing the impact of alcohol and other drug abuse on their lives. These courts distinguish themselves from formal drug courts as being less focused on the court-related structure and procedures and more focused on healing the individual, his/her family, and community. Mental Health Court (37): Modeled after drug courts in response to the overrepresentation of people with mental illnesses in the criminal justice system. Individuals with substance abuse issues and co-occurring mental illness are invited to participate following screening and assessment, but they may choose to decline participation. Veterans Treatment Court (104): A hybrid integration of adult drug court and mental health court principles, specifically serving military veterans and sometimes active- duty personnel who have substance abuse and emotional difficulties. Federal Reentry/Drug Court (31): A postincarceration cooperative effort of U.S. district attorneys, probation officers, and federal public defenders, providing a combination of treatment and sanctions to facilitate re-integration into the community for nonviolent, substance abusing offenders who have been released from federal prison. Reentry Drug Court (30): A specialty court modeled after the Federal Reentry/Drug Court (see above) for nonviolent, substance abusing offenders who have been released from local or state correctional facilities.
Source: Bureau of Justice Assistance (2003, April). Tribal healing to wellness courts: The key components. Washington, DC: Bureau of Justice Assistance, U.S. Department of Justice. Information courtesy of the National Drug Court Resource Center, Alexandria, Virginia. http://www.ndcrc.org.
Drug Enforcement … in Focus
drug use relapse and criminal recidivism (repeated offenses in the future) through a risk and needs assessment, judicial proceedings, monitoring and supervision, a combination of incentives and sanctions, and, most importantly, treat- ment and rehabilitation services. The popularity of adult drug courts over the years has encouraged the development of comparable drug courts for juveniles, DWI offenders, veterans, and families, as well as target populations having
substance abuse problems along with difficulties with the law (Drug Enforcement … in Focus).15
Several of the characteristics of drug courts include early identification and placement of eligible participants, drug treatment with clearly defined rules and goals, a nonadver- sarial approach, a monitoring of abstinence, judicial involve- ment and extensive interaction with participants, and a team approach comprised of a judge, coordinator, public defender/
Chapter 8 Drugs, Courts, and Correctional Systems ■ 149
a comparison group on key demographic variables in order to make the two groups relatively equivalent at the start. Despite the methodological shortcomings, however, a major review of 60 evaluations of adult drug courts indicated that 90 percent of them showed a significant benefit in reducing recidivism. In seven out of eight DWI court evaluations, significant reduc- tions in recidivism were observed. However, in six out of seven juvenile drug court evaluations, lower r ecidivism was found among participants but not to a significant degree, relative to a comparison group.18
On the basis of other criteria, drug court programs have substantial benefits. They are certainly cost effective. Approximately $250 million in incarceration costs are saved each year in New York State alone by diverting 18,000 nonvi- olent drug offenders into treatment. Nationwide, it has been calculated that the $515 million in the annual budgets for drug courts produces $2.12 for every $1 spent.19
Drug courts also increase the length of time an individ- ual remains in treatment. The coercive power of the criminal justice system with respect to getting into treatment and staying in treatment is dramatic. Ordinarily, between 40 and 80 percent of drug abusers drop out of treatment within 90 days, and between 80 and 90 percent drop out within 12 months. In sharp contrast, more than two-thirds of drug court participants com- plete a treatment program lasting a year or more. Interestingly, according to experts in the field of drug-abuse treatment, the mandated treatment approach in drug court programs is more likely to result in a successful outcome than in circumstances in which the decision to go for treatment is made voluntarily.20 Unfortunately, it has been acknowledged that the number of drug courts around the country are far from adequate to handle all the nonviolent drug offenders arrested each year. One esti- mate is that judges and courtrooms are presently available to serve approximately 70,000 drug court clients, when there are 30 times as many actual drug offenders who could be served through a drug court system.21
Since the early 1990s, a number of problem-solving court programs have been created to foster treatment for other psychosocial difficulties. Mental health courts, for example, provide mentally ill defendants who have commit- ted nonviolent criminal offenses with psychiatric evaluations and treatment.22
Meanwhile, the debate continues over imposing criminal sanctions over illicit drug-taking behavior in general (Drugs . . . in Focus).
Correctional Systems
A natural response to an individual whose behavior poses a significant threat to society is to remove that individual from society and provide some form of incarceration in a prison, jail, or other secure environment. Besides protecting soci- ety at large, incarceration is intended to be preventive in the long run by (1) reducing the likelihood that the individual will behave in a similar way in the future, after the sentence
defense attorney, prosecutor, evaluator, treatment provider, law enforcement officer, and probation officer. Those offend- ers who complete the program successfully may have their charges dropped or sentences revoked, whereas unsuccess- ful participants are returned to the regular court system and face possible imprisonment. Since the first drug court began operation in Florida in 1989, more than 2,700 drug courts have been established in the United States and its territories as well as in other nations.16
The first step in the drug court program begins with defense attorneys, probation officers, or prosecutors refer- ring a potential candidate to the drug court itself. A proba- tion officer then screens candidates for eligibility. Candidates must be judged (using a screening instrument) to be serious drug abusers, cannot be on parole, and cannot have a prior serious or violent felony conviction. When he or she agrees to enter the program, the candidate waives his or her right to a jury and agrees to enter a treatment program for a year during which he or she is subject to random drug tests. Participants are supervised by a probation officer to insure that they adhere to program rules. Best practice standards for adult drug courts were established by the National Association of Drug Court Professionals in 2013.17
How effective are drug courts in reducing the rate of recidivism (repetition of offense) among participants? The eval- uations of drug courts unfortunately do not lend themselves to a rigorous methodology in which individuals are randomly as- signed to a drug court proceeding or to a traditional judicial pro- ceeding. In most studies, drug court participants are compared to drug offenders who were eligible for participation in a drug court but declined participation (“refusers”) or to drug offenders who were referred to drug court but deemed ineligible by drug court administrators (“rejects”). Making comparisons in these ways leaves open the question of whether differences could be attributed more to factors such as the motivation to take advan- tage of the drug court program (in the case of refusers) or the court’s perception of the seriousness of the drug problem (in the case of rejects) than the actual effect of drug courts. Some efforts are made to match drug court participants with those in
The court system in the United States is greatly burdened with the large number of cases that involve drug-law violations. The establishment of drug courts for nonviolent drug-law offenders is an effort to ease the judicial burden and maximize effective drug-abuse treatment.
150 ■ Part Two Drugs, Crime, and Criminal Justice
A Simulated debate: Should We legalize drugs? The following discussion of viewpoints represents the opinions of people on both sides of the controversial issue of the legaliza- tion of drugs. Read them with an open mind. Don’t think you have to come up with the final answer, nor should you necessar- ily agree with the argument you heard last. Many of the ideas in this discussion come from the sources listed.
Point Legalization would get the problem under some degree of control. The “war on drugs” does nothing but increase the price of illicit drugs to what the market will bear, and it subsidizes the drug dealers and drug kingpins around the world. If we legalize drugs, we can take the profit out of the drug business because legalization would bring the price down dramatically. We could regulate drug sales, as we do now with nicotine and alcohol, by setting up centers that would be licensed to sell cocaine and heroin, as well as sterile syringes, while any drug sales to minors would remain a criminal offense. Regulations would also insure that drugs maintained standards of purity; the health risks of drug contamination would be drastically reduced.
counterpoint Legalization is fundamentally immoral. How can we allow people to run to the nearest store and destroy their lives? Don’t we as a society have a responsibility for the health and welfare of people in general? If the drugs (pure or impure) were avail- able, the only effect would be to increase the number of drug abusers. When Britain allowed physicians to prescribe heroin to “registered” addicts, the number of heroin addicts rose fivefold (or more according to some informal estimates), and there were then cases of medical abuse as well as drug abuse. A few unscru- pulous doctors were prescribing heroin in enormous amounts, and a new drug culture was created.
Point How moral is the situation now? We have whole communities living at the mercy of drug dealers. Any increase in drug users would be more than compensated for by the gains of freedom from such people. Even if the sale of crack were kept illegal, conceding that this drug is highly dangerous to society, we would have an 80 percent reduction in the black market for drugs, a substantial gain for the welfare of society. We can’t guarantee that our inner cities would no longer be places of hopelessness and despair, but at least we would not have the systemic violence associated with the drug world. Besides, with all the money saved from programs set up to prevent people from getting hold of illicit drugs, we could increase the funding for drug treatment programs for all the drug abusers who want them and for research into ways of understanding the nature of drug dependence.
counterpoint No doubt, many drug abusers seek out treatment and want to break their drug dependence. Perhaps there may be some in- dividuals who seek treatment under legalization because there would no longer be a social stigma associated with drug abuse, but many drug abusers have little or no long-term commitment toward drug treatment. In the present situation, the illegality of their behavior allows us to compel them to seek and stay in treatment, as well as monitor their abstinence by periodic drug testing. How could we do this when the drug was legal? Besides, how would we approach the education of young people if drugs were legal? We could not tell them that cocaine would give them cancer or emphysema, as we warn them of the dangers of tobacco, only that it would prevent them from being a pro- ductive member of society and would have long-term effects on their brains. If the adults around them were allowed to use cocaine, what would be the message to the young? Simply wait until you’re 21?
Point We already have educational programs about alcohol abuse; the message for heroin and cocaine abuse would be similar. The loss of productivity due to any increased availability of drugs would not be as significant as the present loss of productivity we have with alcohol and cigarettes. With the tax revenues obtained from selling drugs legally, we could have money for more extensive anti-drug advertising. We could send a comprehensive message to our youth that there are alternatives to their lives that do not include psychoactive substances. In the meantime, we would be removing the “forbidden fruit” factor in drug-taking behavior. Drugs wouldn’t be a big deal.
counterpoint Arguing that people take drugs because drugs are forbidden or hard to get ignores their basic psychological allure. If you lowered the price of a very expensive sports car, would you have fewer people wanting to buy one? Of course not. People would want a fast car because they like fast cars, just as people will still want to get high on drugs. Legalizing present drugs would only encourage the development of more dangerous drugs in the future. Look at what happened with crack. Cocaine was bad enough, but when crack appeared on the scene, it made the situ- ation far worse.
Point It can be argued that crack was marketed because standard co- caine powder was too expensive for people in the inner cities. If cocaine had been legally available, crack might not ever have been created because the market would not have been there. Even with crack remaining illegal under a legalization plan, there is at least the possibility that the appeal of crack would decline. The trend has been lately that illegal drugs are getting stronger, while legal drugs (alcoholic beverages and cigarettes) are getting weaker as people become more health conscious.
Drugs … in Focus
Chapter 8 Drugs, Courts, and Correctional Systems ■ 151
incarceration is to achieve any degree of rehabilitation for these individuals, it is necessary to provide drug treatment programs of some kind. Yet, according to a major 2010 study of American prisoners, only about 11 percent of these prison- ers receive any formal drug treatment at all.24
While prisoners are similar in many ways to the popula- tion at large with respect to drug treatment, in some ways they are unique. Incarcerated individuals have particular difficul- ties dealing with anger and hostility, the issues that, not sur- prisingly, brought them to the attention of law enforcement in the first place. Their self-esteem is likely to be low, as they suffer the guilt and shame of being stigmatized as a criminal.25
While counseling and some training in anger man- agement may be useful for prisoners in local jail, the short interval of their incarceration makes it challenging to provide an effective drug treatment program. Nonetheless, intensive 30-day drug treatment programs have been designed for this population.26
For prisoners in state or federal prisons, an extended structured approach can be made. The best known in-prison treatment program of this type is the therapeutic community. Components of a therapeutic community (TC) program include:
●■ A separate residential place isolated (except for meals and other standard activities) from the general prison popula- tion to provide a sense of safety and belonging as the TC participants begin the process of change.
●■ Active participation among TC inmates and a demanding program that requires emotional, physical, and intellec- tual work on their part.
●■ A requirement that TC participants take responsibility for their own recovery program.
●■ Close collaboration between treatment and corrections staff.27
is completed, and (2) conveying the message to others who might contemplate engaging in similar behavior that a com- parable punishment would apply to them as well. The first goal is referred to as rehabilitation; the second goal is re- ferred to as deterrence.
Prison-Based Treatment Programs For those drug-law offenders who are sentenced to prison, a previous history of substance abuse continues to present diffi- culties that do not go away just because they are now behind bars. Substance abuse issues affect not only these drug-law offenders, but also prisoners sentenced for offenses that have no direct relationship to a history of substance abuse.23 It is estimated that 65 percent of inmates in federal prisons, state prisons, and local jails, 1.5 million individuals out of the total inmate population of 2.3 million, meet the criteria for substance use disorder according to medical criteria in the DSM-5 classification of mental disorders (see Chapter 4). Another 20 percent, approximately 500,000 inmates, do not meet these criteria but, nevertheless, are substance involved in that they were under the influence of alcohol or other drugs when arrested, committed some form of theft to buy drugs, or else violated a specific drug or alcohol law. If
Legalization might make presently illicit drugs weaker in strength, as public opinion turns against them. The main prob- lem we face is that spending 57 percent of a multibillion-dollar drug-law enforcement program on the “supply” side of the ques- tion, and only 43 percent on reducing the demand for drugs is not working. If one source of drugs is controlled, another source takes its place. The link between drugs and crime is a direct result of the illegality of drugs. It’s not the individuals with drug dependence that are destroying the country; it’s the drug dealers. Right now, the criminals are in charge. We have to change that. Only legalization would take away their profits and refocus our law enforcement efforts on other crimes that continue to under- mine our society.
counterpoint The frustration is understandable, but let’s not jump into some- thing merely because we’re frustrated. We can allocate more funds for treatment without making drugs legal. We can increase funds for scientific research without making drugs legal. We
need a more balanced program, not an entirely new one. Polls do not indicate general support for drug legalization. A majority of the U.S. public supports continued prohibition of drugs. Most citizens appear to recognize that legalization would make a bad situation worse, not better.
Sources: Dennis, Richard J. (1990, November). The economics of legalizing drugs. The Atlantic, 126–132. Goldstein, Avram (2001). Addiction: From biology to drug policy (2nd ed.). New York: Oxford University Press. Goode, Erich (1997). Between politics and reason: The drug legalization debate. New York: St. Martin’s Press. Gray, James P. (2001). Why our drug laws have failed and what we can do about it. Philadelphia: Temple University Press. Kleiman, Mark A. R. (2001, May/June). Science and drug abuse control policy. Society, 7–12. Levinthal, Charles F. (2003). Point/counterpoint: Opposing perspectives on issues of drug policy. Boston: Allyn and Bacon, Chapter 1. U.S. Department of Justice, Drug Enforcement Administration. Speaking out against drug legalization. http://www.usj.gov. Wilson, James Q. (1990, February). Against the legalization of drugs. Commentary, 21–28.
therapeutic community (Tc): A structured residential grouping of individual in treatment, concentrating on mutual support and a sense of personal responsibility for change.
deterrence: The concept that punishment for a specific behavior will discourage the discourages the person being punished or another person from behaving in the same way in the future.
rehabilitation: The concept that a process of treatment can improve an individual’s condition or situation.
152 ■ Part Two Drugs, Crime, and Criminal Justice
The criminal Justice System ●● The criminal justice system in the United States is com-
prised of four phases of judicial events: prosecution and pretrial services, adjudication, sentencing and sanctions, and corrections. At each phase, defendants may exit the system if no further action is required.
●● About 1.5 million arrests are made each year for a drug- law violation of some kind.
●● According to 2013 statistics, about 51 percent of federal prisoners and about 16 percent of state prisoners are being incarcerated solely for a drug-law violation.
criminal Penalties for drug-law Offenses ●● Federal guidelines for drug-law violation penalties
make the distinction between drug trafficking and simple possession of controlled substances. In addi- tion, separate guidelines are made for drug traffick- ing of marijuana and controlled substances other than marijuana.
●● Federal drug trafficking penalties are most severe for controlled substances in Schedule I and Schedule II categories.
●● For all schedules, the federal penalty for a first-time simple possession offense is a maximum of one year imprison- ment and a fine of between $1,000 and $5,000.
●● State penalties for drug trafficking and simple possession can vary greatly from federal penalties.
●● U.S. states and local municipalities have regulatory authority for the sale and distribution of drug parapherna- lia that is associated with illicit drug use.
rethinking drug-law Penalties: 1970s—Present ●● Mandatory minimum sentencing has required a judge to
impose a fixed minimal length of imprisonment for indi- viduals convicted of certain crimes, regardless of a person’s role in the crime or other mitigating factors. Strict manda- tory minimum sentencing laws in New York have been referred to as the Rockefeller Drug Laws, enacted in 1973.
●● In recent years, there has been a significant shift toward providing judges with a greater degree of discretion in their sentencing of drug offenders. Penalties with respect to powder cocaine and crack cocaine were revised as a result of the Fair Sentencing Act of 2010, to reduce a disparity that had been considered to be unjust.
The Advent of drug courts ●● Drug courts are specialized courts designed to handle
adult, nonviolent offenders with substance abuse prob- lems. They involve an intensely supervised drug treatment program as an alternative to standard sentencing.
Summary
The Stay’n Out program in New York, KEY-CREST program in Delaware, Texas Kyle New Vision program, and Amity Prison TC program in San Diego, California, are in-prison TC programs that have been demonstrated to be effective in reducing recidivism and reentries into prison, although the likelihood of positive outcomes appears to depend on the availability of postrelease com- munity aftercare programs.28 The essential features of in-prison TC programs are similar to TC programs that have been implemented for drug-law offenders who have been adjudicated through the drug court system.29
However challenging it may be to incorporate drug treatment programs in prisons, the benefits are substantial, both on a personal and monetary basis. The benefit of one inmate becoming substance abuse-free, crime-free and employed following release from prison has been calculated to be a savings of approximately $91,000, when compared to the expenses that would be expected if the individual returned to a life of substance abuse and criminal behavior. Another way of looking at the potential benefits is to imag- ine that if all 1.3 million inmates with untreated substance use disorders were treated in prison and approximately $12–13 billion were spent in doing so, the “break-even” point would be reached within one year after the prisoner was released.30
Quick Concept Check
Understanding Problem-Solving Courts Check your understanding of problem-solving courts and the correctional system by answering True or False to the following statements.
1. A DWI court is an example of a problem-solving court.
2. A “refuser” refers to an individual who is eligible for a drug court but declines to participate.
3. Juvenile drug courts have yet to be established.
4. Drug courts have tremendous social value but little or no cost-effectiveness.
5. Therapeutic communities are a popular treatment strategy for incarcerated individuals.
6. About one-half of incarcerated individuals who need drug treatment are receiving it.
Answers: 1. True 2. True 3. False 4. False 5. True 6. False
8.2
Chapter 8 Drugs, Courts, and Correctional Systems ■ 153
●● Correctional systems have had to contend not only with a substantial number of drug-law offenders pres- ently incarcerated but also incarcerated individuals who have a history of substance abuse even though their offense may not have been the reason for their incarceration.
●● Unfortunately, too few incarcerated individuals who need drug treatment services receive them.
●● Other “problem-solving” courts, modeled after the drug court concept, include DWI courts, juvenile drug courts, mental health courts, veteran treatment courts, and reen- try drug courts.
●● Evaluations of drug courts in terms of reduced recidivism and other measures have been generally positive, and the cost benefits have been substantial.
drugs and the correctional System ●● Inmates serving time for drug-law violations represent a
significant portion of the prison population in the United States.
1. Describe the judicial events in the four phases of the American criminal justice system.
2. Describe the special circumstances that require an imposition of an increase in the federal penalties for drug trafficking.
3. Briefly describe the history of events that created the manda- tory minimum sentences for drug-law offenders.
4. Describe the purposes and operations of three problem-solving courts, modeled over the years after the drug court concept.
5. Discuss the pro and con arguments with respect to drug courts. 6. Describe the present situation with respect to prison-based
drug treatment.
Review Questions
Table 8.2 lists the federal penalties for trafficking in marijuana and other cannabis products. Given the federal penalties for simple possession of a controlled substance, no matter what category
(schedule) the controlled substance might belong to, would you modify these penalties with respect to simple possession of mari- juana. If yes, how would you do it? If not, justify your answer.
Critical Thinking: What Would You Do?
Key Terms
adjudication, p. 139 deterrence, p. 151 drug courts, p. 147 drug paraphernalia, p. 144 drug trafficking, p. 142
felony, p. 143 incarceration, p. 139 mandatory minimum
sentencing, p. 145 misdemeanor, p. 143
parole, p. 139 prosecution and pretrial
services, p. 139 rehabilitation, p. 151
sentencing and sanctions, p. 139 simple possession, p. 142 therapeutic community, p. 151
1. Federal Bureau of Investigation (2014). Estimated number of arrests. United States, 2013. Crime in the United States 2013. Washington, DC: Federal Bureau of Investigation, U.S. Department of Justice, Table 29.
2. Bureau of Justice Statistics. Criminal justice system flowchart. http://www.bjs.gov/content/largechart.cfm (accessed November 27, 2013).
3. Federal Bureau of Investigation, Crime in the United States 2013, Table 29.
4. Ibid. Arrests for drug abuse violations, p. 2. 5. Carson, E. Ann (2014, September). Prisoners in 2013.
Bureau of justice statistics bulletin. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice, Tables 14 and 15.
6. Drug Enforcement Administration, U.S. Department of Justice, Washington, DC. Statutes of the Controlled Substances Act of 1970, as amended and revised in 1986 and 1988.
7. Drug Enforcement Administration. Yeh, Brian T. (2012, December 13). CRS Report to Congress: Drug offenses: Maxi- mum fines and terms of imprisonment for violation of the Federal Controlled Substances Act and related laws. Washington, DC: Congressional Research Services, United States Congress.
8. Healey, Kerry (1988). State and local experience with drug paraphernalia laws. Washington DC: U.S. Government Print- ing Office, pp. 69–73.
9. Office of National Drug Control Policy (1989). National Drug Control Strategy. Washington, DC: Office of National Drug Control Policy, Executive Office of the President, p. 18.
10. Gray, Madison (2009, April 2). New York’s Rockefeller drug laws. Time Magazine Online, http://content.time.com/time/ nation/article/0,8599,1888864,00.html http://content.time.com/ time/nation/article/0,8599,1888864,00.html
11. Donohue, John J., III; and Siegelman, Peter (1998). Allocating resources among prisons and social programs in
Endnotes
154 ■ Part Two Drugs, Crime, and Criminal Justice
Oxford University Press, pp. 368–410. Roman, John K.; Chal- fin, Aaron; Reid, Jay; and Reid, Shannon (2008). Impact and cost-benefit analysis of the Anchorage Wellness Court. Rockville, MD: National Criminal Justice Reference Service.
22. Huddleston, C. West, III; Marlowe, Douglas B.; and Casebolt, Rachel (2008, May). Painting the current picture: A national report card on drug courts and other problem-solving court pro- grams in the United States. Washington, DC: Bureau of Justice Assistance, U.S. Department of Justice.
23. Chandler, Redonna K.; Fletcher, Bennett W.; and Volkow, Nora D. (2009). Treating drug abuse and addiction in the criminal justice system: Improving public health and safety. Journal of the American Medical Association, 301, 183–190. Larney, Sarah; Toson, Barbara; Burns, Lucy; and Dolan, Kate (2012). Effect of prison-based opioid substitution treatment and postrelease retention in treatment on risk of reincarcera- tion. Addiction, 107, 372–380. Mears, Daniel P.; Winterfield, Laura; Hunsaker, John; Moore, Gretchen E.; and White, Ruth M. (2003, January). Drug treatment in the criminal justice sys- tem: The current state of knowledge. Washington, DC: Urban Institute Justice Policy Center.
24. The National Center on Addiction and Substance Abuse at Columbia University (2010, February). Behind bars II: Sub- stance abuse and America’s prison population. New York: The National Center on Addiction and Substance Abuse, pp. i, 4.
25. Center for Substance Abuse Treatment (2005, September). Substance abuse treatment for adults in the criminal justice system. Treatment Improvement Protocol (TIP), Series 44. Rockville, MD: Substance Abuse and Mental Health Services Administration, p. xix. Yang, Yang; Knigh, Kevin; Flynn, Pat- rick M.; and Lehman, Wayne (2012). The impact of criminal thinking and treatment engagement on recidivism. Offender Programs Report, 16, 49–54.
26. Bahr, Stephen J.; Harris, Paul E.; Hobson, Janalee; and Taylor, Bryan M. (2011). Can drug treatment for jail inmates be effec- tive? An evaluation of the OUT program. Offender Programs Report, 15, 17–22.
27. Center for Substance Abuse Treatment, TIP, Series 44, pp. 199–204.
28. Welsh, Wayne N.; and Zajac, Gary (2013). A multisite evalu- ation of prison-based drug treatment: Four-year follow-up results. The Prison Journal, 93, 251–271.
29. Center for Substance Abuse Treatment, TIP, Series 44, pp. 201–204. De Leon, George (1988). Legal pressure in therapeutic communities. In Carl G. Leukefeld; and Frank M. Tims (Eds.), Compulsory treatment of drug abuse: Research and clinical practice. NIDA Research Monograph Series 86. Rockville, MD: National Institute on Drug Abuse, pp. 160–177.
30. The National Center, Behind Bars II, pp. 95–96.
the battle against crime. Journal of Legal Studies, 27, 30–43. Horowitz, Heather; Sung, Hung-En; and Foster, Susan E. (2006, January–February). The role of substance abuse in U.S. juvenile justice systems and populations. Corrections Compendium, 31(1), 1–4, 24–26.
12. Associated Press (2009, December 20). Prison population to have first drop since 1972. Greenhouse, Linda (2007, Decem- ber 11). Justices restore judges’ control over sentencing. New York Times, pp. A1, A28. Peters, Jeremy W. (2009, March 11). Legislation to overhaul Rockefeller drug laws advances swiftly. New York Times, p. 20. Stout, David (2007, December 12). Retroactively, panel reduces drug sentences. New York Times, pp. A1, A31.
13. Mitchell, Ojmarrh (2011). Drug and other specialty courts. In Michael Tonry (ed.), The Oxford Handbook of crime and crimi- nal justice. New York: Oxford University Press, pp. 843–871.
14. Ibid., p. 849. 15. National Criminal Justice Reference Service. In the spotlight:
Drug courts. Washington, DC: Office of Justice Programs U.S. Department of Justice. http://wwwncjrs,.gov/spotlight/drug_ courts/summary/html (accessed November 26, 2013).
16. Ferdinand, Jo Ann; Edwards, Christine; and Madonia, Joseph (2012). Addiction, treatment, and criminal justice: An inside view of the Brooklyn Treatment Court. New York: Center for Court Innovation. Who is on an adult drug court team? National Drug Court Resource Center Web site. http://www. ndcrc.org (accessed November 26, 2013).
17. National Association of Drug Court Professionals (2013). Adult drug court best practice standards, Vol. 1. Alexandria, VA: National Association of Drug Court Professionals.
18. Mitchell, Drug and other specialty courts. 19. Bhati, Avinash Sing; Roman, John K.; and Chalfin, Aaron
(2008, April). To treat or not to treat: Evidence on the prospects of expanding treatment to drug-involved offenders. Washington, DC: Urban Institute, Justice Policy Center. Finigan, Michael W.; Carey, Shannon M.; and Cox, Anton (2007, April). The impact of a mature drug court over 10 years of operation: Recidi- vism and costs. Portland, OR: NPC Research.
20. Gottfredson, D. C.; Najaka, S. S.; and Kearley, B. (2003). Effectiveness of drug treatment courts: Evidence from a ran- domized trial. Criminology and Public Policy, 2, 401–426. Mitchell, Drug and other specialty courts. Rossman, Shelli B.; Roman, John K.; Zweig, Janine M.; Rempel, Michael; and Lindquist, Christine H. (2011, November). The mutlistate adult drug court evaluation: Executive summary. Washington, DC: Urban Institute, Justice Policy Center.
21. Boyum, David A.; Caulkins, Jonathan P.; and Kleiman, Mark A. R. (2011). Drugs, crime, and public policy. In James O. Wilson; and Joan Petersilla (Eds.), Crime and public policy. New York:
Opioids: Heroin and Prescription Pain
Medications
9
Edna certainly was a formidable lady, especially when it came
down to talking about her pain medication. “I’m a 50-year-old
grandmother,” she began with a stern look on her face. I listened
closely to what she had to say.
“My spinal stenosis surgery was a goddam nightmare, and the
only thing that saved my life was OxyContin, if you call it a life. You
might say I fake leading a normal life. I mean I can do the little things,
wash the dishes for a little while, without anyone knowing that I’m
crying inside. I’m 90 percent disabled and miserable 100 percent of
the time. God help me, I get thinking about ending it all.”
“So don’t take away my medicine! Maybe I’m addicted, I don’t
know. I can tell you this: If the doctor took away my OxyContin, I’d
probably be out there with those people who rob the drugstores…
maybe even killing people like that Laffer guy I heard about. I just
don’t know what I would do. Maybe I wouldn’t be here at all.”
People like Edna used to be just stories I would read about in
the newspapers. I never had a chance to meet someone who felt
as strongly about it as Edna did. I won’t forget the look in her eyes
when she talked about her pain and her OxyContin.
After you have completed this chapter, you should have an understanding of the following:
●● The history of opium and opioid drugs
●● The behavioral and neurochemical effects of opioid drugs
●● The patterns of heroin abuse
●● The potential lethality of heroin abuse
●● The issue of controlled heroin intake
●● Treatment strategies for opioid dependence
●● Patterns of prescription opioid medication abuse
chapter
PA r t t h r e e
Legally Restricted Drugs and
Criminal Justice
156 ■ Part Three Legally Restricted Drugs and Criminal Justice
two Small towns Contending with the heroin epidemic Hudson, Wisconsin (population 12,719), and Rutland, Vermont (population 16,495), are two picturesque American towns situ- ated more than 1,200 miles apart. One is a riverfront town in the Midwest; the other is surrounded by the Green Mountains of New England. However, they share an unfortunate public health and public safety crisis: The sudden domination of heroin abuse and surge of heroin overdose deaths in their communities.
There were more than 8,000 heroin overdose deaths nation- wide in 2013, about 40 percent more than reported in 2012 and nearly three times the number reported in 2010. More than half were between 25 and 44 years old, and more than 80 percent in this age range were white. The greatest increases in recent years have been seen in the Midwest region of the country. County coroners in Wisconsin, for example, reported 199 heroin-related deaths in 2012, a 50 percent increase over 2011 and seven times the average number in the years between 2000 and 2007.
Elsewhere, heroin abuse has been on a rampage in larger suburban as well as urban areas. In New York City, 420 people died of heroin overdose in 2013, more than double the number over the previous three years. On Long Island, a suburban region immediately east of New York City, 144 people died of heroin overdose in 2013.
Regardless of geographical location or population size, a number of common developments can be observed. Hudson, Rutland, and other smaller communities are experiencing a “rude awakening” that they are not immune to the tragic consequences of heroin abuse. They recognize the connection
between the current heroin epidemic and an earlier period of extensive prescription opioid medication abuse. A 2013 federal study showed that four out of five heroin initiates had previously abused opioid medications such as OxyContin and Vicodin. In Hudson, a mother of a 21-year-old girl, who died from a heroin overdose, has acknowledged that her daughter’s addiction began “like most kids in this town, at the [prescription] pad of a doctor.”
There is also increasing focus on dealing with the heroin crisis in terms of public health issues as much as issues related to law enforcement. Police have been meeting with social service workers; revitalization of neighborhoods has been receiving much-needed attention. In Rutland, the first methadone clinic has opened for heroin abuse treatment. Hudson residents have become advocates of a “Good Samaritan law” at the state level that would grant immunity from drug prosecution to those who called 911 or otherwise helped an overdose victim. No one in any community is proud to find themselves in this circumstance, but as a community leader in Rutland expressed it, “…we confront our problems and deal with them.”
Sources: Hedegaard, Holly; Chen, Li-Hui; and Warner, Margaret (2015, March). Drug-poisoning deaths involving heroin: United States, 2000-2013. NCHS Data Brief, No. 190. Atlanta, GA: Centers for Disease Control and Prevention. Seelye, Katherine Q. (2014, February 28). A call to arms on a Vermont heroin epidemic. New York Times, pp. A1, A17. Second quotation on p. A17. Sontag, Deborah (2014, February 11). Heroin’s small-town toll, and a mother’s grief. New York Times, pp. A1, A13. First quotation on p. A13.
Drugs … in Focus
75 Tons of oxycodone produced in the world 27,400,000 Grams of hydrocodone that Americans demand annually 3,247 Grams of hydrocodone that people demand in Britain, France, Germany, and Italy combined.
Source: Ricks, Delthia (2012, January 22). Narcotics nation. Newsday, pp. A10–A11.
Numbers Talk…
same time, the potential for enslaving our minds and bringing ruin to our lives and our families. This chapter will concern itself with the medical uses and recreational abuses of opioid drugs, with a focus on problems associated with prescription opioid medications and, most recently, the epidemic of heroin abuse and heroin-related deaths across America, in communi- ties large and small (Drugs … in Focus). We begin by explain- ing what it means for a drug to be called an opioid.
There is no escaping the love–hate relationship we have with opium and a category of similarly acting drugs collectively known as opioids.1 Here is a group of psychoactive drugs with the astonishing ability to banish pain from our lives and, at the
opioids (Oh-Pee-OIDS): Drugs that share the psychoactive properties of opium and opium extracts.
Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 157
hydrocodone (brand names: Hycodan, Vicodin), and buprenorphine (brand names: Subutex, Suboxone).
●■ The fourth category comprises drugs that are created entirely in the laboratory. They are often referred to as synthetic opioids. Examples include methadone, meperidine (brand name: Demerol), propoxyphene (brand names: Darvon, Darvocet), LAAM (brand name: Orlaam), and tramadol (brand names: Ultram, Ultracet).
For decades, opioid drugs have been referred to as narcotics (from the Greek word for “stupor”), based on their ability to produce a dreamlike effect on the user and at higher doses induce a state of sleep. In fact, the term “narcotic” was used at one time (inappropriately) to mean any illicit psy- choactive drug or at least any drug that caused some degree of dependence, including such unlikely drugs as cocaine and amphetamine, which are anything but sleep-inducing (see Chapter 10). Even today, it is likely that a police unit assigned to the enforcement of drug laws will be called a “narcotics unit.” So the name has definitely stuck. Ironically, there are specific drugs that have no relationship to opium or opioids but have far greater effectiveness in inducing sleep (see Chapter 14).
What Are Opioids?
The term, opioid, means “opium-like.” This means that any opioid drug is similar to opium in its pharmacological effect on the body. Technically speaking, opioid drugs share the common feature of binding to morphine-sensitive receptors in the brain (see Chapter 5). Some of these opioid drugs are derived directly from some of the compounds in opium while others are created (synthesized) in the laboratory.
Putting it all together, we can understand the diver- sity of opioid drugs in terms of four broad categories (see Figure 9.1).
●■ The first category comprises three natural compounds that are directly extracted from opium itself: morphine, codeine, and thebaine. All opioids having their origin in these compounds are referred to as opioid extracts.
●■ The second category comprises derivative compounds that are created by making specific changes in the chemical composition of morphine. Examples are heroin, hydro- morphone (brand name: Dilaudid), oxymorphone (brand names: Numorphan, Opana), and the extended-release form of oxymorphone (brand name: Opana ER).
●■ The third category comprises derivative compounds that are created by making specific changes in the chemi- cal compo sition of codeine or thebaine. Examples are oxycodone (brand names: Percodan, Percocet), the extended- release form of oxycodone (brand name: OxyContin),
narcotics: A general term referring to opium, opium extracts, opioid derivatives, and related drugs. Historically, it has been used to refer to non-opioid drugs as well.
Opium Extracts
methadone meperidine (Demerol)
propoxyphene (Darvon, Darvocet)
tramadol (Ultram, Ultracet)
buprenorphine (Subutex, Suboxone)
Opioid Derivatives
oxycodone (Percodan, Percocet)
controlled-release oxycodone
(OxyContin)
morphine
heroin
LAAM (Urlaam)
hydromorphone (Dilaudid)
oxymorphone (Numorphan,
Opana IR)
extended-release oxymorphone (Opana ER)
codeine
hydrocodone (Hycodan, Vicodin)
Synthetic Opioids
opium
thebaine
F Igure 9 .1 .
Major opioid drugs
Source: Based on information from Physicians’ desk reference (69th ed.) (2015). Montvale, NJ: PDR Network. Raj, P. Prithvi (1996). Pain medicine: A comprehensive review. St. Louis: Mosby, pp. 126–153.
158 ■ Part Three Legally Restricted Drugs and Criminal Justice
In the second century c.e., Claudius Galen, a famous Greek physician and surgeon to Roman gladiators, recommended opium for practically everything. According to Galen, opium could cure ailments such as chronic headaches, coughs of all kinds, laryngitis, colic, asthma, deafness, seizures, spitting of blood, and leprosy, to name a few.4 Galen’s enthusiasm seems to have been boundless (although he was correct about the ben- efits of opium for coughing). Interestingly, there are no records in ancient times that refer to the recreational use of opium or to any problems of opium abuse.5
Western Europe was introduced to opium in the elev- enth and twelfth centuries by returning crusaders who had learned of it from the Arabs. During the first stirrings of mod- ern medicine in Europe, opium began to be regarded as a therapeutic drug. In 1520, a physician named Paracelsus, promoting himself as the foremost medical authority of his day, introduced a medicinal drink combining opium, wine, and an assortment of spices. He called the mixture laudanum (derived from the Latin phrase meaning “something to be praised”), and before long the formula of Paracelsus was being called the “stone of immortality.” Even though Paracelsus himself denounced many of the doctrines of Galen and earlier physicians in history, he continued the time-honored tradition of recommending opium for practically every known disease.
In 1680, the English physician Thomas Sydenham, considered the father of clinical medicine, introduced and promoted a version of opium drink similar to that of Paracelsus, called Sydenham’s Laudanum. Not surprisingly, Sydenham’s Laudanum was enormously popular. For the next 200 years or so, the acceptable means of taking opium among Europeans and, later, Americans would be in the form of a drink, either Sydenham’s recipe or a host of variations. Sydenham’s enthusiasm for opium was no less than that of his predecessors. “Among the remedies,” he wrote, “which it has pleased Almighty God to give man to relieve his sufferings, none is so universal and so efficacious as opium.”6 Opium was one of the very few medications that physicians had to treat their patients in those days.
The Opium War
Sometime in the eighteenth century, China invented a novel form of opium use, opium smoking, which eventually became synonymous in the Western mind with China itself. However, for at least 800 years before that, the Chinese had used opium only in a very limited way. They took it almost exclusively on a medicinal basis, consuming it orally in its raw state as a highly effective painkiller and treatment for diarrhea (see Table 9.1, page 166).
The picture was soon to change dramatically, strangely enough, when the British people discovered and fell in love with Chinese tea. Sensing a business opportunity, British merchants in China sought a way to buy Chinese tea and transport it home for a handsome profit. But what could they sell to the Chinese in exchange? The problem was that there
Opioids in History
The history of heroin and the other opioid drugs can be traced back to faraway times and places. This particular story begins with a method of harvesting of raw opium that has not changed much in more than 3,000 years. It takes place today in remote villages of Myanmar (formerly, Burma), Laos, Thailand, Afghanistan, Kazakhstan, Mexico, Colombia, Peru, and other countries where the weather is hot and labor is cheap. The source of opium is the opium poppy, known by its botanical name as Papaver somniferum (literally, “the poppy that brings sleep”), an annual plant growing three to four feet high. Its large flowers are typically about four or five inches in diameter and can be white, pink, red, or purple.
The process of extracting opium out of the opium poppy is simple. When the petals of the opium poppy have fallen but the seed capsule of the plant underneath the petals is not yet completely ripe, laborers make small, shallow inci- sions in the capsules during the day, allowing a milky white juice to ooze out during the night. By the next morning, this substance will have oxidized and hardened by contact with cool air. Now, they go from plant to plant, collecting the juice onto large poppy leaves. At this point, opium is reddish brown in color and has the consistency of heavy syrup. Later, it darkens further and forms small gumlike balls.2
The first written references to opium date back to the early third century b.c., but we can be fairly sure that it was used for at least a thousand years before that. A ceramic opium pipe has been excavated in Cyprus, dating from the Late Bronze Age, about 1200 b.c. Cypriot vases from that era depict incised poppy capsules. From evidence contained in the Ebers Papyrus writings (see Chapter 3), we know that Egyptians were knowl- edgeable about the medicinal value of opium.3
opium: An analgesic and euphoriant drug acquired from the dried juice of the opium poppy.
Local villagers harvest opium in a poppy field in the Khogyani district of Jalalabad, east of Kabul, Afghanistan in 2013.
Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 159
itself was everywhere. The important difference between China and Britain with respect to opium was not in the extent of its consumption but in the way it was consumed. The acceptable form of opium use in Victorian England was opium drinking through the consumption of laudanum. However, the Asian form of opium use was opium smoking, a practice that was seen from a European perspective as being linked to a lifestyle of vice and degradation and associated with the least desirable elements of society.
The contrast was strikingly ironic. Opium dens, with all the evil connotations that the phrase has carried into modern times, were the places where opium was smoked; the respectable parlors of middle-class British families were the places where opium was drunk.
Opium drinking was pervasive in British society at the time. Supplies of opium were unlimited, cheaper than gin or beer, and an entirely legal commodity. Medical opinion was at most divided on the question of any potential harm; there was no negative public opinion and seldom any trou- ble with the police. As long as there were no signs of opium smoking, a chronic opium abuser was considered no worse than a drunkard. Nearly all infants and young children in Britain during this period were given opium, often from the day they were born. Dozens of laudanum-based patent medicines (with appealing names such as Godfrey’s Cordial, A Pennysworth of Peace, and Mrs. Winslow’s Soothing Syrup) were used to dull teething pain or colic, or merely to keep the children quiet. The administration of opium to babies was particularly attractive in the new, industrial-age lifestyle of female workers, who had to leave their infants in the care of elderly women or young children when they went off to work in the factories.
Out of this climate of acceptance sprang a new cultural phenomenon: the opium-addict writer. Just as LSD and other hallucinogens were to be promoted in the 1960s as an avenue toward a greatly expanded level of creativity and imagination (see Chapter 11), a similar belief was spreading among intel- lectuals during this period with respect to opium. The leader of the movement was Thomas DeQuincey, and his book
were few, if any, commodities that China really wanted from the outside. In their eyes, the rest of the world was populated by “barbarians” with an inferior culture, offering little or nothing the Chinese people needed.
The answer turned out to be opium. In 1773, British forces had conquered Bengal Province in India and suddenly had a monopoly on raw opium. Consequently, the British had great quantities of opium on their hands. Here was an opportunity to introduce Indian-grown opium to China as a major item of trade. Despite the understandable opposi- tion by the Chinese government, British opium soon flooded into China, smuggled in by local British and Portuguese merchants. This tactic enabled the British government and its official trade representative, the East India Company, to maintain a public image of not being directly involved. Opium was traded for Chinese tea, a satisfactory arrange- ment from the perspective of Britain but certainly not from the perspective of China.
Huge quantities of opium found a ready market in south- ern port cities such as Canton. With the influx of opium into China, the character of opium use changed from its origi- nal medicinal purposes to a form of recreational drug-taking behavior. It did not take long for Chinese opium smoking and opium dependence to become a major social problem. Repeated edicts by the Chinese emperor to reduce the use of opium within China or cut the supply line from India failed. The situation was out of control.7
In 1839, tensions had reached a peak. In a historic act of defiance against the European powers, specifically Britain, an imperial commissioner appointed by the Chinese emperor to deal with the opium problem once and for all, confiscated a shipment of opium and burned it publicly in Canton. His courageous act, however, was not appreciated by the British. Events escalated shortly thereafter, until open fighting broke out between Chinese and British soldiers. The Opium War had begun.
By 1842, British artillery and warships had overwhelmed a nation unprepared to deal with European firepower. In a humiliating treaty, China was forced to sign over to Britain the island of Hong Kong and its harbor (until the distant year of 1997), grant to British merchants exclusive trading rights in major Chinese ports, and pay a large amount of money to reimburse Britain for losses during the war. Despite these agreements, fighting broke out again between 1858 and 1860; with French and American forces joining the British. In a treaty signed in 1860, China was required to legalize opium within its borders. The Opium War succeeded in opening up the gates of China, much against its will, to the rest of the world.8
Opium in Britain and the United States
To the average British citizen in the mid-1800s, the Opium War in China was purely a trade issue, a faraway conflict with little or no direct impact on one’s daily life. Nonetheless, opium
A nineteenth-century advertising card for Mrs. Winslow’s Soothing Syrup, a popular opium remedy, was directed toward young mothers and their children.
160 ■ Part Three Legally Restricted Drugs and Criminal Justice
smoking was well known to them, and it served as a safety valve for an obviously oppressed society of men. In 1875, San Francisco outlawed opium smoking for fear, to quote local authorities of the time, that “many women and young girls, as well as young men of respectable family, were being induced to visit the dens, where they were ruined morally and otherwise.”12 No mention was ever made of any moral ruin resulting from drinking opium at home. The anti-Chinese prejudice in America with respect to opium would parallel racial prejudice with respect to cocaine (see Chapter 10).
A federal law forbidding opium smoking soon followed, whereas the regulation of opium use by any other means failed to receive legislative attention at that time. By the beginning of the twentieth century, however, the desire for social control of opium dens became overshadowed by the emergence of opium-derived drugs that presented a substantially greater threat to society than smoked opium.13
Morphine and the Advent of Heroin
In 1803, a German drug clerk named Friedrich Wilhelm Adam Sertürner first isolated a yellowish-white substance in raw opium that turned out to be its primary active ingredient. He called it morphine, in honor of Morpheus, the Greek god of dreams. For the first time, more than three-fourths of the total weight of opium (containing inactive resins, oils, and sugars) could be separated out and discarded. Morphine represented roughly 10 percent of the total weight of opium, but it was found to be roughly ten times stronger than raw opium. All two dozen or so compounds that were eventually isolated from opium were found to be weaker than morphine and formed a far smaller proportion of opium. Besides morphine, two other major compounds were isolated from opium: codeine (about 0.5% of raw opium) and thebaine (about 0.2% of raw opium). Both codeine and thebaine were found to have considerably weaker opioid effects.
With the invention of the hypodermic syringe in 1856, morphine could now be injected into the bloodstream rather than administered orally, thus bypassing the gastrointestinal tract and speeding the delivery of effects (see Chapter 4). The new potential for pain relief through morphine injection was welcomed by the medical profession, owing to its usefulness in dealing with the traumas of the Civil War in the United States (1861–1865) and later the Franco-Prussian War in Europe (1870–1871). It is not surprising, however, that large numbers of soldiers became dependent on morphine and maintained the condition in the years that followed. After the Civil War, morphine dependence was so widespread among Union and Confederate veterans that the condition was often called the “soldier’s disease.”14
Against the backdrop of increasing worry about opiate dependence, a new painkilling morphine derivative called heroin was introduced into the market in 1898 by the Bayer Company in Germany, the same company that had been
Confessions of an English Opium Eater, published in 1821, became the movement’s bible. It is impossible to say how many people started to use opium recreationally as a direct result of reading DeQuincey’s ecstatic revelations about “opium eating” (by which he meant opium drinking in the form of laudanum), but there is no doubt that the book made the practice fashion- able. Prominent English authors enamored with laudanum included Elizabeth Barrett Browning and Samuel Taylor Coleridge (whose exotic poem Kubla Khan was undoubtedly inspired by his numerous “opium high” experiences).9
Opium use was not limited to Britain. In many ways, opium consumption in the United States paralleled its wide- spread use in Britain. In one survey of 35 Boston drugstores in 1888, three out of four prescriptions that had been refilled three or more times contained opium. Until 1942, opium poppies were cultivated in Vermont and New Hampshire, in Florida and Louisiana, and later in California and Arizona. Women outnumbered men in opium use during the nine- teenth century by as much as 3 to 1. As one historian has suc- cinctly put it, “husbands drank alcohol in the saloon; wives took opium at home.”10
Throughout the 1800s, opium coexisted alongside alcohol, nicotine (in tobacco products), and cocaine as the dominant recreational drugs of the day. As late as 1897, the popular Sears, Roebuck and Company mail-order catalog was advertising lau- danum for sale for about six cents an ounce. In a clever market- ing move directed to alcoholic men, Sears’s “White Star Secret Liquor Cure” was promoted as an addition to the gentleman’s after-dinner coffee so that he would be less inclined to join his friends at the local saloon. In effect, he would probably fall asleep at the table or nod off shortly afterward, since the “cure” was opium. If customers became dependent on opium, perhaps as a result of taking the “liquor cure,” then fortunately they could order “A Cure for the Opium Habit,” promoted on another page of the same catalog. If you guessed that the ingre- dients in this one included a heavy dose of alcohol, you would be right.11
Given the openness of opium drinking in the nineteenth- century United States, we can only surmise that the fanatical reaction against the practice of opium smoking was based on anti-Chinese prejudice rather than any position with respect to opium itself. It is clear that intense hostility existed toward the thousands of Chinese men and boys brought to the West in the 1850s and 1860s to build American railroads. Since most of the Chinese workers were recruited from the area around Canton (now named Guangzhou), where opium trafficking was particularly intense, the practice of opium
heroin: A chemical derivative of morphine. It is approximately three times as potent as morphine and a major drug of abuse.
thebaine (thee-bayn): One of three active ingredients in opium.
codeine (COh-deen): One of the three active ingredients in opium, used primarily to treat coughing.
morphine: The major active ingredient in opium.
Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 161
we rely on the upper estimate, then we are speaking of roughly one out of every hundred Americans, young or old, living at that time. It is difficult to say how many of them were specifi- cally dependent on heroin; but if a large proportion were, then we can make a comparison to the 2013 estimate of 289,000 Americans (aged 12 or older) who have used heroin alone within the past month, out of a present-day population that is roughly four times the population in 1900. In other words, one out of every thousand Americans, young or old, is an active heroin abuser, according to the 2013 National Survey on Drug Use and Health. You can appreciate the impact that opi- oids were having on American society in the early twentieth century.16
The size of the opioid-abusing population alone at that time probably would have been sufficient grounds for social reformers to seek some way of controlling these drugs, but there was also the growing concern that the problems of opioid abuse were becoming closely associated with crimi- nal elements. There was a gnawing anxiety and fear that opioid drugs, specifically heroin, were creating a signifi- cant disruption in American society. A movement began to build toward instituting some system of governmental regulation. Opioid use would soon be enmeshed in the world of criminal justice.
Opioid Use and Heroin Abuse after 1914 The Harrison Act of 1914 (see Chapter 3) radically changed the face of opioid use and abuse in the United States. It ushered in an era in which the abuser (predominantly male) was no longer a victim of drugs worthy of society’s sympathy. Instead, he was now viewed as weak, degenerate, and self- indulgent, a “contaminant” infecting his community’s social order and, as a result, deserving society’s moral outrage and whatever legal sanction it could devise.17
The situation, however, did not change overnight. Most importantly, the 1914 legislation did not actually ban opioids. It simply required that doctors register with the Internal Revenue Service the opioid drugs (as well as cocaine and other coca products) that they were prescribing to their patients and pay a small fee for the right to prescribe such drugs. The real impact of the new law came later, in the early 1920s, as a result of several landmark decisions sent down from the U.S. Supreme Court that interpreted the Harrison Act in broader terms. Under the Court’s interpretation of the Harrison Act, no physician was permitted to prescribe opioids for “nonmedical” use. In other words, it was now illegal for addicted individuals to obtain drugs merely to maintain their habit, even from a physician. Without a legal source for their drugs, opioid abusers were forced to abandon them alto- gether or turn to illegal means, and the drug dealer suddenly provided the only place where opioids, particularly heroin, could be obtained.
Heroin became the perfect black market drug. It was easier and more profitable to refine it from raw opium over- seas and ship it into the country in small bags of odorless
highly successful in developing acetylsalicylic acid as an analgesic drug and marketing it as “Bayer’s Aspirin.” About three times stronger than morphine, and, strangely enough, believed initially to be free of morphine’s dependence- producing properties, heroin (from the German heroisch, meaning “powerful”) was hailed as an entirely safe cough sup- pressant (preferable to codeine) and as a medication to relieve the chest discomfort associated with pneumonia and tuber- culosis. In retrospect, it is incredible that from 1898 to 1905, no fewer than 40 medical studies concerning injections of heroin failed to recognize its potential for dependence! The abuse potential of heroin, which we now know exceeds that of morphine, was not fully recognized until as late as 1910.15
Why is heroin more potent than morphine? The answer lies in its chemical composition. Heroin consists of two acetyl groups joined to a basic morphine molecule. These attach- ments make heroin more fat soluble and hence more rapidly absorbed into the brain. Once inside the brain, the two ace- tyl groups break off, making the effects of heroin chemically identical to that of morphine. One way of understanding the relationship between the two drugs is to imagine morphine as the contents inside a plain cardboard box and the heroin as fancy box covered with gift wrapping. The contents remain the same, but the wrapping increases the chances that the box will be opened.
Opioids in American Society
The introduction of heroin at the end of the nineteenth cen- tury was the beginning of a new era in the history of opioid drugs. By 1900, there were, by one conservative estimate, 250,000 opioid-dependent people in the United States, and the actual number could have been closer to 750,000 or more. If
An original heroin bottle as marketed by the Bayer Company in 1898.
162 ■ Part Three Legally Restricted Drugs and Criminal Justice
drank it mixed with alcohol, even though most of the drug was lost as it was filtered through the liver en route to the bloodstream.21
In 1971, it was estimated from survey data that about 11 percent of American troops were regular users of heroin and about 22 percent had tried it at least once. Beyond the concern for the soldiers overseas, there was the consider- able worry that at least 1 in 10 Vietnam veterans would be returning home heroin dependent and continuing a pattern of heroin abuse. As a response, the military instituted a man- datory program of urinalysis testing (appropriately named Operation Golden Flow), conducted near the end of a soldier’s tour of duty. In October 1971, three months of test- ing showed that about 5 percent of soldiers tested positive for heroin. The percentage of heroin abusers at that time could very well have been higher since there were strong indications that soldiers had voluntarily given up heroin prior to their being shipped home.22 Fortunately, a compre- hensive investigation in 1974 showed that only 1–2 percent of Vietnam veterans were regular heroin abusers one year following their return from overseas—approximately the same percentage as those entering the military from the general population.
Even if the original numbers of heroin abusers in Vietnam had been exaggerated in the first place (and evidence now sug- gests that the story was hyped out of proportion by the media at the time), the low number among returnees presents an interesting question. What happened to those who had been previously heroin abusers after they returned to the United
heroin powder than it was to transport raw opium with its characteristic odor. In addition, because it had to be obtained illegally and supplies were short, heroin’s price tag skyrock- eted to 30–50 times what it had cost when it was available from legitimate sources, a classic example of the economic law of supply and demand (see Chapter 6).18
With the emergence of restrictive legislation, the demo- graphic profile of opioid users changed dramatically. No longer could the typical consumers of opioid drugs be char- acterized as female, predominantly white, middle aged, and middle class, as likely to be living on a Nebraskan farm as in a Chicago townhouse. In their place were young, predomi- nantly white, urban adult males, whose opioid drug of choice was intravenous heroin and whose drug supply was con- trolled by increasingly sophisticated crime organizations.19
Heroin Abuse in the 1960s and 1970s In the minds of most Americans prior to the 1960s, heroin and heroin abusers could be comfortably relegated to the social and moral fringes of America. Three major social developments were to bring the heroin story back into the mainstream of the United States. The first began in late 1961, when a crackdown on heroin smuggling resulted in a significant shortage of heroin on the street. The price of heroin suddenly increased, and heroin dosages became more adulterated than ever before. Predictably, the high costs of maintaining heroin dependence encouraged new levels of criminal behavior. Heroin abuse soon imposed a cultural stranglehold on many African American and Latino commu- nities in major U.S. cities.
A second development, beginning in the 1960s, affected the white majority more directly. Fanned by extensive media attention, a youthful counterculture of hippies, flower chil- dren, and the sexually liberated swept the country. The unconventionality of fashions and the antiestablishment attitudes of young people in all parts of the country led to a wave of experimentation with a variety of illicit drugs, includ- ing heroin. Heroin could no longer be someone else’s prob- lem. It was now making its insidious way into the homes and neighborhoods of middle America.20
Finally, disturbing reports about heroin abuse began to appear, which focused not only on Americans at home but also on American armed forces personnel stationed in Vietnam. Reports beginning in the late 1960s indicated an increas- ingly widespread recreational abuse of heroin, along with alcohol, marijuana, and other drugs, among U.S. soldiers. With regard to heroin, in particular, the circumstances could not have been worse. Vietnamese heroin was 90–98 percent pure, compared to 2–10 percent pure in the United States at the time, and incredibly cheap to buy. A 250- milligram dose of heroin, for example, could be purchased for $10, whereas the standard intravenous dose on the streets of a major U.S. city would amount to only 10 milligram. A comparable 250 milligram of highly diluted U.S. heroin would have cost about $500. With the purity of heroin supplies so high, most U.S. soldiers smoked or sniffed heroin to get an effect; some
Military involvement in Vietnam brought U.S. soldiers in contact with unusually potent doses of heroin and other psychoactive drugs.
Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 163
white-powder heroin in the United States, judged from the analysis of drug seizures, was no longer Asia but South America, principally Colombia. Street heroin from South American sources was now both cheaper and purer. The purity of Colombian heroin during this time exceeded 60 percent, at least ten times more powerful than the typi- cal street heroin in the 1970s. In 1994, a 90-percent-pure brand of heroin circulating in New York City took her- oin abusers by surprise; several overdose deaths occurred within a period of five days. Street prices for a milligram of heroin in New York fell from $1.81 in 1988 to as little as 37 cents in 1994. By government estimates, heroin con- sumption nationwide in 1996 had doubled from a decade earlier. As one writer put it, it was as though the an auto- mobile were suddenly redesigned to go 180 miles per hour and people could buy it at half the former price!25
In the mid-1990s, there was also a shift in the percep- tion of heroin abuse itself. As the popularity of cocaine abuse declined and the incidence of crack abuse began to ebb, the spotlight once more turned toward the allure of heroin itself. For a brief time, popular movies (Pulp Fiction in 1994, Trainspotting in 1995), fashion photography, and the introduction of the Calvin Klein fragrance “Opium” in 1996 contributed to a glamorization of heroin abuse. The media dubbed the phenomenon “heroin chic.”
As the potency of heroin increased during the 1990s, a significant change occurred in the way heroin was abused. Due to the availability of increasingly pure heroin, the drug no longer needed to be injected. Instead, it could be snorted (inhaled through the nose) or smoked. New heroin abus- ers were frequently smoking mixtures of heroin and crack cocaine or heating heroin and inhaling its vapors. These methods of heroin abuse avoided potential HIV infections or hepatitis through contaminated needles, but they did not prevent the dependence that heroin could produce or the risk of heroin overdose.
Unfortunately, heroin snorting or smoking opened the door to new populations of potential heroin abusers, who had previously stayed away from the drug because of their aversion to hypodermic needles. The University of Michigan survey indicated in 2013 that 1–2 percent of all high school seniors used heroin at some time in their lives, with a majority of them smoking heroin rather than injecting it.26
More than 90 percent of the world’s supply of heroin today originates from the opium crop in Afghanistan, but rel- atively little is destined for the United States. The major sup- plies of U.S. heroin come from opium grown in Colombia and Mexico. Mexico serves as the principal transport route
States? It has been proposed that heroin use was specific to involvement in Vietnam. Once the soldiers returned home, the stressful environmental cues and motivational factors for drug abuse were no longer present.23 Does that mean that it is possible to abuse heroin without becoming dependent on it? This question will be addressed later in the chapter.
Heroin since the 1980s At one time, the major source of white powder heroin smuggled into the United States was Turkey, where the opium was grown, and the center of heroin manufac- ture and distribution was Marseilles in southern France (Chapter 2). When this heroin trafficking route was closed in 1973, other parts of the world were encouraged to fill the vacuum. The “Golden Triangle” region of Laos, Myanmar (formerly, Burma), and Thailand became the principal players in providing the United States with heroin. Joining Southeast Asian heroin suppliers were southwest Asian nations such as Afghanistan, Pakistan, and Iran (in the “Golden Crescent”), as well as the central Asian nations of Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan. As a consequence of these new sources, the purity of imported heroin at this time increased from around 5 percent to more than 18 percent.24
Although the growth of crack cocaine abuse in the 1980s pushed the issue of heroin abuse temporarily off the front page, heroin abuse itself continued in new forms and varia- tions. Besides the influx of an inexpensive form of Mexican heroin (“black tar”), new synthetic forms of heroin were appearing on the street as well. One synthetic opioid, created in illegal drug laboratories within the United States was derived from fentanyl, a prescription opioid drug. Chemical modifications of fentanyl, anywhere from ten to a thousand times stronger than heroin, were sold for recreational use, with the name “China White” (not to be confused with the name given to Southeast Asian heroin in the 1970s).
Owing to an unfortunate loophole in drug laws at the time, fentanyl derivatives and similar “designer drugs” were not illegal substances and therefore could not be dealt with by law enforcement. Because they were not chemically identical to heroin or other specific drugs covered by the Controlled Substances Act of 1970, drug-control laws did not apply to them. In 1986, the Controlled Substance Analogue Act was enacted, establishing any drug with a chemical struc- ture or pharmacological effect similar to that of a controlled substance to be as illegal as the genuine article. As men- tioned in Chapter 1, however, present-day technologies have made it possible for hundreds of new chemical formulation of controlled substances, including opioids and marijuana, to be synthesized and then introduced into the illicit drug mar- ket. Drug-control authorities are continually playing “catch up” as each new formulation becomes available. As a result, the enforcement of the law (to the extent that was intended) remains a major challenge.
The mid-1990s witnessed still another shift in the pattern of heroin trafficking. The dominant source of
fentanyl (FeN-teh-nil): A chemical derivative of thebaine, used as a prescription painkiller. The street name for fentanyl and related compounds is China White.
black tar: A potent form of heroin, generally brownish in color, originating in Mexico.
164 ■ Part Three Legally Restricted Drugs and Criminal Justice
variously described as a “rush” or a “flash,” followed later by a state of tranquil drowsiness that heroin abusers often call being “on the nod.” During this period, which lasts from three to four hours, any interest in sex is greatly diminished. In the case of male heroin abusers, the decline in sexual desire is due, at least in part, to the fact that opiates reduce the levels of testosterone, the male sex hormone. Withdrawal symptoms can begin in about four hours. Therefore, main- taining a relatively constant “heroin high” often requires three or four administrations in a given day.29
Ironically, an individual’s first-time experience with her- oin may be considerably unpleasant. Opioids in general cause nausea and vomiting, as the reflex centers in the medulla are suddenly stimulated. Some first-time abusers find the vomit- ing so aversive that they never try the drug again; others con- sider the discomfort largely irrelevant because the euphoria is so powerful.
There are a number of additional physiological changes in the body. A sudden release of histamine in the bloodstream produces an often intense itching over the entire body and a reddening of the eyes. Heroin also causes pupillary constric- tion, resulting in the characteristic “pinpoint pupils” that are used as an important diagnostic sign for narcotic abuse in general. Like sedative–hypnotic drugs (see Chapter 14), heroin reduces the sensitivity of respiratory centers in the medulla to levels of carbon dioxide, resulting in a depression in breathing. At high doses, respiratory depression is a major risk factor that can result in death. Blood pressure is also depressed from heroin intake. A suppression of the immune system over time increases the risk of infectious disease. Finally, a distressing, though nonlethal, effect of heroin is the slowing down of the gastrointestinal tract, causing labored defecation and intense constipation.30
How Opioids Work in the Brain
As a result of major discoveries in the 1970s, it is clear that we are dealing with a more direct effect: the activation of receptors in the brain that are specifically sensitive to mor- phine. During the 1960s, suspicions grew that a morphine- sensitive receptor, or a family of them, existed in the brain. One major clue came from the discovery that small chemical alterations in the morphine molecule would result in a group of new drugs with strange and intriguing properties. Not only would these drugs produce little or no agonistic effects—that is, they would not act like morphine—but they would instead act as opioid antagonists—that is, they would reverse or block the effects of morphine.
The most complete opioid antagonist to be identified, naloxone (brand name: Narcan), has turned out to have enormous therapeutic benefits in the emergency treatment of opioid-overdose patients. In such cases, intramuscular or intravenous injections of naloxone reverse the depressed breathing and blood pressure in a matter of a minute or
for Colombian heroin. As detailed in Chapter 2, however, illicit drug trafficking is in constant flux, subject to shifting market demands and the continuing challenges to traffickers posed by U.S. and international law enforcement agencies.27
Effects on the Mind and the Body
Recreational opioid use in the United States involves a range of drugs other than heroin itself, but we will concen- trate on acute effects from the perspective of the heroin abuser. We have to be careful, however, to recognize that the specific effects are quite variable. The intensity of a response to heroin changes as a function of (1) the quantity and purity of the heroin taken, (2) the route through which heroin is administered, (3) the interval since the previous dose of heroin, and (4) the degree of tolerance of the user to heroin itself. In addition, there are psychological factors related to the setting, circumstances, and expectations of the user that make an important difference in what an indi- vidual feels after taking heroin.28 Nonetheless, there are several major effects that occur often enough to qualify as typical of the experience.
If heroin is injected intravenously, there is an almost immediate tingling sensation and sudden feeling of warmth in the lower abdomen, resembling a sexual orgasm, for the first minute or two. There is a feeling of intense euphoria,
naloxone (nah-LOX-ohn): A pure antagonist for morphine and other opioid drugs. Brand name is Narcan.
Quick Concept Check
Understanding the History of Opium and Opioids Check your understanding of the historical background for opium and opioids by answering the following question. Imagine yourself to be living as a male adult in the year 1900. Check yes or no to indicate whether the following psychoactive drugs would be available to you.
1. Heroin □ yes □ no
2. Opium □ yes □ no
3. Fentanyl □ yes □ no
4. Oxycodone □ yes □ no
5. Morphine □ yes □ no
Answers: 1. yes 2. yes 3. no 4. no 5. yes
9.1
Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 165
A long-acting form of naloxone, naltrexone (brand name: ReVia, previously marketed as Trexan), administered orally three times per week, has since been found to be a useful medication in the treatment of heroin abuse, mainly for patients who are highly motivated to stop their drug- taking behavior. Such patients include doctors, nurses, and other health professionals who must end a pattern of heroin abuse to retain their licenses and former heroin abusers on parole who are at risk of returning to prison if they suffer a relapse. Injectable slow-release formulations that extend the effects of naltrexone over 30 days or more are presently being investigated, in an effort to free patients from having to rely on a more frequent oral administration schedule. A once-per-month slow-release form of naltrexone (brand name: Vivitrol) has been available for alcohol dependence since 2006 (see Chapter 15). In 2009, a combined naltrex- one and extended-release morphine capsule (brand name: Embeda) was introduced to provide a morphine-induced analgesia while reducing the possibility of abuse. The com- bination makes it impossible to crush and snort the capsules, because crushing releases the naltrexone and counteracts the morphine effect (see pages 173–176 for the problems of OxyContin abuse).32
Patterns of Heroin Abuse
The dominant route of administration in heroin abuse is intravenous injection, usually referred to as either mainlining or shooting. Heroin also can be administered through a variety of other routes. Heroin smoking is pop- ular in Middle Eastern countries and in Asia, but until very recently it has seldom been observed in the United States. Newcomers to heroin may begin their abuse either by snorting the drug through the nose or injecting it sub- cutaneously (skin popping). Experienced heroin abusers may snort heroin to avoid using a needle or choose the subcutaneous route when they can no longer find veins in good enough condition to handle an intravenous injection. As mentioned earlier, an oral administration of heroin is usually worthless because absorption is extremely poor. American soldiers in Vietnam who were abusing heroin often took the drug orally, but because of the extremely high purity of the heroin being consumed, their effective dose levels equaled or slightly exceeded levels found on American streets at the time.
so, an effect so fast that emergency department specialists view the reaction as “miraculous.” The effect lasts for one to four hours. Higher doses of naloxone bring on symptoms that are similar to those observed following an abrupt with- drawal of opioids. Interestingly, in nondrugged people, naloxone produces only negligible changes, on either a physiological or a psychological level. Only if morphine or other opioid drugs are already in the body does naloxone have an effect.31
Beyond its practical application, the discovery of nal- oxone had important theoretical implications. The argu- ment went as follows: If such small molecular changes could so dramatically transform an agonist into an antago- nist, then the drug must be acting on some receptor in the brain that can be easily excited or inhibited. The concept of a special morphine-sensitive receptor fulfilled these requirements.
The actual receptors themselves were discovered in 1973, precisely where you would have expected them to be: in the spinal cord and brain, where pain signals are known to be processed, and in the limbic system of the brain, where emotional behaviors are coordinated. In other words, it was clear that the analgesic and euphoric properties of morphine were due to the stimulation of these receptors. Today, we refer to these receptors as opioid receptors in that all opioid drugs have the common feature of stimulating them.
Why would opioid receptors exist in the first place? No one seriously considered the possibility that receptors in the brain had been patiently waiting, during millions of years of evolutionary history, for the day that the juice of the opium poppy could finally slip inside them! The only logical answer was that we must have been producing our own opioid chemicals that had the ability to activate these receptors.
As a result of a series of important discoveries from 1975 to the early 1980s, three groups of natural morphinelike mol- ecules have been identified: enkephalins, beta-endorphins, and dynorphins. Together, they are known as endogenous opioid peptides, inasmuch as they are all (1) peptide mole- cules (amino acids strung together like a necklace), (2) opioid in function, and (3) produced within the central nervous sys- tem. Unfortunately, this is such an unwieldy name that more frequently they are simply referred to as endorphins.
What can we then conclude about the effect of opioids on the brain? The answer, as we now understand it, is that the brain has the ability to produce its own “opioid” substances, called endorphins, and contains a specific set of receptors to receive them. By an amazing quirk of fate, the opium poppy yields a similarly shaped chemical that fits into these recep- tors, thus producing equivalent psychological and physiologi- cal effects. Naloxone acts as an opioid antagonist because its structural features enable it to fit into these receptors, replac- ing the opioid molecules that have gotten in. The receptors themselves, however, are inactivated by naloxone. This is why naloxone can “undo” the acute effects of an opioid drug such as heroin.
naltrexone (nal-treX-ohn): A long-lasting form of naloxone. Brand name prior to 1994 was Trexan; brand name has since been changed to ReVia.
endogenous opioid peptides (en-DODge-eh-nus Oh- pee-oid PeP-tides): Also known as endorphins. A class of chemicals produced inside the body that mimic the effects of opioid drugs.
166 ■ Part Three Legally Restricted Drugs and Criminal Justice
the withdrawal symptoms are comparable to a moderate to intense case of the flu. In more severe cases, the withdrawal process can result in a significant loss of weight and body fluids. With recent increases in the purities of street heroin in the 1990s, the symptoms of withdrawal are greater. Only rarely, however, is the process of heroin withdrawal life threatening, unlike the withdrawal from barbiturate drugs (see Chapter 14).
It should not be surprising that withdrawal symptoms are essentially the mirror image of symptoms observed when a person is under the influence of heroin. If we are dealing with a group of endorphin-sensitive receptors that are, in the case of the heroin abuser, being stimulated by the opioids coming in from the outside, then it is reasonable to assume that over time, the production of endorphins would decline. Why produce something on your own when you are getting it from an external source? By that argument, withdrawal from heroin would then be a matter of cutting off those receptors from that external source, resulting in a reaction opposite to the one that would have occurred had the recep- tors been satisfied in the first place. Over a period of time, coinciding with the withdrawal period for a heroin abuser, we would expect that the normal production of endorphins would reestablish itself and there would be little or no need for the external supply of heroin.
The receptor explanation for heroin dependence sounds reasonable and does account for the presence of withdrawal symptoms, but unfortunately it is an oversimplification for heroin abuse in general. We would expect that once the endorphin-sensitive receptors regain their natural supply of endorphins, heroin abuse should end, but we know that it does not.
In the case of heroin abusers, their tendency to continue taking heroin is propelled by a number of factors. There is, first of all, the combination of fear and distress associated with the prospect of experiencing withdrawal symptoms, along with a genuine craving for the effects themselves, reflect- ing the physical and psychological dependence that heroin inflicts. In addition, long-term heroin abuse frequently pro- duces such a powerful conditioned-learning effect that the social setting in which the drug-taking behavior has occurred takes on reinforcing properties of its own (see Chapter 4). Even the act of inserting a needle can become pleasurable. Some heroin abusers (called needle freaks) continue to insert needles into their skin and experience heroinlike effects even when there is no heroin in the syringe. In effect, the heroin abuser is responding to a placebo. Any long-term treatment for heroin abuse, as will be discussed in a later section, must address a range of physical, psychological, and social factors to be successful (Table 9.2).
The Lethality of Heroin Abuse Considering the numbers of hospital emergencies and deaths associated with heroin abuse (see Chapter 1), you might be surprised that one would question the toxicity of
Tolerance and Withdrawal Symptoms A prime feature of chronic heroin abuse is the tolerance that develops, but the tolerance effects themselves do not occur in every bodily system. Gastrointestinal effects of constipation and spasms do not show much tolerance at all, whereas distinctive pupillary responses (the pinpoint feature of the eyes) eventually subside with chronic use. The greatest signs of tolerance are seen in the degree of analgesia, euphoria, and respiratory depression. The intense thrill of the intravenous injection will be notice- ably lessened. The overall decline in heroin reactions, however, is dose dependent. If the continuing dose level is high, then tolerance effects will be more dramatic than if the dose level is low.
The first sign of heroin withdrawal, a marked craving for another fix, generally begins about four to six hours after the previous dose and intensifies gradually to a peak over the next 36–72 hours, with other symptoms beginning a few hours later (Table 9.1). The abuser is essentially over the withdrawal period in five to ten days, though mild physio- logical disturbances, chiefly elevations in blood pressure and heart rate, are observed as long as six months later. Generally, these long-term effects are associated with a gradual with- drawal from heroin rather than an abrupt one.
The overall severity of heroin-withdrawal symptoms is a function of the dosage levels of heroin that have been sustained. When dosage levels are less than 10 percent,
tAbLe 9.1
Symptoms of administering heroin and of withdrawing heroin
ADMINISterINg WIthDrAWINg
Lowered body temperature Elevated body temperature
Decreased blood pressure Increased blood pressure
Skin flushed and warm Piloerection (gooseflesh)
Pupil constriction Pupil dilation
Constipation Diarrhea
Respiratory depression Yawning, panting, sneezing
Drying of secretions
Decreased sex drive
Tearing, runny nose
Spontaneous ejaculations and orgasms
Muscular relaxation Restlessness, involuntary twitching and kicking movements*
Nodding, stupor Insomnia
Analgesia Pain and irritability
Euphoria and calm Depression and anxiety
*The source of the expression “kicking the habit.”
Source: Adapted from Grilly, David M.; and Salamone, John. D. (2012). Drugs, brain, and behavior (6th ed.). Boston: Pearson Education, p. 298.
Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 167
●■ Heroin has a relatively small ratio of LD (lethal dose) to ED (effective dose). Increase a dose that produces a high in a heroin abuser by 10 or 15 times, and you will be in the dosage range that is potentially fatal. As a result, death by overdose is an ever-present risk. If we take into account the virtually unknown potency of street heroin in any given fix, we can appreciate the hazards of a drug overdose. The “bag” sold to a heroin abuser may look like the same amount each time, but the actual heroin content may be anywhere from none at all to 90 percent. Therefore, it is easy to underestimate the amount of heroin being taken in.
●■ Heroin abusers risk possible adverse effects from any toxic substance that has been “cut” with the heroin. Adding to the complexity, deaths from heroin overdose are frequently consequences of synergistic combinations of heroin with other abused drugs such as stimulants like cocaine or depressants like alcohol, Valium, or barbitu- rates. In some cases, individuals have smoked crack as their primary drug of abuse and snorted heroin to ease the agitation associated with crack. In other cases, lines of cocaine and heroin are alternately inhaled in a single session, a practice referred to as “criss-crossing.”
●■ It is also possible that some heroin abusers develop unstable levels of tolerance that are tied to the environmental setting in which the heroin is administered. As a result of condi- tioned tolerance (see Chapter 4), a heroin dose experienced in an environment that has not been previously associated with drug taking may have a significantly greater effect on the abuser than the same dose taken in more familiar sur- roundings. Consequently, the specific effect on the abuser is highly unpredictable. The surge in heroin overdose deaths around the country in recent years is at least partially due to this phenomenon (Drugs … in Focus).
●■ Although the overriding danger of excessive amounts of heroin is the potentially lethal effects of respiratory depression, abusers can die from other physiological reac- tions. In some instances, death can come so quickly that the victims are found with a needle still in their veins; such deaths are usually due to a massive release of hista- mine or to an allergic reaction to some filler in the heroin to which the abuser was hypersensitive. Intravenous injec- tions of heroin increase the risks of hepatitis or HIV infec- tions, and unsterile water used in the mixing of heroin for these injections can be contaminated with bacteria.
●■ An additional risk began to appear during the mid- 1980s. In some forms of synthetic heroin illicitly pro- duced in clandestine laboratories in the United States, “manufacturers” failed to remove an impurity called MPTP that destroys dopamine-sensitive neurons in the substantia nigra of the midbrain. As a result, young people exposed to this type of heroin could acquire full-blown symptoms of Parkinson’s disease that were virtually identical to the symptoms observed in elderly patients suffering from a progressive loss of dopamine- sensitive neurons in their brains.
tAbLe 9.2
Street names for opioid and opioid-combination drugs
tyPe OF OPIOID Street NAMe
morphine Big M, Miss Emma, white stuff, M, dope, hocus, unkle, stuff, morpho
white heroin junk, smack, horse, scag, H, stuff, hard stuff, dope, boy, boot, blow, jolt, spike, slam
Mexican heroin black tar, tootsie roll, chapapote (Spanish for “tar”), Mexican mud, peanut butter, poison, gummy balls, black jack
heroin combined with amphetamines
bombitas
heroin combined with cocaine
dynamite, speedball, whizbang, goofball
heroin combined with marijuana
atom bomb, A-bomb
heroin combined with cocaine and marijuana
Frisco special, Frisco speedball
heroin combined with cocaine and morphine
cotton brothers
codeine combined with Doriden (a nonbarbiturate sedative–hypnotic)
loads, four doors, hits
Sources: U.S. Department of Justice, Drug Enforcement Administration. (1986). Special report: Black tar heroin in the United States, p. 4. Bureau of Justice Statistics Clearinghouse. (1992). Drugs, crime, and the justice system: A national report from the Bureau of justice statistics. Washington, DC: U.S. Department of Justice, pp. 24–25.
heroin itself. To understand the toxicity of heroin, we first need to separate the effects of chronic heroin abuse from the drug’s acute effects. From a long-term perspective with regard to one’s physical health, on the one hand, heroin is considered relatively nontoxic, particularly when compared to several other drugs of abuse. Organ systems are not dam- aged or impaired by even a lifetime of heroin abuse, by vir- tue of ingesting the drug itself. There are no malformations, tissue damage, or physical deterioration directly tied to the use of any opioid drug, including heroin.33 A notable excep- tion, however, is found in the case of heroin administered by inhaling the heated heroin vapors (sometimes referred to as “chasing the dragon”). This form of heroin abuse has been linked to leukoencephalopathy, a neurological disease in which a progressive loss of muscle coordination can lead to paralysis and death.34
On the other hand, it is abundantly clear that the prac- tice of heroin abuse is highly dangerous and potentially lethal. The reasons have to do with a number of situations resulting from heroin administration itself.35
168 ■ Part Three Legally Restricted Drugs and Criminal Justice
Heroin Abuse and Society
Over the years, society has had to deal with the reality of drug abuse in many forms, but many people still look upon heroin abuse as the ultimate drug addiction and view the heroin abuser as the ultimate “dope addict.” It is true that many heroin abusers fit this image: people driven to stay high on a four- to eight-hour schedule, committing a con- tinuing series of predatory crimes. Yet, the actual picture of the present-day heroin abuser is more complex. A major study has shown that although robbery, burglary, and shop- lifting accounted for 44 percent of an abuser’s income and for nearly two-thirds of that abuser’s criminal income, a substantial amount of income came from either victimless crimes (such as pimping or prostitution) or noncriminal activity. Often a heroin abuser would work in some capac- ity in the underground drug industry and be paid in heroin instead of dollars (see Chapter 6).36
A related question with regard to our image of the her- oin abuser is whether controlled heroin abuse is possible. Is heroin abuse a situation that is, by definition, out of con- trol? For most heroin abusers, the answer is yes. Yet, for some individuals, heroin may not be a compulsion. The practice of controlled or paced heroin intake is referred to as chipping, and the occasional heroin abuser is known as a chipper. An important study conducted by Norman E. Zinberg in 1984 analyzed a group of people who had been using heroin on a controlled basis for more than four
chipping: The taking of heroin on an occasional basis.
Quick Concept Check
Understanding the Effects of Administering and Withdrawing Heroin Without looking at Table 9.1, check your understanding of the effects of heroin, relative to withdrawal symptoms, by noting whether the following symptoms are associated with administering heroin or withdrawing it.
symptom administering withdrawing
1. Twitching and sneezing
2. Skin flushed and warm
3. Decreased sex drive 4. Yawning and
panting 5. Pain and
irritability 6. Pupillary constriction 7. Increased blood
pressure 8. Diarrhea 9. Analgesia
Answers: 1. withdrawing 2. administering 3. administering 4. withdrawing 5. withdrawing 6. administering 7. withdrawing 8. withdrawing 9. administering
9.2
the heroin Surge and Narcan for First responders In 2013, there were more than 8,000 heroin overdose fatalities, striking at the heart of American communities large and small. The surge in heroin use among young people, due to the relative inexpensiveness of heroin compared to prescription opioid medica- tions such as Vicodin and OxyContin, has galvanized public health officials not only to reduce the incidence of heroin abuse but also to provide a means for emergency treatment of heroin overdoses.
In 2014, the FDA approved an easy-to-use device for delivering naloxone (brand name: Narcan) by automatic injection in opioid overdose emergencies. The device, called Evzio, is the size of a credit card or small cell phone. When turned on, verbal instructions are provided, much as defibrillators
that are employed in case of cardiac arrest. Narcan is typically injected by syringe in ambulances and emergency departments, but this is the first time that it has been possible to administer Narcan by nonmedical first responders. Physicians are permit- ted to prescribe the device for family members or caregivers in case of emergencies. Narcan kits are currently available to law enforcement agencies in many U.S. states. While Narcan is not intended to be a substitute for immediate medical care, it is certain to be helpful in reducing instances of heroin overdose deaths, which can occur in a very short time.
Sources: Associated Press (April 4, 2014). Overdose antidote approved. Newsday, p. A7. Deutsch, Kevin (2014, April 14). OD antidote on way. Newsday, p. A8. Editorial: Preventing painkiller overdoses (2014, April 15). New York Times, p. A22.
Drugs … in Focus
Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 169
abrupt withdrawal). In medical settings, opioid drugs such as propoxyphene (brand name: Darvon), meperidine (brand name: Demerol), and methadone are administered orally to replace the heroin initially; then, doses of these so-called transitional drugs are decreased over a period of two weeks or so.39
Methadone Maintenance For the heroin abuser seeking out medical treatment for heroin dependence, the most immediate problem is getting the drug out of the abuser’s system during detoxification with a minimum of discomfort and distress. In some pro- cedures, the administration of naloxone has been used to speed up withdrawal and reduce the severity of physiological symptoms.
After detoxification, however, the long-term prob- lem of drug dependence remains. The craving for heroin persists, and the abuser most often has little choice but to return to a drug-oriented environment where the tempta- tions to satisfy the craving still exist. Since the mid-1960s, one strategy has been to have a detoxified heroin abuser participate in a program in which oral administrations of the methadone are essentially substituted for the injected heroin. This treatment approach, called methadone main- tenance, was initiated in New York City through the joint efforts of Vincent Dole, a specialist in metabolic disorders, and Marie Nyswander, a psychiatrist whose interest had focused on narcotic dependence. Their idea was that if a legally and carefully controlled opioid drug was available to heroin abusers on a regular basis, the craving for heroin would be eliminated, their drug-taking lifestyle would no longer be needed, and they could turn to more appropri- ate social behaviors such as steady employment and a more stable family life. The general philosophy behind this approach to heroin-abuse treatment was that heroin abuse was essentially a chronic metabolic disorder requiring a long-term maintenance drug for the body to “normalize” the drug abuser, in the same way as a diabetic patient would need a maintenance supply of insulin.
There are several advantages of the methadone mainte- nance approach in heroin-abuse treatment. Since it is a legal, inexpensive narcotic drug (when dispensed through autho- rized drug treatment centers), criminal activity involved
years.37 Over the course of one year, 23 percent reported taking heroin less than once a month, 36 percent reported taking it one to three times a month, and 41 percent reported taking it twice a week. Four years of exposure to heroin would seem to have been sufficient time to develop a compulsive dependence, but that did not happen. The observation that most compulsive heroin-dependent indi- viduals never had any period of controlled use implies that controlled heroin abuse actually might not be an early transitional stage that eventually turns into uncontrolled heroin dependence.
Although the Zinberg findings have provided support for the possibility of long-term heroin abuse on a controlled basis, newer evidence from studies of heroin abusers over more than three decades—a period of time much longer than that studied by Zinberg—indicates a somewhat darker scenario. During the 1970s, 1980s, and 1990s, a series of follow-up investigations were carried out on nearly 600 male heroin abusers who had been admitted to a compulsory drug- treatment program for heroin-dependent criminal offenders from 1962 to 1964. By 1996–1997, only 42 percent of indi- viduals in the original sample, on average about 58 years old at the time, were available for interview. About 9 percent were of unknown status, and 49 percent had died. The most common cause of death (22%) was accidental poisoning from heroin adulterants or heroin overdose. Homicide, sui- cide, or accident accounted for 20 percent of the deaths, with the remainder being related to liver disease, cardiovascular disease, or cancer. Regarding the drug-taking behavior of the survivors, the researchers concluded that heroin depen- dence had been very difficult for them to avoid.38 A large proportion of these men were engaged in alcohol, cocaine, or amphetamine abuse as well.
The bottom line is this: Dabbling in a drug as poten- tially dependence inducing as heroin is an extremely risky business. To paraphrase the words of a nationally prominent drug-abuse counselor, it is equivalent to playing a pharmaco- logical form of Russian roulette.
Treatments for Heroin Abuse
For the heroin abuser seeking treatment for heroin depen- dence, the two primary difficulties are the short-term effects of heroin withdrawal and the long-term effects of heroin craving. Any successful treatment, therefore, must combine a short-term and a long-term solution.
Heroin Detoxification Traditionally, it has been possible to make the process of withdrawal from heroin, called detoxification (“detox”), less distressing to the abuser by reducing the level of heroin in a gradual fashion under medical supervision, rather than withdrawing from heroin “cold turkey” (a term inspired by the gooseflesh appearance of the abuser’s skin during
methadone maintenance: A treatment program for heroin abusers in which heroin is replaced by the long-term intake of methadone.
methadone: A synthetic (laboratory-based) opioid useful in treating heroin abuse.
propoxyphene (pro-POX-ee-feen): A synthetic (laboratory- based) opioid useful in reducing pain. Brand names are Darvon, Darvocet.
detoxification: The process of drug withdrawal in which the body is allowed to rid itself of the chemical effects of the drug in the bloodstream.
170 ■ Part Three Legally Restricted Drugs and Criminal Justice
for illicit use. The availability of street methadone remains a matter of great concern.44
Alternative Maintenance Programs Two alternative orally administered maintenance drugs for heroin abusers have been developed that avoid the problems associated with the daily dosage approach of methadone programs. The first is the opioid LAAM (levo- alpha-acetylmethadol), marketed under the brand name Orlaam. The advantage of LAAM is its substantially longer duration, relative to methadone, so that treatment clients need to receive the drug only three times a week instead of every day.45
The second drug is the opioid buprenorphine (brand name: Subutex), also available as a three-times-a-week medication. Both medications have been shown to be use- ful in treating heroin abuse. To reduce the potential for buprenorphine tablets to be made into an injectable form and abused, buprenorphine is also available in combina- tion with naloxone (brand name: Suboxone). If the tablets are crushed and dissolved into an injectable solution, the combined formulation triggers undesirable withdrawal symptoms.
The advantage of buprenorphine as a heroin-abuse treatment is that it can be prescribed by office-based physi- cians rather than having to be dispensed through mainte- nance centers, as is the case with methadone and LAAM. When it is combined with naloxone, the abuse potential of buprenorphine is minimized, and while long-term blockage of opioid receptors occurs, there is less of an opioid “high.” Buprenorphine treatment substantially reduces the cost to public health clinics because it can be administered more widely in less heavily secured medical locations, such as pri- mary-care clinics and physicians’ offices. It also reduces the inconvenience and stigmatization faced by treatment clients, particularly for teenage heroin abusers who would be disin- clined to seek treatment at facilities that are associated with older people. Continuing advances in the forms of buprenor- phine administration have made this option increasingly attractive as a heroin-abuse treatment (Help Line).46
Behavioral and Social-Community Programs To help deal with the tremendous social stresses that rein- force a continuation of heroin abuse as well as substance abuse in general, programs called therapeutic communities (see Chapter 8) have been developed. Daytop Village, Samaritan Village, and Phoenix House are examples of therapeutic communities. These “mini-communities” are drug-free residential settings based on the idea that stages of treatment and recovery should reflect increased levels of per- sonal and social responsibility on the part of the abuser. Peer influence, mediated through a variety of group processes, is used to help individuals learn and assimilate social norms
in the purchase of heroin on the street can be avoided. Methadone is slower acting and more slowly metabolized, so that, unlike heroin, its effects last approximately 24 hours and it can be easily absorbed through an oral administration. Because it is an opioid drug, methadone binds to the same endorphin-sensitive receptors in the brain as does heroin and prevents feelings of heroin craving. The rush of a heroin high is avoided, thanks to its relatively slow rate of absorption by brain tissue.
Typically, clients in the program come to the treatment center daily for an oral dose of methadone, dispensed in orange juice, and the dose is gradually increased to a main- tenance level over a period of four to six weeks. The chances of an abuser turning away from illicit drug use are increased if the higher doses of methadone are made conditional on a “clean” (drug-free) urinalysis.40
As a social experiment, methadone maintenance pro- grams have met with a mixture of success and failure. On the one hand, evaluations of this program have found that 71 percent of former heroin abusers who have stayed in methadone maintenance for a year or more have stopped intravenous drug taking, thus reducing the risk of AIDS. In a major study, drug-associated problems declined from about 80 percent to between 17 and 28 percent, criminal behavior dropped from more than 20 percent to less than 10 percent, and there was a slight increase in permanent employment.41 Although it attracts only a fraction of the heroin-dependent community, methadone maintenance does attract those who perceive themselves as having a negligible chance of becom- ing abstinent on their own.42
Although opioid maintenance programs do help many heroin abusers, particularly those who stay in the program over an extended period of time, there are strong indications that the programs do not reduce the overall vulnerability to drug abuse in general. In other words, methadone blocks the yearn- ing for heroin, but it is less effective in blocking the simple craving to get high. Alcohol abuse among methadone main- tenance clients, for example, ranges from 10 to 40 percent, suggesting that alcohol may be substituting for opioids during the course of treatment, and one study found that as many as 43 percent of those who had successfully given up heroin had become dependent on alcohol.43 Furthermore, methadone is sometimes diverted away from the clinics and onto the streets
therapeutic communities: Living environments for individuals in treatment for heroin and other drug abuse, where they learn social and psychological skills needed to lead a drug-free life.
buprenorphine (byOO-preh-NOr-feen): A synthetic (laboratory-based) opioid used in the treatment of heroin abuse. Brand names are Subutex and (in combination with naloxone) Suboxone.
LAAM: The synthetic narcotic drug levo-alpha- acetylmethadol, used in the treatment of heroin abuse. Brand name is Orlaam.
Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 171
Anonymous, modeled after similar programs for those recov- ering from alcohol or cocaine dependence.
The Reality of Opioid Abuse Treatment and Recovery It is important to point out that recovery from opioid depen- dence is a life-long endeavor. A heroin abuser successfully completing a program of treatment remains a recovering heroin abuser, not a recovered heroin abuser. The concept of a sub- stance abuser in recovery holds for all forms of substance abuse (particularly see Chapter 17). In the meantime, it is also impor- tant to recognize the devastation experienced by the families of heroin abusers over the years. Some degree of “reconstruc- tive surgery” of social relationships at home and at work is needed, and it is a continuing challenge to accomplish it.
and develop more effective social skills. Typically, counselors are former heroin abusers or former abusers of other drugs.47
Other approaches have been developed that combine detoxification, treatment with naltrexone, psychotherapy, and vocational rehabilitation under a single comprehen- sive plan of action. These programs, called multimodal- ity programs, are designed to focus simultaneously on the multitude of needs facing the heroin abuser, the goal being a successful reintegration into society. As a continuing effort to help the recovering heroin abuser over time, there are also 12-step group support programs such as Narcotics
Help Line buprenorphine: the bright/Dark Side of heroin-Abuse treatment
When buprenorphine (brand name: Subutex) and buprenor- phine combined with naloxone (brand name: Suboxone) received FDA approval in 2002, public health officials hailed it as the beginning of a new era in opioid-abuse treatment. Because buprenorphine is only a partial activator of opioid- sensitive receptors in the brain, as opposed to full activators such as heroin and methadone, clients in treatment are more likely to discontinue their heroin intake without experiencing withdrawal symptoms, and the symptoms that do occur are considerably milder. At the same time, the sustained-release formulation avoids the typical heroin effects of rapid eupho- ria and respiratory depression because of a slower time of release. There is also no evidence of significant impairment of cognitive or motor performance in the course of long-term buprenorphine maintenance.
In recent years, significant developments have increased the convenience of buprenorphine administration as a method of treatment. Buprenorphine can be administered by injection by a certified primary-care physician, making it possible for heroin abusers to obtain treatment only once per month and has less- ened the potential for diversion. Federal legislation enacted in 2007 allows a certified physician to treat a caseload of up to 100 patients. Previous regulations had limited caseloads to no more than 30 patients. A buprenorphine transdermal patch (brand name: Butrans), delivering 5–20 micrograms of bu- prenorphine hourly over a seven-day period, has been available since 2011. In 2013, a generic version of Suboxone sublingual tablets became available as well.
The dark side of the buprenorphine story, however, has to do with an unfortunately inevitable diversion of Suboxone from therapeutic use to recreational abuse purposes. It has become not only a medicine for pain but also, when crushed or dissolved, a street and prison drug. Unscrupulous physi- cians with prescription privileges have caused an oversupply of
prescriptions that make their way into a growing black market. More than 10 percent of physicians authorized to prescribe buprenorphine have been sanctioned for offenses including excessive prescribing, insurance fraud, sexual misconduct, and practicing medicine while impaired (presumably as opioid abusers themselves). A recently available “dissolvable filmstrip” form of Suboxone has made it easy to smuggle into prisons. It has been called “prison heroin.”
The Web site given below provides the best way of getting information.
Where to go for assistance www.buprenorphine.samhsa.gov/about.html
This Web site, sponsored by the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services, provides extensive information on treatment options and a list of available buprenorphine treatment locations. While problems associated with buprenor- phine abuse exist, they should not deter individuals who can benefit from its therapeutic use from contacting health care providers for information and possible treatment.
Sources: http://www.businesswire.com/news/ home/20130225005607/en/Amneal-Pharmaceuticals- Receives-FDA-Approval-Generic-Suboxone%C2%AE. Martin, Kimberly R. (2004, September). Once-a-month medication for heroin addiction? NIDA Notes, p. 9. Mitka, M. (2003). Office-based primary care physicians called on to treat the “new” addict. Journal of the American Medical Association, 290, 735–738. Opioid detox study shows buprenorphine improves retention rate for teens (2005, October 10). Alcoholism and Drug Abuse Weekly, pp. 1–2. Sontag, Deborah (2013, November 16). Addiction treatment with a dark side. New York Times, pp. A1, A20–22.
multimodality programs: Treatment programs in which a combination of detoxification, naltrexone treatment, psychotherapy, and group support is implemented.
172 ■ Part Three Legally Restricted Drugs and Criminal Justice
●■ The first and foremost medical use of opioids today is for the treatment of pain. For a patient suffering severe pain following surgical procedures or from burns or cancer, the traditional drug of choice has been morphine. Recently, pain treatment with fentanyl through a transdermal patch administration (see Chapter 4) has been found to be more effective as an analgesic than morphine in an oral time- release administration and is preferred by patients with chronic pain because the pain relief is achieved with less constipation and an enhanced quality of life. A transder- mal buprenorphine patch (brand name: Butrans) has recently become available as well.48
●■ The second application capitalizes on the effect of opioids in slowing down peristaltic contractions in the intestines that occur as part of the digestive process. As noted earlier,
Medical Uses of Opioid Drugs
While the focus in this chapter has been on opioid drugs in the context of heroin abuse, it important to look at the bene- ficial effects as well as the adverse side effects that these drugs can have in a medical setting (Table 9.3).
Beneficial Effects Excluding heroin, which is a Schedule I controlled sub- stance in the United States and therefore unavailable for medical use, opioid drugs are useful as prescription medica- tions (Schedule II controlled substances) for three primary therapeutic purposes: the relief of pain, the treatment of acute diarrhea, and the suppression of coughing.
tAbLe 9.3
Major opioid pain medications
geNerIC NAMe
brAND NAMe*
reCOMMeNDeD DOSe FOr ADuLtS
geNerIC NAMe
brAND NAMe*
reCOMMeNDeD DOSe FOr ADuLtS
morphine
codeine
hydromorphone
oxymorphone
oxycodone
Avinza
Duramorph
Kadian
MS Contin
Oramorph SR
Embeda
Dilaudid
Numorphone
Opana IR
Opana ER
OxyContin
Percocet
Percodan
Targiiniq ER
30–120 mg (oral, combined immediate release, and extended release)
5–10 mg (i.v.)
10–200 mg (oral, extended release)
15–200 mg (oral, controlled release)
15–100 mg (oral, sustained release)
20–100 mg morphine/ 0.8–4 mg with naltrexone (oral, sustained release)
30–60 mg (oral, i.m., or s.c.)
1–8 mg (oral, i.m., i.v., or s.c.)
Suppository, injectable
5–10 mg (immediate release)
5–40 mg (extended release)
10–80 mg (oral, extended release)
2.5–10 mg (oral) with acetaminophen
4.5 mg (oral) with aspirin
10–40 mg (oral, extended release) with 5–20 mg naloxone
hydrocodone
methadone
meperidine
propoxyphene
fentanyl
tramadol
Hycodan
Vicodin
Lortab
Zohydro ER
Hysingla ER
Dolophine
Demerol
Darvocet-N
Darvon
Duragesic
Actiq
Ultracet
Ultram ER
5 mg (oral)
5–10 mg (oral) with 300 mg acetaminophen
5–10 mg (oral) with 300–500 mg acetaminophen
10–50 mg (oral, extended release)
60–120 mg (oral, extended release, once daily)
5–10 mg (oral, i.v., or s.c.)
50–100 mg (oral, i.m., i.v.)
50 mg (oral) with acetaminophen
65 mg (oral)
12.5–100 mcg/hour (extended-release transdermal patch)
200–1,600 mcg (“lollipop” form),
12.5–100 mcg/hour (extended-release transdermal patch)
37.5 mg (oral) with acetaminophen
100–300 mg (oral, extended release)
*Various forms of buprenorphine are described in Help Line on page 171). Some opioid drugs are available only under their generic names, and some are available under either their generic or brand name.
Note: i.v.=intravenous; i.m.=intramuscular; s.c.=subcutaneous.
Source: Based on information from Physicians’ desk reference (69th ed.) (2015). Montvale, NJ: PDR Network.
Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 173
one problem associated with the chronic abuse of heroin, as well as of other opioids, is constipation. However, for individuals with dysentery, a bacterial infection of the lower intestinal tract causing pain and severe diarrhea, this negative side effect becomes desirable. Therefore, the control of diarrhea by an opioid is literally lifesaving, since acute dehydration (loss of water from the body) can be fatal. Fortunately, the opioid medication loperamide (brand name: Imodium), which is available on an over- the-counter basis, effectively controls diarrhea symptoms by its action on the gastrointestinal system. Because it can- not cross the blood–brain barrier, loperamide does not produce any psychoactive effects.
●■ The third application focuses on the capacity of these drugs to suppress the cough reflex center in the medulla. In cases in which an antitussive (cough-suppressing) drug is nec- essary, codeine is frequently prescribed, either by itself or combined with other medications such as aspirin or acetaminophen (brand name: Tylenol, among others). As an alternative treatment for coughing, dextromethorphan is available in over-the-counter syrups and lozenges, as well as in combination with antihistamines. Unfortunately, the abuse of dextromethorphan among young people, who are consuming it on a recreational basis, has become a relatively new cause for concern and one of the continuing challenges of present-day substance abuse.
Prescription Opioid Medication Side Effects Despite the overall beneficial effects of prescription opi- oid medications, there are serious adverse side effects. For example, respiration will be depressed for four to five hours following even a therapeutic dose of morphine, so caution is advised when the patient suffers from asthma, emphy- sema, or pulmonary heart disease. In addition, opioid medi- cations decrease the secretion of hydrochloric acid in the stomach and reduce the pushing of food through the intes- tines, a condition that can lead to intestinal spasms. Finally, although opioids have a sleep-inducing effect in high doses, it is not recommended that they be used as a general sedative– hypnotic treatment, unless sleep is being prevented by pain or coughing.49
Prescription Opioid Medication Abuse
The nonmedical use of prescription opioid medications (in other words, the recreational use of opioid medications) has been acknowledged as a national epidemic. Every year since 2003, between 11 and 12 million Americans over the age of 12 have reported nonmedical use of these medica- tions over the previous 12 months.50 Fortunately, preva- lence rates among secondary school students have decreased
considerably from those reported in previous years, most likely a reflection of extensive media coverage of the dan- gers of opioid medication abuse, but the numbers are still substantial. According to the 2013 University of Michigan survey, approximately 5 and 4 percent of high school seniors reported nonmedical use over the past year of Vicodin or OxyContin, respectively.51
In terms of public health, prescription opioid medica- tion abuse continues to be a major concern. In 2013, more than 16,000 drug overdose deaths in the United States were attributed to opioid medications, accounting for three out of four deaths from overdoses of pharmaceutical drugs in general and exceeding the number of overdose deaths attrib- uted to cocaine and heroin combined. Opioid medication overdose deaths accounted for about one-third of all drug overdose deaths in 2013.52
Clearly, opioids are needed by millions of people who seek legitimate relief from pain. Yet, the abuse of opioids present significant personal and social problems for millions of others. This situation poses a unique challenge for law enforcement authorities and public health officials.
Patterns of OxyContin Abuse The principal medications of concern are well known: oxycodone with acetaminophen (brand name: Percocet), the continuous-release form of oxycodone (brand name: OxyContin), hydrocodone, and hydrocodone with acet- aminophen (brand name: Vicodin). Prior to 2013, all opioid medications were Schedule II controlled substances, with sole exception of Vicodin, which was classified as a Schedule III controlled substance. In 2013, the FDA recommended a reclassification of Vicodin from a Schedule III to a Schedule II controlled substance, a move that had been recommended by the DEA for several years. Substance abuse is common with respect to all the prescription opioid medications, but the focus here will be on patterns of OxyContin abuse, since it has received in recent years the most public attention and concern.
Introduced in 1995, OxyContin was promoted ini- tially as being relatively safe from potential abuse and more acceptable to the general public because it lacked the social stigma associated with morphine. In its original FDA-approved continuous-release formulation, OxyContin
Vicodin: Brand name for hydrocodone combined with acetaminophen, used in pain treatment.
OxyContin: Brand name for a continuous-release form of oxycodone, used in the treatment of chronic pain.
Percocet: Brand name for oxycodone combined with acetaminophen, used in pain treatment.
dextromethorphan (DeX-troh-meh-thOr-fan): A popu- lar ingredient used in over-the-counter cough remedies. The “DM” designation on these preparations refers to dextromethorphan.
antitussive: Having an effect that controls coughing.
174 ■ Part Three Legally Restricted Drugs and Criminal Justice
The second group of patients (10% of the patients), who were seeing one doctor and taking a high opioid dose (at least 100 mg morphine-equivalent dose per day), repre- sented 40 percent of drug overdose cases. The third group (10% of the patients) were seeing multiple doctors and typically involved in drug diversion. This “at-risk” group represented 40 percent of drug overdose cases. A signifi- cant proportion of persons who died of opioid drug over- dose did not have a prescription in their medical records for the opioid that killed them. In death records in Ohio, West Virginia, and Utah, for example, 25–66 percent of individuals who died of opioid overdose had used an opi- oid prescribed to someone else.55
Two primary sources of drug diversion, defined as the means by which prescription medications become avail- able for nonmedical use, have been identified. The first source includes patients who visit multiple doctors (“doctor shoppers”) and obtain multiple prescriptions by convincing doctors that there is a genuine reason for opioid treatment. Other individuals visit legal storefront stress and pain clinics (often called “pill mills”) where they speak with a physi- cian, are typically required to take a psychological test, and undergo a perfunctory physical examination, after which they leave with a prescription for a controlled substance regardless of their medical condition. Since no controlled substances are stored on the premises, no DEA license is required for these clinics to operate. Frequently, however, these clinics are raided in a “buy-bust” law enforcement operation (see Chapter 7), although it is difficult to close them down per- manently. As will be mentioned later, some individuals using medications for nonmedical purposes are not patients at all,
would be taken orally and absorbed slowly over a period of 12 hours, killing pain without inducing a sudden feel- ing of euphoria. For several years, however, OxyContin tablets could be easily crushed and then either inhaled as a powder or injected after diluting the powder into a solution, producing a pharmacological effect similar to that of heroin. Even without altering the tablets in any way, some patients suffered severe withdrawal symp- toms, similar to those experienced during heroin with- drawal, when they abruptly stopped taking high-dosage levels of the OxyContin.
In 2010, under intense pressure from public health authorities, Purdue Pharma, manufacturer of OxyContin, introduced a new formulation containing an added chemical called Remoxy that changed the tab- let into a gummy, less easily abusable substance when crushed or dissolved. Unfortunately, some abusers have turned to microwaving the new formulation and sniff- ing the burned remains, a far more inconvenient but nonetheless viable option.53 For a time, others turned to the extended-release form of another opioid medica- tion, oxymorphone (brand name: Opana ER), which could be crushed and dissolved like the original form of OxyContin. In 2012, a new formulation of Opana ER was launched with a modification similar to that implemented with OxyContin.
The demographic features of OxyContin abusers, unlike that of heroin abusers, cut across age, socioeconomic status, geographic location, and gender. As is the case with meth- amphetamine (see Chapter 10), communities particularly hard-hit by this form of substance abuse have been located in rural areas (Portrait) where treatment facilities are less readily available, pharmacy security is less rigorous, and there are fewer safeguards against illegitimate access to prescription opioid medications in general.54
Prescription Opioid Medication Abuse, Overdose, and Drug Diversion Where are prescription opioid medications being obtained for nonmedical purposes? Surprisingly, about 68 percent of opioid abusers in 2012 and 2013 either bought the drug from a friend or relative in the past month or were given the drug free. About 84 percent of the friends or relatives, who were the source, obtained the drug as a prescribed medication from a single doctor. Multiple doctors were involved in less than 3 percent of all opioid medication abuse cases.
How likely is it that a patient receiving an opioid pre- scription experiences a drug overdose? It is necessary to look at three subgroups of patients receiving opioid pre- scriptions in 2010 (Figure 9.2). The first group (80% of the patients), who were seeing one doctor and taking a low opi- oid dose (less than 100 mg morphine-equivalent dose per day), represented 20 percent of the drug overdose cases.
80%
20%
10%
40%
10%
40%
0%
20%
40%
60%
80%
100%
Patients Overdoses
Patients seeing multiple doctors and typically involved in drug diversion
Patients seeing one doctor, high dose
Patients seeing one doctor, low dose
F Igure 9 .2
Percentage of risk circumstances in overdose cases among pain patients and overdose cases.
Source: Based on Manchikanti, L.; Standiford, H., II; Fellows, B.; Janata, J. W.; Pampati, V.; et al. (2012). Opioid epidemic in the United States. Pain Physician, 15, p. ES30.
Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 175
would bring all or part of the drugs back to him, presumably for his personal use. He was also found guilty of willingly fail- ing to file income tax forms for multiple years when he had a gross income exceeding $1 million.57
Abuse of Other Opioid Pain Medications Vicodin and Percocet are based on opioids (hydrocodone and oxycodone, respectively) that have been available for a longer period of time, and they unfortunately have a longer record of abuse and dependence. An additional problem has been the addition of acetaminophen (up to 1,000 mg in the case of one form of Percocet) to the hydrocodone and oxycodone in these medications. This combination is par- ticularly dangerous because excessive dosages of acetamin- ophen increase the risk of liver toxicity and death. In order to reduce the incidence of adverse effects, the FDA ordered
but instead the medications are obtained directly from a friend or relative.
The second source is the health care provider, typically a private-practice physician (sometimes unlicensed) or phar- macist who has issued or dispensed prescription medications in a fraudulent manner. The DEA Drug Diversion Task Force initiates prosecution of more than 30 physicians and pharmacists each year, generally cases involving the most fla- grant instances of drug diversion.56 As an example, a recent prosecution concerned a private-practice family medicine physician in Tennessee who received a 23-year sentence after being convicted of improperly writing prescriptions for opioid medications as well as other controlled substances without sufficient medical necessity. He charged patients $80 to $100 in cash for each visit, without performing a physical examination, even after receiving information that particular patients were abusing their drugs or selling them to others. Agreements had been made with patients that they
POrtrAIt Billy Thomas and Ricky Franklin— The Two Sides of OxyContin
Billy Thomas’ pain had become so excruciating that he was on the verge of suicide. A former salesman of plumbing sup- plies in North Plainfield, New Jersey, Thomas had endured pulsating back pain for six years. Seven surgeries, end- less doctor’s appointments, thousands of pills, acupuncture, and other alternative treatments had all proved unsuccessful. When Thomas began taking OxyContin, however, a relatively normal lifestyle returned. His perceived pain level (on a scale of 1 to 10, with 10 being the most horrible pain imaginable) was an accept- able 2 or 3—a dramatic improvement from his continual ratings of 8 or 9 before the advent of OxyContin. The drug had literally saved his life.
For every Billy Thomas, however, there has been a Ricky Franklin. Prescribed OxyContin following hip-re- placement surgery, Franklin found that the drug was difficult to give up even after his recovery was complete. In 1999, this resident of rural Maine was con- victed of selling guns to finance the pur- chase of a steady supply of OxyContin. In May 2001, while on parole for the firearms theft conviction, Franklin was charged with walking into a Rite Aid pharmacy with a gun and pushing a note across the counter that read: “Give me all your OxyContin or I will shoot
you.” The gun turned out to be an un- loaded BB gun. Franklin was sentenced in federal court in 2002 to 46 months in prison and three years of supervised release.
Franklin has not been alone in his descent into criminal activity as a result of compulsive OxyContin abuse (see Portrait in Chapter 6). Arrests have been made in all parts of the United States (the drug has been called the “rural heroin”) for crimes ranging from simple theft to murder and drug trafficking, all related to the illicit abuse of this drug. At the same time, demands to remove OxyContin from the market until a completely full-proof abuse-reducing formulation is developed would return people like Billy Thomas and millions of other Americans to a life of abject mis- ery. The problem is that it is difficult to predict which path a patient will follow. As a neurologist and pain management specialist has expressed it, “A practic- ing physician has to be mindful that someone, even if they don’t come with ‘addict’ written all over them, may be one. . . The physician has to establish a relationship with the patient they’re taking care of on a long-term basis.” It is unclear whether it will ever be possible to have completely positive outcomes
from the development of pain medica- tion, without the negative consequences of substance abuse.
Note: In May 2007, three top executives of Purdue Pharma, the company that makes OxyContin, pleaded guilty to criminal charges that, from 1995 to 2001, they had misled federal regulators, physi- cians, and patients about the potential for OxyContin to be an abused drug. The company agreed to $600 million in fines and other payments; the executives them- selves were fined $34 million for their wrongdoing.
Note: The names of the two men in this Portrait have been changed.
Sources: Adler, Jerry (2003, October 20). In the grip of a deeper pain. Newsweek, pp. 48–49. Garland, Nancy (2002, May 16). Teleconference used to sentence OxyContin thief. Bangor Daily News, p. B1. Meier, Billy (2003). Pain killer: A “wonder” drug’s trail of addiction and death. New York: Rodale Press. Meier, Billy (2007, May 11). Narcotic maker guilty of deceit over marketing. New York Times, pp. A1, C4. Sontag, Deborah (2013, November 16). Addiction treatment with a dark side. New York Times, p. A1. Susman, Tina (2001, July 29). Good drug, bad drug: OxyContin eases pain, lures addicts. Newsday, pp. A6, A36. Quotations on p. A36.
176 ■ Part Three Legally Restricted Drugs and Criminal Justice
(pharmacists) check on their own and neighboring states before writing and filling prescriptions for controlled substances with high abuse potential. Database speed is crucial for physicians to receive information of possible fraud while the patient is still in the office. Again, some U.S. states have these programs, but individuals living in communities near state borders can circumvent these safe- guards by crossing state lines.
●■ Greater examination is required of nonopioid treat- ments as a first treatment option when a patient comes in with pain.
●■ Physicians should have enhanced knowledge about strategies that patients might employ to gain opioid pre- scriptions when they are not warranted.60
Nonetheless, an opposing perspective is held by many substance abuse professionals and other public health authorities who are directly involved in opioid medication abuse treatment. They have argued that the increase in painkillers in general have given rise to a host of unantici- pated economic and social costs, including more hospital emergency department visits, expansion of treatment facili- ties to handle the influx of opioid abusers, more prescrip- tions for opioid treatment drugs such as buprenorphine and naltrexone, larger law enforcement budgets to cover costs for monitoring “doctor shopping” and illegitimate pain clinics.61
in 2011 a limit of 325 milligram of acetaminophen when combined with a prescription pain medication. Recently, two new opioid medications, Zohydro ER and Hysingla ER, have been introduced, which contain no acetaminophen (see Table 9.3).59
Responses to Prescription Opioid Medication Abuse From a criminal-justice perspective, the DEA has imple- mented a number of programs to reduce the incidence of prescription opioid medication abuse that involve both educational and law enforcement strategies (see Drug Enforcement … in Focus).
Efforts are also being made to reduce opioid medication abuse within the medical practice of pain treatment. A major policy statement issued by the American College of Physicians in 2013 recommended a number of changes in clinical practice:
●■ Prescriptions for all controlled substances should be issued electronically and not on paper to reduce the incidence of forged prescriptions and other fraudulent practices on the part of patients. Electronic prescriptions for controlled substances are mandated in some U.S. states, but a nation- wide requirement is needed.
●■ A nationwide program for prescription drug monitoring should be implemented so that prescribers and dispensers
National Prescription Drug take- back Day and rogue Pharmacies In 2010, the DEA initiated National Prescription Drug Take-Back Day in an effort to provide a more environ- mentally responsible and secure way to dispose off expired or unwanted medications that are highly susceptible to diversion, misuse, and abuse. At that time, individuals across the country turned in over 121 tons of medications at more than 4,000 take-back locations. In 2013, Take-Back Day yielded a total of 324 tons of medications at more than 5,000 locations. Each year, the program has set a new record for response from the public.
On another front, the three most-used Internet search engines in the United States adopted in 2010 policies prohibit- ing Internet pharmacies from advertising on the sidebars of
search result pages unless they have been identified as Verified Internet Pharmacy Practice Sites by the National Association of Boards of Pharmacy and operate in compliance with U.S. phar- macy laws and practice standards. The policies are intended to reduce the number of “rogue pharmacies” that operate on the Internet. These pharmacies are typically unlicensed Web-based operations, operating from foreign countries that do not require valid prescriptions to dispense medications.
Sources: Drug Enforcement Administration (2013, November 6). Press Release: Americans turn out in droves for DEA’s Seventh National Prescription Drug Take-Back Day. Drug Enforcement Administration, U.S. Department of Justice, Washington, DC. Drug Enforcement Administration (2013). 2013 National Drug Threat Assessment Summary. Washington, DC: Drug Enforcement Administration, U.S. Department of Justice.
Drug Enforcement … in Focus
Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 177
Opium in history ●● A drug with a very long history, opium has been used for
medicinal and recreational purposes for approximately 5,000 years.
●● During the nineteenth century, opium figured in global politics as the instigating factor for the Opium War fought between China and Britain. At the time, opium use was widespread in Britain and the United States at all levels of society.
Morphine and the Advent of heroin ●● The discovery of morphine in 1803 as the principal active
ingredient in opium revolutionized medical treatment of pain and chronic diseases.
●● At the end of the nineteenth century, heroin was intro- duced by the Bayer Company in Germany. Initially, it was believed that heroin lacked the dependence-producing properties of morphine.
Opioids in American Society ●● The abuse potential of morphine and especially of heroin
was not fully realized until the beginning of the twentieth century. Social and political developments in the United States after the passage of the Harrison Act in 1914 drove heroin underground, where it acquired a growing associa- tion with a criminal lifestyle.
●● Heroin abuse became associated with African American and other minority communities in urban ghettos after World War II; later, the countercultural revolution and the military involvement in Vietnam during the 1960s and 1970s brought the issue of heroin abuse to a wider population.
effects on the Mind and the body ●● The effects of opioids such as heroin include eupho-
ria, analgesia, gastrointestinal slowing, and respiratory depression.
●● Respiratory depression is the major risk factor for heroin intake.
how Opioids Work in the brain ●● Since the 1970s, we have known that the effects of mor-
phine and related opioid drugs are the result of the activa- tion of opioid-sensitive receptors in the brain.
●● Three families of chemical substances produced by the brain bind to these receptors. These chemicals are collec- tively known as endorphins.
Patterns of heroin Abuse ●● Chronic heroin abuse is subject to tolerance effects over
time. Withdrawal effects include intense craving for heroin and physical symptoms such as diarrhea and dehydration.
●● One of the major problems surrounding heroin abuse is the unpredictable content of a heroin dose.
treatment for heroin Abuse ●● Treatment for heroin abuse includes short-term detoxifica-
tion and long-term interventions that address the continu- ing craving for the drug and physical dependence factors in the body.
●● Methadone maintenance programs focus primarily on the physiological needs of the heroin abuser, whereas thera- peutic communities and support groups focus on his or her long-term reintegration into society.
Prescription Opioid Medication use and Misuse ●● In medical settings, opioid drugs have been extremely
helpful in the treatment of pain, the treatment of dysen- tery, and the suppression of coughing.
●● Side effects of opioid medications include respiratory depression, intestinal spasms, and sedation.
Prescription Opioid Medication Abuse ●● There has been great concern since the late 1990s that
opioid pain medications have been diverted to nonmedi- cal purposes and are subject to abuse. Three medications of this type are OxyContin, Vicodin, and Percocet. There are numerous instances of pharmacy robberies, with the intent of securing supplies of opioid pain medication, particularly OxyContin.
Summary
Key Terms
antitussive, p. 173 black tar, p. 163 buprenorphine, p. 170 chipping, p. 168 codeine, p. 160 detoxification, p. 169 dextromethorphan, p. 173
endogenous opioid peptides, p. 165
fentanyl, p. 163 heroin, p. 160 LAAM, p. 170 methadone, p. 169 methadone maintenance, p. 169
morphine, p. 160 multimodality programs, p. 171 naloxone, p. 164 naltrexone, p. 165 narcotics, p. 157 opioids, p. 156 opium, p. 158
OxyContin, p. 173 Percocet, p. 173 propoxyphene, p. 169 thebaine, p. 160 therapeutic communities,
p. 170 Vicodin, p. 173
178 ■ Part Three Legally Restricted Drugs and Criminal Justice
1. Opening vignette adapted and rewritten from a composite of anonymous contributors to the Sober Living by the Sea blog, www.soberliving.com/blog.
2. Levinthal, Charles F. (1988). Messengers of paradise: Opiates and the brain. New York: Anchor Press/ Doubleday, p. 4.
3. Courtwright, David T. (2001). Forces of habit: Drugs and the making of the modern world. Cambridge, MA: Harvard University Press, pp. 31–39. Merlin, M. D. (1984). On the trail of the ancient opium poppy. Cranbury, NJ: Associated University Press.
4. Scott, James M. (1969). The white poppy: A history of opium. New York: Funk and Wagnalls, p. 111.
5. Nencini, Paolo (1997). The rules of drug-taking: Wine and poppy derivatives in the ancient world. VIII. Lack of evidence of opium addiction. Substance Use and Misuse, 32, 1581–1586.
6. Levinthal, Messengers of paradise, pp. 3–25. Snyder, Solomon H. (1977). Opiate receptors and internal opiates. Scientific American, 236(3), 44.
7. Beeching, Jack (1975). The Chinese opium wars. New York: Harcourt Brace Jovanovich, p. 23. Hanes, W. Travis III; and Sanello, Frank (2002). The opium wars. Napierville, IL: Sourcebooks.
8. Owen, David E. (1934). British opium policy in China and India. New Haven, CT: Yale University Press. Waley, Arthur. (1958). The opium war through Chinese eyes. London: Allen and Unwin.
9. DeQuincey, Thomas (1822/2002). Confessions of an English opium-eater. In David F. Musto (Ed.), Drugs in America: A documentary history. New York: New York University, pp. 197–199. Fay, Peter W. (1975). The opium war 1840–1842. Chapel Hill: University of North Carolina Press, p. 11.
10. Brecher, Edward M.; and the editors of Consumer Reports (1972). Licit and illicit drugs. Boston: Little, Brown, p. 17.
11. Kaplan, Eugene. H.; and Wieder, Herbert (1974). Drugs don’t take people; people take drugs. Secaucus, NJ: Lyle Stuart.
12. Brecher, Licit and illicit drugs, pp. 42–43. 13. Levinthal, Messengers of paradise, pp. 16–17.
14. Courtwright, David. T. (1982). Dark paradise: Opiate addiction in America before 1940. Cambridge, MA: Harvard University Press, p. 47.
15. Inciardi, James A. (2002). The war on drugs III. Boston: Allyn and Bacon, p. 24. Terry, Charles E.; and Pellens, Mildred (1928/1970). The opium problem. Montclair, NJ: Patterson Smith.
16. Center for Behavioral Health Statistics and Quality (2014). Results from the 2013 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration, Table 1.1A.
17. Smith, Roger (1966). Status politics and the image of the addict. Issues in Criminology, 2(2), 157–175.
18. Zackon, Frank (1986). Heroin: The street narcotic. New York: Chelsea House Publishers, p. 44.
19. McCoy, Alfred W.; with Read, Cathleen B.; and Adams, Leonard P. (1972). The politics of heroin in Southeast Asia. New York: Harper & Row, pp. 5–6.
20. Zackon, Heroin, p. 45. 21. Bentel, David J.; Crim, D.; and Smith, David E. (1972). Drug
abuse in combat: The crisis of drugs and addiction among American troops in Vietnam. In David E. Smith; and George R. Gay (Eds.), It’s so good, don’t even try it once: Heroin in perspective. Englewood Cliffs, NJ: Prentice-Hall.
22. McCoy, The politics of heroin in Southeast Asia, pp. 220–221. 23. Kuzmarov, Jeremy (2010). The myth of the addicted army: Viet-
nam and the modern war on drugs. Amherst, MA: University of Massachusetts Press. Robins, Lee N.; David, Darlene H.; and Goodwin, Donald W. (1974). Drug use by U.S. Army enlisted men in Vietnam: A follow-up on their return home. American Journal of Epidemiology, 99(4), 235–249.
24. Greenhouse, Steven (1995, February 12). Heroin from Burmese surges as U.S. debates strategy. New York Times, p. 3.
25. Holloway, Lynette (1994, August 31). 13 heroin deaths spark wide police investigation. New York Times, pp. A1, B2. Leland, John (1996, August 26). The fear of heroin is shooting up. Newsweek, pp. 55–56.
Endnotes
You are an internal medicine physician in private practice. A 50-year-old woman visits your office as a new patient. She appears extremely distraught, complaining of chronic debilitating pain. An examination of her reveals no specific basis for the pain. Do
you prescribe an opioid medication to her? If so, what precautions do you take to reduce the likelihood of encouraging or creating a pattern of opioid medication abuse in the future? If not, are you fulfilling your professional obligations as a health care provider?
Critical Thinking: What Would You Do?
1. Summarize the four categories of opioid drugs and give two examples in each category.
2. How did the development of morphine injections change the pattern of opioid use from a previous era of opioid ingestion through the drinking of laudanum?
3. Discuss the changes in heroin use and abuse following the Harrison Narcotics Act of 1914.
4. Discuss three significant events in the 1960s and 1970s that changed society’s view of heroin abuse.
5. Discuss the basis for opioid effects in terms of brain chemistry. 6. Contrast the treatment strategies and goals of methadone main-
tenance and therapeutic communities? 7. How does present-day prescription opioid medication abuse
take place? What is the role of drug diversion?
Review Questions
Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 179
heroin addiction. NIDA Notes, 16(4), 1, 5, 7. Treaster, Joseph B. (1992, July 22). Executive’s secret struggle with heroin’s powerful grip. New York Times, pp. A1, B4.
39. Schuckit, Marc A. (2006). Drug and alcohol abuse: A clinical guide to diagnosis and treatment (6th ed.). New York: Springer, pp. 178–182.
40. Stitzer, Maxine L.; Bickel, Warren K.; Bigelow, George E.; and Liebson, Ira A. (1986). Effect of methadone dose contingencies on urinalysis test results of polydrug-abusing methadone-main- tenance patients. Drug and Alcohol Dependence, 18, 341–348.
41. Maddux, James F., and Desmond, David P. (1997). Outcomes of methadone maintenance 1 year after admission. Journal of Drug Issues, 27, 225–238. Sees, Karen L.; Delucchi, Kevin L.; Masson, Carmine; Rosen, Amy; Clark, H. Wesley; et al. (2000). Methadone maintenance vs. 180-day psychosocially enriched detoxification for treatment of opioid dependence. Journal of the American Medical Association, 283, 1303–1310.
42. Office of National Drug Control Policy (2000, April). Methadone. ONDCP Drug Policy Information Clearinghouse Fact Sheet. Washington, DC: Office of National Drug Control Policy.
43. Wasserman, David A.; Korcha, Rachel; Havassy, Barbara E.; and Hall, Sharon M. (1999). Detection of illicit opioid and cocaine use in methadone maintenance treatment. American Journal of Drug and Alcohol Abuse, 25, 561–571.
44. Faupel, Charles E. (1991). Shooting dope: Career patterns of hard-core heroin users. Gainesville: University of Florida Press, pp. 170–173. Gollnisch, Gernot (1997). Multiple predictors of illicit drug use in methadone maintenance clients. Addictive Behaviors, 22, 353–366. Substance Abuse and Mental Health Services Administration (2003, January). Narcotic analgesics. The DAWN report. Rockville, MD: Substance Abuse and Mental Health Services Administration, Figure 2.
45. Eissenberg, Thomas; Bigelow, George F.; Strain, Eric C.; Walsh, Sharon L.; Brooner, Robert K.; et al. (1997). Dose-related efficacy of levomethadryl acetate for treatment of opioid dependence: A randomized clinical trial. Journal of the American Medical Association, 277, 1945–1951.
46. Martin, Kimberly R. (2004, September). Once-a-month medication for heroin addiction? NIDA Notes, 19(3), p. 9. Mitka, Mike (2003). Office-based primary care physicians called on to treat the “new” addict. Journal of the American Medical Association, 290, 735–736. Butrans (buprenorphine) Transdermal System CIII now available. News and media release, Purdue Pharma, January 20, 2011.
47. Martin, Stevan S.; O’Connell, Daniel J.; Paternoster, Raymond; and Bachman, Ronet D. (2011). The long and winding road to desistance from crime for drug-involved offenders: The long-term influence of TC treatment on re-arrest. Journal of Drug Issues, 11, 179–196. National Institute on Drug Abuse (2002). Therapeutic community. National Institute on Drug Abuse Research Report. Rockville, MD: National Institute on Drug Abuse.
48. Allan, Laurie; Hays, Helen; Jensen, Niels-Henrik; Le Polain de Waroux, Bernard; Bolt, Michael; et al. (2001). Randomised crossover trial of transdermal fentanyl and sustained-release oral morphine for treating chronic non-cancer pain. British Medical Journal, 322, 1154–1158.
49. Julien, Richard M. (2005). A primer of drug action (10th ed.). New York: Worth, pp. 461–500.
50. Manchikanti, Laxmaiah; Standiford, Helen, II; Fellows, Bert; Janata, Jeffrey W.; Pampati, Vidyasagar; et al. (2012). Opioid
26. Herbert, Keith (2010, January 3). Deadly drug’s toll in black and white. Newsday, pp. A5–A6. Hernandez, D. (2003, May 23). Heroin’s new generation: Young, white, and middle class. New York Times, p. 34. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G; Schulenberg, John E.; and Miech, Richard A. (2014). Monitoring the future: National survey results on drug use, 1975–2013, Vol. I: Secondary school students, 2013. Rockville, MD: National Institute on Drug Abuse, Table 2-1. Jones, Richard G. (2008, January 13). Heroin’s hold on the young. New York Times, Long Island section, pp. 1, 8. Richey, Warren (1996, October 25). Boycott groups: Klein ads carry scent of “heroin chic.” Christian Science Monitor, p. 3.
27. National Drug Intelligence Center (2011). National drug threat assessment 2011. Washington, DC: U.S. Department of Justice, pp. 26–28.
28. Winger, Gail; Hofmann, Frederick G.; and Woods, James H. (1992). A handbook on drug and alcohol abuse: The biomedical aspects. New York: Oxford University Press, 1992, pp. 44–46.
29. Abel, Ernest L. (1985). Psychoactive drugs and sex. New York: Plenum Press, pp. 175–204.
30. McHugh, P. F.; and Kreek, Mary Jeanne (2008). The medical consequences of opiate abuse and addiction and methadone pharmacotherapy. In John Brick (Ed.), Handbook of the medical consequences of alcohol and drug abuse, 2nd ed. New York: Routledge, pp. 303–339. Winger; Hofmann; and Woods, Handbook on drug and alcohol abuse, pp. 46–50.
31. Julien, Richard M. (2005), A primer of drug action (10th ed.). New York: Worth, pp. 490–492. Yaksh, T. L.; and Wallace, M. S. (2012). In Laurence L. Brunton; Bruce A. Chabner; and Bjorn C. Knollman (Eds.), Goodman and Gilman’s the pharmacological basis of therapeutics (12th ed.). New York: Macmillan, pp. 481–525.
32. Levinthal, Messengers of paradise. Mathias, Robert (2003, March). New approaches seek to expand naltrexone use in her- oin treatment. NIDA Notes, 17(6), p. 8. Self, David W. (1998). Neural substrates of drug craving and relapse in drug addiction. Annals of Medicine, 30, 379–389. Teagle, Sarah (2007, April). Depot naltrexone appears safe and effective for heroin addic- tion. NIDA Notes, p. 7.
33. Goode, Erich (1999). Drugs in American society (5th ed.). New York: McGraw-Hill, p. 328. McHugh; and Kreek, Medical con- sequences, pp. 326–327. Strang, J.; Griffiths, P.; and Gossop, M. (1997). Heroin smoking by “chasing the dragon”: Origins and history. Addiction, 92, 673–684.
34. Buxton, J. A.; Sebastian, R.; Clearsky, L.; Angus, N.; Shah, L.; et al. (2011). Chasing the dragon—characterizing cases of leukoencephalopathy associated with heroin inhalation in British Columbia. Harm Reduction Journal, 8, 3.
35. McHugh and Kreek, Medical consequences. 36. Johnson, Bruce D.; Goldstein, Paul J.; Preble, Edward;
Schmeidler, James; Lipton, Douglas S.; et al. (1985). Taking care of business: The economics of crime by heroin abusers. Lexington, MA: Lexington Books.
37. Zinberg, Norman E. (1984). Drug, set, and setting: The basis for controlled intoxicant use. New Haven, CT: Yale University Press, pp. 46–81.
38. Hser, Yih-Ing; Hoffman, Valerie; Grella, Christine; and Anglin, M. Douglas (2001). A 33-year follow-up of narcotics addicts. Archives of General Psychiatry, 58, 503–508. Goode, Erich (2012). Drugs in American Society (8th ed.). New York: McGraw-Hill, pp. 278–281. National Institute on Drug Abuse (2001). 33-year study finds lifelong, lethal consequences of
180 ■ Part Three Legally Restricted Drugs and Criminal Justice
(2011, December 26). Millions for doctor-shoppers. Newsday, pp. A4–A5. Substance Abuse and Mental Health Services Administration (2010, November/December). Rise in treatment admissions for prescription pain relievers. SAMHSA News, p. 19.
55. Manchikanti, Laxmaiah; et al., Opioid epidemic in the United States, pp. ES29–ES30. Center for Behavior Health Statistics and Quality (2014). Results from the 2013 National Survey on drug use and health: Summary of national findings. Figure 2.16.
56. Lyman, Michael D. (2007). Practical drug enforcement. Boca Raton, FL: CRC Press, Chapter 9, p. 211.
57. Drug Diversion Task Force, Drug Enforcement Administration, U.S. Department of Justice. http://www.justice. gov;usao/tne/drug_diversion.html.
58. Lyman, Practical drug enforcement, pp. 224–226. 59. Associated Press (2011, January 23). FDA orders lower doses in
prescription painkiller. 60. Kirscher, Neil; Ginsburg, Jack; and Sulmasy, Lois S. (2013).
Prescription drug abuse: A policy position paper from the American College of Physicians. Annals of Internal Medicine, published online 10 December 2013, doi: 10-7326M13-2209.
61. Centers for Disease Control and Prevention (2012, July). Vital Signs: Prescription painkiller overdoses. Atlanta, GA: Centers for Disease Control and Prevention. Centers for Disease Control and Prevention (2011, November 4). Vital signs: Overdoses of prescription opioid pain relievers—United States, 1999–2008. Morbidity and Mortality Weekly Report, 60, 1487–1492. Meier, Barry (2013, June 23). Profiting from pain. New York Times, p. 4. Ricks, Delthia (2012, January 22). Narcotics nation. News- day, pp. A10–A11. Simopoulos, Thomas T. (2013). Editorial: Prescription opioid abuse in the US: The perfect storm with no proven strategies to mitigate the escalating problem. Journal of Substance Abuse and Alcoholism, 1, 1003.
epidemic in the United States. Pain Physician, 15, ES9–ES38. Center for Behavior Health Statistics and Quality (2014). Results from the 2013 National Survey on Drug Use and Health: Detailed tables, Table 1-1A.
51. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G; Schulenberg, John E.; and Miech, Richard A. (2014). Monitoring the Future: National survey results on drug use, 1975–2013, Vol. I: Secondary school students, 2013. Rockville, MD: National Institute on Drug Abuse, Table 2-2.
52. Tavernise, Sabrina (2013, January 26). F.D.A. likely to add limits on painkillers. New York Times, pp. A1, A13. Centers for Disease Control and Prevention (2012, January 13). CDC Grand Rounds: Prescription drug overdoses— A U.S. epidemic. Morbidity and Mortality Weekly Report, 61, 10–13. Centers for Disease Control and Prevention (2015, March 2). Prescription drug overdose in the United States: Fact sheet. Atlanta, GA: Centers for Disease Control and Prevention.
53. Basbaum, Allan I.; and Julius, David (2006, June). Toward better pain control. Scientific American, pp. 60–67. Meier, Barry (2003, November 23). The delicate balance between pain and addiction. New York Times, pp. F1, F6. FDA approves new formulation of OxyContin (2010, April 5). News release from the U.S. Food and Drug Administration, Washington, DC. Goodnough, Abby; and Zezima, Katie (2011, June 16). Drug is harder to abuse, but users persevere. New York Times, p. A21. RPT-painkiller Opana, new scourge of rural America (2012, March 12). Reuters News Service.
54. Meier, Barry (2012, April 9). Tightening the lid on pain prescriptions. New York Times, pp. A1, A12. Rosenberg, Debra (2001, April 9). How one town got hooked. Newsweek, pp. 49–50. Tavernise, Sabrina (2011, April 20). Ohio county losing its young to painkillers’ grip. New York Times, pp. A1, A16. Van Sant, Will; Peddie, Sandra; and Lewis, Robert
Cocaine and Methamphetamine
10 chapter
S.F. is a brilliant young physician attending a conference at a met-
ropolitan hospital where he is a medical resident. He has been on
call for 36 hours and can barely stay awake, much less concentrate
on the presentations. S.F. is lonely, depressed, and overworked. All he
can think about is his fiancée, Martha, who is several hundred miles
away. He knows that Martha’s father will not permit her to marry him
until he is able to support her. With all his debts and meager salary,
that could take years.
He excuses himself from the conference, takes a syringe from
the nurses’ station, and locks himself in a bathroom stall. He gets
out a packet of cocaine powder, fills the syringe with a 7-percent
solution, and plunges the needle into his arm. Within seconds, the
young doctor feels a rush of euphoria. His fatigue is gone; his com-
posure is regained. He is a totally rejuvenated man.
At once, S.F. rejoins the conference. He is determined to write
an essay documenting the medical effects of this magical drug. If
the essay is published, the entire scientific world now will know his
name. Fame and fortune should likely follow.
The date is 1884, the place is Vienna, and the physician is Sigmund Freud.
After you have completed this chapter, you should have an understanding of the following:
●● The history of cocaine
●● How cocaine works in the brain
●● Patterns of cocaine abuse
●● Treatment programs for cocaine abuse
●● The history of amphetamines
●● How amphetamines work in the brain
●● Patterns of methamphetamine abuse
●● Stimulant treatment for attention-deficit/hyperactivity disorder (ADHD)
●● Stimulant abuse
182 ■ Part Three Legally Restricted Drugs and Criminal Justice
The History of Cocaine
Cocaine is derived from small leaves of the coca shrub (Erythroxylon coca), grown in the high-altitude rain forests and fields that run along the slopes of the Peruvian and Bolivian Andes in South America, although coca cultiva- tion can be found in other regions of the world with similar climate and soil conditions.
Like many other psychoactive drugs, cocaine use has a long history. We can trace the practice of chewing coca leaves, which contain about 2 percent cocaine, back to the Inca civilization, which flourished from the thirteenth century until its conquest by the Spaniards in 1532, as well as to other Andean cultures dating back 5,000 years. Coca was considered a gift from the god Inti to the Incas, allowing them to endure a harsh and physically demanding life in the Andes.2
To this day, coca chewing is part of the culture of this region. It is estimated that about 2 million Peruvian men who live in the Andean highlands, representing 90 percent of the male population in that area, chew coca leaves.3 These people, called acullicadores, mix their own blend of coca, chalk, lime, and ash to achieve the desired effects, whether their goal is to fight fatigue or simply relax with friends.4
This form of cocaine use among these people produces few instances of toxicity or abuse. The reason lies in the very low doses of cocaine that chewed coca leaves provide; in this form, absorption from the digestive system is slow, and rela- tively little cocaine enters the bloodstream and is distributed to the brain (see Chapter 4). A much more serious problem has been availability of a coca paste containing a much higher percentage of cocaine mixed with tobacco and smoked as a cigarette (referred to as a bazuco). Now delivered to the brain directly from the lungs, cocaine is more likely to produce abuse and dependence. Making matters worse, dangerously high levels of kerosene, gasoline, and ether are involved in the coca-refining process and end up as adulterants in the cigarettes themselves.5
The time, place, and identity of S.F. in this fictional vignette are based on the life of Sigmund Freud. It may have surprised you to know that the founder of psychoanalysis started out as a physician interested more in the workings of the brain and the stimulant effects of cocaine than the deep recesses of the unconscious mind.1 It is worth commenting that the year could have been 1984 (or any other year since then) instead of 1884, and the individual involved could have been anyone 28 years old, as Freud was at the time, or some other age. Freud was extremely lucky; he never became dependent on cocaine, although a close friend did—and countless numbers of people have succumbed to cocaine dependence since Freud’s time.
As with the story of opium, the story of cocaine is both ancient and modern. Although its origins stretch back more than 4,000 years, cocaine abuse continues to represent a major portion of the present-day drug scene. For this rea- son, it is important to understand its history, the properties of the drug itself, and ways it has the potential to control and ultimately, in many cases, destroy a person’s life.
This chapter will focus not only on cocaine but also on a group of stimulant drugs, referred to collectively as amphet- amines, the most prominent example being methamphet- amine (meth). Although cocaine and amphetamines are distinct in terms of their pharmacology (their characteristics as biochemical substances), there are enough similarities in their behavioral and physiological effects to warrant their being discussed together. The emphasis will be on issues surrounding abuse and dependence. We will also examine the widespread medical application of amphetamines and amphetamine-like drugs in the treatment of attention-deficit/ hyperactivity disorder (ADHD), as well as recent concerns about their nonmedical use for “cognitive enhancement.”
In general, cocaine and amphetamines represent the two major classes of psychoactive stimulants, drugs that energize the body and create intense feelings of euphoria.
cocaine: An extremely potent and dependence- producing stimulant drug, derived from the coca leaf.
17.3 Percentage of high school seniors in 1985 who reported that they had used cocaine sometime in their lives. Between 1979 and 1987, the lifetime prevalence rate of cocaine use among high school seniors exceeded 15 percent.
23,828 Number of domestic meth lab seizures by the Drug Enforcement Administration during the peak year of 2004. More than 2,900 seizures were carried out in Missouri alone.
11,593 Number of domestic meth lab seizures in 2013. Missouri had dropped to third place, behind Kentucky and Indiana.
Sources: Information courtesy of the Drug Enforcement Administration, U.S. Department of Justice, Washington, DC. Johnston, Lloyd D.; O’Malley, Patrick M.; and Bachman, Jerald G. (1994), National Survey Report on Drugs: The Monitoring the Future Study, 1975–1993. Vol. 1. Secondary School Students. Rockville, MD: National Institute on Drug Abuse, Table 11.
Numbers Talk…
Chapter 10 Cocaine and Methamphetamine ■ 183
Pius X and Leo XII, to name just a few of Mariani’s fans. In a letter to Mariani, Frederic Bartholdi wrote that if he had been drinking Vin Mariani while designing the Statue of Liberty, it would have been more than three times taller.6 We can only assume that his remark was intended to be complimentary.
Meanwhile in the United States, Atlanta pharmacist John Pemberton promoted an imitation form of Vin Mariani that he called French Wine Cola. In 1885, however, as a con- cession to the American temperance movement, he took out the alcohol (see Chapter 15), added carbonated water, and reformulated the basic mixture to combine the coca with the syrup of the African kola nut containing about 2 percent caf- feine. In doing so, Coca-Cola was born.
On the strength of the beverage containing both coca and caffeine, early advertisements for Coca-Cola emphasized the drink as a “stimulating brain tonic” that made you feel more productive and as a remedy for such assorted nervous ailments as sick headaches and melancholia (in the nine- teenth century, the term was used to mean depression).7 The medicinal slant to the early promotion of Coca-Cola is probably the reason why soda fountains first appeared and continued for years to be located in drugstores.8
A number of competing brands with similar formulations sprang up with names such as Care-Cola, Dope Cola, Kola Ade, and Wiseola.9 Eventually, public pressure brought about official restrictions on the patent medicine industry, which, by the beginning of the twentieth century, was marketing more than 50,000 unregulated products.10 The Pure Food and Drug Act of 1906 specified that all active ingredients had to be listed on patent medicine labels. In Canada, the Proprietary and Patent Medicine Act of 1908 banned cocaine from patent medicines entirely, but in the United States no further restrictions on cocaine sales or use were imposed until the Harrison Act of 1914 (see Chapter 3).
Coca and Cocaine in Nineteenth-Century Life Coca leaves were brought back to Europe from the Spanish colonies soon after the conquest of the Incas in 1533, but their potency was nearly gone after the long sea voyage. Perhaps, it was said at the time, the legendary effects of coca were merely exaggerations. Coca leaves were ignored for 300 years.
By the late 1850s, however, there was a revival of inter- est in coca. The active ingredient of the coca plant was chemically isolated in 1859 by the German chemist Alfred Niemann, who observed its anesthetic effect on his tongue and named it “cocaine.” The patent medicine industry in the United States and Europe lost no time in marketing either stimulating beverages containing coca extract or topical anes- thetics (useful to relieve a toothache) containing cocaine.
Commercial Uses of Coca By far the most successful commercial use of coca in the nineteenth century was a mixture of coca and wine invented in 1863 by a Corsican chemist and businessman, Angelo Mariani. We know now that the combination of alcohol and cocaine produces a metabolite with an elimination half-life several times longer than cocaine alone, so the mixture tends to be quite intoxicating (see Help Line). No wonder “Vin Mariani” became an instant sensation.
In a stroke of marketing genius, Mariani also invented the concept of the “celebrity endorsement.” Over the next few decades, advertisements for Vin Mariani carried testimo- nials from satisfied customers such as U.S. president William McKinley, Thomas Edison, the surgeon general of the U.S. Army, General Ulysses S. Grant, Sarah Bernhardt, Jules Verne, the Prince of Wales, the czar of Russia, and Popes
Help Line Cocaine after Alcohol: The Risk of Cocaethylene Toxicity
The risks of dying from cocaine arise from the drug’s powerful excitatory effects on the body, such as abnormal heart rhythms, labored breathing, and increased blood pressure. The toxicity potential for any of these toxic reactions is, unfortunately, increased when alcohol is already in the bloodstream. The biotransformation of cocaine and alcohol (ethanol), when ingested in combination, produces a metabolite called cocaethylene. One effect of cocaethylene is a three- to fivefold increase in the elimination half-life of cocaine. As a result, cocaine remains in the bloodstream for a much longer time. More important, cocaethylene has a specific excitatory effect on blood pressure and heart rate that is greater than that produced by cocaine alone.
While the combination of alcohol and cocaine is associated with a prolonged and enhanced euphoria, it also brings an 18–25-fold increased risk of immediate death. The fact that
62–90 percent of cocaine abusers are also abusers of alcohol makes the dangers of cocaethylene toxicity a significant health concern.
Where to go for assistance www.nida.nih.gov/MedAdv/00/NR6–26.html
This Web site is sponsored by the National Institute of Drug Abuse and contains a comprehensive examination of cocaine risks, including the combination of cocaine with alcohol.
Sources: Andrews, Paul (1997). Cocaethylene toxicity. Journal of Addictive Diseases, 16, 75–84. Harris, Debra S.; Everhart, E. Thomas; Mendelson, John; and Jones, Reese T. (2003). The pharmacology of cocaethylene in humans following cocaine and ethanol administration. Drug and Alcohol Dependence, 72, 169–182.
184 ■ Part Three Legally Restricted Drugs and Criminal Justice
The Coca-Cola Company, aware of the growing tide of public sentiment against cocaine, changed the formula in 1903 from regular coca leaves to decocainized coca leaves, which eliminated the cocaine but retained the coca flavoring that remains to this day (Drugs … in Focus). The “pause that refreshed” America would henceforth be due only to the pres- ence of sugar and caffeine.
The use of cocaine also was becoming a major fac- tor in the practice of medicine. In the United States, William Halstead, one of the most distinguished surgeons of the time and one of the founders of the Johns Hopkins School of Medicine, studied the effect of cocaine in anesthetizing nerves and whole limbs. In the process, he acquired a cocaine habit of his own (which was replaced several years later by dependence on morphine). It was in Europe, however, that the applications of cocaine were explored most extensively, largely through the promotional efforts of an obscure Viennese physician named Sigmund Freud.
Freud and Cocaine In 1884 Freud was a struggling young physician, given to bouts of depression and self-doubt but nonetheless deter- mined to make his mark in the medical world. He had read a report by a German army physician that supplies of pure cocaine helped soldiers endure fatigue and feel bet- ter in general. Freud secured some cocaine for himself and found the experience exhilarating; his depression lifted, and he felt a new sense of boundless energy. His friend and col- league Dr. Ernst von Fleischl-Marxow, taking morphine
What Happened to the Coca in Coca-Cola? Every day, in a drab factory building in a New Jersey suburb of Maywood, a select team of employees of the Stepan Company carries out a chemical procedure that has been one of the primary responsibilities of the company since 1903. They remove cocaine from high-grade coca leaves. The remainder, technically called “decocainized flavor essence,” is then sent to the Coca-Cola Company as part of the secret recipe for the world’s favorite soft drink.
Each year, the Stepan Company is legally sanctioned by the U.S. government (and carefully monitored by the DEA) to receive shipments of about 175,000 kilograms of coca leaves from Peruvian coca farms, separate the cocaine chemically, and produce about 1,750 kilograms of high-quality cocaine. Its annual output is equiv- alent to approximately 20 million hits of crack, worth about $200 million if it were to make it to the illicit drug market. Fortunately, the Stepan Company has an impeccable security record.
In case you are wondering what happens to the cocaine after it is removed from the coca leaves, it turns out that Stepan finds a legitimate market in the world of medicine. Tincture of cocaine is used regularly as a local anesthetic to numb the skin prior to minor surgical procedures such as stitching up a wound. Surgeons frequently use cocaine as a topical ointment when working on the nose or throat.
As a result, the Stepan Company essentially has it both ways. It is the exclusive U.S. supplier of cocaine for use in medical settings as well as decocainized coca for your next can of Coke. As the Wall Street Journal put it, “The two markets end up sending Stepan’s products into virtually every bloodstream in America.”
Sources: Inclardi, James A. (2002). The war on drugs III. Boston: Allyn and Bacon, p. 21. Miller, Michael W. (1994, October 17). Quality stuff: Firm is peddling cocaine, and deals are legit. Wall Street Journal, pp. A1, A14.
Drugs … in Focus
In the late nineteenth century, the Coca-Cola Company advertised its beverage in medicinal terms. A company letterhead of this period spoke of Coca-Cola as containing “the tonic properties of the wonderful coca plant.”
Chapter 10 Cocaine and Methamphetamine ■ 185
Users also experience a general sense of well-being, although in some instances cocaine may precipitate a panic attack.14 As levels of cocaine diminish, the mood changes dramatically. The user becomes irritable, despondent, and depressed (Figure 10.1). These aftereffects are uncomfortable enough to produce a powerful craving for another dose.
The depression induced in the aftermath of a cocaine high can lead to thoughts of suicide. In 1985, during one of the peak years of cocaine abuse in the United States, as many as one out of five suicide victims in New York City showed evidence of cocaine in their blood at autopsy. The prevalence of cocaine use was greatest among victims who were in their twenties and thirties, and for African Americans and Latinos.15 In a 1989 survey of teenage callers to the 1-800-COCAINE hotline, one out of seven reported a previ- ous suicide attempt.16 On the basis of these studies, cocaine use has become recognized as a significant risk factor for attempted suicide.
and enduring a painful illness, borrowed some cocaine from Freud and found favorable results as well.
Before long, Freud was distributing cocaine to his friends and his sisters and even sent a supply to his fiancée Martha Bernays. In the words of Freud’s biographer Ernest Jones, “From the vantage point of our present knowledge, he was rapidly becoming a public menace.”11 We can gain some perspective on the effect cocaine was having on Freud’s behavior at this time through an excerpt from a personal letter to Martha:
Woe to you, my Princess, when I come. I will kiss you quite red and feed you till you are plump. And if you are forward you shall see who is the stronger, a gentle little girl who doesn’t eat enough or a big wild man who has cocaine in his body [underlined in the original]. In my last severe depression I took coca again and a small dose lifted me to the heights in a wonderful fashion. I am just now busy collecting the literature for a song of praise to this magical substance.12
Within four months, his “song of praise” essay, “Über Coca” (Concerning Coca), was written and published.
Unfortunately, fame that the essay brought Freud was short-lived, and the sweetness of his romance with cocaine soon turned sour. Freud himself escaped becoming depen- dent upon cocaine, though later in his life he clearly became dependent on nicotine (see Chapter 16). His friend, Fleischl, however, was not so lucky. Within a year, Fleischl had increased his cocaine dose to 20 times the amount Freud had taken and had developed a severe cocaine-induced psy- chosis in which he experienced hallucinations that snakes were crawling over his skin (a phenomenon now referred to as formication). Fleischl suffered six years of painful agony and anguish until his death. By 1887, Freud had retracted his earlier stance on the drug.
The story of Freud’s infatuation with cocaine and his later disillusionment with it can be seen as essentially a miniature version of the modern history of cocaine itself.13 Between 1880 and 1910, the public reaction to cocaine went from wild enthusiasm to widespread disapproval. As this chapter will later describe, a similar cycle of attitudes swept the United States and the world between 1970 and 1985.
Acute Effects of Cocaine
The effects of cocaine on the user vary in degree with the route of administration, the purity of the dose, and the user’s expectations about the experience, but certain features remain the same. The most prominent reaction is a power- ful burst of energy. If the cocaine is injected intravenously or smoked, the extremely intense effect (often referred to as a “rush” or “high”) is felt within a matter of seconds, and lasts only five or 10 minutes. If the drug is snorted through the nose, the effect is less intense than when injected or smoked but lasts somewhat longer, approximately 15–30 minutes.
Quick Concept Check
Understanding the History of Cocaine Check your understanding of the history of cocaine by match- ing the names on the left with the identifications on the right. Some identifications may not match with any of the names.
10.1
formication: Hallucinatory behavior produced by chronic cocaine or amphetamine abuse, in which the individual feels insects or snakes crawling either over or under the skin.
1. Angelo Mariani
2. John Pemberton
3. William Halstead
4. Sigmund Freud
5. Ernst von Fleischl-Marxow
a. Friend of Sigmund Freud; first documented case of cocaine psychosis
b. Developer of Coca-Cola, originally containing cocaine
c. Early advocate of restricting cocaine use in the United States
d. Cofounder of Johns Hopkins Medical School; early developer of cocaine to anes- thetize nerves and whole limbs
e. A popular figure in present-day Peru
f. Early advocate of cocaine use; originator of psychoanalysis
g. Promoter of a popular coca-laced wine
Answers: 1. g 2. b 3. d 4. f 5. a
186 ■ Part Three Legally Restricted Drugs and Criminal Justice
Chronic Effects of Cocaine
Repeated and continued use of cocaine produces undesirable mood changes that can be alleviated only when the person is under the acute effects of the drug. Chronic cocaine abusers are often irritable, depressed, and paranoid. As was true in Fleischl’s experience with cocaine, long-term abuse can pro- duce the disturbing hallucinatory experience of formication. The sensation of “cocaine bugs” crawling on or under the skin can become so severe that abusers may scratch the skin into open sores or even pierce themselves with a knife to cut out the imaginary creatures. These hallucinations, together with feelings of anxiety and paranoia, make up a serious mental disorder referred to as cocaine psychosis.
When snorted, cocaine causes bronchial muscles to relax and nasal blood vessels to constrict; the opposite effects occur when the drug wears off. As the bronchial muscles con- tract and nasal blood vessels relax, chronic abusers endure continuously stuffy or runny noses and bleeding of nasal membranes. In advanced cases of this problem, the septum of the nose can develop lesions or become perforated with small holes, both of which present serious problems for breathing.
Medical Uses of Cocaine
When applied topically on the skin, cocaine has the ability to block the transmission of nerve impulses, deadening all sen- sations from the area. The use of cocaine as an anesthetic for nasal, lacrimal duct (tear duct), and throat surgery remains its only legitimate medical application.20
Even though cocaine is available for use in these situ- ations, other topical anesthetics are typically preferred because they present fewer problems in their use. One disad- vantage of cocaine is that it might be inadvertently absorbed into the bloodstream, leading to an acute cocaine response that is unrelated to the anesthetic effect. Another problem is that cocaine produces intense vasoconstriction (constriction of blood vessels). This can be helpful in reducing bleeding during a surgical procedure, but the intensity of the vasocon- striction may have undesirable side effects. Finally, the local anesthetic effects are brief because cocaine breaks down so rapidly and would require reapplications to be effective. Other local anesthetics, such as lidocaine (brand name: Xylocaine), have the advantage of being active over a lon- ger period of time and not causing the problems associated with cocaine.
How Cocaine Works in the Brain
Cocaine greatly enhances the activity of dopamine, and, to a lesser extent, norepinephrine in the brain (see Chapter 5). In the case of both neurotransmitters, the actual effect is to stimulate receptors longer and to a greater degree. Unlike
Cocaine’s effect on sexual arousal is often cited as having been the basis for its purported allure as an aphrodisiac. On the one hand, interviews of cocaine users frequently include reports of spontaneous and prolonged erections in males and multiple orgasms in females during initial doses of the drug. On the other hand, cocaine’s reputation for increasing sexual performance (recall Freud’s reference in his letter to Martha) may bias users toward a strong expectation that there will be a sexually stimulating reaction, when in reality the effect is a much weaker one. The fact is that chronic cocaine use results in decreased sexual performance and a loss of sexual desire, as the drug essentially takes the place of sex.17
Cocaine produces a sudden change in a number of sys- tems in the body. Heart rate and respiration are increased, while appetite is diminished. Blood vessels constrict, pupils in the eyes dilate, and blood pressure rises. The cocaine user may start to sweat and appear suddenly pale. These effects can lead to a cerebral hemorrhage or congestive heart fail- ure. Cardiac arrhythmia results from cocaine’s tendency to bind to heart tissue itself. As you may recall from Chapter 1, cocaine is the drug most often involved in drug-related hos- pital emergency department visits and one of the drugs most frequently involved in drug-related deaths.18
Given the extreme excitatory effects of cocaine on bodily organs, it is not surprising that behavioral skills, particu- larly those requiring fine motor control, would be adversely affected. In a study of drivers showing reckless behavior on the road, those found to have been under the influence of cocaine were wildly overconfident in their abilities, taking turns too fast or weaving through traffic. One highway patrol officer called this behavior “diagonal driving. They were just as involved in changing lanes as in going forward.” Yet they passed the standard sobriety tests (such as walking a straight line) that are designed to detect alcohol intoxication.19
cocaine psychosis: A set of symptoms, including hallucina- tions, paranoia, and disordered thinking, produced from chronic use of cocaine.
Depressed
Manic
Euphoric
Normal
Sad
Cocaine administration
“Crash”
Moderate use
Heavy use
F iguRe 10 .1
Ups and downs of a typical dose of cocaine.
Chapter 10 Cocaine and Methamphetamine ■ 187
that “If it is used no more than two or three times a week, cocaine creates no serious problem… At present chronic cocaine use does not usually present a medical problem.”23
These attitudes began to change as the 1980s unfolded. The death of actor-comedian John Belushi in 1982, followed by the drug-related deaths of other entertainers and sport figures (see Drugs … in Focus, page 11) produced a reversal of opinion about the safety and desirability of cocaine. The most influential development, however, was the emergence of crack cocaine on the drug scene in the mid-1980s, which will be examined in the next sections.
From Coca to Cocaine To understand the full picture of present-day cocaine abuse, it is necessary to examine the various forms that cocaine can take, beginning with the extraction of cocaine from the coca plant itself (Figure 10.2). During the initial extraction pro- cess, coca leaves are soaked in various chemical solvents so that cocaine can be drawn out of the plant material itself. Leaves are then crushed, and alcohol is percolated through them to remove extraneous matter. After sequential washings
the amphetamines (discussed later in this chapter), the struc- ture of cocaine does not appear to resemble the structure of either dopamine or norepinephrine, so why cocaine should have this effect on receptors is not at all clear. Nonetheless, what has been determined is that the acute effect of eupho- ria experienced through cocaine is directly related to an increase in dopamine activity in the region of the brain that controls pleasure and reinforcement in general: the nucleus accumbens. The current scientific thinking is that this alteration in neurochemistry has a profound effect on an individual’s decision-making skills and an individual’s potential for developing a dependence on cocaine (or some other drug of abuse).
Chronic cocaine abuse, however, leads to the loss of about 20 percent of the dopamine receptors in this region of the brain over time. The depletion of dopamine recep- tors among long-term cocaine abusers has been observed up to four months after the last cocaine exposure, even though the cocaine abuser no longer has cocaine in his or her system. As a result, there is a tendency toward a decline in the experience of pleasure from any source. In fact, cocaine abusers frequently report that their craving for cocaine no longer stems from the pleasure they felt when taking it initially. Their lives may be in a shambles and the acute effects of euphoria from cocaine may no longer be strong, but they still crave the drug more than ever. In other words, there is now a disconnection between “liking” and “wanting.”21
One feature of cocaine is quite unlike that of other psy- choactive drugs. Although cocaine abusers over repeated cocaine exposures develop a pattern of drug tolerance to its euphoric effect, they develop a pattern of sensitization (a heightened responsiveness) with respect to motor behav- ior and brain excitation. This phenomenon, referred to as the kindling effect, makes cocaine particularly dangerous because cocaine has the potential for setting off brain sei- zures. Repeated exposure to cocaine can lower the thresh- old for seizures, through a sensitization of neurons in the brain over time. As a result of the kindling effect, deaths from cocaine overdose may occur from relatively low dose levels.22
Present-Day Cocaine Abuse
The difficult problems of cocaine abuse in the United States and around the world mushroomed during the early 1970s and continue to the present day, although the inci- dence of abuse is down from peak levels reached around 1986. In ways that resembled the brief period of enthusiasm for cocaine in 1884, attitudes during the early period of this “second epidemic” were incredibly naive. Fueled by media reports of use among the rich and famous, touted as the “champagne of drugs,” cocaine became synonymous with the glamorous life. At the same time, the medical profession at this time was equally nonchalant about cocaine. The widely respected Comprehensive Textbook of Psychiatry (1980) stated
Coca
Coca paste moderate concentration
Cocaine hydrochloride
high concentration (snorted, i.v. injected)
Free base
high concentration (smoked)
Crack
high concentration (smoked)
chemical extraction
chewed leaves low concentration
“complicated” reverse extraction
“easy” reverse extraction
F iguRe 10 .2
Steps in producing various forms of cocaine from raw coca.
kindling effect: A phenomenon in the brain that produces a heightened sensitivity to repeated administrations of some drugs, such as cocaine. This heightened sensitivity is the opposite of the phenomenon of tolerance.
188 ■ Part Three Legally Restricted Drugs and Criminal Justice
Inhaling high-potency cocaine (the purity of cocaine in crack averages about 75%) into the lungs, and almost immediately into the brain, sets the stage for a pattern of psychological dependence. And at a price of $5–10 per dose, cocaine is no longer out of financial reach (Table 10.1). These factors have made crack cocaine abuse particularly problematic.
At its height of popularity in metropolitan regions of America, crack cocaine had major societal impact on com- munities where prevalence rates were high. Women who were crack abusers found that their drug cravings overwhelmed their maternal instincts, resulting in their neglecting the basic needs of their children, either in postnatal or prenatal stages of life. In New York, for example, the number of reported cases
and a treatment with kerosene, the yield is cocaine that is approximately 60 percent pure. This is the coca paste that is, as mentioned earlier, combined with tobacco and smoked in many South American countries.
Coca paste, however, is not water-soluble and there- fore cannot be injected into the bloodstream. An additional step of treatment with oxidizing agents and acids is required to produce a water-soluble drug. The result is a white crystalline powder called cocaine hydrochloride, about 99 percent pure cocaine and classified chemically as a salt. When in the form of cocaine hydrochloride, the drug can be injected intravenously or snorted. The amount injected at one time is about 16 mg. Intravenous cocaine also can be combined with heroin in a highly dangerous mixture called a speedball.
If cocaine is snorted, the user generally has the option of two methods. In the first method, a tiny spoonful of cocaine is carried to one nostril while the other nostril is shut, and the drug is taken with a rapid inhalation. In the second method, cocaine is spread out on a highly polished surface (often a mirror) and arranged with a razor blade in several lines, each containing from 20 to 30 mg. The cocaine is then inhaled into one nostril by means of a straw or rolled piece of paper. During the early 1980s, a $100 bill was a fashionable choice, drawing attention to the level of income necessary to be using cocaine in the first place.24
From Cocaine to Crack Options for using cocaine widened with the development of free-base cocaine during the 1970s and crack cocaine (or simply crack) during the mid-1980s. In free-base cocaine, the hydrochloride is removed from the salt form of cocaine, thus liberating it as a “free base.” The aim is to obtain a smokable form of cocaine, which, by entering the brain more quickly, produces a more intense effect. The technique for produc- ing free-base cocaine, however, is extremely hazardous, as it is necessary to treat cocaine powder with highly flammable agents such as ether. If the free base still contains some resi- due of ether, igniting the drug will cause it to explode into flames.
Crack cocaine is the result of a cheaper and safer chemi- cal method, but the objective is essentially the same: a smok- able form of cocaine. Treatment with baking soda yields small rocks, which can then be smoked in a small pipe.25 When they are smoked, a cracking noise accompanies the burning, hence the origin of the name “crack.”
There is no question that the effect of cocaine when smoked exceeds the effect of cocaine when snorted; for some users, it even exceeds the effect of cocaine when injected.
TAble 10.1
Street names for cocaine
Type oF CoCAine STReeT nAme
Cocaine hydrochloride (powder)
blow, C, coke, big C, lady, nose candy, snowbirds, snow, stardust, toot, white girl, happydust, cola, flake, pearl, Peruvian lady, freeze, geeze, doing the line
Free-base cocaine freebase, base
Crack cocaine crack, rock, kibbles and bits, crell
Crack cocaine combined with PCP (see Chapter 11)
beam me up Scottie, space cadet, tragic magic
Cocaine combined with heroin speedball, snowball
Cocaine combined with heroin and LSD
Frisco special, Frisco speedball
Source: Bureau of Justice Statistics Clearinghouse (1992). Drugs, behavior and crime. Washington, DC: U.S. Department of Justice, pp. 24–25.
Public demonstrations in urban communities in the 1980s and 1990s were one way of responding to the desolation and misery resulting from crack cocaine abuse.
crack cocaine or crack: A smokable form of cocaine. free-base cocaine: A smokable form of cocaine.
cocaine hydrochloride: The powder form of cocaine that is inhaled (snorted) or injected into the bloodstream.
Chapter 10 Cocaine and Methamphetamine ■ 189
medical emergencies associated with cocaine use, as mea- sured through the DAWN statistics, have increased dra- matically. In 2011, there were approximately 505,000 cocaine-related ED visits reported by metropolitan hospi- tals. It is evident that emergency departments have borne a great burden in the acute care of cocaine abusers, just as law enforcement agencies have borne the burden of reducing the availability of cocaine and cocaine derivatives (Drugs . . . in Focus).29
Treatment for Cocaine Abuse
One way of grasping the magnitude of the cocaine-abuse problem is to look at the number of people who have wanted to get help. In 1983, a nationwide toll-free hotline, 1-800-COCAINE, was established as a 24-hour service for emergency and treatment information. From 1983 to 1990, more than 3 million callers responded, averaging more than 1,000 per day.30
The statistics gathered from the hotline during the 1980s also revealed the changed face of cocaine abuse over that span of time. In 1983, the typical cocaine abuser was col- lege educated (50%), employed (83%), earning more than $25,000 per year (52%), and taking cocaine powder intrana- sally (61%). By 1988, however, the typical cocaine abuser had not gone to college (83%) and was earning less than $25,000 per year (80%). From 1983 to 1988, the percentage of indi- viduals reporting an abuse of a free-base form of cocaine had more than doubled to 56 percent. In 1986 alone, one year after the introduction of crack, half of all calls to the hotline referred to problems of crack abuse.31
of child abuse and neglect increased from 36,000 in 1985 to 59,000 in 1989, a change largely attributed to the introduction of crack. Inner-city crime and violence skyrocketed. As the hugely profitable crack cocaine trade took root, systemic vio- lence became a fact of life for people living in the inner cit- ies of America. The profitability of selling crack cocaine on a domestic level was fueled by the enormous profits made by traffickers in the global illicit drug trade (Figure 10.3).26
Although crack abuse remains a problem today, the number of new crack abusers has declined substantially, particularly in urban communities. In 1998, whereas 36 per- cent of all males over 36 years old who were arrested in New York in 1998 had used crack, little more than 4 percent of those 15–20 years old had done so. A principal reason for this change in prevalence rates has been the current stigmatized image of the “crack head,” considered by one’s peers in the community to be a social loser.27
Patterns of Cocaine Abuse
In 2013, the National Survey on Drug Use and Health esti- mated that approximately 33 million Americans aged 12 or older had used cocaine at some time in their lives, 4.1 million had used it during the past year, and 1.5 million had used it during the past month. Approximately 9 million Americans had used crack at some time in their lives, 632,000 had used it during the past year, and 377,000 had used it during the past month. The past month prevalence rate for crack in 2013 had declined by 44 percent, relative to 2005.28
Although the present-day incidence of cocaine abuse in the United States is lower than it was during the 1980s,
1 2 3
$300 to $700: Payment to Peruvian farmers for the 400 pounds of coca leaves necessary to produce one pound of cocaine
$1,500 to $2,000: Value of one pound of refined cocaine when it leaves Colombia for Mexico
$10,000 to $26,000: Street price of small doses of crack cocaine when bought in major American cities
Shipments of cocaine from Colombia are transported through Mexico and broken down into smaller units for smuggling across the U.S. border. After crossing the border, cocaine is reconsolidated and driven to distribution points for manufacture into street doses of crack cocaine.
F iguRe 10 .3
From the coca farm to crack cocaine on the street, values increase by approximately 8600 percent to as much as $26,000 for the 400 pounds of raw coca required to produce one pound of cocaine and an equivalent amount of crack cocaine.
190 ■ Part Three Legally Restricted Drugs and Criminal Justice
an environment where cocaine and other drugs are prevalent and peer pressure to resume drug-taking behavior is intense. The difficulty is that they have been so alienated from the mainstream and have few if any friends that are not users.35
A third alternative is a combined approach in which a shortened inpatient program, 7–14 days in length, is followed by an intensive outpatient program that continues for several months (Portrait).
Whether on an inpatient or an outpatient basis, there are several approaches for treatment. One alternative is the self-help support group Cocaine Anonymous, modeled after the famous 12-step Alcoholics Anonymous program (see Chapter 15). In this program, recovering cocaine abusers meet in group sessions, learn from the life experiences of other members, and gain a sense of accomplishment from remaining drug-free in an atmosphere of fellowship and mutual support. In another drug treatment option, cocaine abusers meet with cognitive-behavioral therapists, who teach them new ways of acting and thinking in response to their environment. During the course of cognitive-behavioral therapy, cocaine abusers are urged to avoid situations that lead to drug use, recognize and change irrational thoughts, manage negative moods, and practice drug-refusal skills. While the success rates of both approaches are approximately the same for patients in cocaine-abuse treatment overall, some evidence suggests that a cocaine abuser’s personal characteristics may affect the kind of treatment that will work best (Figure 10.4).
Whatever the approach taken, however, it is clear that an intensive relearning process has to go on because cocaine abusers often cannot remember a life without cocaine.36
Treating cocaine abuse presents difficulties that are peculiar to the power of cocaine itself. Coming off cocaine is one of the most anguished and depressing of experiences. Some abusers feel like they are having a heart attack. They will do almost anything to keep from crashing.32
The varieties of treatment for cocaine abuse all have cer- tain features in common. The initial phase is detoxification and total abstinence. The cocaine abuser aims to achieve total withdrawal with the least possibility of physical injury and minimal psychological discomfort. During the first 24–48 hours, the chances are high that there will be profound depres- sion, severe headaches, irritability, and disturbances in sleep.33
In severe cases involving a pattern of compulsive use, the cocaine abuser needs to be admitted for inpatient treatment in a hospital facility. The most intensive interventions, medical supervision with psychological counseling, can be made in this kind of environment. The early stages of withdrawal are clearly the most difficult, and the recovering abuser can benefit from the around-the-clock attention that only a hospital staff can give.
An alternative approach is an outpatient program, under which the individual remains at home but travels regularly to a facility for treatment. An outpatient program is clearly a less expensive route to take, but it works only for those who recog- nize the destructive impact of cocaine dependence on their lives and enter treatment with a sincere desire to do whatever is needed to stop.34
For cocaine abusers who have failed in previous attempts in outpatient treatment or for those who are in denial of their cocaine dependence, an inpatient approach may be the only answer. For most abusers, it is important to stay away from
Cocaine Contamination in u.S. paper Currency It is a fact of life in drug enforcement that supplies of illicit drugs are very difficult to trace. As a result of a clever experiment conducted in 2001, however, the opposite appears to be true. A strange but reliable phenomenon came to light with respect to the paper currency that Americans handle every day: the contamination of this currency with detect- able levels of cocaine. Analyses were made of 50 randomly sampled one dollar bills from five cities in the United States and Puerto Rico (Baltimore, Chicago, Denver, Honolulu, and San Juan). Detectable amounts of cocaine were found in an astounding 92 percent of these bills. There is little doubt that a similar result would have been reported for bills of higher denominations, but the study focused only on one dollar bills.
The explanation given for this finding was based on the pattern of cocaine abuse and the present-day system
of currency processing and distribution. Contamination is believed to begin with the handling of currency during cocaine trafficking (see Chapter 2) and with the rolling up of bills for cocaine snorting. The contaminated money is then transferred from bill to bill during automated counting in banks and other financial institutions. The extremely high incidence of cocaine-contaminated money is attributed to cross-contamination after the act of drug-taking behavior, rather than to the behavior itself. A lower incidence of con- tamination was found with respect to other illicit drugs such as methamphetamine or heroin, due largely to the relatively lower prevalence rates of abuse in general and the fact that currency would not as likely be directly involved in their consumption.
Source: Jenkins, Amanda J. (2001). Drug contamination of U.S. paper currency. Forensic Science International, 3, 189–193.
Drugs … in Focus
Chapter 10 Cocaine and Methamphetamine ■ 191
her baby’s diaper. She used baby powder and the sight of the white powder induced a tremendous craving for cocaine.”37
Currently, pharmacological approaches in cocaine-abuse treatment, as well as the combination of pharmacological and behavioral approaches, are being vigorously pursued. The
The potential for relapse is particularly challenging among recovering cocaine abusers, primarily as a result of powerful conditioned cues that have been associated with the drug. A spe- cialist in cocaine abuse rehabilitation tells this story: “A woman was doing well in treatment. Then one day she was changing
poRTRAiT Robert Downey, Jr.—Cleaned Up After Cocaine
The parade of celebrities who have struggled against cocaine abuse is seemingly end- less. Over the years, we have witnessed their personal triumphs and failures and have seen some lives lost (see Chapter 1), some careers lost, and occasionally careers regained. In 1986, the nation was galva- nized by the untimely deaths of college basketball player Len Bias and profes- sional football player Dan Rogers within months of each other; the death of come- dian and actor John Belushi had occurred just four years earlier. The deaths of River Phoenix in 1993, Chris Farley in 1998, and Mitch Hedberg in 2005, all of them due to a lethal combination of cocaine and heroin, have underscored the ever- present dangers of drug-taking behavior.
Fortunately, the story of Robert Downey, Jr., an Academy Award nominee for his performance in the title role of the movie Chaplin in 1992, has all the marks of a Hollywood comeback screenplay—the story of a life and career derailed for several years by the abuse of cocaine and
other drugs but somehow managing to come out right in the end. For a time, his fans held their breath as events unfolded. In 2003, Downey was beginning to rec- ognize that he had to turn his life around. It was about one year into serving a three- year probation period, after pleading no-contest to cocaine possession and being under the influence during a November 2000 arrest in a Palm Springs hotel (see photo on left). In 1999, Downey had spent a year in prison after being convicted on charges of cocaine possession. Upon his release, he was featured on the successful Aly McBeal TV show, only to be fired in 2000. His drug-abuse problems had first begun making headlines in 1996 when he was found with cocaine, heroin, and a pistol in his car.
In earlier editions of Drugs, Society, and Criminal Justice, this Portrait feature portrayed the story of Robert Downey, Jr., in considerably less positive terms or, at best, considerable caution. However,
today there is considerable reason for optimism that his self-destructive lifestyle is behind him. In 2008, Downey achieved a major comeback in his starring role in the highly successful blockbuster movie Ironman (see photo on right). He has followed with Ironman 2 (2010) and Ironman 3 (2013), Sherlock Holmes (2009) and its sequel (2011), and other successful films. His personal life seems to have regained a stability that bodes well for the future. In 2003, Downey and his wife Susan Levin formed Team Downey, an entertainment company actively engaged in a num- ber of film projects. He has frequently acknowledges his wife for her critical role in his continuing journey of recovery.
Sources: Carr, David (2008, April 20). Been up, been down. Now? Super. New York Times, pp. 1, 13. Downey’s back, older and “mildly wiser” (2003, January 21). Newsday, p. A12. Lemonick, Michael D. (2000, December 11). Downey’s downfall. Time, p. 97.
Cognitive- Behavioral
Therapy
12-Step Cocaine
Anonymous Program
50% 25%
18% 48%
35% 40%
46% 54%
Patients with high abstract reasoning
Patients with low abstract reasoning
Patients with high religious beliefs
All patients
F iguRe 10 .4
Percentage of patients achieving four consecutive weeks of cocaine abstinence comparing two types of treatment.
Source: Adapted from Shine, Barbara (2000, March). Some cocaine abusers fare better with cognitive-behavioral therapy, others with 12-step programs. NIDA Notes, 15 (1), 9.
192 ■ Part Three Legally Restricted Drugs and Criminal Justice
have wanted, at some time in our lives, to be a superhero. Cocaine, as we know, gives us that illusion. The remainder of this chapter will examine another powerful drug source for these feelings of invincibility: amphetamines. As we will see, the attractions and problems of abuse associated with cocaine and amphetamines are very similar.
The History of Amphetamines The origin of modern amphetamines dates back almost 5,000 years to a Chinese medicinal herb called ma huang (Ephedra vulgaris) that was used to clear bronchial passageways dur- ing bouts of asthma and other forms of respiratory distress. According to Chinese legend, this herb was first identified by the Emperor Shen Nung, who also is credited with the discovery of tea and marijuana.
German chemists isolated the active ingredient of ma huang in 1887, naming it ephedrine. It was soon obvious that ephedrine stimulated the sympathetic nervous system in
development of any drug that reduces craving would be a great advance in the treatment of cocaine dependence and in the prevention of problems associated with cocaine dependence.38
Whether the strategy is behavioral or pharmacological, treatment and prevention approaches to cocaine abuse reflect a general orientation toward reducing the negative impact of drug-taking behavior on the individual and society (the “demand” side), as opposed to reducing the availability of the drugs themselves (the “supply” side). Drug Enforcement … in Focus examines the continuing difficulties in controlling the supply line of cocaine.
Amphetamines
One of humanity’s fondest dreams is to have the power of unlimited endurance, to be able to banish fatigue from our lives, to be fueled by endless energy as though we had dis- covered some internal perpetual motion machine. We all
Comparison Shopping inside the global Cocaine black market As detailed in Chapter 2, a continuing battle rages between domestic and international drug-control authorities and illicit drug dealers that employ increasingly sophisticated high- technology methods to distribute their drugs. A prime example is the number of Web-based marketplaces such as Silk Road 2.0 (see Drug Enforcement … in Focus on page 21) that allow anonymous purchases to be made of illicit drugs. From a crimi- nal justice perspective, these struggles exemplify the difficulties in controlling illicit drug purchases when present-day technolo- gies permit untraceable financial transactions.
Nonetheless, as long as Silk Road 2.0 and other Web-based marketplaces manage to exist, we can have an “inside look” at the “market conditions” for purchases of various illicit drugs. In other words, it is possible to compare the prices of various illicit drugs, as a function of the country in which the drug is being purchased. What is the going price for cocaine, for example, when purchased in a specific country?
Here is a comparison chart of prices for a gram of cocaine in eight nations of the world, as of October 7, 2013, with the virtual currency of bitcoins converted to U.S. dollars, according to the exchange rate at the time ($140 to one bitcoin). Naturally, the bitcoin currency rate, as with any other currency, continu- ally changes. On November 3, 2014, for example, the bitcoin exchange rate had risen to $330. For a price in dollars on the day (or hour) you are reading this, check the numerous bitcoin currency exchanges on the Internet and adjust the figures below, accordingly.
To the extent that Silk Road 2.0 accurately reflected the ongoing prices in October 2013 for illicit drugs in a particular nation, it is evident that cocaine was most expensive in Australia and relatively cheap in the United States. It was inexpensive in Peru, probably due to the fact that Peru is one of the top sources of cocaine in the world.
Drug Enforcement … in Focus
Source: Data provided by the Web site http://money.nn .com/2013/10/09/technology/silk-road-drug-price//
$270
$184
$148 $139 $122 $116
$99 $73
0
50
100
150
200
250
300
Au str
ali a
Un ite
d
Ki ng
do m
Ge rm
an y
Be lgi
um
Ne th
erl an
ds
Ca na
da
Un ite
d S ta
tes Pe ru
Chapter 10 Cocaine and Methamphetamine ■ 193
however, is only one version of amphetamine, the “right- handed” form, since amphetamine contains a “left-handed” version as well (imagine a mirror image of Figure 10.5). The more potent version is the right-handed form, called dextro- amphetamine or d-amphetamine (brand name: Dexedrine). It is stronger than the left-handed form, called levoamphet- amine or l-amphetamine, which is not commonly available. A modified form of d-amphetamine, formulated by sub- stituting CH3 (called a methyl group) instead of H at one end, is called methamphetamine. This slight change in the formula allows for a quicker passage across the blood–brain barrier and therefore a more powerful effect on the brain. It is methamphetamine (meth, speed, or crank) that has been the primary form of amphetamine abuse in recent years.
Acute Effects of Amphetamines The acute effects of amphetamine, in either d-amphetamine or methamphetamine form, closely resemble those of cocaine. However, amphetamine effects extend over a longer period of time. For intervals of 8–24 hours, there are signs of increased sympathetic autonomic activity such as faster breathing and
general. In 1932, the pharmaceutical company Smith, Kline and French Laboratories marketed a synthetic form of ephed- rine called amphetamine under the brand name Benzedrine as a nonprescription CNS stimulant appetite suppressant and bronchial dilator.
During World War II, both U.S. and German troops were being given amphetamine to keep them awake and alert. Japanese kamikaze pilots were on amphetamine dur- ing their suicide missions. The advantages over cocaine, the other stimulant drug available at the time, were twofold: Amphetamine was easily absorbed into the nervous system from the gastrointestinal tract, so it could be taken orally, and its effects were much longer lasting.
After the war, amphetamine use was adapted for peace- time purposes. Amphetamine, often referred to as “bennies,” was a way for college students to stay awake to study for exams and for long-distance truck drivers to fight fatigue on the road. Truckers would take a “St. Louis” if they had to go from New York to Missouri and back or a “Pacific turnabout” if they needed to travel completely across country and back, without stopping to sleep.39
In the meantime, the word got around that amphet- amine produced euphoria as well, and soon amphetamine became popular for recreational purposes. People found ways of opening up the nonprescription amphetamine inhal- ers, withdrawing the contents, and getting high by drinking it or injecting it intravenously. Since each inhaler contained 250 mg of amphetamine, there was enough for several powerful doses. During the early 1960s, injectable amphet- amines could be bought with forged prescriptions or even by telephoning a pharmacy and posing as a physician. By 1965, amendments to federal drug laws tightened the supply of pre- scription amphetamines, requiring manufacturers, wholesal- ers, and pharmacies to keep careful records of amphetamine transactions, but amphetamines soon became available from illegal laboratories.40
Amphetamine abuse in the United States reached a peak about 1967, declining slowly over the 1970s as other stimulant drugs, notably cocaine, grew in popularity. By 1970, 10 percent of the U.S. population over 14 years of age had used amphetamine, and more than 8 percent of all drug prescriptions were for amphetamine in some form.41 For about two decades afterward, amphetamine abuse steadily faded from prominence in the drug scene. Cocaine and later crack cocaine became the dominant illicit stimulant of abuse. Only since the mid-1990s has amphetamine abuse resurfaced as a significant social concern.
The Different Forms of Amphetamine To understand amphetamine abuse, both past and present, it is necessary to know something about the molecular struc- ture of amphetamines themselves and their relationship with important neurotransmitters in the brain. As you can see at the top of Figure 10.5, amphetamine can be represented chiefly as carbon (C), hydrogen (H), and nitrogen (N) atoms, in a prescribed arrangement. What you are seeing,
Dextroamphetamine
Methamphetamine
Dopamine
Norepinephrine
C C——
C
C C H C H
CH3 C HC
—— —
— — — — ——
—
H
H
N ——
C C——
C
C C H C H
CH3 C HC
—— —
— — — — ——
—
H
CH3
N ——
HO
HO
C C——
C
C C H C H
H C HC
—— —
—— — — — ——
—
—
H
H
N ——
HO
HO
C C——
C
C C OH C H
H C HC
—— —
—— — — — ——
—
—
H
H
N ——
F iguRe 10 .5
The molecular structure of dextroamphetamine, metham- phetamine, dopamine, and norepinephrine.
d-amphetamine: Shortened name for dextroamphetamine, a potent form of amphetamine, marketed under the brand name Dexedrine.
methamphetamine: A type of amphetamine, once marketed under the brand name Methedrine. Methamphetamine abusers refer to it as meth, speed, or crank.
amphetamine (am-FeH-ta-meen): A family of powerful stimulant drugs.
194 ■ Part Three Legally Restricted Drugs and Criminal Justice
methamphetamine in Figure 10.5. Notice how similar they all are, with only slight differences among them. Because of the close resemblance to dopamine and norepinephrine, it is not hard to imagine amphetamines increasing the activity level of these two neurotransmitters.
Methamphetamine
In the 1960s, methamphetamine abuse was intermingled with the psychedelic drug scene, most prominently during San Francisco’s “Summer of Love and Peace” in 1967. Almost from the beginning, however, speed freaks—as methamphet- amine abusers were called—whose behaviors were anything but loving or peaceful, became the outcasts of that society. They were more often than not wild-eyed, manic burnout cases, given to erratic and violent behavior. They were typi- cally shunned by the rest of the drug users in the community.
As crack cocaine became increasingly associated with the urban poor and powder cocaine with upscale affluence in the 1980s, amphetamine abuse declined dramatically. In the 1990s, however, as crack cocaine and powder cocaine abuse began to diminish, methamphetamine abuse reemerged, with a totally new demographic profile. Its popularity was now concentrated among working-class people rather than among those who were associated with the drug scene of the 1960s, individuals with traditional rather than countercultural social values. Without the stigma of being a “hard drug,” metham- phetamine would become one of the few drugs reported as equally or more prevalent than other illicit drugs in areas out- side America’s inner cities.
Methamphetamine in the Heartland of America As methamphetamine (meth) abuse expanded into midwest- ern, central, and southern U.S. states, communities that had not traditionally been considered to be involved with illicit drug-taking behavior were having to deal with major prob- lems of public safety and public health. By the mid-2000s, for example, meth abuse had gotten so bad in a county in North Carolina (population 51,000) that it had nicknamed itself “the county that never sleeps.” Law enforcement raids on meth laboratories in the region were a common occurrence. Because of the combustible ingredients in meth production, every fire emergency was treated as if it were a “meth-lab fire.”
A survey of more than 500 county sheriffs in the United States, conducted by the National Association of Counties in 2005, documented the alarming proportions of meth abuse across the country. Fifty-eight percent of sheriffs in the survey regarded meth abuse as the biggest drug problem they faced, ahead of concerns about heroin, cocaine, or marijuana. In half of the counties surveyed, one in five current prison inmates had been incarcerated due to meth-related crimes. In 17 percent of the counties, more than half of the inmate population had been incarcerated for such crimes. A majority
heart rate as well as hyperthermia (increased body tempera- ture) and elevated blood pressure. Users experience feelings of euphoria and invincibility, decreased appetite, and an extraor- dinary boost in alertness and energy. Adverse and potentially lethal bodily changes include convulsions, chest pains, and stroke. In 2011, approximately 103,000 drug-related ED vis- its in the United States were attributable to amphetamines, practically all of them being specifically associated with methamphetamine.42
Chronic Effects of Amphetamines The chronic effects of amphetamine abuse are both bizarre and unpleasant, particularly in the case of methamphetamine. Heavy methamphetamine abusers may experience formi- cation hallucinations similar to those endured by cocaine abusers. They may become obsessed with the delusion that parasites or insects have lodged in their skin and so attempt to scratch, cut, or burn their skin in an effort to remove them. It is also likely that they will engage in compulsive or repetitive behaviors that are fixated upon ordinarily trivial aspects of life; an entire night might be spent, for example, counting the corn flakes in a cereal box. Compulsive jaw movements and teeth grinding can cause significant dental damage over time.43
The most serious societal consequence of methamphet- amine abuse is the appearance of paranoia, wildly bizarre delusions, hallucinations, tendencies toward violence, and intense mood swings. In the words of one health professional, “It’s about the ugliest drug there is.”44 Because the symptoms have been observed with the chronic abuse of amphetamines of any type, they are referred to collectively as amphetamine psychosis. These “psychotic” effects, often persisting for weeks or even months after the drug has been withdrawn (called “tweaking” by the drug-abuse community), so closely resem- ble the symptoms of paranoid schizophrenia that it has been speculated that the two conditions have the same underlying chemical basis in the brain: an overstimulation of dopamine- releasing neurons in those regions that control emotional reac- tivity.45 A study of heavy methamphetamine users has shown changes in chemical metabolites in those regions of the brain that are associated with Parkinson’s disease, suggesting that this group may be predisposed to acquiring Parkinson symp- toms later in life, due to their methamphetamine exposure. Fortunately, however, recent evidence indicates that chemical changes in the brain in chronic methamphetamine users can be at least partially reversed by abstaining from the drug for a year or more.46
How Amphetamines Work in the Brain We can get a good idea of how amphetamines work in the brain by looking carefully at the molecular structures of dopa- mine and norepinephrine alongside d-amphetamine and
amphetamine psychosis: A set of symptoms, including hallucinations, paranoia, and disordered thinking, resulting from high doses of amphetamines.
Chapter 10 Cocaine and Methamphetamine ■ 195
and streams. Families suffered from the inhalation of toxic fumes emitted during meth production and from fire and explosions resulting from flammable precursor chemicals.48
Present-Day Methamphetamine Abuse The Comprehensive Methamphetamine Control Act of 1996 increased the penalties for trafficking and manufacture of methamphetamine, but as domestic meth labs became a widespread social problem, it was apparent that more aggressive legislation was needed. In 2005, the Combat Methamphetamine Epidemic Act established nationwide sales restrictions on precursor chemicals for meth produc- tion. Since then, retail outlets have been required by federal law to limit the sales of numerous cough-and-cold remedies that contain pseudoepinephrine—an essential ingredient in the making of methamphetamine. In effect, these “over- the-counter” drugstore products have become “behind-the- counter.” Under present pseudoepinephrine regulations, customers cannot make a legitimate purchase of more than the equivalent of approximately seventy 60 mg tablets per day and must provide photo identification upon purchase and sign a logbook recording the transaction. Because liquid anhydrous ammonia, commonly used as a farm fertilizer, is another ingredient in the making of methamphetamine, fertilizer dealers have resorted to the installation of security systems to protect their supplies from theft.
As described in Chapter 2, restrictions imposed under present federal law have resulted in a “downsizing” of these meth labs. Meth cookers now rely on recipes that yield smaller quantities of methamphetamine and no longer participate in significant meth trafficking. While domestic meth lab seizures continue to be made, present-day meth- amphetamine trafficking in the United States has shifted to sources in Mexico and North Korea (Drug Enforcement … in Focus). As a result of the large quantities that are available, methamphetamine abuse continues to be a significant drug- control issue. In 2013, the National Survey on Drug Use and Health estimated that approximately 12 million Americans aged 12 or older had used methamphetamine at some time in their lives, 1.2 million had used it during the past year, and 595,000 had used it during the past month.49
Table 10.2 includes some of the street names used by abusers of methamphetamine and other amphetamines such as dextroamphetamine.
In the late 1980s, a smokable form of methamphetamine called ice (also referred to as crystal meth) appeared on the drug scene in Hawaii, expanding to the mainland United States a decade later as a major club drug in New York, Los Angeles, and other cities. Its name originates from its quartz-like, chunky crystallized appearance. A combination of a purity level of 98–100 percent and a highly efficient route of administration
of sheriffs reported that methamphetamine was the major contributing factor for increases in robberies or burglaries, domestic violence, and simple assaults. At the same time, only one in six counties reported that they had the financial resources to support a rehabilitation center or program.
The impact of meth abuse on children was a par- ticular concern. There were significant increases in cases in which children needed to be placed out of the home as a result of neglect and abuse by parents who were meth abusers or a child’s proximity to the hazards of home-grown meth labs. Nearly three-fourths of county child welfare officials in California and Colorado, for example, reported an increase in such cases. More than 69 percent of counties in Minnesota reported an increase in methamphetamine-related child placements between 2004 and 2005. Meanwhile, social service networks were ill prepared to handle the increased numbers of foster chil- dren, and the chances of reunifying families torn apart by meth abuse were considerably lower than in cases involv- ing other forms of substance abuse, due to the relatively high rate of relapse in treatment.47
Environmental consequences included the accumula- tion of toxic materials remaining as waste residue from meth manufacture, seeping into the soil and contaminating rivers
In a makeshift but sophisticated “meth factory,” seized in a DEA raid in Altamont, Tennessee, a combination of ephedrine, hydrochloric acid, and red phosphorus (shown in the red liquid in the picture) was heated in a flask placed in an electric pot. Rubber tubes attached to each side of the glass condenser circulated cold water to reduce the escape of toxic fumes.
ice: A smokable form of methamphetamine hydrochloride. It is often referred to as crystal meth, due to its quartz-like appearance.
196 ■ Part Three Legally Restricted Drugs and Criminal Justice
behavior for each type of drug has its own distinctive char- acter. Methamphetamine abusers typically use the drug throughout their waking day, at two- to four-hour intervals, in a pattern that resembles taking medication. Cocaine abusers
(through the lungs), the dependence potential of this form of meth abuse is relatively high. The association with high-risk sexual behavior remains a major public health concern.50
Patterns of Methamphetamine Abuse Even though methamphetamine and cocaine are simi- lar in their stimulant effects and both trigger a major release of dopamine in the brain, the pattern of drug-taking
TAble 10.2
Street names for methamphetamine and other amphetamines
Type oF AmpHeTAmine STReeT nAme
Amphetamine in general bennies, uppers, ups, A, pep pills, white crowns, whites
Dextroamphetamine dexies, cadillacs, black beauties
Methamphetamine* meth, speed, Tina, crank, little whites, white crosstops, crystal meth, quill, yellow bam, zip, go fast, chalk, shabu, spoosh, get go
Smokable methamphetamine*
ice, crystal, crystal meth, L.A., L.A. glass, quartz, cristy, hanyak, Christina, Tina
Methcathinone, mephedrone khat, cat, goob
*Slang terms often confuse smokable and nonsmokable forms of methamphetamine, so some street names may overlap the two categories.
Source: Drug Enforcement Administration and the Office of National Drug Control Policy, Washington, DC.
Drug Enforcement … in Focus
north Korea: A new player in methamphetamine Trafficking Until recently, drug-control authorities have regarded Mexico as the primary foreign supplier of methamphetamine (meth), originating from “superlab” facilities (see Chapter 2). Now there are signs that North Korea too may be emerging as a significant source of meth. In 2013, DEA officials announced the arrest and indictment of five individuals, charged with conspiring to import 100 kilograms of North Korean-produced meth into the United States. Two of the defendants, members of a Hong Kong-based criminal organization, had been responsible in 2012 for traf- ficking more than 30 kilograms of meth en route to the United States. The shipment was seized by law enforcement agents in
Thailand and the Philippines; subsequent testing revealed purity levels between 96 and 99 percent. From the perspective of law enforcement, the prospect of North Korea entering as a new player in the global illicit drug trade is a great concern.
It is difficult to predict the extent to which North Korea will be a serious challenge to Mexico’s present dominance in meth trafficking. It is safe to say that the global illicit drug trade is constantly changing, and new trafficking sources are bound to develop over time.
Sources: Five extradited, charged with North Korean drug trafficking conspiracy (2013, November 20). News release. Drug Enforcement Administration, U.S Department of Justice, Washington, DC. Hays, Tom (2013, November 25). New drug scourge: North Korean meth. Newsday, p. A31.
Quick Concept Check
Understanding Patterns of Stimulant Drug Abuse Check your understanding of the changing patterns of stimu- lant drug abuse from 1975 to the present by identifying the following statements with (a) an event prior to 1986 or (b) an event subsequent to 1986.
1. Cocaine use is very expensive and restricted primarily to the wealthy.
2. Crack cocaine presents serious societal problems in the inner cities.
3. The typical cocaine abuser has not gone to college and earns less than $25,000 per year.
4. The nationwide toll-free hotline 1-800-COCAINE is established.
5. A smokable form of methamphetamine called ice becomes a major drug of abuse.
6. The number of d-amphetamine prescriptions declines by 90 percent.
Answers: 1. prior 2. subsequent 3. subsequent 4. prior 5. subsequent 6. prior
10.2
Chapter 10 Cocaine and Methamphetamine ■ 197
created a new stimulant drug called methcathinone (also referred to as mephedrone), which was still more powerful.
These discoveries were more or less scientific curi- osities until 2010, when a family of white-crystal designer drugs containing cathinone or cathinone-related ingredients appeared on the drug scene, marketed to appear like legal bath products (like epsom salts), hence the name “bath salts.” The packaging stated “not for human consumption” to avoid prosecution under the federal laws forbidding the sale of drugs substantially similar to already classified Schedule I controlled substances. In 2011, dramatic increases in health emergencies involving “bath salts” had been reported. According to the DAWN survey (see Chapter 1), more than 22,000 ED visits were associated with “bath salts.” Only a third of these drugs, however, were later found to contain cathinone alone; two-thirds were found to be combined with marijuana, synthetic marijuana, or other drugs. In 2012, President Obama signed into law the Synthetic Drug Abuse Prevention Act, banning synthetic drugs commonly appear- ing in “bath salts.” The law also banned other synthetic drugs related to marijuana, marketed under the names “Spice” and “K2” (see Chapter 12).
Fortunately, media reports of the dangers of “bath salts” have resulted in very low prevalence rates at the secondary school level. According to the University of Michigan survey, only 1 percent of eighth graders and less than 1 percent of high school seniors reported in 2013 any use in the past year.53
While immediate concerns about “bath salts” may have receded for now, public health and public safety concerns regarding designer synthetic drugs such as “bath salts” and similar designer synthetic drugs are likely to continue for some time. As mentioned in Chapter 1, these drugs these drugs are “advertised” as being synthetic forms of existing drugs such as marijuana or MDMA (Ecstasy), their chemi- cal properties are totally unknown to the user. This serious problem will be addressed further in Chapter 11 with respect to the availability of a drug called “Molly.”
Amphetamines and Other Stimulants as Medications
It is well known that there are approved medical applications for amphetamines and amphetamine-like stimulant drugs in specific circumstances. Stimulants are prescribed primarily for elementary school-age children diagnosed as unable to main- tain sufficient attention levels and impulse control in school or as behaviorally hyperactive. These symptoms are collec- tively referred to as attention deficit/hyperactivity disorder (ADHD). When there is no evidence of hyperactivity, the designation is shortened to attention deficit disorder (ADD).
typically use the drug in the evening and nighttime rather than during the day, taking it in a continuous (binge-like) fashion until all the cocaine on hand has been exhausted. This latter pattern of drug-taking behavior fits the typical picture of the recreational user.
The duration of response to the two drugs helps to explain the differences in usage. Methamphetamine effects generally last longer than cocaine effects. Therefore, cocaine abusers need relatively more frequent administrations to maintain their “high.” On tests that evaluate different forms of cognitive functioning, methamphetamine and cocaine abusers show significant differences in the type of cognitive impairment that is produced. Methamphetamine abusers are generally impaired on tests of perceptual speed or manip- ulation of information, effects observed to a lesser extent among cocaine abusers. The greatest difference between the two groups is observed when tests require both speed and the manipulation of information.51
Treatment for Methamphetamine Abuse The course of methamphetamine withdrawal—and of amphet- amine withdrawal in general—is very similar to the course of events described earlier for cocaine. First, there is the “crash” when the abuser feels intense depression, hunger, agitation, and anxiety within one to four hours after the drug-taking behavior has stopped. Withdrawal from amphetamines, during total abstinence from the drug, takes between six and 16 weeks, during which the intense craving for amphetamine slowly subsides.
As in cocaine-abuse treatment, there are inpatient and outpatient programs for methamphetamine abuse, depending on the circumstances and motivation of the abuser. Self-help groups such as Cocaine Anonymous can be useful as well, since the symptoms of amphetamine withdrawal and cocaine withdrawal are nearly identical. Methamphetamine abusers represent approximately one in 12 individuals in treatment for substance abuse, but relatively few methamphetamine abusers attempt treatment, much less succeed in recovery. The reason is that they perceive themselves as remaining in control over their drug use, despite evidence to the contrary. The attitude of denial makes it difficult for methamphet- amine abusers to seek treatment.52
Overall, methamphetamine abusers find it extremely dif- ficult to become drug-free, and their relapse rate is one of the highest for any category of illicit or licit drug abuse.
Cathinone as a New Form of Stimulant Abuse
In the 1970s, a medicinal chemist discovered a new type of stimulant by adding an oxygen atom to a section of the amphetamine molecule, resulting in a new stimulant com- pound that is more powerful than amphetamine, now known as cathinone. Adding a methyl group to methamphetamine
attention deficit/hyperactivity disorder (ADHD): A behav- ioral disorder characterized by increased motor activity and reduced attention span.
198 ■ Part Three Legally Restricted Drugs and Criminal Justice
reducing growth to about 80–90 percent normal levels. Fortunately, growth spurts during the summer, when chil- dren are typically no longer taking medication (referred to as “drug holidays”), usually compensate for this problem. Discontinuance of medication, however, has to be carefully monitored. Symptoms such as lethargy, lack of motivation, and, in some cases, depression can occur during this time.
A more serious concern is the increased risk of cardiovas- cular disease due to the effects of stimulant drugs. In 2006, the FDA recommended a “black box” warning on ADHD medications as a guide for patients and physicians. Recent studies indicate that stimulant treatment for ADHD in child- hood does not increase the risk for substance abuse later in life. In fact, the risks for future problems with alcohol and other drugs appear to be reduced.57
Until recently, the phenomenon of reducing hyperactiv- ity with methylphenidate and related stimulant drugs, rather than increasing it, had been quite puzzling to professionals in this field. It is now known that orally administered meth- ylphenidate and related stimulant drugs produce a relatively slow but steady increase in dopamine activity in the brain (see Chapter 5). This change in brain chemistry is hypothesized to have two effects that are beneficial to an individual with ADHD. First, increased dopamine may amplify the effects of environmental stimulation, while reducing the back- ground firing rates of neurons. Thus, there would be a greater “signal-to-noise” ratio in the brain, analogous to having now a stronger radio signal received by a radio that no longer emits a large amount of background static. The behavioral effect would be an improvement in attention and decreased distractibility. Symptoms of ADHD may be a result of not having a sufficient “signal-to-noise” ratio in the processing of information for tasks that require concentration and focus. Second, increased dopamine may heighten one’s motivation with regard to a particular task, enhancing the salience and interest in that task and improving performance. An individ- ual might perform better on a task simply because he or she likes doing it. The slow rate of absorption achieved through oral administration (Chapter 4) and the relatively slow action of dopamine release in the brain avoids the emotional high that is experienced when stimulants are smoked, snorted, or injected.58
The theory that increased activity in dopamine alone accounts for the reduction in ADHD symptoms, however, may be incomplete. In 2003, a new medication, atomox- etine (brand name: Strattera), was approved by the FDA for the treatment of ADHD in both children and adults. Since Strattera produces an increase in norepinephrine activity in the brain, it is possible that lowered norepinephrine levels may play a role in ADHD as well. Strattera has been mar- keted as a once-a-day nonstimulant medication that reduces ADHD symptoms by increasing norepinephrine levels—not dopamine levels—in the brain. The full story may be either that both norepinephrine and dopamine are jointly involved in ADHD or that ADHD itself may be two separable disor- ders, one related to dopamine activity and the other related to norepinephrine activity. According to this hypothesis, the
ADHD is the most common psychological disorder among children. It is estimated that 3–7 percent of all school- age children meet the criteria for ADHD. The prevalence rate is three times greater and the symptoms are generally more severe for boys than for girls. These children have aver- age to above-average intelligence but typically underperform academically. As many as two-thirds of school-age children with ADHD have at least one other psychiatric disorder, including anxiety and depression.54 Despite the public image of ADHD as an exclusively childhood phenomenon, longitu- dinal studies have shown that ADHD symptoms persist from childhood into adolescence in about 75 percent of the cases and into adulthood in about 50 percent of the cases.55
Stimulant Medications for ADHD Commonly prescribed stimulant medications for the treatment of ADHD include oral administrations of an amphetamine- like drug, methylphenidate (brand name: Ritalin), a com- bination of dextroamphetamine and amphetamine (brand name: Adderall), and a combination of dextroamphetamine and the amino acid lysine, lisdexamfetamine (brand name: Vyvanse).
For decades, Ritalin dominated the market in prescrip- tions written for ADHD. While a growing number of alterna- tive medications are now available for this purpose, Ritalin remains the most recognizable “brand” with respect to ADHD treatment. In this drug’s original formulation, the rapid onset and short duration of Ritalin requires two administrations dur- ing a school day: one at breakfast and another at lunchtime, supervised by a school nurse. In the evening, blood levels of Ritalin decline to levels that permit normal sleep. Adderall has a longer duration of action, making it possible to admin- ister a single dose and avoiding school involvement in treat- ment. In comparative studies, Ritalin and Adderall have been found to be equivalent in effectiveness.56
New drug treatments for ADHD have become available that are essentially variations of the traditional methylpheni- date medication. They include a sustained-release formula- tion (brand name: Concerta), a formulation that produces an initial rapid dose of methylphenidate followed by a sec- ond sustained-release phase (brand name: Metadate), and a chemical variation of methylphenidate that allows for a longer duration of action (brand names: Attenade, Focalin). A methylphenidate patch (brand name: Daytrana), designed to release the drug through the skin slowly over a period of nine hours, was approved in 2006.
About 70 percent of the approximately 1 million children in the United States who take stimulants for ADHD each year respond successfully to the treatment. In 1999, a major study examining the effects of medication over a 14-month period found that medication was more effective in reducing ADHD symptoms than behavioral treatment and nearly as effec- tive as a combined approach of medication and behavioral treatment.
One side effect of stimulant medications is a suppres- sion of height and weight gains during these formative years,
Chapter 10 Cocaine and Methamphetamine ■ 199
unclear how many of these emergencies were a result of the nonmedical use of these medication, the age range reported makes it likely that nonmedical use was involved. More than 7 percent of high school seniors reported in 2013 using Adderall nonmedically in the past year, while 2.3 percent reported using Ritalin. Prevalence rates among college stu- dents are much higher. Nearly 11 percent reported using Adderall nonmedically in the past year, while 3.6 percent reported using Ritalin.61
Stimulant Medications as Cognitive Enhancers
In 2007, a surprising (and controversial) article, entitled “Professor’s Little Helper” was published in Nature, one of the world’s leading scientific journals. It reported that 62 percent of respondents said they took Ritalin to enhance their mental performance. More than 1,400 presumably healthy people in 60 different countries participated in the survey. Since then, the question of “cognitive enhancement” with respect to stimulant medications became the subject of much discussion and debate. Undoubtedly, stimulants of all kinds fight fatigue and the need for sleep as well as sharpen one’s attention and remain focused when carrying out dull, repetitive tasks. In that sense, staying up late to finish a paper or a project of some sort and the ability to focus on a rou- tine task at hand could result in a higher level of performance (although the same could be said for caffeine), but the pos- sible benefits for higher-level cognitive processing such as long-term memory, problem solving and creative thought are unclear. Despite ethical concerns regarding so-called smart pills, however, the popularity of stimulant medications for these purposes has soared. Unfortunately, the ever-rising expectations of students and professionals in the workplace, as well as athletes, have made stimulant medications attractive options to their already high levels of performance, despite the health risks involved. It is evident that we are dealing with the “super-motivated” rather than the “unmotivated” individual in this situation (see Chapter 13).62
symptoms may overlap to such a degree that it is difficult to distinguish the two disorders on a strictly behavioral basis.
Other Medical Applications Narcolepsy (an unpredictable and uncontrollable urge to fall asleep during the day) is another condition for which stimu- lant drugs have been applied in treatment. In 1999, modafinil (brand name: Provigil) was approved for treating narcolepsy. The advantage of Provigil over traditional stimulant treat- ments such as dextroamphetamine is that it does not present problems of abuse and produces fewer adverse side effects. Alternative medications for narcolepsy that do not work by stimulating the CNS are presently under development.59
There are also several amphetamine-like drugs available to the public, some of them on a nonprescription basis, for use as nasal decongestants. In most cases, their effectiveness stems from their primary action on the peripheral nervous system rather than on the CNS. Even so, the potential for misuse exists: Some users continue to take these drugs over a long period of time because stopping their use may result in unpleasant rebound effects such as nasal stuffiness. This reaction, by the way, is similar to the stuffy nose that is experi- enced in the chronic administration of cocaine.60
Ritalin and Adderall Abuse In 1996, the Swiss pharmaceutical company Ciba-Geigy sent letters to hundreds of thousands of pharmacies and phy- sicians in the United States, warning them to exert greater control over Ritalin tablets and prescriptions to obtain them. The alert came in response to reports that Ritalin was becom- ing a drug of abuse among young people, who were crushing the tablets and snorting the powder as a new way of getting a stimulant high. Diversion of prescription medications was beginning to be a concern.
Since then, the problem of stimulant medication abuse, primarily the nonmedical use of Adderall, has become a major issue. Hospital emergencies related to stimulant medications such as Ritalin or Adderall have increased dramatically from 2006 to 2010 among individuals aged 18–25. While it is
The History of Cocaine ●● Cocaine, one of the two major psychoactive stimulants,
is derived from coca leaves grown in the mountainous regions of South America. Coca chewing is still prevalent among certain groups of South American Indians.
●● During the last half of the nineteenth century, several patent medicines and beverages were sold that contained cocaine, including the original (pre-1903) formulation for Coca-Cola.
●● Sigmund Freud was an early enthusiast of cocaine as an important medicinal drug, promoting cocaine as a cure
for morphine dependence and depression. Soon after- ward, Freud realized the strong dependence that cocaine can bring about.
Acute and Chronic effects of Cocaine ●● Cocaine produces a powerful burst of energy and sense of
well-being. In general, cocaine causes an elevation in the sympathetic autonomic nervous system.
●● Long-term cocaine use can produce hallucinations and deep depression, as well as physical deterioration of the nasal membranes if cocaine is administered intranasally.
Summary
200 ■ Part Three Legally Restricted Drugs and Criminal Justice
●● In the late 1990s and mid-2000s, meth abuse became widespread in rural and nonurban regions of the United States. The proliferation of homegrown meth labs created considerable social and public health problems in com- munities that were ill prepared for the consequences of illicit drug abuse.
●● Federal legislation in 2005 succeeded in reducing access to precursor chemicals, for domestic meth production, resulting in smaller meth labs and lesser involvement in meth trafficking. Present-day meth trafficking originates primarily in Mexico.
●● Methamphetamine abusers typically use the drug through- out their waking day, while cocaine abusers typically use the drug in a binge-like fashion in the evening and night- time rather than during the day. However, treatment for methamphetamine abuse generally follows along the same lines as treatment for cocaine abuse.
Cathinone as a new Form of Stimulant Abuse ●● In 2010, a family of white-crystal designer drugs contain-
ing cathinone or cathinone-related ingredients appeared on the drug scene, marketed to resemble legal bath prod- ucts (like epsom salts), hence the name “bath salts.”
●● The designer synthetic drug called “bath salts” is an exam- ple of a large number of recently available chemicals that are “advertised” as being synthetic forms of existing drugs such as marijuana or MDMA (Ecstasy). Their chemical properties, however, are typically unknown to the user.
Amphetamines and Similar Stimulant Drugs as medications
●● Amphetamine-like stimulant drugs have been developed for approved medical purposes.
●● Methylphenidate (brand name: Ritalin), atomoxetine (brand name: Strattera), and dextroamphetamine (brand name: Adderall) are three examples of drugs prescribed for children diagnosed with attention deficit/hyperactiv- ity disorder (ADHD). There has been growing concern about the nonmedical use of these medications, either for recreational purposes or to stay alert for longer periods of time.
●● Other medical applications for amphetamine-like drugs include their use as a treatment for narcolepsy and as a means for the temporary relief of nasal congestion.
Stimulant medications as “Cognitive enhancers” ●● The widespread nonmedical use of stimulant medica-
tions such as Ritalin and Adderall by healthy individuals for the purpose of enhancing cognitive performance has been a subject of much discussion and debate. Beyond its effects on fighting fatigue and increasing one’s focus on routine tasks, the effects on higher-level processing are unclear.
●● It is evident that use of stimulants for cognitive enhance- ment has been embraced by the “super-motivated” rather than the “unmotivated” individual.
medical uses of Cocaine and How Cocaine Works in the brain
●● The only accepted medical application for cocaine is its use as a local anesthetic.
●● Cocaine causes faster breathing and heart rate as well as elevated blood pressure and hyperthermia. Within the CNS, cocaine increases the activity of dopamine and, to a lesser extent, norepinephrine in the brain.
present-Day Cocaine Abuse ●● Compared with the permissive attitude toward cocaine
use seen during the 1970s and early 1980s, attitudes toward cocaine use since the second half of the 1980s have changed dramatically.
●● The emergence in the mid-1980s of relatively inexpensive, smokable crack cocaine expanded the cocaine-abuse prob- lem to new segments of the U.S. population and made cocaine abuse one of the major social issues of our time.
Treatment programs for Cocaine Abuse ●● Cocaine abusers can receive treatment through inpatient
programs, outpatient programs, or a combination of the two. Relapse is a continual concern for recovering cocaine abusers.
Amphetamines ●● Amphetamines have their origin in a Chinese medicinal
herb, used for thousands of years as a bronchial dilator; its active ingredient, ephedrine, was isolated in 1887.
●● The drug amphetamine (brand name: Benzedrine) was developed in 1927 as a synthetic form of ephedrine. By the 1930s, various forms of amphetamines, specifically d-amphetamine and methamphetamine, became avail- able around the world.
●● Like cocaine, amphetamines causes faster breathing and heart rate as well as elevated blood pressure and hyperther- mia. Unlike cocaine, however, the effects are more long lasting. Amphetamines increase dopamine and norepi- nephrine activity in the brain.
Acute and Chronic effects of Amphetamines ●● Amphetamine is effective as a general arousing agent, as an
antidepressant, and as an appetite suppressant, in addition to its ability to keep people awake for long periods of time.
●● Although the acute effects of amphetamines resemble those of cocaine, amphetamines (when taken in large doses) have the particular feature of producing symptoms of paranoia, delusions, hallucinations, and violent behav- iors, referred to as amphetamine psychosis. The bizarre behaviors of the “speed freak” illustrate the dangers of chronic amphetamine abuse.
methamphetamine ●● In the 1960s, methamphetamine (meth) abuse was inter-
mingled with the psychedelic drug scene. At the time, meth abusers, referred to as “speed freaks,” were known for their violent and erratic behavior.
Chapter 10 Cocaine and Methamphetamine ■ 201
1. Discuss the differences in the way cocaine was treated as a form of drug-taking behavior in the nineteenth century as opposed to the twentieth and twenty-first centuries. Include in your answer a discussion of Vin Mariani and Coca-Cola.
2. Describe the bodily changes involved in the acute effects of cocaine. Describe the mood changes and hallucinatory experiences in chronic cocaine abuse.
3. Describe how cocaine is extracted from the coca plant and how crack cocaine and free-base cocaine are made from cocaine.
4. Describe the general prevalence rates for cocaine, the medical emergencies associated with cocaine abuse, and the options for cocaine-abuse treatment.
5. Describe the various forms of amphetamines. Why is d-amphetamine more effective as a stimulant drug than l-amphetamine?
6. What are the differences in the patterns of methamphetamine abuse in the 1960s and methamphetamine abuse in the late 1990s and mid-2000s?
7. What are the benefits of stimulant medications for the treat- ment of attention deficit disorder? What are some of the concerns in using these drugs for treating children?
8. What are the arguments for and against the nonmedical use of stimulant medications for purposes of “cognitive enhance- ment” or other forms of increased performance?
Review Questions
You are a student taking a chemistry exam, and you know that a person sitting next to you (who seems as capable as you are in mas- tering the subject matter) used Adderall the night before and was able to study 50 percent longer than you were able to without taking
any stimulant medication. You later find out the exam score of that other student; it is a full letter grade higher than yours. Do you feel that you have recourse in appealing your grade to the instructor in charge? If so, how would you argue your case to the instructor?
Critical Thinking: What Would You Do?
Key Terms
amphetamine, p. 193 amphetamine psychosis, p. 194 attention deficit/hyperactivity
disorder (ADHD), p. 197
cocaine, p. 182 cocaine hydrochloride, p. 188 cocaine psychosis, p. 186 crack cocaine or crack, p. 188
d-amphetamine, p. 193 formication, p. 185 free-base cocaine, p. 188
ice, p. 195 kindling effect, p. 187 methamphetamine, p. 193
1. Rosencan, Jeffrey S.; and Spitz, Henry I. (1987). Cocaine reconceptualized: Historical overview. In Henry I. Spitz and Jeffrey S. Rosencan (Eds.), Cocaine abuse: New directions in treatment and research. New York: Brunner/Mazel, p. 5.
2. Inciardi, James A. (2002). The war on drugs III. Boston: Allyn and Bacon, p. 129. Inglis, Brian (1975). The forbidden game: A social history of drugs. New York: Scribner’s, pp. 49–50. Rivera, Mario A.; Aufderheider, Arthur C.; Cartmell, Larry W.; Torres, Constantino M.; and Langsjoen, O. (2005). Antiquity of coca-leaf chewing in the south central Andes: A 3,000 year archeological record of coca-leaf chewing from northern Chile. Journal of Psychoactive Drugs, 37(4), 455–458.
3. Jaffe, Jerome (1985). Drug addiction and drug abuse. In Louis S. Goodman and Alfred Gilman (Eds.), The pharmacological basis of therapeutics (7th ed.). New York: Macmillan, p. 552.
4. Nahas, Gabriel G. (1989). Cocaine: The great white plague. Middlebury, VT: Paul S. Eriksson, pp. 154–162.
5. Kusinitz, Marc (1988). Drug use around the world. New York: Chelsea House Publishers, pp. 91–95.
6. Karch, Steven B. (1996). The pathology of drug abuse (2nd ed.). Boca Raton, FL: CRC Press, pp. 2–3. Nuckols, Caldwell C. (1989). Cocaine: From dependency to recovery (2nd ed.). Blue Ridge Summit, PA: Tab Books, p. x.
7. Brecher, Edward M.; and the editors of Consumer Reports (1972). Licit and illicit drugs. Boston: Little, Brown, p. 270.
Weiss, Roger D.; and Mirin, Steven M. (1987). Cocaine. Washington, DC: American Psychiatric Press, p. 6.
8. McKim, William A. (2007). Drugs and behavior (6th ed.). Upper Saddle River, NJ: Prentice Hall, p. 243.
9. Erickson, Patricia G.; Adlaf, Edward M.; Murray, Glenn F.; and Smart, Reginald G. (1987). The steel drug: Cocaine in perspective. Lexington, MA: D. C. Heath, p. 9.
10. Musto, David (1973). The American disease: Origins of narcotic control. New Haven, CT: Yale University Press.
11. Jones, Ernest (1953). The life and work of Sigmund Freud, Vol. 1. New York: Basic Books, p. 81.
12. Ibid., p. 84. 13. Brecher, Licit and illicit drugs, pp. 272–280. 14. Aronson, Thomas A.; and Craig, Thomas J. (1986). Cocaine
precipitation of panic disorder. American Journal of Psychia- try, 143, 643–645. National Institute on Drug Abuse (2010, March). NIDA InfoFacts: Cocaine. Rockville, MD: National Institute on Drug Abuse.
15. Marsuk, Peter M.; Tardiff, Kenneth; Leon, Andrew C.; Stajic, Marina; Morgan, Edward B.; and Mann, J. John (1992). Prevalence of cocaine use among residents of New York City who committed suicide during a one-year period. American Journal of Psychiatry, 149, 371–375.
16. Office of Substance Abuse Prevention (1989). What you can do about drug use in America (DHHS publication No. ADM
Endnotes
202 ■ Part Three Legally Restricted Drugs and Criminal Justice
A6. Hearn, Kathy (2006, April 5). Abuse of the highly addictive cocaine by-product “paco” is causing officials to revamp drug laws. Christian Science Monitor, p. 4. Ryzik, Melena (2007, June 10). Cocaine: Hidden in plain sight. New York Times, Section 9, pp. 1, 9. Center for Behavior Health Statistics and Quality (2013). Drug Abuse Warning Network, 2011: Selected tables of national estimates of drug-related emergency depart- ment visits. Rockville, MD: Substance Abuse and Mental Health Services Administration, ED visits by drug.
30. Gold, Mark S. (1990). 800–COCAINE. New York: Bantam Books.
31. Nuckols, Cocaine, pp. 144–146. Lee, Felicia R. (1994, September 10). A drug dealer’s rapid rise and ugly fall. New York Times, pp. 1, 22.
32. Nuckols, Cocaine, p. 42. 33. Ibid., pp. 71–72. 34. Weiss and Mirin, Cocaine, p. 125. 35. Fox, C. Lynn; and Forbing, Shirley E. (1992). Creating
drug-free schools and communities: A comprehensive approach. New York: HarperCollins, p. 165.
36. Shine, Barbara (2000, March). Some cocaine abusers fare better with cognitive-behavioral therapy, others with 12-step programs. NIDA Notes, 15(1), 9–11.
37. Barnes, Deborah M. (1988). Breaking the cycle of addic- tion. Science, 241, p. 1029. Whitten, Lori (2005, August). Cocaine-related environmental cues elicit physiological stress responses. NIDA Notes, 20(1), 1, 6–7.
38. Brodie, Jonathan D.; Figueroa, Emilia; Laska, Eugene M.; and Dewey, Stephen L. (2005). Safety and efficacy of gamma-vinyl GABA (GVG) for the treatment of methamphetamine and/ or cocaine addiction. Synapse, 55, 122–125. Schiffer, Wynne K.; Marsteller, Douglas; and Dewey, Stephen L. (2003). Sub-chronic low dose gamma-vinyl GABA (vigabatrin) inhib- its cocaine-induced increases in nucleus accumbens dopa- mine. Psychopharmacology, 168, 339–343. Information from ClinicalTrials.gov, a service of the U.S. National Institutes of Health, June 2009.
39. McKim, William A. (2000). Drugs and behavior (4th ed.). Upper Saddle River, NJ: Prentice Hall, p. 205.
40. Brecher, Licit and illicit drugs, pp. 282–283. 41. Greaves, George B. (1980). Psychosocial aspects of amphet-
amine and related substance abuse. In John Caldwell (Ed.), Amphetamines and related stimulants: Chemical, biological, clinical, and sociological aspects. Boca Raton, FL: CRC Press, pp. 175–192. Peluso, Emanuel; and Peluso, Lucy S. (1988). Women and drugs. Minneapolis: CompCare Publishing.
42. Center for Behavior Health Statistics and Quality (2013). Drug Abuse Warning Network.
43. Goode, Erich (2005). Drugs in American society (6th ed.). New York: McGraw-Hill College, p. 276.
44. Bai, Matt (1997, March 31). White storm warning: In Fargo and the prairie states, speed kills. Newsweek, pp. 66–67. Quotation by Mark A. R. Kleiman, p. 67.
45. McKim (2007). Drugs and behavior, p. 249. 46. Ernst, Thomas; Chang, Linda; Leonido-Yee, Maria; and Speck,
Oliver (2000). Evidence for long-term neurotoxicity associated with methamphetamine abuse: A 1H MRS study. Neurology, 54, 1344–1349. London, E. D.; Simon, S. L.; Berman, S. M.; Mandelhern, M. A.; et al. (2004). Mood disturbances and regional cerebral metabolic abnormalities in recently abstinent methamphetamine abusers. Archives of General Psychiatry, 61, 73–84. Sheff, David (2008). Beautiful boy: A father’s journey
88–1572). Rockville, MD: National Clearinghouse for Alcohol and Drug Information.
17. Philips, Joel L.; and Wynne, Ronald D. (1974). A cocaine bibliography—nonannotated. Rockville, MD: National Institute on Drug Abuse. Cited in Ernest L. Abel. (1985). Psychoactive drugs and sex. New York: Plenum Press, p. 100.
18. Kaufman, Marc J.; Levin, Jonathan M.; Ross, Marjorie H.; Lange, Nicholas; Rose, Stephanie L.; Kukes, Thellea J.; Mendelson, Jack H.; Lukas, Scott E.; Cohen, Bruce M.; and Renshaw, Perry F. (1998). Cocaine-induced cerebral vaso- constriction detected in humans with magnetic resonance angiography. Journal of the American Medical Association, 279, 376–380.
19. Experiment in Memphis suggests many drive after using drugs (1994, August 28). New York Times, p. 30.
20. Courtesy of the American Academy of Otolaryngology-Head and Neck Surgery, March 1998.
21. Whitten, Lori (2009, April). Low dopamine receptor avail- ability may promote cocaine addiction. NIDA Notes, 22(3), 15, 18. Robinson, Terry E.; and Berridge, Kent C. (2000). The psychology and neurobiology of addiction: An incentive- sensitization view. Addiction, 95 (supplement), S91–S117. Volkow, Nora D.; Wang, Gene-Jack; Fowler, Joanna S.; Logan, Jean; Gatley, Samuel J.; Hitzemann, Richard; Chen, A. D.; and Pappas, Naomi (1997). Decrease in striatal dopaminer- gic responsiveness in detoxified cocaine-dependent subjects. Nature, 386, 830–833.
22. Robinson, Terry E. (1993). Persistent sensitizing effects of drugs on brain dopamine systems and behavior: Implications for addiction and relapse. In Stanley G. Korenman and Jack D. Barchas (Eds.), The biological basis of substance abuse. New York: Oxford University Press, pp. 373–402. Weiss and Mirin, Cocaine, pp. 48–49.
23. Kaplan, Harold I.; Freedman, Arnold M.; and Sadock, Ben- jamin J. (1980). Comprehensive textbook of psychiatry, Vol. 3. Baltimore, MD: Williams and Wilkins, p. 1621.
24. Flynn, John C. (1991). Cocaine: An in-depth look at the facts, science, history, and future of the world’s most addictive drug. New York: Birch Lane/Carol Publishing, pp. 38–46.
25. Ibid., p. 44. 26. Humphries, Drew (1998). Crack mothers at 6: Prime-time
news, crack/cocaine, and women. Violence against Women, 4, 45–61. Massing, Michael (1998). The fix. New York: Simon and Schuster, p. 41. Singer, Lynn T.; Minnes, Sonia; Short, Elizabeth; Arendt, Robert; Farkas, Kathleen; Lewis, Barbara; Klein, Nancy; Russ, Sandra; Min, Meeyoung O.; and Kirch- ner, H. Lester (2004). Cognitive outcomes of preschool chil- dren with prenatal cocaine exposure. Journal of the American Medical Association, 291, 2448–2456.
27. Egan, Timothy (1999, September 19). A drug ran its course, then hid with its users. New York Times, pp. 1, 46. Furst, R. Terry; Johnson, Bruce D.; Dunlap, Eloise; and Curtis, Richard (1999). The stigmatized image of the “crack head”: A socio- cultural exploration of a barrier to cocaine smoking among a cohort of youth in New York City. Deviant Behavior, 20, 153–181.
28. Center for Behavior Health Statistics and Quality (2014). Results from the 2013 national survey on drug use and health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration, Table 1.1A.
29. Barrionuevo, Alexei (2008, February 23). Cheap cocaine floods a slum in Argentina, devouring lives. New York Times, pp. A1,
Chapter 10 Cocaine and Methamphetamine ■ 203
54. Findling, Robert L. (2008). Evolution of the treatment of attention-deficit/hyperactivity disorder in children. Clinical Therapeutics, 30, 942–957. Julien, Robert M. (2001). A primer of drug action (9th ed.). New York: Worth, pp. 207–213.
55. Julien, A primer of drug action, p. 208. Wilens, Timothy E. (2003). Drug therapy for adults with attention-deficit hyper- activity disorder. Drugs, 63, 2385–2411. Wilens, Timothy E.; Biederman, Joseph; Spencer, Thomas J.; and Prince, Jefferson (1995). Pharmacotherapy of adult attention deficit/hyperactiv- ity disorder: A review. Journal of Clinical Psychopharmacology, 15, 270–279. Wilens, Timothy E.; and Fusillo, Steven (2007). When ADHD and substance use disorders intersect: Relation- ship and treatment implications. Current Psychiatry Reports, 9, 408–414.
56. Julien, A primer of drug action, pp. 211–212. 57. Nissen, Steven E. (2006, April 6). ADHD drugs and cardiovas-
cular risks. New England Journal of Medicine, pp. 1445–1448. The MTA Cooperative Group (1999). A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyper- activity disorder. Archives of General Psychiatry, 56, 1073–1086. Upadhyaya, Himanshu P. (2008). Substance use disorders in children and adolescents with attention-deficit/hyperactivity disorder: Implications for treatment and the role of the primary care physician. Journal of Clinical Psychiatry, 10, 211–221. Wilens, Timothy E.; Faraone, Stephen V.; Biederman, Joseph; and Gunawardene, Samantha (2003). Does stimulant therapy of attention deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics, 111, 179–185.
58. Julien, A primer of drug action, p. 211. Volkow, Nora D.; Wang, Gene.-Jack; Fowler, Joanna S.; Logan, Jean; Gera- simov, Madina; Maynard, Laurence; Ding, Yu-Shin; Gatley, Samuel J.; Gifford, Andrew; and Franceschi, Dinko (2001). Therapeutic doses of oral methylphenidate significantly increase extracellular dopamine in the human being. Journal of Neuroscience, 21 (121RC), 1–5. Volkow, Nora D.; Wang, Gene-Jack, Kollins, Scott H.; Wigal, Tim L.; Newcorn, Jeffrey H.; et al. (2009). Evaluating dopamine reward pathway in ADHD: Clinical implications. Journal of the American Medical Association, 302, 1084–1091.
59. Green, Phillip M.; and Stillman, Michael J. (1998). Narcolep- sy. Signs, symptoms, differential diagnosis, and management. Archives of Family Medicine, 7, 472–478. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; and Schulenberg, John E. (2009, December 14). Teen marijuana use tilts up, while some drugs decline in use. Ann Arbor, MI: University of Michigan News Service, Table 1. Tuller, David (2002, January 8). A quiet revolution for those prone to nodding off. New York Times, p. F7.
60. Julien, Robert M. (1998). A primer of drug action (8th ed.). New York: Freeman, pp. 141–143.
61. Arria, Amelia M.; Caldeira, Kimberly M.; O’Grady, Kevin E.; Vincent, Kathryn B.; et al. (2008). Nonmedical use of prescription stimulants among college students: Associations with attention-deficit-hyperactivity disorder and polydrug use. Pharmacotherapy, 28, 156–169. Johnston; O’Malley; Bach- man; Schulenberg; and Miech, Monitoring the Future, Vol. I, Table 2-2. Marks, Alexandria (2000, October 31). Schoolyard hustler’s new drug: Ritalin. Christian Science Monitor, p. 1. Substance Abuse and Mental Health Services Administration (2009, April 7). Nonmedical use of Adderall among full-time college students. The NSDUH Report, pp.1–4. Thomas, Karen
through his son’s addiction. New York: Houghton Mifflin. Sheff, Nic (2008). Tweak: Growing up with methamphetamine. New York: Ginee See Books/Atheneum Books for Young Readers, pp. 113–115.
47. National Association of Counties (2005, July 5). The meth epidemic in America. Two surveys of U.S. counties: The crimi- nal effect of meth on communities and the impact of meth on children. Washington, DC: National Association of Counties. Young, Stanley (1989, July). Zing! Speed: The choice of a new generation. Spin magazine, pp. 83, 124–125. Reprinted in Erich Goode (Ed.) (1992) Drugs, society, and behavior 92/93. Guilford, CT: Dushkin Publishing, p. 116. Zernike, Kate (2005, July 11). A drug scourge creates its own form of orphan. New York Times, pp. A1, A15.
48. Butterfield, Fox (2004, January 4). Across rural America, drug casts a grim shadow. New York Times, p. 10. Harris, Gardiner (2005, December 15). Fighting methamphetamine, lawmak- ers reach accord to curb sales of cold medicines. New York Times, p. A33. Jefferson, David J. (2005, August 5). America’s most dangerous drug. Newsweek, pp. 41–48. Johnson, Dirk (2004, March 8). Policing a rural plague: Meth is ravaging the Midwest. Newsweek, p. 41. National Association of Counties (2006, January). The meth epidemic in America. Washington, DC: National Association of Counties. Zernicke, Kate (2006, February 26). With scenes of blood and pain, ads battle meth- amphetamine in Montana. New York Times, p. 18. National Drug Intelligence Center (2008, December). National meth- amphetamine threat assessment 2009. Washington, DC: Nation- al Drug Intelligence Center, U.S. Department of Justice, p. 5.
49. Center for Behavior Health Statistics and Quality (2014). Results from the 2013 National survey on drug use and health: Detailed tables, Table 1.1A. Methamphetamine lab incidents, 2004–2012. Washington, DC: Drug Enforcement Administration, U.S. Department of Justice.
50. Jacobs, Andrew J. (2004, January 12). The beast in the bathhouse: Crystal meth use by gay men threatens to reignite an epidemic. New York Times, pp. B1, B5. Shernoff, Michael (2005, July–August). Crystal’s sexual persuasion. The Gay & Lesbian Review, pp. 24–26.
51. Zickler, Patrick (2001). Methamphetamine, cocaine abusers have different patterns of drug use, suffer different cognitive impairments. NIDA Notes, 16(5), 11–12.
52. National Institute of Justice (1999, May). Meth matters: Report on methamphetamine users in five western cities. Washington, DC: National Institute of Justice, U.S. Department of Justice. Center for Behavior Health Statistics and Quality (2013). Treat- ment episode data set (TEDS) 2001–2011. National admissions to substance abuse treatment services. Rockville, MD: Substance Abuse and Mental Health Administration, Table 1.1B.
53. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; Schulenberg, John E.; and Miech, Richard A. (2014). Monitor- ing the Future: National survey results on drug use, 1975–2013, Vol. I: Secondary school students 2013. Ann Arbor, MI: Institute for Social Research, University of Michigan, Table 2-2. Chemi- cals used in “spice” and “K2” type products now under federal control and regulation (2011, October 21). News Release. Office of Public Affairs, Drug Enforcement Administration, Washington, DC. Substance Abuse and Mental Health Ser- vices Administration (2013, September 17). “Bath salts” were involved in over 20,000 drug-related emergency department visits in 2011. The DAWN Report. Rockville, MD: Substance Abuse and Mental Health Services Administration, p. 1.
204 ■ Part Three Legally Restricted Drugs and Criminal Justice
Adolescent Medicine, 160, 481–485. Students tapping pills for academic boost (2006, June 20). Newsday, p. B13, Greely, Henry; Sahakian, Barbara; Harris, John; Kessler, Ronald C.; Gazzaniga, Michael; et al. (2008). Toward responsible use of cognitive-enhancing drugs by the healthy. Nature, 456 702–705. Harris, John; and Quigley, Mulreann (2008). Commentary on “Professor’s little helper”: Humans have always tried to improve their condition. Nature, 451, 521. Stix, Gary (2009, October). Turbocharging the brain. Scientific American, pp. 46–55.
(2000, November 27). Stealing, dealing and Ritalin: Adults and students are involved in abuse of drug. USA Today, p. D1. Wilens, Timothy E.; Adler, Lenard A.; Adams, Jill; Sgambati, Stephanie; Rotrosen, John; et al. (2008). Misuse and diversion of stimulants prescribed for ADHD: A systematic review of the literature. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 21–31.
62. Carroll, Bronwen C.; McLaughlin, Thomas J.; and Blake, Diane R. (2006). Patterns and knowledge of nonmedical use of stimulants among college students. Archives of Pediatric and
LSD and Other Hallucinogens
11chapter
On an April afternoon in 1943, Albert Hofmann, a research chemist at
Sandoz Pharmaceuticals in Basel, Switzerland, went home early from
work. He was feeling unusually restless and dizzy. For reasons he never
divulged in any of his later memoirs, Hofmann had decided that day to
have a fresh look at a particular chemical compound, the twenty-fifth
in a series of compounds, which he had synthesized five years earlier.
At first, Hofmann could not explain why he was feeling so strange.
Then he remembered. About an hour and a half earlier, his finger-
tips had made contact with an extremely minute trace of the com-
pound he was testing. He had made some contact with hundreds of
compounds before, but nothing like this had ever happened.
Hofmann barely made it home. At this point, he felt that he
had to lie down and close his eyes, hoping to feel better. But it got
worse. Suddenly (as he would later write) an uninterrupted stream
of fantastic pictures, extraordinary shapes, and an intense kaleido-
scope of colors bombarded his senses. He opened his eyes, and
objects around him started to change their form: A doorknob had
become a miniature dragon with fire coming out of its mouth. The
sound of a passing car outside his window was now a shooting
comet across the ceiling.
It was as if he had entered a totally new world.
After you have completed this chapter, you should have an understanding of the following:
●● The classification of hallucinogenic drugs
●● The history of LSD
●● Facts and fictions about LSD
●● Hallucinogens other than LSD
●● Current issues surrounding MDMA (Ecstasy) and “Molly”
●● The current status of Salvia divinorum (Salvia) abuse
206 ■ Part Three Legally Restricted Drugs and Criminal Justice
of visual images and body sense, the frightening reaction that often occurs when everyday reality is so dramatically changed, and the strange intermingling of visual and auditory sensa- tions. This chapter will focus on a collection of special chem- icals called hallucinogenic drugs or simply hallucinogens, that have the common ability to distort perceptions and alter the user’s sense of reality.
A Matter of Definition
Definitions are frequently reflections of one’s attitude toward the thing that is being defined, and the terminology used to describe hallucinogens is no exception. For those viewing these drugs with a “positive spin,” particularly for those who took LSD in the 1960s, hallucinogens have been described as psychedelic, meaning “mind-expanding” or “making the mind manifest.” In cases where a spiritual experience has been reported, such as with the ingestion of ayahuasca, hal- lucinogens have been entheogenic, meaning “generating the divine within.” On the other hand, for others viewing these drugs with more alarm than acceptance, the popular descriptive adjectives have been psychotomimetic, meaning “having the appearance of a psychosis”; psychodysleptic, meaning “mind-disrupting”; or even worse, psycholytic, meaning “mind-dissolving.” You can see that the description one chooses to use conveys a strong attitude, pro or con, with regard to these psychoactive substances.
As a result of all this emotional baggage, describing these drugs as hallucinogenic, meaning “hallucination-producing,” is probably the most evenhanded way of defining their effects, which is the way they will be referred to in this chapter. Some problems, however, still need to be considered. Technically, a hallucination is the reported perception of something that does not physically exist. For example, a schizophrenic patient might hear voices that no one else hears, and there- fore we must conclude (at least the nonschizophrenic world must conclude) that such voices are not real. In the case of hallucinogens, the effect is more complicated because we are dealing with a perceived alteration in the existing physi- cal environment. Some researchers have suggested using the term illusionogenic as a more accurate way of describing drugs that produce these kinds of experiences.
You might have guessed that Hofmann had inadver- tently made contact with lysergic acid diethylamide (LSD), and as the chapter opening suggests, Hofmann had unknow- ingly experienced history’s first “acid trip.” Three days later, in a more deliberate experiment, Hofmann chose a dose of 0.25 milligram, a concentration that could not, so he thought, possibly be effective. His plan was to start with this dose and gradually increase it to see what would happen. The dose Hofmann had considered inadequate was actually about five times greater than an average dose for LSD. As he later recalled his experience,
My condition began to assume threatening forms. Every- thing in my field of vision wavered and was distorted as if seen in a curved mirror. I also had the sensation of being unable to move from the spot.1
A little while later, however, his experience worsened:
The dizziness and sensation of fainting became so strong at times that I could no longer hold myself erect, and had to lie down on a sofa. My surroundings had now trans- formed themselves in more terrifying ways. Everything in the room spun around, and the familiar objects and pieces of furniture assumed grotesque, threatening forms … I was seized by the dreadful fear of going insane. I was taken to another place, another time.2
His experience then became pleasant:
It was particularly remarkable how every acoustic per- ception, such as the sound of a door handle or a passing automobile, became transformed into optical perceptions. Every sound generated a vividly changing image, with its own consistent form and color.3
Hofmann’s vivid remembrances are presented here at length because they succinctly convey some of the bizarre aspects of the hallucinogenic drug experience: the distortions
hallucinogens (ha-LOO-sin-oh-jens): A class of drugs producing distortions in perception and body image at moderate doses.
566,990 Approximate number of LSD doses in one ounce of pure LSD, based on 50 microgram as a typical LSD dosage level
1 The number of documented cases of deaths due to LSD ingestion alone, since 1960
Source: Fysh, R. R.; Oon, M. C. H.; Robinson, K. N.; Smith, R. N.; White, P. C.; and Whitehouse, M. J. (1985). A fatal poisoning with LSD. Forensic Science International, 28, 109–113.
Numbers Talk…
lysergic acid diethylamide (LSD) (lye-SER-jik ASS-id di-ETH-il-la-mide): A synthetic, serotonin-related hallucinogenic drug.
Chapter 11 LSD and Other Hallucinogens ■ 207
We also should be aware of another qualification when we use the term “hallucinogen.” Many drugs that produce distinctive effects when taken at low to moderate dose levels turn out to produce hallucinations when either the dose lev- els are extremely high or drug use is extended over a period of time. Examples of this possibility appeared in Chapter 10 with cocaine and amphetamines and will appear in Chapter 14 with inhalants. Here, the category of hallucinogens will be limited to only those drugs that produce marked changes in perceived reality at relatively low dosages and in acute cir- cumstances only.
Categories of Hallucinogens
It is relatively easy to define what hallucinogens are by virtue of their effects on the users, but categorizing them can be complicated. In general, most hallucinogens can be classi- fied in terms of the particular neurotransmitter in the brain (see Chapter 5) that bears a close resemblance to the molecu- lar features of the drug. Basically, we are speaking of three possible neurotransmitters: serotonin, norepinephrine, and acetylcholine. A relatively small remainder of hallucinogens, however, bears no resemblance to any neurotransmitter at all.
TAbLE 11.1
Major categories of hallucinogens
CATEgORy SOuRCE Hallucinogens related to serotonin
Lysergic acid diethylamide (LSD) A synthetic derivative of lysergic acid, which is, in turn, a component of ergot
Psilocybin Various species of North American mushrooms
Lysergic acid amide or morning glory seeds Morning glory seeds
Dimethyltryptamine (DMT) The bark resin of several varieties of trees and some nuts native to Central and South America
Harmine The bark of a South American vine
Hallucinogens related to norepinephrine
Mescaline The peyote cactus in Mexico and the U.S. Southwest
2,5-dimethoxy-4-methylamphetamine (DOM or more commonly STP)
A synthetic mescalinelike hallucinogen
MDMA (Ecstasy) and MDA Two synthetic hallucinogens
Hallucinogens related to acetylcholine
Atropine Atropa belladonna plant, known as deadly nightshade, and the datura plant
Scopolamine (hyoscine) Roots of the mandrake plant, henbane herb, and the datura plant
Hyoscyamine Roots of the mandrake plant, henbane herb, and the datura plant
Ibotenic acid Amanita muscaria mushrooms
Miscellaneous hallucinogens
Phencyclidine (PCP) A synthetic preparation, developed in 1963, referred to as angel dust
Ketamine
Salvia divinorum
A PCP-like hallucinogen
A hallucinogenic Mexican herb, in the mint family
Source: Based on information from Schultes, Richard E.; and Hofmann, Albert (1979). Plants of the gods: Origins of hallucinogenic use. New York: McGraw-Hill.
Table 11.1 shows the overall four-group classification scheme. The first three categories are (1) hallucinogens that are chemically similar to serotonin (LSD, psilocybin, morn- ing glory seeds, DMT, and harmine), (2) hallucinogens that are chemically similar to norepinephrine (mescaline, DOM, MDMA, and MDA), and (3) hallucinogens that are chemi- cally similar to acetylcholine (atropine, scopolamine, hyo- scyamine, and ibotenic acid). The fourth category comprises three hallucinogens (PCP, ketamine, and Salvia divinorum) that are chemically unlike any known neurotransmitter; these drugs are called miscellaneous hallucinogens. Most of these drugs have natural botanical origins (see four examples in Figure 11.1).
Lysergic Acid Diethylamide
Like many of the drugs that have been examined in the preceding chapters, hallucinogenic drugs such as LSD and several others have a story that belongs both in our contem- porary culture and in the distant past. Hofmann worked in the modern facilities of an international pharmaceutical company, but the basic material on his laboratory bench was an extract from a fungus that has been around for millions
208 ■ Part Three Legally Restricted Drugs and Criminal Justice
heads were made of copper, their bodies wrapped in snakes, their limbs swollen to gigantic size or shrunken to tiny appendages … Animals went berserk. Dogs ripped bark from trees until their teeth fell out.6
Albert Hofmann’s professional interest in ergot alkaloids cen- tered on their ability to reduce bleeding and increase contrac- tions in smooth muscle, particularly the uterus. He was trying to find a nontoxic chemical version that would be useful in treating problems associated with childbirth. The LSD mol- ecule was number 25 in a series of variations that Hofmann studied in 1938, and his creation was officially named LSD- 25 for that reason. He thought at the time that the compound had possibilities for medical use but then went on to other pursuits. He returned to these investigations five years later in 1943, the year of his famous LSD experience.
The Beginning of the Psychedelic Era Sandoz Pharmaceuticals applied for Food and Drug Administration (FDA) approval of LSD in 1953, and as was a common practice at the time, the company sent out samples of LSD to laboratories around the world for scientific study. The idea was that LSD might be helpful in the treatment of schizophrenia by allowing psychiatrists to gain insight into subconscious processes, which this drug supposedly unlocked. One of the researchers intrigued by the potential psychotherapeutic applications of LSD was the psychiatrist Humphrey Osmond of the University of Saskatchewan in Canada, who coined the word “psychedelic” to describe its effects and whose interest also extended to other hallucino- gens such as mescaline.
of years. It has been estimated that as many as 6,000 plant species around the world have some psychoactive properties.4
LSD does not exist in nature but is synthetically derived from ergot, a fungus present in moldy rye and other grains. One of the alkaloids in ergot is highly toxic, inducing a con- dition called ergotism. Historians have surmised that wide- spread epidemics of ergotism (called St. Anthony’s fire) occurred periodically in Europe during the Middle Ages, when extreme famine forced people to bake bread from infected grain (Drugs … in Focus).
In one particularly deadly episode in the year 944, an outbreak of ergotism claimed as many as 40,000 lives. The features of this calamity were twofold. One form of ergotism produced a reduction in blood flow toward the extremities, leading to gangrene, burning pain, and the eventual loss of limbs. The other form produced a tingling sensation on the skin, convulsions, disordered thinking, and hallucinations.5
Even though the link between this strange affliction and ergot in moldy grain has been known since the 1700s, outbreaks of ergotism have continued to occur in recent times. A major outbreak took place in a small French community in 1951. Hundreds of townspeople went totally mad on a single night:
Many of the most highly regarded citizens leaped from windows or jumped into the Rhône, screaming that their
(d)(a) (c)(b)
F iguRE 11 .1
Botanical sources for four hallucinogenic drugs: (a) Claviceps tulasne (ergot), (b) Amanita muscaria (ibotenic acid), (c) Atropa belladonna (atropine), (d) Datura stramonium, called jimsonweed (atropine, scopolamine, and hyoscyamine). They are shown as being of the same size, when in actuality they are not.
ergotism: A physical and/or psychological disorder acquired by ingesting ergot-infected grains. One form of ergotism involves gangrene and eventual loss of limbs; the other form is associated with convulsions, disordered think- ing, and hallucinations.
ergot (ER-got): A fungus infecting rye and other grains.
Chapter 11 LSD and Other Hallucinogens ■ 209
and off campus. At first, these studies retained some sem- blance of scientific control. For example, a physician was on hand, and objective observers of behavior reported the reac- tions of the subjects. Later, these procedures were altered. Physicians were no longer invited to the sessions, and Leary himself began taking the drug at the same time. His argu- ment was that he could communicate better with the subject during the drug experience, but his participation seriously undermined the scientific nature of the studies.
In 1961, Leary, Alpert, and other associates turned to LSD as the focus of their investigations, in their homes and other locations off the Harvard campus. Though these experi- ments were technically separate from the university itself, public relations concerns on the part of the Harvard adminis- tration were mounting. Leary further aggravated the situation through his increasingly incendiary writings. In a 1962 article published in the Bulletin of the Atomic Scientists, he sug- gested that the Soviets could conceivably dump LSD into the water supply and, to prepare for such an attack, Americans should dump LSD into their own water supply so that citi- zens would then know what to expect. Needless to say, the U.S. government was not amused.
In 1963, after a Harvard investigation, Leary and Alpert were dismissed from their academic positions, mak- ing it the first time in the twentieth century that a Harvard
In 1953, Osmond introduced the British writer Aldous Huxley to mescaline, and Huxley later reported his experi- ences, under Osmond’s supervision, in his book, The Doors of Perception. Prior to 1960, LSD was being administered to humans under fairly limited circumstances, chiefly as part of research studies in psychiatric hospitals and psychother- apy sessions on the West Coast. As would be revealed later in court testimony in the 1970s, there were also top-secret experiments conducted by the Central Intelligence Agency (CIA), which was interested in LSD for possible application in espionage work. Word of its extraordinary effects, however, gradually spread to regions outside laboratories or hospitals. One of those who picked up on these events was a young clin- ical psychologist and lecturer at Harvard University named Timothy Leary.
Leary’s first hallucinatory experience (in fact his first psychoactive drug experience of any kind, other than alco- holic intoxication) was in Mexico in 1960, when he ate some mushrooms containing the hallucinogen psilocybin. For five hours, Leary had what he would later call the “deepest reli- gious experience” of his life.7
Back at Harvard, his revelations sparked the interest of a colleague, Richard Alpert (later to be known as Baba Ram Dass). The two men were soon holding psilocybin sessions with university students and whoever else was interested, on
Strange Days in Salem: Witchcraft or Hallucinogens? In the early months of 1692, in Salem, Massachusetts, eight young girls suddenly developed a combination of bizarre symp- toms: disordered speech, odd body postures, and convulsive fits. They also began to accuse various townspeople of witchcraft. Meanwhile, the townspeople began to turn the accusations back on the girls themselves. During the summer, in a series of tri- als, more than 150 people were convicted of being witches and 20 were executed. Accusations were also made in neighboring villages in the county and in Connecticut. Nothing approaching the magnitude of the Salem witch trials has since occurred in American history.
Over the years, a number of theories have attempted to account for these strange events: a case of adolescent pranks, general hysteria, or some kind of political scapegoating. An interesting and controversial speculation has been advanced that these girls were showing the hallucinogenic and convulsive symptoms of ergotism, acquired from fungus-infected rye grain. Arguments that support this theory include the following: • Rye grain, once harvested, was stored in barns for months,
and the unusually moist weather in the area that year could
have promoted the growth of ergot fungus during storage. Of 22 Salem households with some afflicted members, 16 were located close to riverbanks or swamps.
• Children and teenagers would have been particularly vulnerable to ergotism because they ingest more food, and hence more poison, per pound of body weight than do adults.
• The Salem girls as well as the accused “witches” frequently displayed hallucinatory behavior and physical symptoms common to convulsive ergotism The role of ergotism in the Salem witch trials of 1692 has
been vigorously debated by both historians and pharmacologists. The readings listed below provide more information on this intriguing possibility.
Sources: In favor: Caporael, Linnda R. (1976). Ergotism: The Satan loosed in Salem? Science, 192, 21–26. Matossian, Mary K. (1982). Ergot and the Salem witchcraft affair. American Scientist, 70, 355–357. Matossian, Mary K. (1989). Poisons of the past: Molds, epidemics, and history. New Haven, CT: Yale University Press, pp. 113–122. Against: Spanos, Nicholas P.; and Gottlieb, Jack (1976). Ergotism and the Salem village witch trials. Science, 194, 1390–1394.
Drugs … in Focus
210 ■ Part Three Legally Restricted Drugs and Criminal Justice
established, older generation. Leary himself told his follow- ers that they were “the wisest and holiest generation that the human race has ever seen” and advised them to “turn on to the scene, tune in to what’s happening; and drop out—of high school, college, grade school … and follow me, the hard way.”9 The era was marked with psychedelic rock festivals and light shows, psychedelic music and art, psychedelic jar- gon and slang—all to the considerable consternation of an older generation of Americans.10
To borrow the words of songwriter and singer Bob Dylan, “the times were a-changin’,” but not always for the better. LSD became a battleground unto itself. In congres- sional hearings on LSD use by the nation’s youth, scientists, health officials, and law-enforcement experts testified to a growing panic over the drug. Newspaper stories empha- sized the dangers with alarmist headlines: “A monster in our midst—a drug called LSD” and “Thrill drug warps mind, kills,” among them. Sandoz quietly allowed its LSD pat- ent to lapse in 1966 and did everything it could to distance itself from the controversy. Hofmann himself called LSD his “problem child.”
In 1966, LSD was made illegal, later becoming a Schedule I drug, with possession originally set as a misde- meanor and later upgraded to a felony. By the 1970s, LSD had become entrenched as a street drug, and taking LSD had become a component of the already dangerous world of illicit
PORTRAiT Timothy Leary: Mr. LSD and the Psychedelic Era
For the average college stu- dent (or maybe a lot of people under the age of 50), the question regarding Timothy Leary (also known as Mr. LSD) might not be “Whatever hap- pened to him?” but rather “Who was this guy anyway?” For those of you who ask the latter question, here is a capsule ren- dition of Leary’s impact on the drug scene in the 1960s, along with an update.
Until 1960, Leary’s career was a world apart from what would follow. It had none of the unconventionality that would later characterize his life. As a clinical psychologist, he had written a widely ac- claimed textbook and devised a respected personality test (called the Leary). An experience with psilocybin in Mexico in 1960, however, turned his life around. The more extensive his exposure to hallucinogenic drugs became, the more he took on the self-appointed role of Pied Piper for what was referred to then as the “acid generation.”
By the middle of the 1970s, Leary had been sentenced to 20 years for
marijuana possession (the longest sentence ever imposed for such an
offense), had gone to federal prison, had escaped, had evaded the authorities in Algeria, Afghanistan, and Switzerland for a few years, had been recaptured, and finally had been released after a successful appeal of his original convic- tion. LSD advocacy was no longer on his agenda by this time, and in fact LSD had lost its mystique years earlier. Leary hit the college lecture circuit, talking about space migration and life exten- sion and calling himself a “stand-up philosopher.”
In the late 1980s, Leary discovered computers. He formed a software company, marketed a number of successful video games, and viewed interactive computer programming and virtual reality in particular as the con- sciousness expansion of the 1990s, the newest route to cerebral stimulation.
Leary never stopped being a social ac- tivist, with his own brand of opportunism. In 1994, he was detained by the police in
an Austin, Texas, airport for smoking—a cigarette, this time. Leary said that he wanted to draw attention to people being “demonized” by no-smoking restrictions on their lives.
A year after his death in 1996, Leary’s friends arranged to have his cremated remains delivered by rocket into space. It was estimated that he would orbit Earth every 90 minutes for approximately two years or so, before burning up during reentry. It was to be his ultimate trip.
Sources: Brozan, Nadine (1994, May 12). Chronicle: Timothy Leary lights up. New York Times, p. D26. Greenfield, Robert (2006). Timothy Leary: A biography. New York: Harcourt. Lee, Martin A.; and Shlain, Bruce (1985). Acid dreams: The complete social history of LSD. New York: Grove Weidenfeld. Simons, Marlise (1997, April 22). A final turn-on lifts Timothy Leary off. New York Times, pp. A1, A4. Stone, Judith (1991, June). Turn on, tune in, boot up. Discover, pp. 32–35.
The multicolored images, inspired by the LSD experience, epitomized the psychedelic era of the 1960s.
faculty member had been fired. As you can imagine, such events brought enormous media exposure. Leary was now “Mr. LSD” (see Portrait), and suddenly the public became acquainted with a class of psychoactive drugs that had been previously unknown to them.8
For the rest of the 1960s, LSD became not only a drug but also one of the symbols for the cultural revolt of a gen- eration of youth against the perceived inadequacies of the
Chapter 11 LSD and Other Hallucinogens ■ 211
Street forms of LSD may contain color additives or adul- terants with specific flavors, but the drug itself is odorless, tasteless, and colorless. LSD is sold on the street in single-dose “hits.” It is typically swallowed in the form of powder pellets (microdots) or gelatin chips (windowpanes) or else licked off small squares of absorbent paper that have been soaked in liq- uid LSD (blotters). In the past, blotters soaked with LSD have been decorated with pictures of mystical symbols and signs, rocket ships, or representations of Mickey Mouse, Snoopy, Bart Simpson, or other popular cartoon characters.
LSD initially produces an excitation of the sympathetic autonomic activity: increased heart rate, elevated blood pressure, dilated pupils, and a slightly raised body temperature. There is an accompanying feeling of restlessness, euphoria, and a sensa- tion that inner tension has been released. There may be laugh- ing or crying, depending on one’s expectations and the setting.14
Between 30 minutes and two hours later, a “psychedelic trip” begins, characterized by a number of distinctive features15 that include the following:
●■ Images seen with the eyes closed ●■ An intermingling of senses called synesthesia, which usu-
ally involves sounds being perceived as hallucinatory visions ●■ Perception of a multilevel reality ●■ Strange and exaggerated configurations of common
objects or experiences
During the third and final phase, approximately three to five hours after first taking LSD, the following features begin to appear:
●■ Great swings in emotions or feelings of panic ●■ A feeling of timelessness ●■ A feeling of ego disintegration, or a separation of one’s
mind from one’s body
Whether any or all of these strong reactions result in a “good trip” or a “bad trip” depends heavily on the set of expec- tations for the drug, the setting or environment in which the LSD is experienced, and the overall psychological health of the individual.
Effects of LSD on the Brain LSD closely resembles the molecular structure of serotonin. Therefore, it is not surprising that LSD should have effects on receptors in the brain that are sensitive to serotonin (see Chapter 5). As a result of research in the 1980s, it turns out that the critical factor behind LSD’s hallucinogenic effects lies in its ability to stimulate a special subtype of serotonin- sensitive receptors called serotonin-2A receptors. In fact, all
drugs. The story of LSD will be updated in a later section, but first it is important to understand the range of effects that LSD typically produces.
Acute Effects of LSD LSD is considered one of the most, if not the most, powerful psychoactive drugs known. Its potency is so great that effective dose levels have to be expressed in terms of microgram, one- millionths of a gram, often called mikes. The typical street dose ranges from 50 to 150 microgram, though sellers often claim that their product contains more. The effective dose can be as small as 10 microgram, with only one-hundredth of a percent being absorbed into the brain. You can appreciate the enormous potency of LSD by comparing these figures to the fact that a single regular-strength aspirin tablet contains 325,000 microgram of aspirin.11
Taken orally, LSD is rapidly absorbed into the blood- stream and the brain, and its effects begin to be felt within 30 to 60 minutes. Once its concentration has peaked (in about 90 minutes), the elimination half-life, or the time it takes for 50 percent of the drug to diminish in the bloodstream (see Chapter 4), is approximately three hours. Within 5–12 hours, LSD effects are over.12
Surprisingly, given its extreme potency, the toxicity of LSD is relatively low. Generalizing from studies of animals given varying doses of LSD, we can estimate that a lethal dose of LSD for humans would have to be roughly 300 to 600 times the effective dose, a fairly comfortable margin of safety. In 2011, the Drug Abuse Warning Network (DAWN) statistics showed that less than 0.5 percent of all drug-related ED visits were associated with the ingestion of LSD. To this day, there has been only one definitive case in which a death has been attributed solely to an LSD overdose.13
Acid blotters with a typical design
synesthesia: A subjective sensation in a modality other than the one being stimulated. An example is a visual experience when a sound is heard.
212 ■ Part Three Legally Restricted Drugs and Criminal Justice
Will LSD Produce Substance Dependence? There are three major reasons why LSD is not likely to result in drug dependence, despite the fact that the experience at times is quite pleasant.19
First, LSD and other hallucinogens cause the body to build up a tolerance to their effects faster than any other drug category. As a result, one cannot remain on an LSD-induced high day after day, for an extended period of time.
Second, LSD is not the drug for someone seeking an easy way to get high. An LSD experience can be an emo- tional roller-coaster ride over a period of eight hours or more. The sensory overload and alternating feelings of blissfulness and despair can be draining and exhausting.20
Third, the LSD experience seems to control the user rather than the other way around. It is virtually impossible to “come down” from LSD at will. Besides, the unpredictability of the LSD experience is an unpopular feature for those who would want a specific and reliable drug effect every time the drug is taken.
Will LSD Produce a Panic Attack or Psychotic Behavior? One of the most notorious features of LSD is the possibility of a bad trip. Personal accounts abound of sweet, dreamlike states rapidly turning into nightmares. Perhaps the greatest risks are taken when a person is slipped a dose of LSD and begins to experience its effect without knowing that he or she has taken a drug. But panic reactions may also occur even when a person is fully aware of having taken LSD. Although the probability of having a bad trip is difficult to estimate, there are very few regular LSD abusers who have not experi- enced a bad trip or had a disturbing experience as part of an LSD trip. The best treatment for adverse effects is the com- panionship and reassurance of others throughout the period when LSD is active. Help Line includes some specific proce- dures for dealing with LSD panic episodes.
Despite the possibility of an LSD panic, there is no strong evidence that the panic will lead to a permanent psychiatric breakdown. Long-term psychiatric problems are relatively uncommon; one study conducted in 1960 showed that there was no greater probability of a person’s attempting suicide or developing a psychosis after taking LSD than when undergo- ing ordinary forms of psychotherapy.21 The incidents that do occur typically involve people who were unaware that they were taking LSD, showed unstable personality characteristics prior to taking LSD, or were experiencing LSD under hostile or threatening circumstances.
The possible link between the character of LSD effects and certain symptoms of schizophrenia also has been examined closely. It is true that on a superficial level, the two behaviors show some similarities, but there are important dif- ferences. LSD hallucinations are primarily visual, are best
hallucinogens, even those drugs whose structures do not resemble serotonin, are linked together by a common abil- ity to excite these particular receptors. Drugs that specifi- cally block serotonin-2A receptors, leaving all other subtypes unchanged, will block the behavioral effects of hallucino- gens. In addition, the ability of a particular drug to produce hallucinogenic effects is directly proportional to its ability to bind to serotonin-2A receptors.16
Patterns of LSD Use The enormous publicity surrounding Timothy Leary and his followers in the 1960s made LSD a household word. As many as 50 popular articles about LSD were published in major U.S. newspapers and magazines between March 1966 and February 1967 alone. By 1970, however, the media had lost interest, and hardly anything was appearing about LSD. Even so, while media attention was diminish- ing, the incidence of LSD abuse was steadily rising. In four Gallup Poll surveys conducted between 1967 and 1971, the percentage of college students reported to have taken LSD at least once in their lives rose dramatically from 1 to 18 percent.17
From the mid-1970s to the early 1990s, the num- bers showed a steady decline. By 1986, the University of Michigan survey indicated that the lifetime incidence of LSD intake among high school seniors was 7 percent, down from 11 percent in 1975. By the end of the 1990s, preva- lence rates were once again on the rise, reaching and later exceeding the levels of a quarter-century earlier. Since 1997, however, LSD use has declined substantially. Four percent of high school seniors in 2013 reported taking LSD at some time in their lives. A parallel trend has been observed in col- lege students.
It should be noted that today’s LSD users are different from those of a previous generation in a number of ways. Typical LSD users now take the drug less frequently, and because the dosage of street LSD is presently about one-fourth the level common to the 1960s and 1970s, they remain high for a briefer period of time. Their motivation behind using LSD is also not the same. They report using LSD simply to get high, rather than to explore alternative states of conscious- ness or gain a greater insight into life. For current users, LSD no longer has the symbolic or countercultural significance that it had in an earlier time.18
Facts and Fictions about LSD
Given the history of LSD use and the extensive publicity sur- rounding it, it is important to look carefully at the facts about LSD and to unmask the myths (of which there are many). Following are six basic questions that are frequently asked about the acute and chronic effects of this drug.
Chapter 11 LSD and Other Hallucinogens ■ 213
not use drugs, whereas three additional studies reported no chromosomal effect at all.
By the end of that year, a second study was published by the people whose report had started the controversy in the first place. They wrote that 18 LSD abusers had two to four times the number of chromosomal abnormalities in their white blood cells, when compared with 14 control sub- jects. Interestingly, the subjects in this study were not exactly model citizens. Every one of them had taken either one or more of amphetamines, barbiturates, cocaine, hallucinogens, opiates, or antipsychotic medication, and some had abused more than one of these substances.
The picture was confused, to say the least. Not only were many of these studies never replicated, but many were meth- odologically flawed in the first place. Most important, when studies actually looked at the chromosomes of reproductive cells themselves for signs of breakage from exposure to LSD, the results were either ambiguous or entirely negative. By 1971, after nearly a hundred studies had been carried out, the conclusion was that LSD did not cause chromosomal damage in human beings at normal doses and that there was no evidence of a high rate of birth defects in the chil- dren of LSD users.24 Yet, in the highly politicized climate of the late 1960s, the media tended to emphasize the nega- tive findings without subjecting their validity or relevance to any scrutiny. The public image of LSD causing genetic (mutation-generating) damage still persists, despite the lack of scientific evidence. This is not to say, however, that there is no basis for exercising some degree of caution. Women should avoid LSD, as well as other psychoactive and many nonpsychoactive drugs, during pregnancy, especially in the first three months.25
seen in the dark, and, as we noted earlier, are more accurately characterized as illusions or pseudohallucinations; schizo- phrenic hallucinations are primarily auditory, are seen with open eyes, and qualify as true hallucinations. Individuals tak- ing LSD are highly susceptible to suggestion and usually try to communicate the experience to others, whereas the schizo- phrenic individual is typically resistant to suggestion and with- drawn from his or her surroundings. Therefore, it is unlikely that LSD is mimicking the experience of schizophrenia.
Will LSD Increase Your Creativity? The unusual visual effects of an LSD experience may lead you to assume that your creativity is enhanced, but the evi- dence indicates otherwise. Professional artists and musicians creating new works of art or songs while under the influence of LSD typically think that their creations are better than any- thing they have yet produced, but when the LSD has worn off, they are far less impressed. Controlled studies generally show that individuals under LSD feel that they are creative, but objective ratings do not show a significant difference from levels prior to the LSD.22
Will LSD Damage Your Chromosomes? In March 1967, a study published in the prestigious scientific journal Science described a marked increase in chromosomal abnormalities in human white blood cells that had been treated with LSD in vitro (i.e., the cells were outside the body at the time).23 Shortly after, three other studies were reported in which chromosomal abnormalities in the white blood cells of LSD abusers were higher than those of people who did
Help Line Emergency guidelines for a bad Trip on LSD
• Stay calm with the individual. Do not move around quickly, shout, cry, or become hysterical. Any sense of panic on your part will make an LSD panic worse. Speak in a relaxed, controlled manner.
• Reassure the individual that the situation is temporary and that you will not leave until he or she returns to a normal state. Encourage the individual to breathe deeply and calmly. Advise him or her to view the trip as though watching a movie or TV program.
• Reduce any loud noises or bright lights but do not let the individual be in the dark. Darkness tends to encourage hallucinations in a person under LSD.
• Allow the individual to move around without undue restrictions. He or she can sit, stand, walk, or lie down if this helps the situation. You can divert attention from the panic
by encouraging the individual to beat time to music or by dancing.
• If your assistance does not produce a reduction in the panic, seek out medical attention immediately.
Where to go for assistance www.brown.edu/Student_Services/Health_Services/ Health_Education/atod/od_1sd.htm
Brown University sponsors a series of Web sites related to drug use and abuse.
Sources: Palfai, Tibor; and Jankiewicz, Henry (1991). Drugs and human behavior. Dubuque, IA: W. C. Brown, p. 445. Robbins, Paul R. (1996). Hallucinogens. Springfield, NJ: Enslow Publishers, pp. 83–85. Trulson, Michael E. (1985). LSD: Visions or nightmares. New York: Chelsea House, p. 101.
214 ■ Part Three Legally Restricted Drugs and Criminal Justice
physically abused by the man, he had caused her to have an abortion, and the woman already had a serious mental disor- der before going into treatment. The fact that the homicide took place well after the LSD had left her body indicates that the murder was not pharmacologically based (see Chapter 6). Other cases in which violent behavior appeared to be associ- ated with an LSD experience turned out to be associated with the use of other hallucinogenic drugs instead.
It is possible, however, that an individual can “freak out” on LSD. The effects of a euphoriant drug such as LSD can lead to a feeling of invulnerability. This feeling, in turn, can lead to dangerous and possibly life-threatening behavior. We cannot reliably estimate the likelihood of these effects or pin- point the circumstances under which they might occur; we should recognize that psychological reactions to LSD are inherently unpredictable, and caution is advised.
Psilocybin and Other Hallucinogens Related to Serotonin
The source of the drug psilocybin is a family of mush- rooms native to southern Mexico and Central America. Spanish chroniclers in the sixteenth century wrote of “sacred mushrooms” revered by the Aztecs as teonanacatl (roughly translated as “God’s flesh”) and capable of providing extraor- dinary visions when eaten. Their psychoactive properties had been known for a long time, judging from stone-carved repre- sentations of these mushrooms discovered in El Salvador and dating back to as early as 500 b.c. Today, shamans in remote villages in Mexico and Central America (see Chapter 3) con- tinue the use of psilocybin mushrooms, among other hal- lucinogenic plants, to provide healing on both physical and spiritual levels.29
In 1955, a group of Western observers documented the hallucinogenic effects of the Psilocybe mexicana in a native community living in a remote mountainous region of
Will LSD Have Residual (Flashback) Effects? One of the most disturbing aspects of taking LSD is the pos- sibility of reexperiencing the effects of the drug long after the drug has worn off, sometimes as long as several years later. These experiences are referred to as hallucinogen persisting perception disorder, or simply “flashbacks.” The likelihood of LSD flashbacks is not precisely known. Some studies esti- mate its rate of incidence as only 5 percent, whereas others estimate it as high as 33 percent. It is reasonable to assume that the range of estimates is related to differences in the dos- age levels ingested.
Flashback effects sometimes can be frightening and at other times can be quite pleasant; they can occur among LSD novices or “once-only” drug takers as well as among experienced LSD abusers. They can appear without warning, but there is a higher probability that they will occur when the individual is beginning to go to sleep or has just entered a dark environment.26
Because they are not common to any other psychoactive drug, the reason why LSD flashbacks might occur is not well understood. It is possible that LSD has a peculiar ability to produce some biochemical changes that remain dormant for a period of time and then suddenly reappear or that some remnant of the drug has the ability to persist over extended periods of time. It is also possible that individuals who ingest LSD are highly suggestible to social reminders about the orig- inal exposure to LSD.
Whether LSD produces major long-term deficits in the behavior of the user remains largely unknown. Memory prob- lems and visuospatial impairments have been reported in some studies but not confirmed in others. Unfortunately, sev- eral problems persist in research studies examining long-term effects of LSD. Often, they have included either individuals with a history of psychiatric disorders prior to LSD ingestion or regular users of other illicit drugs and alcohol. As a result, it has been impossible in these studies to tease out the long- term effects of LSD alone from other factors.27
Will LSD Increase Criminal or Violent Behavior? As noted in Chapter 6, it is very difficult to establish a clear cause-and-effect relationship between a drug and criminal or violent behavior. In the highly charged era of the 1960s, sto- ries related to this question were publicized and conclusions were drawn without any careful examination of the actual facts. Take, for example, the 1964 case of a woman undergo- ing LSD therapy who murdered her lover three days after her last LSD session.28 The details of the case, overlooked by most subsequent media reports, reveal that the woman had been
Psilocybe mexicana mushrooms, the source of psilocybin.
psilocybin (SiL-oh-SigH-bin): A serotonin-related hallucino- genic drug originating from a species of mushrooms.
Chapter 11 LSD and Other Hallucinogens ■ 215
The LAA experience, judging from Hofmann’s report, is similar to that of LSD, though LAA is only one-tenth to one-thirtieth as potent and the hallucinations tend to be dom- inated by auditory rather than visual images. Commercial varieties of morning glory seeds are available to the public, but to minimize their abuse, suppliers have taken the precau- tion of coating them with an additive that causes nausea and vomiting, if they are eaten.33
Dimethyltryptamine (DMT) The drug dimethyltryptamine (DMT) is obtained chiefly from the resin of the bark of trees and nuts native to the West Indies as well as to Central and South America, where it is generally inhaled as a snuff. An oral administration does not produce psychoactive effects. The similarity of this drug’s effects to those of LSD and its very short duration gave DMT the reputation during the psychedelic years of the 1960s of being “the businessman’s LSD.” Presumably, someone could take a DMT trip during lunch and be back at the office in time for work in the afternoon.
An inhaled 30 milligram dose of DMT produces physi- ological changes within ten seconds, with hallucinogenic effects peaking around 10 to 15 minutes later. Paranoia, anxiety, and panic also can result at this time, but most symptoms are over in about an hour.34 A chemical found in Bufo toads is similar to DMT (see Drugs … in Focus, page 216).
Harmine Among native tribes in the western Amazon region of South America, the bark of the Banisteriopsis vine yields the powerful drug harmine. A drink containing harmine, called ayahuasca, is frequently used by local shamans for healing rites. It is chemically similar to serotonin, like LSD and the other hallucinogens examined so far. Its psycho- logical effects, however, are somewhat different. Unlike LSD, harmine makes the individual withdraw into a trance, and the hallucinatory images (often visions of animals and supernatural beings) are experienced within the context of a dreamlike state. Reports among shamans refer to a sense of suspension in space or flying, falling into one’s body, or expe- riencing one’s own death.35
southern Mexico. Three years later, samples worked their way to Switzerland, where Albert Hofmann, already known for his work on LSD, identified the active ingredient and named it psilocybin. As was his habit, Hofmann sampled some of the mushrooms himself and later wrote that his hallucinations took on a distinctly Mexican character. He saw Mexican designs and colors. When a doctor who was supervising the experiment bent over him to check his blood pressure, Hofmann saw him transformed into an Aztec priest!30
An interesting question is whether the Aztec character of the hallucinations Hofmann was experiencing was simply a result of suggestion, given the environmental and social context in which drug-taking behavior was occurring, or, alternatively, Aztec designs may have been inspired over the centuries by the effects of psilocybin.
Once ingested, psilocybin loses a portion of its mole- cule, making it more fat soluble and more easily absorbed into the brain. This new version, called psilocin, is the actual agent that works on the brain. Because LSD and psilocin are chemically similar, the biochemical effects are also similar.31
Far less potent than LSD, psilocybin is effective at dose levels measured in the more traditional units of milligram rather than in microgram. At doses of 4 to 5 milligram, psi- locybin causes a pleasant, relaxing feeling; at doses of 15 milligram and more, hallucinations, time distortions, and changes in body perception appear. A psilocybin trip gener- ally lasts from two to five hours, considerably shorter than an LSD trip.
Individuals who have experienced both kinds of hallu- cinogens report that, compared to LSD, psilocybin produces effects that are more strongly visual, less emotionally intense, and more euphoric, with fewer panic reactions and less chance of paranoia. On the other hand, experimental studies of volunteers taking high doses of psilocybin have established that the drug produces drastic-enough changes in mood, sensory perception, and thought processes to qualify as a psy- chotic experience.
Like LSD, psilocybin (often called simply “shrooms”) has become relatively easy to obtain as a drug of abuse. In 2013, about 37 percent of high school seniors reported that non-LSD hallucinogens (including “shrooms”) were “fairly easy” or “very easy” to get, whereas about 25 percent felt the same way about LSD itself.32
Lysergic Acid Amide (LAA) In addition to their reverence for psilocybin mushrooms, the Aztecs ingested locally grown morning glory seeds, calling them ololuiqui, and used their hallucinogenic effects in reli- gious rites and healing. Like many Native American practices, the recreational use of morning glory seeds has survived in remote areas of southern Mexico. In 1961, Albert Hofmann (once again) identified the active ingredient in these seeds as lysergic acid amide (LAA), after having sampled its halluci- nogenic properties. As the chemical name suggests, this drug is a close relative to LSD.
harmine (HAR-meen): A serotonin-related hallucinogenic drug frequently used by South American shamans in healing rituals.
dimethyltryptamine (DMT) (dye-METH-il-TRiP-ta-meen): A short-acting hallucinogenic drug.
lysergic acid amide (LAA) (lye-SER-jik ASS-id A-mide): A hallucinogenic drug found in morning glory seeds, producing effects similar to those of LSD.
psilocin (SiL-oh-sin): A brain chemical related to serotonin, resulting from the ingestion of psilocybin.
216 ■ Part Three Legally Restricted Drugs and Criminal Justice
grows above ground and a long carrotlike root. This cactus is found over a wide area, from the southwestern United States to northern regions of South America, and many communi- ties in these regions have discovered its psychoactive prop- erties. Given the large distances between these groups, it is remarkable that they prepare and ingest mescaline in a highly similar manner. The crowns of the cactus are cut off, sliced in small disks called buttons, dried in the sun, and then con- sumed. An effective dose of mescaline from peyote is 200 milligram, equivalent to about five buttons. Peak response to the drug takes place 30 minutes to two hours after consump- tion. Mescaline is still used today as part of religious worship among many American Indians in the United States and Canada (Drugs … in Focus).
The psychological and physiological effects of mescaline are highly similar to those of LSD, though some have reported that mescaline hallucinations are more sensual, with fewer changes in mood and the sense of self. Nonetheless, double- blind studies comparing the reactions to LSD and mescaline show that subjects cannot distinguish between the two when dose levels are equivalent. Although the reactions may be the same, the mescaline trip comes at a greater price, as far as physiological reactions are concerned. Peyote buttons taste extremely bitter and can cause vomiting, headaches, and, unless the stomach is empty, distressing levels of nausea.36
Today, mescaline can be synthesized as well as obtained from the peyote cactus. The mescaline molecule resembles
Hallucinogens Related to Norepinephrine
Several types of hallucinogens have a chemical composition similar to that of norepinephrine. As you may recall from Chapter 10, amphetamines are also chemically similar to norepinephrine. Consequently, some of the norepinephrine- related hallucinogens are capable of producing amphet- aminelike stimulant effects. As we will see, this is the case with MDMA (Ecstasy) but not with mescaline or DOM.
Mescaline The hallucinogen mescaline is derived from the peyote plant, a spineless cactus with a small, greenish crown that
bufotenine and the Bufo Toad Bufotenine is a drug with a strange past. Found in a family of beans native to Central and South America, bufotenine is bet- ter known as a chemical that can be isolated from the skin and glands of the Bufo toad, from which it gets its name. As noted in Chapter 3, Bufo toads figured prominently in the magical po- tions of European witches. Evidence also exists that Bufo toads were incorporated into the ceremonial rituals of ancient Aztec and Mayan cultures. Largely as a result of these historical refer- ences, it has been widely assumed that bufotenine was the pri- mary contributor to the psychoactive effects of these concoctions and that bufotenine itself is a powerful hallucinogen.
It turned out that these conclusions were wrong. The few studies in which human volunteers were administered bufoten- ine indicate that the substance induces strong excitatory effects on blood pressure and heart rate but no hallucinatory experi- ences. Some subjects report distorted images with high dosages of the drug, but this might well occur as oxygen is cut off from parts of the body, particularly the optic nerve carrying visual information to the brain. It is likely that whatever hallucino- genic effects Bufo toads may produce are brought on by another
chemical also found in these toads that functions similarly to the hallucinogen DMT.
Despite the confusion as to which substance is responsible for its psychoactive properties, Bufo toads continue to fascinate the public. Wildly exaggerated and frequently unsubstantiated accounts of “toad licking” and “toad smoking” periodically circu- late in the social media. Reportedly, a small group calling them- selves Amphibians Anonymous was formed in the late 1980s; the group’s motto was, “Never has it been so easy to just say no.”
The bottom line, however, is that the dangers of consuming toad tissue are substantial. Besides the extreme cardiovascular reactions, toxic effects include a skin condition called cyanosis (literally, “turning blue”). Actually, the description may be an understatement. Skin color has been observed to be closer to an eggplant purple.
Sources: Horgan, J. (1990, August). Bufo abuse. Scientific American, pp. 26–27. Iniardi, James A. (2002). The war on drugs III. Boston: Allyn and Bacon, pp. 4–5. Lyttle, Thomas; Goldstein, David; and Gartz Jochen (1996). Bufo toads and bufotenine: Fact and fiction surrounding an alleged psychedelic. Journal of Psychoactive Drugs, 28, 267–290.
Drugs … in Focus
peyote (pay-yO-tay): A species of cactus that is the source for the hallucinogenic drug mescaline.
mescaline (MES-kul-leen): A norepinephrine-related hallu- cinogenic drug. Its source is the peyote cactus.
cyanosis (SigH-ah-NOH-sis): A tendency for the skin to turn bluish purple. It can be a side effect of the drug bufotenine.
bufotenine (byoo-FOT-eh-neen): A serotonin-related drug obtained either from a bean plant in Central and South America or from the skin of a particular type of toad.
Chapter 11 LSD and Other Hallucinogens ■ 217
DOM A group of synthetic hallucinogens have been developed that share mescaline’s resemblance to amphetamine but do not produce the strong stimulant effects of amphetamine. One example of these synthetic drugs, DOM (short for 2,5-dimethoxy-4-methylamphetamine), appeared in the 1960s and 1970s, when it was frequently combined with LSD and carried the street name of STP. To some, the nickname was a reference to the well-known engine oil additive; to others, the letters stood for “serenity, tranquility, and peace” or, alternatively, “super terrific psychedelic.” It is roughly 80 times more potent than mescaline, though still far weaker than LSD. At low doses of about 3–5 milligram, DOM pro- duces euphoria; with higher doses of 10 milligram or more,
the chemical structure of norepinephrine but stimulates the same serotonin-2A receptors as LSD and other hallucino- gens that resemble serotonin. As a result, mescaline and LSD share a common brain mechanism.37
Present-Day Peyotism and the Native American Church Among American Indians within the United States, the ritual use of peyote buttons, called peyotism, can be traced to the eigh- teenth century when the Mescalero Apaches (from whom the word mescaline was derived) adopted the custom from Mexican Indians, who had been using peyote for more than 3,000 years. By the late 1800s, peyotism had become widely popular among tribes from Wisconsin and Minnesota to the West Coast. It was not until the early twentieth century, however, that peyote use became incorporated into an official religious organization, the Native American Church of North America, chartered in 1918.
The beliefs of the Native American Church membership, es- timated to include anywhere from 50,000 to 250,000 American Indians in the United States and Canada, combine traditional tribal customs and practices with Christian morality. To them, life is a choice between two roads that meet at a junction. The Profane Road is paved and wide, surrounded by worldly passions and temptations. The Peyote Road is a narrow and winding path, surrounded by natural, unspoiled beauty; it is also a path of sobriety (since alcohol poisons the goodness of the body), hard work, caring for one’s family, and brotherly love. Only the Peyote Road leads to salvation. In their weekly ceremonies, lasting from Saturday night until Sunday afternoon, church members swallow small peyote buttons as a sacrament, similar to the ritual of taking Holy Communion, or drink peyote tea. It is considered sacrilegious to take peyote outside the ceremonies in the church.
While peyote remains classified as a Schedule I drug and therefore banned, federal law and the laws of 23 U.S. states have exempted the sacramental use of peyote from criminal penalties. The Religious Freedom Restoration Act of 1993 established an exemption from federal and state controlled substance laws when peyote is used for religious purposes in traditional American Indian ceremonies. In 2005, a study found that peyote use among church members does not result in impairments on tests of mem- ory, attention, and other aspects of cognitive functioning.
Today, in south Texas near Laredo, a handful of people are licensed by state and federal authorities to harvest peyote for reli- gious purposes. This locale is the only place in the United States where peyote grows in the wild. As one of the harvesters has put it, “This is sacred ground to a lot of American Indian tribes. To some, the land here is very holy because it is the home to the sacred peyote.”
Sources: Calabrese, Joseph D. (1997). Spiritual healing and human development in the Native American Church: Toward a cultural psychiatry of peyote. Psychoanalytic Review, 84, 237–255. Halpern, John H.; Sherwod, Andrea, R.; Hudson, James I.; Yurgelum-Tod, Deborah; and Pope, Harrison G., Jr. (2005). Psychological and cognitive effects of long-term peyote use among Native Americans. Biological Psychiatry, 58, 624–631. Indian religion must say no (1990, October 6). The Economist, pp. 25–26. Milloy, Ross E. (2002, May 7). A forbidding landscape that’s Eden for peyote. New York Times, p. A20. Quotation on p. A20. Morgan, George (1983). Recollections of the peyote road. In Lester Grinspoon and James B. Bakalar (Eds.), Psychedelic reflections. New York: Human Sciences Press, pp. 91–99.
Drugs … in Focus
DOM: A synthetic norepinephrine-related hallucinogenic drug, derived from amphetamine. DOM or a combination of DOM and LSD is often referred to by the street name STP.
The peyote cactus, source of mescaline.
218 ■ Part Three Legally Restricted Drugs and Criminal Justice
suggested the name empathogens (meaning “generating a state of empathy”) to describe MDMA and related drugs. Eventually, after several years of hesitations and reversals, the Drug Enforcement Administration put MDMA perma- nently on the Schedule I list of controlled substances, indi- cating that there is no accepted medical application for the drug. Nonetheless, MDMA remained a legally approved and regulated drug for psychiatric use in Switzerland as late as 1993. There continues to be interest in its positive role in psy- chiatric treatment, though its present status as a Schedule I controlled substance makes it extremely difficult to conduct research studies on this possiblity.39
In the early 1990s, MDMA become prominent among the new club drugs, especially popular at dance clubs and all-night “rave” parties. Widely available under names such as Ecstasy, E, XTC, X, Essence, Clarity, and Adam, MDMA acquired the reputation of having the stimulant qualities of amphetamines and the hallucinogenic qualities of mescaline.
The physical health concerns with respect to Ecstasy center on its short-term and long-term toxicity. The principal acute effect is severe hyperthermia (and heatstroke), which can be lethal when Ecstasy is ingested while engaged in the physical exertion of dancing in an already-overheated club environment. The dehydration associated with hyperther- mia causes an elevation in blood pressure and heart rate and places a strain on kidney functioning. These problems are compounded by the highly risky practice of “Ecstasy stack- ing,” in which multiple Ecstasy tablets are taken at once or
severe hallucinations result, often lasting from 16 to 25 hours. Though similar to LSD in many respects, DOM has the rep- utation of producing a far greater incidence of panic attacks, psychotic episodes, and other symptoms of a very bad trip. Cases have been reported of STP being added as an adulter- ant to marijuana.38
MDMA (Ecstasy) MDMA (generally known by its street name, Ecstasy) could have been included simply as another norepinephrine- related hallucinogenlike mescaline and DOM, but because it has strong amphetaminelike stimulant effects (unlike mesca- line and DOM) and has received so much attention in recent years as a major abused substance, MDMA deserves a sepa- rate section of its own in this chapter.
MDMA first appeared on the scene in the 1980s as a new designer drug. It also became known to a number of psychiatrists, who used the drug as part of their therapy, believing that MDMA had a special ability to enhance empa- thy among their patients. In fact, some therapists at the time
Help Line An Examination of MDMA Toxicity
• Possible Physical Effects Hyperthermia and heatstroke Dehydration and electrolyte depletion Irregular heartbeat or increased heart rate Kidney and liver failure Jaw-clenching and other forms of muscle spasms Long-term neurochemical changes
• Possible Psychological Effects Agitation and confusion Depression and anxiety Long-term impairments in memory recall
Note: As with other illicit drugs, adulterated versions raise significant concerns. In the case of MDMA, adulterants include dextromethorphan (a common cough suppressant) at approximately 13 times the dose found in over-the-counter cough medications. At this dosage, dextromethorphan itself functions as a hallucinogen and inhibits sweating, increasing the risk of hyperthermia and heatstroke. Other drugs have also been identified as adulterants in MDMA batches (see Law Enforcement … in Focus).
In 2003, the federal RAVE (Reducing Americans’ Vulnerability to Ecstasy) Act was signed into law, making it
unlawful to “knowingly open, lease, rent, use, or maintain any place, whether permanently or temporarily for the purpose of manufacturing, distributing, or using any controlled substance.” Supporters of the law view it as helping to reduce illicit drug use in dance clubs; opponents view it more as reflection of prejudice against youth culture.
Where to go for assistance: www.nida.nih.gov/infofacts/ecstasy.html
This Web site is sponsored by the National Institute on Drug Abuse, with an extensive treatment on the hazards of Ecstasy (MDMA).
Sources: Boils, Karen I. (1999). Memory impairment in abstinent MDMA (“Ecstasy”) users. Journal of the American Medical Association, 281, 494. Chonin, Neva (2003, April 27). Congress acts out against club culture. San Francisco Chronicle, p. 35. Leshner, Alan I. (2002). Ecstasy abuse and control: Hearing before the Senate Subcommittee on Governmental Affairs—July 30, 2001. Statement for the record. Journal of Psychoactive Drugs, 34, 133–135. Schwartz, Richard H.; and Miller, Norman S. (1997). MDMA (Ecstasy) and the rave: A review. Pediatrics, 100, 705–708.
MDMA (Ecstasy): A synthetic norepinephrine-related hallucinogenic drug. Once considered useful for psychotherapeutic purposes, this drug is now known to produce significant adverse side effects, including neuronal hyperthermia, dehydration, and neurochemical changes.
Chapter 11 LSD and Other Hallucinogens ■ 219
Hallucinogens Related to Acetylcholine
Of the acetylcholine-related hallucinogens, some enhance the neurotransmitter and some inhibit it. Examples include Amanita muscaria mushrooms, atropine, scopolamine, and hyoscyamine.
Amanita muscaria The Amanita muscaria mushroom, also called the fly agaric mushroom because of its ability to lure and sedate flies and other insects, grows in the upper latitudes of the Northern Hemisphere, usually among the roots of birch trees. The mushroom has a bright red cap speckled with white dots; the dancing mushrooms in Walt Disney’s film Fantasia were inspired by the appearance (if not the hallucinogenic effects) of this fungus (see Figure 11.1).
Amanita mushrooms are one of the world’s oldest intoxi- cants. Many historians hypothesize that this mushroom was the basis for the mysterious and divine substance called soma, which is celebrated in the Rig-Veda, one of Hinduism’s oldest
Ecstasy is combined with LSD, alcohol, marijuana, or other drugs. Heavy and prolonged Ecstasy use can produce confu- sion, anxiety, sleep problems, reductions in impulse control, and declines in memory and attention. In general, women show greater behavioral effects from chronic Ecstasy use than do men.40 The Help Line feature summarizes the major aspects of MDMA toxicity.
In 2013, according to the University of Michigan sur- vey, about 7 percent of high school seniors and about 2 per- cent of eighth graders reported having taken Ecstasy at some point in their lives. In 2001, prevalence rates had reached 12 percent and 5 percent, respectively, causing considerable alarm among public health officials. Since around 2005, however, the rates have decreased and have remained fairly steady at 5–7 percent for seniors and 2–3 percent for eighth graders. 41
The current difficulties with Ecstasy on the drug scene are not with MDMA per se, but rather the fact that drugs that are being sold and distributed as pure MDMA (such as “Molly”) may not contain MDMA at all or else contain MDMA with a number of other psychoactive compounds. The present-day concerns with Molly (see Drug Enforcement … in Focus) parallel the concerns addressed in Chapter 10 with respect to so-called bath salts. These designer synthetic drugs repre- sent only a part of a larger issue—the increasing number of designer synthetic drugs appearing on the scene that have largely unknown chemical compositions and, as a result, largely unpredictable pharmacological consequences.42
Who (or What) is Molly? There are few developments in the present-day drug scene that have more greatly concerned public health and criminal justice professionals alike than the availability of designer synthetic drugs currently flooding the country. These synthetic formula- tions, largely created in Asian laboratories, are composed of chemical ingredients that can only be deciphered through chemical analysis in a forensic laboratory. Yet, they are often promoted as pure forms of existing drugs.
A case in point is the recent introduction of drugs referred to as “Molly.” Between October 2009 and September 2013, out of more than 140 “drug exhibits” (samples of drugs obtained through DEA seizure operations in New York State) that were submitted to the Northeast Regional Laboratory for analysis, 87 percent were found to contain no amount of MDMA whatsoever. Nearly half of the samples contained methylone or 4-MEC, two substances in the cathinone family. You may recall from Chapter 10 that cathinones (particularly methylone) are a principal ingredient in another designer synthetic drug, promoted as “bath salts.”
The confusion regarding the substances contained in Molly is likely to persist for some time. Health professionals are hard put to identify the exact ingredients in emergency hospitals when individuals come in with serious drug reactions. Statistics referring to an increase in hospital emergencies due to MDMA (Ecstasy) are based in large part on the assumption that patients reporting having taken Molly have been actually consuming MDMA. During Labor Day weekend in 2013, two attendees at a music festival in New York City died from drug-related causes after allegedly ingesting Molly. Given the present circumstances with respect to designer synthetic drugs, many of them promoted as Molly, it is unclear whether MDMA was involved at all.
Sources: Crowell, Brian R. (2013, September). Updated “Molly” reporting. Information Bulletin issued by the Drug Enforcement Administration, New York Division. Drug Enforcement Administration (2014). MDMA (Ecstasy) or Molly? Washington, DC: Drug Enforcement Administration, U.S. Department of Justice.
Drug Enforcement … in Focus
Amanita muscaria (a-ma-NEE-ta mus-CAR-ee-ah): A species of mushroom containing the hallucinogenic drug ibotenic acid.
220 ■ Part Three Legally Restricted Drugs and Criminal Justice
dozen or so berries is sufficient for death to occur. Many recipes for poisons through history have been based on this plant. At lower, more benign dose levels, plant ex- tracts can be applied to the eyes, causing the pupils to di- late. Egyptian and Roman women used this technique to enhance their beauty or at least improve their appearance. The term “belladonna” (“beautiful lady”) originates from this application. The psychological effects of atropine are generally associated with the anticholinergic effects of heart-rate acceleration and general arousal.
●■ The mandrake plant is an oddly shaped potatolike plant with a long, forked root that has traditionally been imagined to resemble a human body. In ancient times, mandrake was considered to have aphrodisiac properties. According to medieval folklore, mandrake plants supposedly shrieked when they were uprooted, understandably driving peo- ple mad. Mandrake contains a combination of atropine, scopolamine, and hyoscyamine. Because low doses act as a depressant, mandrake has been used as a sedative– hypnotic drug to relieve anxiety and induce sleep. At higher doses, it produces bizarre hallucinations and mus- cular paralysis.
●■ Henbane is a strong-smelling herb, native to widespread areas of the Northern Hemisphere, with purple-veined, yellowish flowers and hairy leaves. Its English name, meaning “harmful to hens,” originates from the observa- tion that henbane seeds were toxic to chickens and other birds. The lethal possibilities for henbane potions have been described by writers since the days of the Roman Empire. Hamlet’s father in Shakespeare’s play was sup- posedly murdered with henbane poison. Lower doses of henbane, however, have been used in a more benign way, as an anesthetic and painkiller. We now know that the predominant drugs in henbane are scopolamine and hyoscyamine.
●■ Various species of the datura plant, containing a combi- nation of atropine, scopolamine, and hyoscyamine, grow wild in locations throughout the world. In the United States, one particular species, Datura stramonium, is called “jimsonweed,” a contraction of “Jamestown weed” (the name given to it by early American colonists). Consumption of the seeds or berries of jimsonweed pro- duces hypnotic and hallucinogenic effects, together with disorientation, confusion, and amnesia. At high doses, jim- sonweed is quite toxic. In recent years, there have been oc- casional reports of hospitalizations and even deaths among teenagers, who have eaten jimsonweed seeds as an inex- pensive way to get high.46
During medieval times, mixtures of deadly nightshade, mandrake, and henbane were responsible for the psychoac- tive effects of witches’ potions, producing a disastrous com- bination of physiological and psychological effects. Satanic celebrations of the Black Mass centered on the ingestion of such brews. The atropine, in particular, produced a sub- stantial elevation in arousal, probably leading to the feeling
holy books, dating around 1000 b.c. It is strongly suspected that amanita mushrooms were used in Greek mystery cults and were the basis for the legendary “nectar of the Gods” on Mount Olympus.43
The effects of amanita mushrooms can be lethal if dose levels are not watched very carefully. They produce muscu- lar twitching and spasms, vivid hallucinations, dizziness, and heightened aggressive behavior. It was briefly mentioned in Chapter 3 that Viking warriors were reputed to have ingested amanita mushrooms before sailing off to battle. The drug- induced strength and savagery of these “berserk” invaders were so widely feared that a medieval prayer was written espe- cially for protection from their attacks: “From the intolerable fury of the Norseman, O Lord, deliver us.”44
The Hexing Drugs and Witchcraft A number of natural plants contain chemicals that share a common feature: the ability to block the parasympathetic effects of acetylcholine in the body. The drugs with this abil- ity, called anticholinergic drugs, produce specific physiologi- cal effects. The production of mucus in the nose and throat and in the mouth is reduced. Body temperature is elevated, sometimes to very high-fever levels. Heart rate and blood pres- sure go up, and the pupils dilate considerably. Psychological effects include a feeling of delirium, confusion, and a loss of memory for events occurring during the drugged state.45 The amnesic property is one of the primary reasons for the mini- mal street appeal of these drugs.
The principal anticholinergic drugs are atropine, scopolamine (also called hyoscine), and hyoscyamine. They are found in various combinations and relative amounts in a large number of psychoactive plants. Four of the better known ones are examined here:
●■ Atropine is principally derived from the Atropa belladonna plant, also called deadly nightshade. Its lethal reputation is quite justified, since it is estimated that ingesting only a
Datura stramonium (duh-TOOR-ah strah-MOH-nee-um): A species of the datura family of plants with hallucinogenic properties. In the United States, the plant is called jimsonweed.
henbane: An herb containing anticholinergic hallucinogenic drugs.
mandrake: A potatolike plant containing anticholinergic hallucinogenic drugs.
Atropa belladonna (a-TROH-pah bEL-ah-DON-ah): A plant species, also called deadly nightshade, whose berries can be highly toxic. It is the principal source of atropine.
hyoscyamine (HEyE-oh-SEyE-eh-meen): An anticholinergic hallucinogenic drug found in mandrake, henbane, and various species of the datura plant.
scopolamine (scoh-POL-ah-meen): An anticholinergic hallucinogenic drug. Also called hyoscine.
atropine (AT-tro-peen): An anticholinergic hallucinogenic drug derived from the Atropa belladonna plant.
Chapter 11 LSD and Other Hallucinogens ■ 221
Sernyl. It was marketed as a promising new surgical anes- thetic that had the advantage of not depressing respiration or blood pressure or causing heartbeat irregularities as some other anesthetics do. In addition, PCP had a higher thera- peutic ratio than many other anesthetics available at that time. By 1965, however, it was withdrawn from human appli- cations after reports that nearly half of all patients receiving PCP showed signs of delirium, disorientation, hallucina- tions, intense anxiety, or agitation. In 1979, PCP was classi- fied as a Schedule II controlled substance and is still used as an anesthetic for animal surgery.
The weird combination of stimulant, depressant, and hallucinogenic effects makes PCP difficult to classify. Some textbooks treat the discussion of PCP in a chapter on hal- lucinogens, as is done here, whereas others include it in a chapter on stimulants because some features of PCP intoxica- tion resemble the effect of cocaine. A growing consensus of opinion has it that PCP should be described as a dissociative anesthetic hallucinogen because it produces a feeling of being dissociated or cut off from one’s environment.
Acute effects of PCP can be taken orally, intravenously, or by inhalation, but commonly it is smoked either alone or in combination with other drugs. Whatever its mode of administration, the results are extremely dangerous, with an unpredictability that far exceeds that of LSD or other hal- lucinogens. The symptoms may include manic excitement, depression, severe anxiety, sudden mood changes, disordered and confused thought, paranoid thoughts, and unpredictable aggression. Because PCP has analgesic properties as well, individuals taking the drug often feel invulnerable to threats against them and may be willing and able to withstand con- siderable pain. The mechanism behind PCP effects appears to be the blocking of a specific subtype of glutamate receptors in the brain (see Chapter 5).
Hallucinations also occur, but they are quite different from the hallucinations experienced under the influence of LSD. There are no colorful images, no intermingling of sight and sound, no mystical sense of being “one with the world.” Instead, a prominent feature of PCP-induced hallucinations is the change in one’s body image. PCP abusers may imag- ine themselves to be so small that they feel they could walk through a keyhole or that their arm suddenly has grown to ten times its normal length.48
Individuals under the influence of PCP also may stagger, speak in a slurred way, and feel depersonalized or detached from people around them. A prominent feature is a prolonged visual stare, often called “doll’s eyes.”
The effects of PCP last from as little as a few hours to as long as two weeks, and they are followed by partial or total amnesia and dissociation from the entire experience. Considering these bizarre reactions, it is not surprising that
that the person was flying (or at least capable of it), while the hallucinogenic effects enabled the person to imagine “communing with the Devil.”47 Witches were reputed to have prepared these mixtures as ointments and rubbed them on their bodies and on broomsticks, which they straddled. The chemicals would have been easily absorbed through the skin and the membranes of the vagina. The Halloween image of a witch flying on a broomstick has been with us ever since.
Miscellaneous Hallucinogens
Three hallucinogens are referred to as miscellaneous halluci- nogens because they do not have any chemical resemblance to either serotonin, norepinephrine, or acetylcholine. They are phencyclidine (PCP), ketamine, and Salvia divinorum.
Phencyclidine Perhaps the most notorious of all the hallucinogens is phencyclidine (PCP), commonly known as angel dust. Technically, PCP is a synthetic depressant, and it was origi- nally introduced in 1963 as a depressant drug by the Parke- Davis pharmaceutical company, under the brand name of
Quick Concept Check
Understanding the Diversity of Hallucinogens Check your understanding of the psychological differences among major hallucinogens by matching each hallucinatory experience (in the left column) with the hallucinogenic drug most apt to produce such effects (in the right column).
psychological experience hallucinogen
1. “The images I saw were Mexican designs as if they were created by an Aztec artist.”
DMT
LSD
Atropa belladonna
psilocybin
mescaline
Amanita muscaria
2. “As I heard the bells, I also saw the vibrations move through the air.”
3. “The hallucinations were gone sixty minutes after they had started.”
4. “As I ate the red-topped mushrooms, I felt my muscles twitch. I could see vivid hallucinations.”
5. “I felt as if I were flying through the air.”
Answers: 1. psilocybin 2. LSD, principally 3. DMT 4. Amanita muscaria 5. Atropa belladonna
11.1
phencyclidine (PCP) (fen-SigH-klih-deen): A dissocia- tive anesthetic hallucinogen that produces disorientation, agitation, aggressive behavior, analgesia, and amnesia. It has various street names, including angel dust.
222 ■ Part Three Legally Restricted Drugs and Criminal Justice
result. In 2011, more than 75,000 hospital emergency depart- ments visits related to PCP abuse were reported in the DAWN survey (see Chapter 1), four times the number reported in 2005. Individuals aged 25 to 34 accounted for nearly half of these cases.50
Ketamine
Ketamine, a drug chemically similar to PCP, is also classi- fied as a dissociative anesthetic hallucinogen. Like PCP, ket- amine has a mixture of stimulant and depressive properties, though its depressive effect is more extreme and does not last as long as that of PCP. Ketamine (brand name: Ketalar) was used as an emergency surgical anesthetic on the battlefield in Vietnam as well as in standard hospital-based operations in which gaseous anesthetics could not be employed. It has also been used occasionally in short surgical procedures involving the head and neck or in the treatment of facial burns where it is not possible to use an anesthetic mask. Adverse side effects, however, have limited its therapeutic use. These problems include unpredictable and sometimes violent jerking and twitching of the body, as well as vivid and unpleasant dreams during and after surgery. During recovery, patients may expe- rience hallucinations and feelings of disorientation. Delayed effects of ketamine, such as nightmares, have been reported to occur for weeks or longer after surgery.51
Ketamine abuse began to be reported in the 1980s. More recently, under the names “Special K” and “Vitamin K,” it has been available alongside many designer-drug variations (see Chapter 1). Its popularity has increased among college students and patrons of dance clubs and all-night “rave” par- ties. Like PCP, ketamine produces a dreamlike intoxication, accompanied by an inability to move or feel pain. There are
PCP deaths occur more frequently from the behavioral con- sequences of the PCP experience than from its physiologi- cal effects. Suicides, accidental or intentional mutilations, drownings (sometimes in very small amounts of water), falls, and threatening behavior leading to the individual’s being shot are only some of the possible consequences.49
Patterns of PCP Abuse It is strange that a drug with so many adverse effects would be subject to deliberate abuse, but such is the case with PCP. Reports of PCP abuse began surfacing in 1967 among the hippie community in San Francisco, where it became known as the PeaCe Pill. Word quickly spread that PCP did not live up to its name. Inexperienced PCP abusers were suffering the same bizarre effects as had the clinical patients earlier in the decade. By 1969, PCP had been written off as a garbage drug, and it dropped out of sight as a drug of abuse.
In the early 1970s, PCP returned under new street names and in new forms (Table 11.2). No longer a pill to be taken orally, PCP was now in powdered or liquid form. Powdered PCP could be added to parsley, mint, oregano, tobacco, or marijuana, rolled as a cigarette, and smoked. Liquid PCP could be used to soak leaf mixtures of all types, including manufactured cigarettes, which could then be dried and smoked. Many new users have turned to PCP as a way to boost the effects of marijuana.
Making matters worse, in recent years, as many as 120 different designer-drug variations of PCP have been devel- oped in illicit laboratories around the country and the world. The dangers of PCP abuse, therefore, are complicated by the difficulty in knowing whether a street drug has been adul- terated with PCP and what version of PCP may be present. Unfortunately, the common practice of mixing PCP with alcohol or marijuana adds to the unpredictability of the final
Quick Concept Check
Understanding PCP Check your understanding of the effects of PCP by listing three major features of PCP intoxication that are significantly different from the effects of other hallucinogens.
Answer: Correct responses can include any of the following: analgesia, amnesia, prolonged stare, absence of synesthesia, absence of mysticism, unpredictable aggression, extreme disorientation, feelings of being cut off from oneself or the environment.
11.2 TAbLE 11.2
Street names for phencyclidine and related drugs
PCP Jet fuel
Angel dust
Monkey dust
Sherms (derived from the reaction that it hits you like a Sherman tank)
Peep Superkools
Supergrass Cyclones
Killer weed Zombie dust
Ozone Ketamine
Embalming fluid Special K
Rocket fuel Vitamin K
Note: In the illicit drug market, PCP and ketamine are frequently misrepresented and sold as mescaline, LSD, marijuana, amphet- amine, or cocaine.
Source: Based on information from Milburn, H. Thomas (1991). Diagnosis and management of phencyclidine intoxication. American Family Physician, 43, 1293.
ketamine (KET-ah-meen): A dissociative anesthetic hallucinogen related to phencyclidine (PCP).
Chapter 11 LSD and Other Hallucinogens ■ 223
study of Salvia users, 85 percent reported Salvia effects lasting less than 15 minutes.
Considerable media attention has been directed toward recreational use of Salvia. At present, at least 20 U.S. states have classified it as a Schedule I controlled substance, along with other hallucinogens, but the federal government has yet to do so.
According to the 2013 University of Michigan sur- vey, 3 percent of high school seniors reported using Salvia in the past year (about half of the prevalence rate in 2009). In a smaller sample of college students reporting in 2006, 23 percent of students had heard of Salvia. About 7 percent had used it at some time in their life, but the prevalence rate plummeted to less than 1 percent when asked whether they had used it in the last month.
The “snapshots” that surveys of this kind reveal are inter- esting. In the case of Salvia, media coverage increased the level of awareness about it, and its legal availability through Internet sources resulted in a degree of experimentation. However, the Salvia experience as well as its very short dura- tion was evidently unpleasant to many. A majority of the first- time Salvia users in the college sample said that they would not want to use it again.53
also experiences of dizziness, confusion, and slurred speech. As is the case with dissociative hallucinogens, ketamine pro- duces amnesia, wherein abusers frequently cannot remember later what had happened while under its influence. The pri- mary hazard of acute ketamine ingestion is the depression of breathing. Little is known, however, of the chronic effects of extended ketamine abuse over time, except that experiences of “flashbacks” have been reported. As with PCP, the effects of ketamine are associated with the blocking of specific glu- tamate receptors.
As with other club drugs that produce depressive effects on the central nervous system, there is the dangerous poten- tial for ketamine to be abused as a “date-rape” drug. Women who may unwittingly take the drug can be rendered incapac- itated, without the ability to recall the experience. In 1999, ketamine became classified as a Schedule III controlled substance.52
Salvia divinorum The Mexican herb, Salvia divinorum (commonly referred to as Salvia), has a long tradition as a shamanic treatment for diarrhea, headache, rheumatism, and abdominal dis- comfort. When smoked, chewed, or brewed as a tea, Salvia produces intense visual hallucinations (resembling the effect of psilocybin-containing mushrooms), laughter, and an “out of body” dissociative experience. Its potency approaches that of LSD, but the effects are very short lived. In one recent
Salvia divinorum (SAL-via di-vi-NOR-um) or Salvia: A Mexican leafy herb with short-duration hallucinogenic effects.
A Matter of Definition ●● Hallucinogens are, by definition, drugs that produce
distortions of perception and of one’s sense of reality. These drugs have also been called psychedelic (“mind- expanding”) drugs. In some cases, users of hallucinogens feel that they have been transported to a new reality.
●● Other classes of drugs may produce hallucinations at high- dose levels, but hallucinogens produce these effects at low- or moderate-dose levels.
Classifying Hallucinogens ●● Hallucinogens can be classified under four basic groups.
The first three relate to the chemical similarity between the particular drug and one of three major neurotransmit- ters: serotonin, norepinephrine, and acetylcholine.
●● The fourth miscellaneous group includes synthetic hal- lucinogens, such as PCP and ketamine, which bear little resemblance to any known neurotransmitter.
Lysergic Acid Diethylamide (LSD) ●● Lysergic acid diethylamide, the best-known hallucinogenic
drug, belongs to the serotonin group. It is synthetically
derived from ergot, a toxic rye fungus that has been docu- mented as being responsible for thousands of deaths over the centuries.
●● Albert Hofmann synthesized LSD in 1943, and Timothy Leary led the psychedelic movement that popularized LSD use in the 1960s.
●● Although the LSD experience is often unpredictable, cer- tain features are commonly observed: colorful hallucina- tions, synesthesia in which sounds often appear as visions, a distortion of perceptual reality, emotional swings, a feel- ing of timelessness, and an illusory separation of mind from body.
●● It is now known that LSD affects a subtype of brain receptors sensitive to serotonin, referred to as serotonin-2A receptors.
●● In the early 1990s, there was a resurgence in LSD abuse, particularly among young individuals, a trend that began to reverse in 1997.
Facts and Fictions about LSD ●● LSD does not produce psychological or physical depen-
dence and has only a slight chance of inducing a panic or
Summary
224 ■ Part Three Legally Restricted Drugs and Criminal Justice
parasympathetic nervous system, have been involved in sorcery and witchcraft since the Middle Ages.
●● These so-called hexing drugs contain a combination of atropine, scopolamine, and/or hyoscyamine. Sources for such drugs include the deadly nightshade plant, mandrake roots, henbane seeds, and the datura plant family.
Miscellaneous Hallucinogens: PCP, Ketamine, and Salvia divinorum
●● A dangerous form of hallucinogen abuse involves PCP. Originally a psychedelic street drug in the 1960s, PCP quickly developed a reputation for producing a number of adverse reactions.
●● PCP reappeared in the early 1970s, in smokable forms ei- ther alone or in combination with marijuana. Extremely aggressive tendencies, as well as behaviors resembling acute schizophrenia, have been associated with PCP intoxication.
●● Ketamine is popular as a club drug that produces a dream- like intoxication, accompanied by an inability to move or feel pain. Like PCP, ketamine also produces amnesia and potentially a depression in breathing.
●● Salvia divinorum (or simply Salvia) is a Mexican leafy herb, with short-duration hallucinogenic effects when smoked, chewed, or brewed as a tea. It is regarded by the DEA as a “drug of concern.” Some U.S. states have clas- sified Salvia as a Schedule I controlled substance, though the federal government has yet to do so.
psychotic state (providing that there is a supportive setting for the taking of LSD).
●● LSD does not elevate one’s level of creativity. It does not damage chromosomes (though there remains a chance of birth defects if a woman ingests LSD when she is preg- nant), and a relationship between LSD abuse and violent behavior has not been established. Flashback experiences, however, are potential hazards.
Psilocybin and Other Hallucinogens Related to Serotonin
●● Other hallucinogens related to serotonin are psilocybin, lysergic acid amide (LAA), dimethyltryptamine (DMT), and harmine.
Hallucinogens Related to Norepinephrine ●● Mescaline is chemically related to norepinephrine, even
though serotonin-2A receptors are responsible for its hal- lucinogenic effects.
●● Two synthetic hallucinogens, DOM and MDMA, are vari- ations of the amphetamine molecule. MDMA (Ecstasy) is currently a popular club drug, but research studies indi- cate that it poses serious health risks to the user. Designer synthetic drugs (sold and distributed as “Molly”) have pur- ported to be a pure form of MDMA, but forensic analyses reveal that it often contains cathinones and an unknown array of other substances.
Hallucinogens Related to Acetylcholine ●● A number of anticholinergic hallucinogens, so named
because they diminish the effects of acetylcholine in the
Key Terms
Amanita muscaria, p. 219 Atropa belladonna, p. 220 atropine, p. 220 bufotenine, p. 216 cyanosis, p. 216 Datura stramonium, p. 220 dimethyltryptamine (DMT),
p. 215
DOM, p. 217 ergot, p. 208 ergotism, p. 208 hallucinogens, p. 206 harmine, p. 215 henbane, p. 220 hyoscyamine, p. 220 ketamine, p. 222
lysergic acid amide (LAA), p. 215
lysergic acid diethylamide (LSD), p. 206
mandrake, p. 220 MDMA (Ecstasy),
p. 218 mescaline, p. 216
peyote, p. 216 phencyclidine (PCP),
p. 221 psilocin, p. 215 psilocybin, p. 214 Salvia divinorum, p. 223 scopolamine, p. 220 synesthesia, p. 211
1. Discuss the historical roots of LSD, including reference to ergotism and the discovery of LSD by Albert Hofmann.
2. Describe the four main categories of hallucinogenic drugs and identify two hallucinogens in each category.
3. Describe the characteristic features of the LSD experience. Write a sentence or two in the first-person with regard to each of these effects, as though you were taking LSD and reporting your personal reaction to the experience.
4. Discuss the seven questions that may or may not be true about LSD, providing a short answer for each of the questions
5. Discuss the current concerns with the designer synthetic drug called Molly. Explain how the promotion of Molly as a pure form of MDMA may be inaccurate.
6. Identify the substances that have been called “hexing drugs.” Include in your answer the role these drugs have played in history.
Review Questions
Chapter 11 LSD and Other Hallucinogens ■ 225
You are at a music concert and a close friend of yours (someone you have known most of your life and trust implicitly) hands you a powder that he has obtained. He calls it “Molly” and assures you that it is a pure form of Ecstasy. You have used Ecstasy in the past.
Your friend is willing to take this drug along with you. Given the material in this chapter, what would you do? How would you re- spond to your friend?
Critical Thinking: What Would You Do?
1. Hofmann, Albert (1980). LSD: My problem child. New York: McGraw-Hill, p. 17.
2. Ibid., pp. 17–18. 3. Ibid., p. 19. 4. Brophy, James J. (1985). Psychiatric disorders. In Marcus A.
Krupp; Milton J. Chatton; and David Werdegar (Eds.), Current medical diagnosis and treatment. Los Altos, CA: Lange Medical Publication, p. 674.
5. Mann, John (1992). Murder, magic, and medicine. New York: Oxford University Press, pp. 41–51.
6. Fuller, John G. (1968). The day of St. Anthony’s fire. New York: Macmillan, preface.
7. Leary, Timothy (1973). The religious experience: Its produc- tion and interpretation. In Gunther Weil; Ralph Metzner; and Timothy Leary (Eds.), The psychedelic reader. Secaucus, NJ: Citadel Press, p. 191.
8. Lattin, Don (2010). The Harvard psychedelic club. New York: HarperCollins. Lee, Martin A.; and Shlain, Bruce (1985). Acid dreams: The complete social history of LSD. New York: Grove Weidenfeld, pp. 71–118.
9. Greenfield, Robert (2006). Timothy Leary: A biography. New York: H. Silberman Book/Harcourt. Leary, Timothy (1968). High priest. New York: New American Library, p. 46. Manchester, William R. (1974). The glory and the dream: A narrative history of America, 1932–1972. Boston: Little, Brown, p. 1362.
10. Grinspoon, Lester; and Bakalar, James B. (1979). Psychedelic drugs reconsidered. New York: Basic Books, p. 68.
11. Brown, F. Christine (1972). Hallucinogenic drugs. Springfield, IL: Charles C. Thomas, pp. 46–49. Goode, Erich (2008). Drugs and American society (7th ed.). New York: McGraw-Hill College, p. 260.
12. Schuckit, Marc A. (1995). Drug and alcohol abuse: A clinical guide to diagnosis and treatment (4th ed.). New York: Plenum, pp. 189–190.
13. Jacobs, Michael R.; and Fehr, Kevin O’B. (1987). Drugs and drug abuse: A reference text (2nd ed.). Toronto, Canada: Addiction Research Foundation, p. 345. Center for Behavioral Health Statistics and Quality (2013). Drug Abuse Warning Network, 2011. National estimates of drug-related emergency department visits. Rockville, MD: Substance Abuse and Men- tal Health Services Administration, Table 4.
14. Brophy, Psychiatric disorders. Jacobs; and Fehr, Drugs and drug abuse, pp. 337–347.
15. Goode, Drugs and American society, pp. 261–263. Snyder, Solomon H. (1986). Drugs and the brain. New York: Freeman, pp. 180–181.
16. Aghajanian, G. K.; and Marek, G. J. (1999). Serotonin and hallucinogens. Neuropsychopharmacology, 21 (Suppl. 2), 16S–23S. Gresch, Paul J.; Smith, Randy, L.; Barrett, Robert J.;
and Sanders-Bush, Elaine (2005). Behavioral tolerance to lyser- gic acid diethylamide is associated with reduced serotonin-2A receptor signaling in rat cortex. Neuropsychopharmacology, 30, 1693–1702. Julien, Robert M. (2005). A primer of drug action (10th ed.). New York: Worth, p. 602.
17. Goode, Drugs and American society, pp. 259. 18. Brands, Bruna; Sproule, Beth; and Marshman, Joan (1998).
Drugs and drug abuse: A reference text. Toronto, Canada: Addiction Research Foundation, p. 328. Henderson, Leigh A.; and Glass, William J. (Eds.) (1994). LSD: Still with us after all these years. New York: Lexington Books. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; and Schulenberg, John E. (2013, December 18). American teens more cautious about using synthetic drugs. Ann Arbor, MI: University of Michigan News Service, Table 1. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; Schulenberg, John E.; and Miech, Richard A. (2014). Monitoring the future: National survey results on drug use, 1975–2013, Vol. II: Col- lege students and adults ages 19–55. Ann Arbor, MI: Institute for Social Research, University of Michigan, Table 2-1. Karch, Steven B. (1996). The pathology of drug abuse (2nd ed.). Boca Raton, FL: CRC Press, p. 269.
19. Goode, Drugs and American society, pp. 265–266. 20. Ibid., p. 266. 21. Cohen, Sidney (1960). Lysergic acid diethylamide: Side effects
and complications. Journal of Nervous and Mental Diseases, 130, 30–40. Levine, Jerome; and Ludwig, Arnold M. (1964). The LSD controversy. Comprehensive Psychiatry, 5(5), 314–321.
22. Wells, Brian (1974). Psychedelic drugs: Psychological, medical, and social issues. New York: Jason Aronson, pp. 170–188.
23. Cohen, M. M.; and Marmillo, M. J. (1967). Chromosomal damage in human leukocytes induced by lysergic acid diethyl- amide. Science, 155, 1417–1419.
24. Dishotsky, Norman I.; Loughman, William D.; Mogar, Robert E.; and Lipscomb, Wendell R. (1971). LSD and genetic dam- age. Science, 172, 431–440. Grinspoon; and Bakalar, Psyche- delic drugs reconsidered, pp. 188–191.
25. Brown, Hallucinogenic drugs, pp. 61–64. Wells, Psychedelic drugs, pp. 104–109.
26. Abraham, Henry D. (1983). Visual phenomenology of the LSD flashback. Archives of General Psychiatry, 40, 884–889. Schlaadt, Richard G.; and Shannon, Peter T. (1994). Drugs: Use, misuse, and abuse. Englewood Cliffs, NJ: Prentice Hall, p. 273.
27. Halpern, John H.; and Pope, Harrison G. (1999). Do hallucinogens cause residual neuropsychological toxicity? Drugs and Alcohol Dependence, 53, 247–256.
28. Knudsen, Knud (1964). Homicide after treatment with lysergic acid diethylamide. Acta Psychiatrica Scandinavica, 40 (Supplement 180), 389–395.
Endnotes
226 ■ Part Three Legally Restricted Drugs and Criminal Justice
(Ecstasy) or Molly? Washington, DC: Drug Enforcement Administration, U.S. Department of Justice. Feuer, Alan (2000, August 6). Distilling the truth in the ecstasy buzz. New York Times, pp. 25, 28. Martins, Silvia, S.; Mazzotti, Guido; and Chilcoat, Howard D. (2005). Trends in ecstasy use in the Unit- ed States from 1995 to 2001: Comparison with marijuana users and association with other drug use. Experimental and Clinical Psychopharmacology, 13, 244–252.
43. Wasson, R. Gordon (1968). Soma: Divine mushroom of immor- tality. New York: Harcourt, Brace and World.
44. Cohen, Sidney (1964). The beyond within: The LSD story. New York: Atheneum, p. 17.
45. Ramachandran, Vilayanur S.; and Hubbard, Edward M. (2003, May). Hearing colors, tasting shapes. Scientific American, pp. 52–59.
46. Clark, Jason D. (2005). The roadside high: Jimson weed toxic- ity. Air Medical Journal, 24, 234–237. Schultes; and Hofmann, Plants of the gods, pp. 106–111.
47. Schultes; and Hofmann, Plants of the gods, pp. 86–91. 48. James, Jennifer; and Andresen, Elena (1979). Sea-Tac and
PCP. In Harvey V. Feldman; Michael H. Agar; and George M. Beschner (Eds.), Angel dust: An ethnographic study of PCP users. Lexington, MA: Lexington Books, p. 133.
49. Grinspoon and Bakalar, Psychedelic drugs reconsidered, pp. 32–33. Petersen, Robert C.; and Stillman, Richard C. (1978). Phencyclidine: An overview. In Robert C. Petersen; and Richard C. Stillman (Eds.), Phencyclidine (PCP) abuse: An appraisal (NIDA Research Monograph 21). Rockville, MD: National Institute on Drug Abuse, pp. 1–17. Robbins, Hallucinogens, pp. 12–14. Seeman, P.; Ko, F.; and Tallerico, T. (2005). Dopamine receptor contribution to the action of PCP, LSD and ketamine psychotomimetics. Molecular Psychiatry, 10, 877–883.
50. Emergency department visits involving phencyclidine (PCP) (2013, November 12). The DAWN Report, pp. 1–4. Sub- stance Abuse and Mental Health Services Administration, Rockville, MD. PCP-related emergency department visits rose 400 percent over six years (2014, March 9). SAMHSA News Release. Substance Abuse and Mental Health Services Administration, Rockville, MD.
51. Brands; Sproule; and Marshman, Drugs and drug abuse, pp. 523–525.
52. Ibid. Feds classify ketamine as controlled substance (1999, August 2). Alcoholism and Drug Abuse Weekly, p. 7.
53. Braiker, Brian (2008, May 19). Old herb, new controversy. Newsweek, pp. 40–41. González, Débora; Riba, Jordi; Bouso, José C.; Gómez-Jarabo, G.; et al. (2006). Pattern of use and subjective effects of Salvia divinorum among recreational users. Drug and Alcohol Dependence, 85, 157–162. Johnston; O’Malley; Bachman; Schulenberg; and Miech, Monitoring the future, Vol. I, Table 2-2. Julien, A primer of drug action, p. 619. Khey, David N.; Miller, Bryan Lee; and Griffin, O. Hayden (2008). Salvia divinorum use among a college student sample. Journal of Drug Education, 38, 297–306.
29. Metzner, Ralph (1998). Hallucinogenic drugs and plants in psychotherapy and shamanism. Journal of Psychoactive Drugs, 30, 333–341.
30. Hofmann, LSD, p. 112. 31. Brown, Hallucinogenic drugs, pp. 81–88. 32. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald
G.; Schulenberg, John E.; and Miech, Richard A. (2014). Monitoring the future: National survey results on drug use, 1975–2013, Vol. I: Secondary school students. Ann Arbor, MI: Institute for Social Research, University of Michigan, Table 9-8. Vollenweider, Franz X.; Vollenweider-Scherpenhuyzen, Marga- ret F. I.; Babler, Andreas; Vogel, Helen; and Hell, Daniel (1998). Psilocybin induces schizophrenia-like psychosis in humans via a serotonin-2 agonist action. Neuroreport, 9, 3897–3902.
33. Hofmann, LSD, pp. 119–127. Schultes, Richard E.; and Hofmann, Albert (1979). Plants of the gods: Origins of hallucinogenic use. New York: McGraw-Hill, pp. 158–163.
34. Brands; Sproule; and Marshman, Drugs and drug abuse, pp. 512–513.
35. Frecska, Ede; White, Keith, D.; and Luna, Luis E. (2003). Effects of Amazonian psychoactive beverage ayuhuasca on bin- ocular rivalry: Interhemispheric switching or interhemispheric fusion? Journal of Psychoactive Drugs, 35, 367–374. Grin- spoon and Bakalar, Psychedelic drugs reconsidered, pp. 14–15. Trichter, Stephen; Klimo, Jon; and Krippner, Stanley (2009). Changes in spirituality among ayahuasca ceremony novice par- ticipants. Journal of Psychoactive Drugs, 41, 121–134.
36. Ibid., pp. 20–21. Hollister, Leo E.; and Sjoberg, Bernard M. (1964). Clinical syndromes and biochemical alterations fol- lowing mescaline, lysergic acid diethylamide, psilocybin, and a combination of the three psychotomimetic drugs. Comprehen- sive Psychiatry, 5, 170–178.
37. Jacobs, Barry L. (1987). How hallucinogenic drugs work. American Scientist, 75, 386–392.
38. Brecher, Edward; and the editors of Consumer Reports (1972). Licit and illicit drugs. Boston: Little, Brown, pp. 376–377.
39. Metzner, Hallucinogenic drugs and plants in psycho- therapy and shamanism. Schmidt, C. J. (1987). Psychedelic amphetamine, methylendioxymethamphetamine. Journal of Pharmacology and Experimental Therapeutics, 240, 1–7.
40. Boils, Karen I. (1999). Memory impairment in abstinent MDMA (“Ecstasy”) users. Journal of the American Medi- cal Association, 281, 494. Leshner, Alan I. (2002). Ecstasy abuse and control: Hearing before the Senate Subcommit- tee on Governmental Affairs—July 30, 2001. Statement for the record. Journal of Psychoactive Drugs, 34, 133–135. Vollenweider, Franz X.; Liechti, Matthias E.; Gamma, Alex; Greer, George; and Geyer, Mark (2002). Acute psychological and neurophysiological effects of MDMA in humans. Journal of Psychoactive Drugs, 34, 171–184.
41. Johnston; O’Malley; Bachman; Schulenberg; and Miech, Monitoring the future, Vol. I, Table 2-1.
42. Cloud, John (2000, June 5). The lure of ecstasy. Time, pp. 62–68. Drug Enforcement Administration (2014). MDMA
Marijuana 12 chapter
Sam is a friend of my son. One day, he asked me to come by his
place and talk about marijuana. He knew I was interested in the sub-
ject, and it might be good material for my book. When I got there,
it was evident that Sam was smoking. The scent of marijuana was
clearly in the air. We started a conversation, during which I made
every effort to avoid breathing very deeply.
After a while, I asked Sam what he thought was the downside
to smoking marijuana and how he preferred to smoke it. Sam took
a drag from his weed, looked at the ceiling for a moment, then
answered:
“You know, I smoke weed from time to time. But I hate smoking
with other people, ‘cause when I do I get all quiet and, you know,
get stuck in my head with thoughts. My friends get all chatty and
giggly. I have this one friend who won’t ever shut up when she’s
stoned. It’s so annoying. All she wants to do is bring up serious stuff
going on in her life. Can’t hang out with her any more. I like to play
my guitar, maybe run, do yoga, work out, sketch, listen to some re-
ally mellow music and … just chill.”
“A friend of mine tells me that I have to keep my usage under
control, though. He tells me that weed can be a fine accompani-
ment to life but not to let it make you an antisocial bastard. Seems
like good advice. The problem is, I don’t know if I can follow his
advice.”
After you have completed this chapter, you should have an understanding of the following:
●● The history of marijuana and other cannabis products
●● Acute effects of marijuana
●● The neurochemical basis for marijuana effects
●● Long-term effects of marijuana
●● The amotivational syndrome and the gateway theory
●● Patterns of marijuana smoking
●● Medical marijuana issues
●● Marijuana decriminalization and legalization
228 ■ Part Three Legally Restricted Drugs and Criminal Justice
and emphasize the benefits; the anti-marijuana faction tends to do the opposite, pointing out that marijuana continues to be classified as a Schedule I controlled substance by the federal government, along with heroin and LSD. Marijuana often has been regarded since the 1960s not only as a psychoactive drug but also as a symbol of an individual’s attitude toward the estab- lishment. This makes it even more critical that we look at the effects of marijuana as dispassionately as possible.
A Matter of Terminology
Marijuana (sometimes spelled marihuana) is frequently referred to as a synonym for cannabis, but technically the two terms need to be differentiated. Cannabis is the botanical term for the hemp plant Cannabis sativa. With a potential height of about 18 feet, cannabis has sturdy stalks, four-cornered in cross- section, that have been commercially valuable for thousands of years in the manufacture of rope, twine, shoes, sailcloth, and containers of all kinds. Pots made of hemp fiber discovered at archaeological sites in China date the origins of cannabis cul- tivation as far back as the Stone Age. It is arguably the oldest cultivated plant not used for food.3
Spaniards brought cannabis to the New World in 1545, and English settlers brought it to Jamestown, Virginia, in 1611, where it became a major commercial crop, along with tobacco. In 1619, the Virginia assembly considered hemp to be such a valuable commodity that a law was passed that required all farmers in the colony to plant cannabis on their plantations. Like other eighteenth-century Virginian farmers, George Washington grew cannabis in the fields of his estate at Mount Vernon. Entries in his diary indicate that he main- tained a keen interest in cultivating the best possible strains of cannabis, but there is no indication that he was interested in anything more than producing a better-quality rope (Drugs … in Focus).
Marijuana is obtained not from the stalks of the cannabis plant but from its serrated leaves. The key psychoactive factor is contained in a sticky substance, or resin, that accumulates on these leaves. Depending on the growing conditions, can- nabis will produce either a greater amount of resin or a greater
It might be fair to characterize Cannabis sativa, the botanical source of marijuana, as a scrawny weed with an attitude. Whether it is hot or cold, wet or dry, cannabis will grow abundantly from seeds that are unbelievably hardy and prolific. A handful of cannabis seeds, tossed on the ground and pressed in with one’s foot, will usually anchor and become plants. Its roots devour whatever nutrients there are in the soil.1
It is not surprising that, as a result, marijuana has man- aged to grow in some unorthodox places. It can be found in median strips of interstate highways or in ditches alongside country roads. The top prize for most unusual location, if the story is true and not simply an urban legend, has to go to a vari- ety known as Manhattan Silver. It originated from cannabis seeds flushed down a New York sewer during a sudden police raid in the 1960s. Once the seeds hit the sewer, they produced a plant that, in the absence of light, grew silverish white leaves instead of green, hence its name. Reportedly, some people are still looking for it.2
The pharmacological effects of marijuana show some- thing of an independent nature as well. It is not easy to place marijuana within a classification of psychoactive drugs. When we consider a category for marijuana, we are faced with an odd assortment of unconnected properties. Marijuana pro- duces some excitatory effects, but it is not generally regarded as a stimulant. It produces some sedative effects, but a person faces no risk of slipping into a coma or dying. It produces mild analgesic effects, but it is not related chemically to opi- oid drugs. It produces hallucinations at high doses, but its structure does not resemble LSD or any other drug formally categorized as a hallucinogen. Marijuana is clearly a unique drug, in a league of its own.
Few other drugs have been so politicized in recent history as marijuana. It is frequently praised by one side or condemned by the other, on the basis of emotionally charged issues rather than an objective view of research data. The pro-marijuana fac- tion tends to dismiss or downplay reports of potential dangers
114,712,000 Estimated number of Americans who reported in 2013 that they had smoked marijuana sometime in their lifetime.
19,810,000 Estimated number of Americans who reported in 2013 that they had smoked marijuana in the previous month. 23 Number of U.S. states in 2014 that have authorized marijuana use for medical purposes. 4 Number of U.S. states in 2014 that have legalized marijuana use for recreational purposes.
Sources: Center for Behavioral Health Statistics and Quality (2014). Results from the 2013 National Survey on Drug Use and Health. Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration, Table 1.1A. News media, 2014.
Numbers Talk…
Cannabis sativa (CAN-uh-bus sah-TEE-vah): A plant species, commonly called hemp, from which marijuana and hashish are obtained.
Chapter 12 Marijuana ■ 229
amount of fiber. In a hot, dry climate—such as North Africa, for example—the fiber content is weak, but so much resin is produced that the plant looks as if it is covered with dew. In a cooler, more humid climate, such as in North America, less resin is produced, but the fiber is stronger and more durable.4
As many as 100 separate chemical compounds, called cannabinoids, have been identified from canna- bis resin. The best known of these cannabinoids, delta-9- tetrahydrocannabinol (THC), identified in 1964, is the “classic” compound that produces the intoxicating effects of cannabis. The psychoactive characteristics of Cannabis sativa is directly related to the concentration of THC. More recently, another cannabinoid, cannabidiol (CBD), has
Growing Hemp in America: Coming Full Circle In 2005, faced with depressed corn and soybean prices, farmers in North Dakota and other states in the region considered an interesting alternative crop: high-fiber, high-protein hemp. There was only one drawback. The view of the U.S. govern- ment was that hemp is in the same category as marijuana. Since 1970, hemp has remained a Schedule I controlled substance. Hence, growing “industrial” hemp in the United States is illegal.
Pro-hemp advocates have argued that the government per- mits manufacturers of cosmetics, clothing, paper, and foods (hemp bread being a popular example) to import hemp fiber, seed, and oil from Canada and Europe for use in their products. It is hypocritical, from their point of view, to ban its domestic cultivation. Representing the opposite side of the issue, the DEA sees hemp fields turning into marijuana fields. According to a federal official, “The pro-dope people have been pushing hemp for 20 years because they know that if they can have hemp fields, then they can have marijuana fields. It’s … stoner logic.” The
retort is that industrial hemp is high in fiber, protein, vitamin E, and essential fatty acids, and because it has very low concentra- tions of THC, you don’t get high from it.
The economic aspect of the issue weighs heavily on North Dakota farmers. There has been a rapidly emerging global mar- ket for hemp over the last decade or so, and they simply do not want to be left out. They would like to return to the days when it was legal to grow hemp in the United States. Indeed, during World War II, the government encouraged farmers to grow hemp for wartime rope and textiles. Today, the United States is the only developed nation in the world that has not estab- lished hemp as an agricultural commodity. If the current policy changes, we would be returning full circle to an earlier period of American history, when hemp growers (notably George Washington himself) were dominant figures in the agricultural life of the nation.
Sources: Brown, Patricia Leigh (2006, August 28). California seeks to clear hemp of a bad name. New York Times, pp. A1, A13. Healy, Jack (2013, August 6). Groundwork laid, growers turn to hemp in Colorado. New York Times, p. A15.
Drugs … in Focus
A Cannabis farmer carefully tends to his marijuana crop prior to final harvesting.
cannabidiol (CBD) (can-NAB-ih-DYE-ol): A compound found in cannabis resin.
delta-9-tetrahydrocannabinol (THC) (DEL-tah-9- TEH-trah-HIGH-dro-CAN-a-bih-nol): The active psychoac- tive compound in marijuana and other cannabis products.
cannabinoids (can-NAB-ih-noids): Any of an estimated 100 compounds either synthesized in the laboratory or extracted from the cannabis plant. Cannabinoids extracted from cannabis are referred to as phytocannabinoids. Natural substances in the brain and elsewhere in the body that mimic phytocannabinoids are referred to as endocannabinoids
230 ■ Part Three Legally Restricted Drugs and Criminal Justice
been identified with specific psychoactive properties of its own (see pages 236-237).
In general, cannabis products are categorized in terms of two factors: (1) the resin content in the cannabis that is cultivated and (2) the relative concentration of THC that is extracted from the resin.
The best known cannabis product, marijuana, consists of leaves and occasionally flowers of the cannabis plant that are first dried and then shredded. During the 1960s and 1970s, the typical THC concentration of street marijuana imported from Mexico was about 1–2 percent. Since the early 1990s, however, THC concentrations have steadily risen to about 5–10 percent, due primarily to advanced outdoor and indoor cultivation methods. Marijuana, smoked as a cigarette, is the form of cannabis most familiar to North Americans.
A more potent form of marijuana is obtained by cul- tivating only the unpollinated (or seedless) portion of the cannabis plant. Without pollination, the cannabis plant grows bushier, the resin content in the leaves is increased, and a greater THC concentration, up to 15 percent, can be achieved. This form is called sinsemilla, from the Spanish meaning “without seed.”
Another cannabis product, hashish, is achieved when the resin itself is scraped from cannabis leaves and then dried. Either smoked by itself or in combination with tobacco, it can have a THC concentration as high as 24 percent. The most potent forms of cannabis are hashish oil and hashish oil crystals, produced by boiling hashish in alcohol or some other solvent, filtering out the alcohol, and leaving a residue with a THC concentration ranging from 15 to 60 percent.5
The History of Marijuana and Hashish
The first direct reference to a cannabis product as a psycho- active drug dates from 2737 b.c.e., in the writings of the mythical Chinese emperor Shen Nung. The focus was on its
bhang: A liquid form of marijuana popular in India. hashish oil crystals: A solid form of hashish oil.
hashish oil: A drug produced by boiling hashish, leaving a potent psychoactive residue. The THC concentration ranges from approximately 15 to 60 percent.
hashish (hah-SHEESH): A drug containing the resin of cannabis flowers. The THC concentration ranges from approximately 8 to 14 percent.
sinsemilla (SIN-sih-MEE-yah): A form of marijuana obtained from the unpollinated or seedless portion of the canna- bis plant. It has a higher THC concentration than regular marijuana, as high as 15 percent.
marijuana: The most commonly available psychoactive drug originating from the cannabis plant. The THC con- centration ranges from approximately 1 to 6 percent. Also spelled as marihuana.
A merchant sits outside his bhang shop in North India. Bhang ki thandai is a popular cold drink prepared with bhang combined with almonds, spices, milk, and sugar. Bhang lassi, a mixture of bhang and iced yogurt, is another popular drink. It is traditional for many Hindus to drink bhang during religious festivals, particularly in Bengal during the Kali Puja (Festival of Kali, the Mother Goddess).
powers as a medication for rheumatism, gout, malaria, and, strangely enough, absentmindedness. Mention was made of its intoxicating properties, but the medicinal possibilities evi- dently were considered more important. In India, however, its use was clearly recreational. The most popular form, in ancient times as well as in the present day, can be found in a syrupy liquid made from cannabis leaves called bhang, with a THC potency usually equal to that of a marijuana cigarette in the United States.6
The Muslim world also grew to appreciate the psycho- active potential of cannabis, encouraged by the fact that, in contrast to its stern prohibition of alcohol consumption, the Koran did not specifically ban cannabis. It was here in a hot, dry climate conducive to maximizing the resin content of cannabis that hashish was born, and its popularity spread quickly during the twelfth century from Persia (Iran) in the east to North Africa in the west.
Hashish in the Nineteenth Century In Western Europe knowledge about hashish or any other cannabis product was limited until the beginning of the nineteenth century. Judging from the decree made by Pope Innocent VIII in 1484 condemning witchcraft and the use of hemp in the Black Mass, we can assume that the
Chapter 12 Marijuana ■ 231
heard of marijuana, much less thought about the conse- quences of smoking it. Due to an intensive anti-marijuana media campaign, orchestrated by the Federal Bureau of Narcotics (FBN), the American public became acquainted with marijuana in the most negative terms possible (see Chapter 3). It was not long before marijuana would be viewed by the general public as a pestilence infecting the core of American life.
How did this transformation occur? To understand how marijuana smoking went from a localized and innocuous form of drug-taking behavior to a national crisis, we have to look at some important changes in American society that were taking place at the time.
The practice of smoking marijuana and the cultivation of cannabis plants for that purpose had been filtering slowly into the United States since 1900 as a result of an influx of Mexican immigrants. Political turmoil in Mexico leading up to the Revolution of 1910 had encouraged large numbers of Mexicans to cross the border into towns and cities in the Southwest.
More than 1 million Mexicans are estimated to have emigrated to the United States during 1910–1930, estab- lishing themselves as a significant minority group. By 1930, Mexicans represented one in nine residents in Texas alone. As it so often happens, they were met with an intensely hostile reception from communities unaccustomed to an introduction of a different culture and language. The fact that they were smoking an alien and foreign-sounding sub- stance did not help. Throughout the southwestern and west- ern United States, rumors began to circulate about acts of violence committed by super-strong marijuana-intoxicated Mexicans. Newspaper articles included lurid details of these stories, without any effort on the part of editors to check if there was any basis in fact.
Meanwhile, Marco Polo’s account of a twelfth- century sect of professional killers known as “hashish- eaters” (hashashin, from which the word, assassin, is derived) was resurrected with an unfortunate modern-day twist. In the original story, the leader of the sect whose power was sustained through acts of political assassination would assemble the killers prior to their orders to carry out a par- ticular mission. They were given hashish to allow them a drug-induced glimpse of the delights of paradise that would await them as a reward. Then, after the effects of the drug had worn off, the men would accomplish their assign- ment with great enthusiasm, despite an understanding that they would most likely die in the process. The new story was that intoxication with hashish had made them killers in the first place.9
There were also economic issues at play. The social upheavals experienced by many Americans during the Depression made it particularly convenient for them to vent their frustrations on an immigrant group viewed as competing for a dwindling number of American jobs and straining an already weak economy. Anti-marijuana-themed movies with provocative titles such as Reefer Madness and Marihuana: Weed with Roots in Hell were produced and
psychoactive properties of cannabis were known by some portions of the population. Nonetheless, there is no evidence of widespread use.
By about 1800, however, cannabis had become more widely known and the subject of a popular craze. One rea- son was that French soldiers who had served in Napoleon’s military campaigns in Egypt brought hashish back with them to their homes in France. Another reason was a wave of romanticism that swept Europe, including an increased interest in exotic stories of the East, notably the Arabian Nights and the tales of Marco Polo, which contained references to hashish.
In Paris during the 1840s, a small group of prominent French artists, writers, and intellectuals formed the Club des Hachichins (“Club of the Hashish-Eaters”), where they would gather, in the words of their leader, “to talk of literature, art, and love” while consuming large quantities of hashish. The “house recipe” consisted of concentrated cannabis paste, mixed with butter, sweeteners, and flavorings such as vanilla and cinnamon. Members included Victor Hugo, Alexandre Dumas, Charles Baudelaire, and Honoré de Balzac.
Marijuana and Hashish in the Twentieth Century Chances are that anyone living in the United States at the beginning of the twentieth century would not have heard of marijuana, much less hashish. By 1890, cotton had replaced hemp as a major cash crop in southern states, although can- nabis plants continued to grow wild along roadsides and in the fields. Some patent medicines during this era contained marijuana, but it was a small percentage compared with the number containing opium or cocaine (see Chapter 3).7
It was not until the 1920s that marijuana smoking began to be a phenomenon of any social significance. Some his- torians have related the appearance of marijuana as a rec- reational drug to social changes brought on by Prohibition (see Chapter 15), when it was suddenly difficult to obtain good quality liquor at affordable prices. Recreational use was largely restricted to jazz musicians and people in show business. “Reefer songs” became the rage of the jazz world; even the mainstream clarinetist and bandleader Benny Goodman had his popular hit “Sweet Marihuana Brown.” Marijuana clubs, called tea pads, sprang up in the major cities; more than 500 were estimated in Harlem alone, outnumbering the speakeasies where illegal alcohol was dispensed. These marijuana establishments were largely tolerated by the authorities because at that time marijuana was not illegal and patrons showed no evidence of making a nuisance of themselves or disturbing the community. In the culture of the time, marijuana was not considered a societal threat at all.8
The Anti-Marijuana Crusade By the 1930s, however, the picture had changed dramati- cally. Prior to that time, millions of Americans had never
232 ■ Part Three Legally Restricted Drugs and Criminal Justice
distributed during the late 1930s and early 1940s with the encouragement of the FBN Commissioner, Harry J. Anslinger (Portrait). By this time, these movies were rein- forcing a clearly established social message: Marijuana was dangerous and singlehandedly corrupting the innocent youth of America.
Considering the mounting hysteria against marijuana smoking and cannabis use in general during the 1930s, it is not surprising that the Marijuana Tax Act of 1937 had
PorTrAIT Commissioner Harry J. Anslinger—From Devil Rum to Devil Weed
Prior to his appointment in 1930 as the first commis- sioner of the FBN in 1930, Harry J. Anslinger had been a rising young star in the Prohibition Unit at the Treasury Department. The Harrison Act of 1914 had established the nation’s drug-law en- forcement policy, and Anslinger seemed like the right man for this new job. He had been quite vocal in his conviction that drug addiction was absolutely im- moral and that the cure to the illicit drug problem was a matter of prosecuting people who used these drugs and pre- venting them from getting hold of drugs in the first place.
The end of Prohibition in 1933, however, presented a problem. Congress felt the pressure to reduce the Treasury’s enforcement budget, and the Great Depression put strains on federal expenditures in general. Anslinger and the FBN faced hard times. The sav- ior, ironically enough, was marijuana. Beginning in the early 1930s, rumors of “degenerate Spanish-speaking residents” in the Southwest going on criminal rampages while smoking marijuana were being spread in newspapers and popular magazines. Anslinger seized upon these unsubstantiated reports, legitimizing them through his frequent references to them. According to Anslinger, marijuana was the “killer weed” that had to be stopped for the sake of America.
Aslinger wasn’t exactly subtle in his writings. In a 1937 article appearing in the widely read American Magazine entitled “Marijuana: Assassin of Youth,” he laid out his case:
The sprawled body of a young girl lay crushed on the sidewalk the other day
after a plunge from the fifth story of a Chicago apartment house. Every-
one called it suicide, but actually it was murder. The killer was a narcotic known to America as marijuana, and to history as hashish. It is a narcotic used in the form of cigarettes, comparatively new to the United States and as dangerous as a coiled rattlesnake … How many murders, sui- cides, robberies, criminal assaults, holdups, burglaries, and deeds of maniacal insanity it causes each year, especially among the young, can be only conjectured … No one can predict the effect. No one knows, when he places a marijuana cigarette to his lips, whether he will become … a joyous reveller … , a mad insensate, a calm philosopher, or a murderer.
The answer according to Anslinger was new federal legislation outlawing marijuana, not to mention contin- ued financial support for the agency dedicated to enforcing the law. The Marijuana Tax Act of 1937 was Anslinger’s creation.
Anslinger’s 32-year tenure at the FBN and his stature as defender of the purity of American youth, or at least the purity of their circulatory systems, could not have been possible without strong support from several important conservative U.S. legislators in the House and Senate. During the late 1940s and into the 1950s, Anslinger began to emphasize the link between drug addiction in the United States and the threat of international Communism from abroad.
The target was the People’s Republic of China, which Anslinger repeatedly claimed was the primary source of heroin in the United States, despite the avail- able evidence pointing to politically
friendlier nations of Southeast Asia as the real culprits. According to Anslinger’s testimony, China not only was the source of heroin but was also specifically selling opium and heroin to finance the expansion of Communism around the world. The concept of narcoterrorism (see Chapter 2) can be seen as having its origins at this time. On the domestic front, drug abuse was a threat to the American way of life. Only after Anslinger’s resignation in 1962, follow- ing considerable pressure from President Kennedy, did the focus of attention shift to the problem of heroin trafficking in Burma, Laos, and Thailand.
Given the anti-Communist stance of the FBN, it is not surprising that one of Anslinger’s staunchest supporters dur- ing the late 1940s and early 1950s was Senator Joseph R. McCarthy, whose congressional subcommittee was then engaged in a ruthless crusade against “known Communists” inside the federal government. What was not known at the time, however, was that Anslinger during this period was personally allow- ing McCarthy, a morphine addict as well as an alcoholic, to buy unrestricted supplies of morphine without FBN or police interference. When McCarthy died in 1957 of “acute hepatitis, cause unknown,” Anslinger wrote in his memoirs, “I thanked God for relieving me of my burden.”
Sources: Anslinger, Harry J.; and Cooper, Courtney Ryley (1937, July). Marijuana: Assassin of youth. American Magazine, pp. 18–19, 150–153, excerpt on page 18. McWilliams, John C. (1990). The protectors: Harry J. Anslinger and the Federal Bureau of Narcotics, 1930–1962. Cranbury, NJ: Associated University Press.
little difficulty in gaining support in Congress. As with the Harrison Act of 1914, the regulation of marijuana was accomplished indirectly. The law did not ban marijuana; it merely required everyone connected with marijuana, from growers to buyers, to pay a tax. It was a deceptively simple procedure that, in effect, made it virtually impossible to comply with the law. In the absence of compliance, a person was in violation and therefore subject to arrest. It was the state’s responsibility to make possession of marijuana or
Chapter 12 Marijuana ■ 233
Challenging Old Ideas about Marijuana Prior to 1960, arrests and seizures for possession of mari- juana were relatively rare and attracted little or no public attention. The social consensus was that marijuana was a drug that could be comfortably associated with, and iso- lated to, ethnic and racial minorities. It was relatively easy for most Americans to avoid the drug entirely. In any event, involvement with marijuana during the 1950s was a deviant act, in an era when there was little tolerance for personal deviance.
By the mid-1960s, this consensus began to dissolve. Marijuana smoking suddenly was an attraction on the cam- puses of U.S. colleges and universities, affecting a wide cross section of the nation. Strangely enough, the bizarre effects depicted in the anti-marijuana movies failed to occur! At the same time, the experimental use of drugs, particularly marijuana, by young people set the stage for a wholesale ques- tioning of what it meant to respect authority, on an individual as well as a governmental level.
any other product of Cannabis sativa illegal. Shortly after the 1937 legislation was enacted, all of the states adopted a uniform law that did just that.
The official stance of the federal government was that that marijuana smoking was tied to antisocial behavior, and that marijuana control was a central part of what would later evolve into a general war on drugs. For more than 20 years after passage of the Marijuana Tax Act, Harry Anslinger had never let up on his anti-marijuana crusade. In 1953, he wrote:
Those who are accustomed to habitual use of the drug are said eventually to develop a delirious rage after its administration during which they are temporarily, at least, irresponsible and prone to commit violent crimes. . . . Much of the most irrational juvenile violence and killing that has written a new chapter of shame and tragedy is traceable directly to this hemp intoxication.10
In the 1950s, the severity of criminal penalties for involve- ment with marijuana steadily increased. State judges fre- quently had the option of sentencing a marijuana seller or user to life imprisonment. In Georgia, a second offense of sell- ing marijuana to a minor could be punishable by death.
Over time, the “pharmacological violence” theory of marijuana intoxication (see Chapter 6) would fade into oblivion, in the absence of any evidence to support it. In its place, a new concept regarding marijuana smoking would be introduced by the FBN: the gateway theory. According to this idea, marijuana was purported to be dangerous because its abuse would lead to the abuse of heroin, cocaine, or other illicit drugs. This gateway hypothesis will be closely examined later in the chapter.
Ironically, in 1969, more than three decades after its passage, the U.S. Supreme Court ruled the 1937 Marijuana Tax Act to be unconstitutional, precisely because marijuana possession was illegal. The argument was made that requir- ing a person to pay a tax (and that was all that the 1937 law concerned) so as to possess an illegal substance amounted to a form of self-incrimination, which would be a specific viola- tion of the Fifth Amendment to the Constitution. It turns out that the case in question here was brought to the high court by none other than Timothy Leary (see Portrait in Chapter 11), and the court’s decision succeeded in overturning a marijuana conviction judged against him.11
Marijuana tax stamps were issued and valid between 1937 and 1969 when the law was overturned by the U.S. Supreme Court, though during this time stringent governmental regulations made it nearly impossible to obtain these stamps to “register” one’s marijuana use. They became commercially available to stamp collectors in 2005.
This promotional poster for the 1942 film Devil’s Harvest depicted the supposed evils of smoking marijuana.
234 ■ Part Three Legally Restricted Drugs and Criminal Justice
Nonetheless, there is a dose-related increase in heart rate during early stages of marijuana ingestion, up to 160 beats per minute when dose levels are high. Blood pressure either increases, decreases, or remains the same, depending primarily on whether the individual is standing, sitting, or lying down.16 A dilation of blood vessels on the cornea resulting in bloodshot eyes peaks in about an hour after smoking a joint. Frequently, there is a drying of the mouth and an urge to drink.
Other physiological reactions are inconsistent, and at least part of the inconsistency can be attributed to cultural and interpersonal influences. For example, the observation that marijuana smoking makes you feel extremely hungry and crave especially sweet things to eat (often referred to as “having the munchies”) generally holds true in studies of North Americans but not for Jamaicans, who consider mari- juana an appetite suppressant.
Likewise, North Americans often report enhanced sexual responses following marijuana use, whereas in India marijuana is considered a sexual depressant. These reac- tions, being subjective in nature, can very well be slanted in one direction or the other by the mind-set (expectations) of the marijuana smoker going into the experience. A good example is the effect on sexual responses. If you believe that marijuana turns you on sexually, the chances are that it will.
Although expectations undoubtedly play a prominent role here, we should be aware of the possibility that varying effects also may be due to differences in the THC concentra- tion of the marijuana being smoked. In the case of sexual reactivity, studies of male marijuana smokers have shown that low-dose marijuana tends to enhance sexual desire, while high-dose marijuana tends to depress it, even to the point of impotence. It is quite possible that the enhancement is a result of a brief rise in the male sex hormone, testoster- one, and the depression a result of a rebound effect that low- ers testosterone below normal levels. Typically, the THC concentration in India is higher than that in North America. As a result, we would expect different effects on sexual reac- tivity. The same argument could be made with respect to the differences in marijuana’s effect on appetite.17
In 2011, approximately 456,000 drug-related emer- gency department (ED) visits in the DAWN statistics (see Chapter 1) involved marijuana, making it the second highest category behind cocaine. In about one-fourth of these cases, marijuana was the sole drug present in the patient’s system at the time. In general, marijuana-related emergency depart- ment incidents have risen substantially in recent years, with an increase of 21 percent from 2009 and about 62 percent from 2004. It is likely that a higher THC concentration in marijuana has contributed to greater numbers of ED visits, since these increases are greater than the increase in preva- lence rates over these periods of time.18
Acute Psychological and Behavioral Effects In Chapter 9, it was noted that a first-time heroin abuser fre- quently finds the experience more aversive than pleasurable.
Acute Effects of Marijuana
In the United States, THC is usually ingested by smoking a hand-rolled marijuana cigarette referred to as a reefer or, more commonly, a joint. Exactly how much THC is admin- istered depends on the specific THC concentration level in the marijuana (often referred to as its quality), how deeply the smoke is inhaled into the lungs, and how long it is held in the lungs before being exhaled. In general, an experienced smoker will ingest more THC than a novice smoker by virtue of being able to inhale more deeply and hold the marijuana smoke in his or her lungs longer, for 25 seconds or longer, thus maximizing THC absorption into the bloodstream.
The inhalation of any drug into the lungs produces extremely rapid absorption, as noted in earlier chapters, and marijuana is no exception. In the case of THC, effects are felt within seconds. Peak levels are reached in the blood within 10 minutes and start to decline shortly afterward. Behavioral and psychological effects generally last from two to three hours. At this point, low levels of THC linger for several days because they are absorbed into fatty tissue and excretion from fatty tissue is notoriously slow.12
One implication arising from a slow elimination rate is that the residual THC, left over from a previous administra- tion, can intensify the effect of marijuana on a subsequent occasion. In this way, regular marijuana smokers often report a quicker and more easily obtained high, achieved with a smaller quantity of drug, than more intermittent smokers.13
It is also important to see the implication of slow mari- juana elimination with regard to drug testing. Urine tests for possible marijuana abuse typically measure levels of THC metabolites (broken-down remnants of THC); because of the slow biotransformation of marijuana, these metabolites are detectable in the urine even when the smoker no longer feels high or shows any behavioral effects. Metabolites can remain in the body for several days after smoking a single joint and for several weeks later if there has been chronic marijuana smoking. Some tests are so sensitive that a positive level for marijuana can result from passive inhalation of marijuana smoke-filled air in a closed environment, even though the THC levels in these cases are substantially below levels that result from active smoking. The bottom line is that marijuana testing procedures generally are unable to indicate when mar- ijuana has been smoked (if it has been smoked at all), only that exposure to marijuana has occurred (see Chapter 13).14
Acute Physiological Effects Immediate physiological effects after smoking marijuana are relatively minor. It has been estimated that a human would need to ingest a dose of marijuana that was from 20,000 to 40,000 times the effective dose before death would occur.15
joint: A marijuana cigarette. reefer: A marijuana cigarette.
Chapter 12 Marijuana ■ 235
testing positive for THC in their bloodstreams have shown them to be about three to seven times more likely to be involved in an accident than drivers testing negative for THC or alcohol.23
An additional problem is quite serious. The decline in sensory–motor performance will persist well after the point at which the marijuana smoker no longer feels high, when there has been chronic heavy marijuana use. Significant impairments in attention and memory tasks have been dem- onstrated among heavy marijuana users (daily smokers) 24 hours after they had last used the drug. Therefore, we have to recognize the possibility that some important aspects of behavior can be impaired following marijuana smok- ing, even when an individual is not aware of it. This effect is likely due to the very slow rate with which marijuana is eliminated from the body.24 Acute psychological effects such as mild depression, panic reactions, or mild paranoia as a result of smoking marijuana with high levels of THC are possible. With more typical THC levels, about one-half of marijuana users have reported at least one anxiety expe- rience. Severe emotional responses such as a distortion of body image, delusions, hallucinations, and confusion can also occur, although they are associated with very high THC levels and individuals predisposed toward or recovering
With marijuana, it is likely that a first-time smoker will feel no discernible effects at all. It takes some practice to be able to inhale deeply and keep the smoke in the lungs long enough for a minimal level of THC, particularly in low-quality mari- juana, to take effect. Novices often have to be instructed to focus on some aspect of the intoxicated state to start to feel intoxicated, but the psychological reactions, once they do occur, are fairly predictable.
The marijuana high, as the name implies, is a feeling of euphoria and well-being. Marijuana smokers typically report an increased awareness of their surroundings, as well as a sharpened sense of sight and sound. Frequently, they feel that everything is suddenly very funny, and even the most innocent comments or events can set off uproarious laughter. Usually mundane ideas can seem filled with pro- found implications, and the individual may feel that creativ- ity has been increased. As with LSD, however, no objective evidence shows that creativity is enhanced by marijuana. Commonly, time seems to pass more slowly while a person is under the influence of marijuana, and events appear to be elongated in duration. Finally, marijuana smokers fre- quently report that they feel sleepy and sometimes dreamy. Relatively low THC concentrations in a marijuana joint are not sufficient to be particularly sleep-inducing, though stronger cannabis preparations with higher THC can have strong sleep-inducing effects, particularly when combined with alcohol.19
At the same time, marijuana produces significant defi- cits in behavior. The major deficit is a decline in the ability to carry out tasks that involve attention and memory. Speech will be increasingly fragmented and disjointed; individuals often will forget what they, or others, have just said. The prob- lem is that marijuana typically causes such a rush of distract- ing ideas to come to mind that it is difficult to concentrate on new information coming in. By virtue of a diminished focus of concentration, the performance of both short-term and long-term memory tasks is impaired. In general, these difficulties increase in magnitude as a direct function of the level of THC in the marijuana.20
It should not be surprising that complex motor tasks, such as driving a car, are also more poorly performed while a per- son is under the influence of marijuana. It is not necessarily a matter of reaction time; studies of marijuana smokers in auto- mobile simulators indicate that they are as quick to respond as control subjects. The problem arises from a difficulty in attending to peripheral information and making an appropriate response while driving.21 One researcher has put it this way:
Marijuana-intoxicated drivers might be able to stop a car as fast as they normally could, but they may not be as quick to notice things that they should stop for. This is probably because they are attending to internal events rather than what is happening on the road.22
Given these observations in the laboratory and on the road, it should not be surprising that marijuana use would increase the risk of having an automobile accident. Surveys that have examined accident rates among drivers
Quick Concept Check
Understanding the Effects of Marijuana Check your understanding of the effects of marijuana by checking off the response (on the right) that you think is appropriate to the circumstances related to marijuana or other cannabis products (on the left).
increases decreases circumstance the effect the effect
1. The resin content __________ __________ in the cannabis is low.
2. You have decided __________ __________ to inhale more deeply.
3. You are smoking __________ __________ hashish instead of marijuana.
4. This is the first time __________ __________ you have ever smoked marijuana.
5. The THC concentration __________ __________ level is relatively high
Answers: 1. decreases the effect 2. increases the effect 3. increases the effect 4. decreases the effect. 5. increases the effect
12.1
236 ■ Part Three Legally Restricted Drugs and Criminal Justice
with morphine, special receptors in the brain are stimulated specifically by THC. They are concentrated in areas of the brain that are important for short-term memory and motor control. Unlike opioid receptors, however, the THC-sensitive receptors are not found in the lower portions of the brain that control breathing. As a result, no matter how high the THC concentration in the brain, there is no danger of an acciden- tal death by asphyxiation.
Once a specific receptor for a drug has been identified, the question inevitably becomes: Why is it there? As noted in Chapter 9, when opioid receptors were discovered, it made sense to speculate about a natural opioid-like substance that would fit into that receptor. These natural substances were subsequently identified, and we now refer to them as endor- phins. The same speculation surrounded the discovery of the THC-sensitive receptor until 1992, when researchers isolated a natural substance, dubbed anandamide (the name derived from the Sanskrit word for “bliss”). In short, it was found that anandamide activates THC-sensitive receptors and is the basis for the effects of THC in the brain.
Anandamide is only one of dozens of natural substances collectively called endocannabinoids (literally “cannabinoids that exist on the inside”). These endocannabinoids activate (to varying degrees) two types of cannabinoid receptors: CB1
from a psychosis. There is little or no support for the idea that low THC doses will provoke such reactions in other- wise normal individuals. A substantially higher incidence of psychiatric problems arising from THC exposure has been reported in India and North Africa. In such cases, the THC concentrations being ingested, the frequency with which THC is ingested and the duration of THC exposure over a lifetime are all generally greater than would be encountered in the United States.25
Cannabinoids and Endocannabinoids
When THC was isolated in 1964 as the primary agent for the intoxicating properties of marijuana, the next step was to find out specifically how THC affects the brain to produce these effects. In 1990, the mechanism was discovered. Just as
The Neurochemical “Yin and Yang” of Cannabis Considering the dozens of cannabinoids in the cannabis plant, it should not be surprising that individually they might have different neurochemical and behavioral effects. Recent studies indicate that two of the cannabinoids have diametrically oppo- site psychological effects. The first and best known cannabinoid, THC, is the principal psychoactive component, resulting in the marijuana high. It is also considered to be associated with acute symptoms of paranoia and increased anxiety, as well as oc- casional schizophrenia-like reactions, although these reactions tend to occur only when THC concentrations are extremely high The other cannabinoid, cannabidiol (CBD), is associated with opposite effects, producing a reduction in anxiety and fewer instances of severe emotional problems. In effect, CBD can be understood as having a “neuroprotective” effect, making it less likely that adverse emotional reactions will occur. Because of the opposing properties of these cannabinoids, different strains of marijuana have been cultivated to produce varying psychologi- cal effects, depending upon the ratio of THC and CBD.
A 2008 study analyzed hair samples of individuals in three groups: nonusers of cannabis, users testing positive for both CBD and THC, and users testing positive for THC alone. There was a greater incidence of hallucinations and delusions in the
THC-only group, relative to the other groups, with the THC + CBD group showing no greater incidence than nonusers.
It was not possible in this study to examine the behavior of individuals who tested positive for CBD alone, since there are no strains of natural cannabis that have this specific property. Since then, however, it has been possible to extract CBD alone from cannabis or synthesize it in the laboratory. Ironically, the ease with which synthetic cannabinoids can be made available in the illicit drug market (see Help Line later in the chapter) has resulted in a “new frontier” of research into potential medi- cal benefits. The advantage of a CBD-based medical treatment, for example, is that it does not have the classic psychoactive properties of THC and it can be administered orally rather than smoked. Therefore, the potential for CBD abuse and adverse pulmonary problems due to inhaled smoke can be avoided.
Sources: Deshpande, Srinivas R.; Taru, Mahesh; King, K. J.; Gayathree, L; and Somashekhara, S. C. (2013). Biochemical basis for use of cannabinoids in various clinical conditions. Journal of Drug Discovery and Therapeutics, 1, 44–48. Gunderson, Erik W. (2013). Synthetic cannabinoids: A new frontier of designer drugs. Annals of Internal Medicine, 159, 563–564. Morgan, Celia J.; and Curran, H. V. (2008). Effects of cannabidiol on schizophrenia- like symptoms in people who use cannabis. British Journal of Psychiatry, 192, 306–307.
Drugs … in Focus
anandamide (a-NAN-duh-mide): A naturally occurring chemical in the brain that fits into THC-sensitive receptor sites, producing many of the same effects as marijuana.
Chapter 12 Marijuana ■ 237
may have to smoke a relatively large number of marijuana joints initially before they achieve a high. Later, when they have acquired the technique, they may need fewer joints to accomplish the same effect. In these circumstances, a calcu- lation of the number of joints consumed does not reflect the amount of THC ingested. If you were to control the THC content entering the body, as is done in laboratory stud- ies, you would find the predictable results of tolerance over repeated administrations.
Another factor complicating tolerance studies is the slow elimination rate of marijuana. Regular marijuana smokers are likely to have a residual amount of THC still in the sys- tem. This buildup of THC would elevate the total quantity of THC consumed with every joint and induce a quicker high. Once again, the impression of sensitization is false; we are actually observing the enhanced effects of an accumulation of THC in the body. Once dosage levels are controlled, the results indicate a consistent pattern of tolerance rather than sensitization. In general, tolerance effects following repeated administrations of THC are greater as the dosage level of THC increases.27
Withdrawal and Dependence On the basis of early studies conducted in the 1970s, it appeared that evidence of physical dependence (that is, the observation of withdrawal symptoms) following chronic administration of marijuana was limited to circumstances in which the level of THC ingestion was extreme. In one study, human volunteers were administered large doses of THC every four hours for 10–20 days. Within 12 hours after the last administration, subjects reported physical symptoms that included hot flashes, irritability, restlessness, and insomnia. In contrast, in another study in which subjects smoked one marijuana cigarette daily for 28 days, a condition closer to the typical exposure to marijuana, no withdrawal symptoms were observed.28
More recent studies, however, have shown that with- drawal effects can occur even with more moderate levels of THC consumed over shorter periods of time. Abstinence from smoking marijuana cigarettes with approximately 2–3 percent THC levels or equivalent oral doses of THC, administered four times a day over a four-day period, resulted in feelings of irritability, stomach pain, anxiety, and loss of appetite. These symptoms began within 48 hours and lasted at least two days.29 Therefore, it is quite possible that daily marijuana use among chronic marijuana smokers is main- tained, at least in part, because of its alleviation of withdrawal symptoms. Nonetheless, the symptoms involved here are substantially milder than those associated with the chronic use of heroin (Chapter 9) or alcohol (Chapter 15).
There is also evidence of marijuana craving, indicating a degree of psychological dependence in some marijuana smokers, but it is difficult to measure the extent of these feel- ings or to determine whether these effects are due to circum- stances in which marijuana is used in conjunction with other drugs. As was pointed out earlier, any definitive judgment as
receptors that are located primarily in the brain and the gut and CB2 receptors that are located primarily in lymph tissue. Anandamide and THC are associated with CB1 receptors and their increased activity level in the brain corresponds to the specific psychoactive features of marijuana.
As mentioned earlier in the chapter, another cannabi- noid, cannabidiol (CBD), has been identified with psycho- active properties, though not the same as THC (see Drugs … in Focus, page 236). It turns out that CBD has little or no association with CB1 receptors, which explains its “non- THC” effects. Instead, CBD activates CB2 receptors. It is the capability for CBD to activate CB2 receptors that has made it useful for a variety of medical applications.
There is an intriguing aspect to the effects of THC in the brain that connects it to other psychoactive drugs. THC stim- ulates neurons in the nucleus accumbens in rats, the same area that is affected by heroin, cocaine, methamphetamine, alcohol, and nicotine. The effect, however, is much weaker than with drugs that produce strong signs of dependence. Animals will self-administer marijuana in laboratory studies and, in fact, are able to discriminate high-potency from low- potency marijuana, but their behavior is not as compulsive as that observed with heroin, cocaine, alcohol, or nicotine.26
Chronic Effects of Marijuana
Is chronic marijuana smoking harmful over a period of time? What is the extent of tolerance and dependence? Are there long-term consequences for the health of organ systems in the body? Will marijuana lessen one’s potential as a produc- tive human being in society? Will marijuana abuse lead to the abuse of other drugs? These are questions to be consid- ered next.
Tolerance It is frequently reported that experienced marijuana smokers tend to become intoxicated more quickly and to a greater extent than inexperienced smokers, when exposed to mari- juana joints with equivalent THC concentrations. For many years, this observation suggested that repeated admin- istrations of marijuana produced sensitization, or reverse tolerance (a greater sensitivity), rather than tolerance (a lesser sensitivity). If this were true, then we would have been faced with the troubling conclusion that marijuana operates in a totally opposite way to any other psychoactive drug consid- ered so far. As it turns out, when animals or humans are stud- ied in the laboratory, marijuana smoking shows tolerance effects that are consistent and clear-cut.
Why, then, the difference with the experience of humans outside the laboratory? One important factor is the way in which we measure the quantity of THC consumed. Reaching an effective high from marijuana requires some degree of practice. For example, novice marijuana smokers may not have mastered the breathing technique necessary to allow the minimal level of THC to enter the lungs. They
238 ■ Part Three Legally Restricted Drugs and Criminal Justice
Given all these factors, marijuana smoking presents sev- eral risks. One of the immediate consequences affects the process of breathing. When marijuana is inhaled initially, the passageways for air entering and leaving the lungs widen, but after chronic exposure, an opposite reaction occurs. As a result, symptoms of asthma and other breathing difficulties are increased. Overall, while the effects of a single inhalation of marijuana smoke present greater problems than a single inhalation of tobacco smoke, we need to remember that the patterns of consumption are far from comparable. All things considered, on a statistical basis, you can think of one joint as being equivalent to five cigarettes in terms of the amount of carbon monoxide intake and four cigarettes in terms of tar intake. The use of a water pipe reduces the harm somewhat, but the risks are still present.
Molecular abnormalities in the respiratory tracts of heavy marijuana smokers have been identified that resem- ble the changes in the respiratory tracts of cigarette smokers. A recent study has shown that long-term marijuana smoking causes an obstruction of air flow in the lungs, resulting in asthma and bronchitis. The effect of smoking a single mari- juana joint is equivalent to smoking up to five tobacco ciga- rettes in this regard. However, marijuana smoking does not increase the risk of developing emphysema, a chronic lung disease that is closely associated with tobacco smoking (see Chapter 16).
A recent study has indicated that occasional and low- cumulative marijuana use, even over a period of more than 20 years (1985–2006), does not produce adverse effects on lung capacity as indicated by standard pulmonary breath- ing tests. On the other hand, most people who smoke marijuana also smoke tobacco, and the adverse effects of tobacco smoking on lung function is well known. There is a threefold increase in the risk of pulmonary disease among heavy marijuana use combined with tobacco use, suggest- ing that marijuana and tobacco might have a synergistic impact on lung function. It has been difficult for research- ers to find a sufficient number of heavy marijuana smokers who are not also tobacco smokers to make a definitive con- clusion about the pulmonary effects of heavy marijuana use alone.
Risks of Lung Cancer Does smoking marijuana produce a higher incidence of lung cancer? Once again, it has been difficult to isolate the risk of lung cancer due to marijuana use as opposed to concurrent tobacco use. An additional challenge in making a marijuana- lung cancer link is that the peak years in which lung can- cer cases are typically diagnosed are decades later than the years in which marijuana smoking begins and is most fre- quent. It is only recently that these difficulties have been over- come. In a 40-year follow-up study of young Swedish males aged 18–20 years old identified as heavy marijuana smokers in 1969–1970, researchers have found more than a twofold increase in the incidence of lung cancer, separating out the effects of tobacco use over that period of time. The study
to the possibility of psychological dependence or the extent to which psychological dependence may occur in the aver- age marijuana smoker has to rest upon research studies involving THC concentrations that are typical of currently available marijuana.30
Cardiovascular Effects THC produces significant increases in heart rate, but there is no conclusive evidence of adverse effects in the cardiovas- cular functioning in young, healthy people. The reason why the emphasis is on a specific age group is that most of the studies looking at possible long-term cardiovascular effects have involved marijuana smokers under the age of 35; little or no information has been compiled about older populations. For those people with preexisting disorders such as heart dis- ease, high blood pressure, or arteriosclerosis (hardening of the arteries), it is known that the acute effects of marijuana on heart rate and blood pressure can worsen their condition.
Respiratory Effects The technique of marijuana smoking involves the deep and maintained inhalation into the lungs of unfiltered smoke on a repetitive basis, probably the worst scenario for incurring chronic pulmonary problems. In addition, a marijuana joint (when compared with a tobacco cigarette) typically contains about the same levels of tars, 50 percent more hydrocarbons, and an unknown amount of possible contaminants (Table 12.1). Joints are often smoked more completely because the smoker tries to waste as little mari- juana as possible.
TABLE 12.1
A comparison of the components of marijuana and tobacco smoke
CoMPoNENT MArIjuANA ToBACCo
Carbon monoxide (mg) 17.6 20.2
Carbon dioxide (mg) 57.3 65.0
Ammonia (micrograms) 228.0 178.0
Acetaldehyde (micrograms) 1,200.0 980.0
Acetone (micrograms)* 443.0 578.0
Benzene (micrograms)* 76.0 67.0
Toluene (micrograms)* 112.0 108.0
THC (tetrahydrocannabinol) (micrograms)
820.0 —
Nicotine (micrograms) — 2,850.0
Napthalene (nanograms) 3,000.0 1,200.0
*See Chapter 14 for information about the health risks of inhaling some of these chemicals.
Source: Based on data from Julien, Robert M. (2001). A primer of drug action (9th ed.). New York: Worth, p. 317.
Chapter 12 Marijuana ■ 239
suppression to occur. Despite these hormonal changes in both males and females, however, little or no effect on fer- tility has been observed.33
The research is sparse on the question, but there does not appear to be evidence of birth defects in the offspring of women who have smoked marijuana during their preg- nancy. Studies indicate, however, a lower birth weight and shorter length among newborns, as well as a reduction in the mother’s milk. It may be unfair to associate these effects specifically with marijuana smoking because other drugs, including alcohol and nicotine, are often being consumed during the same period. Even so, the best advice remains that women should avoid marijuana during pregnancy.34
Long-Term Cognitive Effects and the Amotivational Syndrome In the 1960s, when marijuana smoking became a main- stream concern among many in the establishment, though chronic exposure to marijuana frequently has been suspected of producing significant brain damage or long-term impair- ment in neural functioning, there is little or no evidence in support of this idea. It also has been suspected that marijuana may produce more subtle neurological changes that would affect one’s personality, motivation to succeed, or outlook on life. In 1968, William McGlothin, a psychologist, and Louis West, a psychiatrist, proposed that chronic marijuana smok- ing among young people was responsible for a generalized sense of apathy in their lives and an indifference to any long- term plans or conventional goals. These changes were called the amotivational syndrome. In their words,
Regular marijuana use may contribute to the develop- ment of more passive, inward-turning personality charac- teristics. For numerous middle-class students, the subtly progressive change from conforming, achievement-oriented behavior to a state of relaxed and careless drifting has fol- lowed their use of significant amounts of marijuana … . Such individuals exhibit greater introversion, become totally involved with the present at the expense of future goals, and demonstrate a strong tendency toward regressive, childlike magical thinking.35
Essentially, McGothlin and West, and probably a sizable pro- portion of the American public in the late 1960s, were saying, “These people don’t seem to care any more about things that we think are important, and marijuana’s to blame for it!”
The issue of the amotivational syndrome revolves around two basic questions that need to be examined separately. The first question deals with whether such a syndrome exists in the first place, and the second deals with whether chronic abuse of marijuana is a causal factor.36
defined heavy marijuana use as self-reports of having smoked marijuana more than 50 times over one’s lifetime.
Important questions, however, remain to be answered on the issue of linking marijuana use to lung cancer. First of all, it is not known from this study to what extent mari- juana smoking continued past late adolescence and early adulthood and what role that might have played in the final outcome. Were the men diagnosed with lung can- cer 40 years later, the ones who smoked marijuana most of their adult life? Adolescence and early adulthood is a time of significant lung development and it is possible that marijuana smoking coincided with a “critical period” of susceptibility to the carcinogens in marijuana smoke, but we cannot determine the relationship at this time. Second, adolescents and young adults are currently smoking higher potency marijuana than was the case 40 years ago. It is pos- sible that decades from now we might find a linkage to lung cancer at more occasional or moderate levels of marijuana use of this factor. On the other hand, the lower incidence of current tobacco smoking among adolescents and young adults, relative to the much higher incidence 40 years ago, might reduce the possibility of synergistic effects of combin- ing marijuana and tobacco.31
Effects on the Immune System When THC is administered to animals, the immune system is suppressed, resulting in a reduction in the body’s defense reactions to infection and disease. In humans, the evidence is inconclusive. Some studies indicate that THC has a suppres- sive effect; others indicate that no immunological changes occur at all. Because marijuana smoking has not been found to be associated with a higher incidence of any major chronic disease, we can tentatively conclude that marijuana smoking does not have a major impact on the immune system. Yet, long-term epidemiological studies, in which marijuana- exposed and control populations are compared with regard to the frequency of various diseases, have not been conducted on a large-scale basis. It has been shown that cannabinoids cause a mobilization of immune-suppressor cells that may potentially have a significant effect in weakening the immune system; it is not clear whether this effect is later seen in a higher incidence of immune system-related diseases.32
Effects on Sexual Functioning and Reproduction The reproductive systems of both men and women are adversely affected by marijuana smoking. In men, mari- juana reduces the level of testosterone, reduces sperm count in the semen, and increases the percentage of abnor- mally formed sperm. In women, marijuana use results in a reduction in the level of luteinizing hormone (LH), a hor- mone necessary for the fertilized egg to be implanted in the uterus. As little as one marijuana joint smoked immedi- ately following ovulation is evidently sufficient for this LH
amotivational syndrome: A state of listlessness and personality change involving a generalized apathy and indifference to long-range plans.
240 ■ Part Three Legally Restricted Drugs and Criminal Justice
correlate with involvement in a deviant subculture, a group of friends and associates who feel alienated from traditional values such as school achievement and a promising future (see Chapter 5). Either of these factors, in combination with the regular ingestion of marijuana, can account for the motivational changes that are observed. The point is that we cannot conclude that such lifestyle changes are purely pharmacological.
It is clear that acute marijuana intoxication produces significant cognitive deficits, as evidenced by reduced scores on tasks of attentiveness and memory, but the question remains whether these problems are increased or perhaps may become irreversible as a result of long-term marijuana use. Large and well-controlled studies have shown that cog- nitive deficits in heavy marijuana smokers, relative to nonus- ers, are observed after 12–72 hours of abstinence. In other words, the specific signs of cognitive impairment among long-term marijuana smokers may linger for as long as three days after active marijuana smoking. In one study, however, testing after 28 days of abstinence revealed equivalent per- formance scores between nonusers and users of marijuana, even though the latter group had smoked a median of about 15,000 times over a period of 10–33 years. No correlation was seen between the test scores after 28 days of abstinence and the number of episodes of marijuana use over an individual’s lifetime. Therefore, it appears that problems related to atten- tion and memory among heavy marijuana smokers can be reversed by stopping marijuana use. It is a hopeful sign in the context of drug-abuse treatment (Chapter 17). On the other hand, recent studies indicate that specific brain abnormali- ties associated with long-term heavy marijuana use have a negative impact on successful information-processing abili- ties, particularly among young smokers and marijuana with high THC levels. These neuroanatomical changes may not be reversible.40
Examining the Gateway Hypothesis
A widely publicized theory about marijuana smoking con- cerns the possibility of a relationship between marijuana use and the subsequent abuse of illicit drugs such as amphet- amines, cocaine, or heroin. The contention that marijuana leads to a greater incidence of drug abuse in general is referred to as the gateway hypothesis. As in the consideration of the amotivational syndrome, the evidence for this hypoth- esis must be studied very carefully.
With respect to the gateway hypothesis, we should address three separate issues: (1) whether a fixed sequen- tial relationship exists between the initiation of marijuana use and other forms of drug-taking behavior, (2) whether marijuana use represents a significant risk factor for future drug-taking behavior, specifically increasing the likelihood of using other illicit drugs, and (3) whether marijuana actually causes the use of other illicit drugs.
As to the existence of the syndrome, the evidence does suggest that students who smoke marijuana are at a disad- vantage academically. Studies of high school students indi- cate that those who smoke marijuana on a regular basis (weekly or more frequently) earn lower grades in school (Figure 12.1), are less likely to continue on to college, are more likely to drop out, and miss more classes than those who do not smoke it.37 In a survey of high school students graduating in the early 1980s, those who smoked marijuana on a daily basis reported several problems in their lives that are related to motivation: a loss of energy (43%), negative effects on relationships (39%), interference with work and the ability to think clearly (37%), less interest in other activi- ties (37%), and inferior performance in school or on the job (34%).38 It is likely that these percentages would be roughly the same today.
These changes are genuine, but we cannot easily establish a direct causal link between marijuana and such global problems, other than to acknowledge that the pres- ence of THC in a student’s system during school hours would be reflected later in a decline in overall academic performance. More broadly speaking, we cannot exclude the possibility that marijuana smoking may be, in the words of one expert in the field, “just one behavior in a constel- lation of related problem behaviors and personality and familial factors” that hamper an adolescent’s ability to do well in school and in life.39 We also cannot exclude the possibility that an involvement with marijuana may closely
gateway hypothesis: The idea that the abuse of a specific drug will inherently lead to the abuse of other, more harmful drugs.
Past month marijuana use
0 5 10 15 20 25
3.1%
6.4%
10.0%
17.9%
A Average B Average C Average D Average or lower
F IGurE 12 .1
Percentages of past month marijuana and blunt use among students aged 12–17 and semester grade average.
Note: Blunts are hollowed-out cigars refilled with marijuana.
Source: Substance Abuse and Mental Health Services Administration (2007). Use of marijuana and blunts among adolescents: 2005. The NSDUH Report, p. 3.
Chapter 12 Marijuana ■ 241
In the final analysis, however, the statistical relation- ship between marijuana smoking and other forms of drug- taking behavior may simply reflect the sequential pattern of drug use among multiple-drug (polydrug) users. Essentially, drug users initiate the use of high-prevalence drugs (such as alcohol, tobacco, marijuana) earlier than they initiate the use of low-prevalence drugs (such as cocaine, heroin). This effect is not due to the drugs themselves but rather due to the relative differences in prevalence rates. Numerous statis- tical relationships exist between other types of common and uncommon behaviors:
For example, most people who ride a motorcycle (a fairly rare activity) have ridden a bicycle (a fairly com- mon activity). Indeed, the prevalence of motorcycle riding among people who have never ridden a bicycle is probably extremely low. Bicycle riding, however, does not cause motorcycle riding, and increases in the former will not lead automatically to increases in the latter.44
The Causation Question The strongest form of the gateway hypothesis relates to the possibility of a causal link between marijuana smoking and the use of other illicit drugs. With respect to the causation issue, Erich Goode, a sociologist and drug-abuse researcher, has distinguished between two schools of thought, which he calls the intrinsic argument and the sociocultural argument. The intrinsic argument asserts that some inherent property of marijuana exposure itself leads to physical or psycho- logical dependence on other illicit drugs. According to this viewpoint, the pleasurable sensations of marijuana create a biological urge to consume more potent substances, through a combination of drug tolerance and drug dependence. In contrast, the sociocultural argument holds that the relation- ship exists not because of the pharmacological effects of marijuana but because of the activities, friends, and acquain- tances that are associated with marijuana smoking. In other words, the sociocultural explanation asserts that those who smoke marijuana tend to have friends who not only smoke marijuana themselves but also abuse other drugs. These friends are likely to have positive attitudes toward substance abuse in general and to provide opportunities for drug experimentation.
Professionals in the drug-abuse field have concluded that if any such causal link exists, the result would be socioculturally based rather than related to the pharma- cological properties of marijuana itself. The consensus is that any early exposure to psychoactive substances in general, and illicit drugs such as marijuana in particular, represents a “deviance-prone pattern of behavior” that will be reflected in a higher incidence of exposure to psycho- active drugs of many types later in life. It is interesting to note that early adolescent marijuana use among males also increases the risk in late adolescence of delinquency, hav- ing multiple sexual partners, not always using condoms during sex, perceiving drugs as not harmful, and having
The Sequencing Question One of the best-replicated findings in the long-term study of drug use is a developmental sequence of involvement (stages of progression) in drug-taking behavior. In the United States as well as other Western societies, use of alcohol and ciga- rettes precedes marijuana use, and marijuana use precedes use of other illicit drugs. In other words, exceedingly few people who have used cocaine or heroin have not used mari- juana at a previous time.41 Yet, it is also true that an over- whelming proportion of young marijuana smokers do not go on to use other illicit drugs. As expressed in a 1999 news- paper editorial on this point, “millions of baby boomers … once did, indeed, inhale. They later went into business, not cocaine or heroin.”42
The Association Question From a statistical perspective, the association between mari- juana use and subsequent use of other illicit drugs is not controversial. Generally speaking, marijuana smokers are several times more likely to consume illicit drugs such as cocaine and heroin during their lifetimes than are nonmari- juana smokers. Not surprisingly, the greater the frequency of marijuana smoking and the earlier an individual first engages in marijuana smoking, the greater the likelihood of his or her becoming involved with other illicit drugs in the future.
A precise determination of the magnitude of risk involved in marijuana use requires studies that take into account a range of genetic and environmental variables that might act as risk or protective factors for drug-taking behavior (see Chapter 5). A study set out to control for these variables by investigating a specific subpopulation of twins, one of whom reported marijuana use by the age of 17 and the other who reported no marijuana use at all. Examining twins permitted the researchers to calculate the increased risk of future drug-taking behavior when environmental fac- tors (in the case of fraternal twins) and both environmen- tal and genetic factors (in the case of identical twins) were controlled. Results showed that early marijuana users were about two and one-half times more likely to use heroin later in life, four times more likely to use cocaine or other stimulants, and five times more likely to use hallucinogens. In general, they were twice as likely to become alcoholic and twice as likely to develop any form of illicit drug abuse or dependence.
The question of whether future twin studies using this approach will find the increased risk from marijuana use to be higher than the increased risk from alcohol or tobacco use remains unanswered. In any case, the fact that mari- juana use is one of the risk factors for illicit drug use in other forms reinforces the need to develop intervention programs for marijuana users that might serve to prevent subsequent drug use, as well as prevention programs for youths to reduce the incidence of marijuana use in the first place.43
242 ■ Part Three Legally Restricted Drugs and Criminal Justice
Marijuana is undoubtedly the dominant illicit drug in U.S. society today. From the National Survey on Drug Use and Health conducted in 2013, it has been estimated that an astounding 115 million Americans, about 44 percent of the U.S. population over the age of 12, have smoked marijuana at least once during their lives. Nearly 20 million Americans are estimated to have smoked marijuana within the past 30 days. For two out of three current illicit drug users in the United States, marijuana is the only illicit drug being used (Figure 12.2).46
Among high school seniors surveyed in 2013, approxi- mately 36 percent reported having smoked marijuana in the past year, 23 percent reported having done so in the past month, and 6 percent smoked on a daily basis. Among eighth graders, 13 percent reported smoking marijuana in the past year and 7 percent in the past month. The current status of prevention programs, understandably under consider- able pressure to reduce rates of marijuana smoking as well as involvement in other drugs among young people, will be examined in Chapter 17.47
Current Trends in Marijuana Smoking
Present-day prevalence rates of marijuana smoking, in general, are substantially lower than those in the 1970s. Nonetheless, there is concern that marijuana smoking is on the rise; the “roller-coaster ride” of marijuana use monitored over the decades (see Figure 1.8) appears to have entered a new phase. On the other hand, an upward trend since about 2006 has been substantial. In 2009, Lloyd Johnston of the University of Michigan survey cautioned that the degree of risk associated with marijuana was a key
Marijuana only
Some illicit drug other than marijuana
Marijuana and some other illicit drug
19%
16%
65%
F IGurE 12 .2
Types of drugs used by illicit drug users aged 12 or older in the past month in 2013.
Source: Based on data from Center for Behavioral Statistics and Quality (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, p. 15.
Quick Concept Check
Understanding the Adverse Effects of Chronic Marijuana Abuse Check your understanding of the possible adverse effects of either acute or chronic exposure to marijuana by checking off true or false next to each of the assertions.
assertion true false
1. The immune system will be suppressed.
_________ _________
2. The chances of getting lung cancer will be unaffected.
_________ _________
3. Driving ability will be significantly impaired.
_________ _________
4. Birth defects will be more frequent.
_________ _________
5. It is likely that academic performance will decline when a person smokes marijuana regularly.
_________ _________
6. Marijuana smoking will cause the smoker to experiment with cocaine or heroin in the future.
_________ _________
7. Marijuana smoking in adolescence will generally be preceded by experimentation with tobacco or alcohol.
_________ _________
Answers: 1. false 2. false 3. true 4. false 5. true 6. false 7. true
12.2
problems with cigarettes and alcohol. Generally speaking, marijuana smokers show a greater inclination toward risk- taking behavior and are more unconventional with regard to social norms.45
Patterns of Marijuana Smoking
From as early as their days in elementary school, most young Americans have had to come to terms with marijuana as a pervasive element in their lives. Just as nearly all adoles- cents have had to make the decision whether to drink or not to drink, and whether to smoke cigarettes or not to smoke them, they also have had to decide whether to smoke or not smoke marijuana.
Chapter 12 Marijuana ■ 243
A final concern applies to any illicit street drug: the pos- sibility for adulteration. As emphasized in earlier chapters, what you buy is not always what you get. Each year brings with it a new group of ingredients, some of them newly introduced drugs and others merely inventive creations from already available materials, ready to be combined with mari- juana either to weaken its effects (and increase the profits of the seller) or to change the overall psychoactive result by some synergistic or other interactive effect. The most recent instance with regard to marijuana involves synthetic canna- binoid compounds such as the designer drug called Spice or K2 (Help Line).
Medical Marijuana
Even though the medicinal benefits of marijuana have been noted for thousands of years, strong anti-marijuana senti- ment in the United States made it difficult until the 1970s to conduct an objective appraisal of its clinical applications. Early research in the effectiveness of marijuana to reduce
belief in predicting prevalence rates of usage among young people, pointing out that “a key belief about the degree of risk associated with marijuana use has been in decline among young people … and the degree to which teens dis- approve of use of the drug has recently begun to decline.”48 In 2013, only 40 percent of high school seniors judged “regular marijuana smoking” as representing “great risk,” while seniors in 1992 had judged it as representing “great risk” by a three to one margin.49
A second concern with regard to present-day marijuana use has to do with an increased potency in the cannabis prod- ucts that are available. As noted earlier, a typical marijuana joint in the psychedelic era three decades ago contained approximately 1–2 percent THC; the average concentration has risen above 6 percent to as high as 10 percent and, in the case of recent strains of sinsemilla, as high as 15 percent. There is a commercial incentive to develop high-THC mari- juana in those U.S. states where marijuana legalization has been approved. It is reasonable to assume that the adverse effects of chronic marijuana smoking will be more intense than the relatively mild symptoms associated with marijuana use in the past.
Help Line Spice and other Designer Synthetic Cannabinoids
In 2010, the Drug Enforcement Administration was alerted to a new leafy herb product, marketed under the name Spice (alternate “brand names” include K2, Fire, Blaze among others), that began to be available through smoke shops and other small retail outlets. At the time, Spice was sold officially as a “herbal incense” and therefore as a legal commodity, retailers were able to get around laws prohibiting sale of marijuana itself. In actuality, the chemical composition of Spice is highly variable, though its primary ingredient is typically a synthetic cannabinoid called JWH-018, capable of binding to CB1 receptors four times more strongly than THC itself. A powerful marijuana-like high is produced as a result. Although standard urinalysis screening tests for THC metabolites (see Chapter 13) typically do not screen for JWH-018, specialized tests have been developed for screening up to 15 synthetic cannabinoids, including JWH-018.
JWH-018 is only one of a growing number of designer syn- thetic cannabinoids that have entered the illegal drug market in recent years. They have obscure chemical names such as JWH-073, JWH-200, HU-210, and CP-47,497, each with indi- vidualized “signatures” with regard to their effects on CB1 and CB2 receptors (see page 236–237). Drugs that are sold simply as “synthetic marijuana” may include any of these or other can- nabinoids, in any proportion. As a result, it is difficult to predict the psychological and physiological responses of these drugs. An estimated 11,000 of the 4.9 million drug-related emergency department visits in 2010 were linked to Spice and related designer synthetic cannabinoids. Emergency physicians had reported individuals ingesting spice with serious side effects
that included convulsions, anxiety attacks, elevated heart rate and blood pressure, vomiting, and disorientation.
It has been a continuing challenge for drug enforcement authorities to keep up with the flood of new synthetic cannabi- noid compounds entering the illicit drug market. Since 2011, the DEA executes expanded scheduling authority (under the Controlled Substances Act) that includes JWH-018 and many other cannabinoids as Schedule I controlled substances.
Where to go for assistance http://www.drugabuse.gov/publications/drugfacts/ spice-synthetic-marijuana
This Web site, issued by the National Institute on Drug Abuse, provides up-to-date information on the health effects and pat- terns of abuse of Spice. Prevention and treatment strategies are also provided.
Sources: NMS Laboratories, Willow Grove, PA. Synthetic Cannabinoid Metabolites Screen Expanded Urine (Forensic) Test. Substance Abuse and Mental Health Services Administration (2012, December 4). Drug- related emergency department visits involving synthetic cannabinoids. The DAWN Report. Rockville, MD: Substance Abuse and Mental Health Services Administration. U.S. Drug Enforcement Administration (2014). Schedules of controlled substances: Temporary placement of four synthetic cannabinoids into Schedule I. Office of Diversion Control, Drug Enforcement Administration, U.S. Department of Justice, Washington, DC.
244 ■ Part Three Legally Restricted Drugs and Criminal Justice
containing THC or a variation of it have been made avail- able in capsule form and classified as Schedule II controlled substances. Dronabinol (brand name: Marinol) is essen- tially THC in a sesame oil suspension; nabilone (brand name: Cesamet) is a synthetic variation of THC. Both drugs have been shown to be clinically effective against nausea, although the personal reactions of patients taking these drugs vary considerably.52
The Evolving Status of Medical Marijuana Laws For many years, U.S. federal authorities have resisted the official reclassification of marijuana itself or of any other cannabinoid extract (including CBD) from the Schedule I category of controlled substances (drugs that have no medi- cal application) to the Schedule II category (which includes morphine and cocaine). For a short period of time, a hand- ful of “compassionate use” applications were approved by the federal government to receive marijuana as a medical treat- ment, but the program for reviewing new applications was curtailed in 1992.
It is interesting that a major endorsement for medical marijuana had been part of a report issued in 1999 by a federally funded institution. The Institute of Medicine, a branch of the National Academy of Sciences, was charged at that time to study the question of the potential for medical marijuana. In the preface to its final report to the president, there was a suggestion of future develop- ments in this area:
Although marijuana smoke delivers THC and other can- nabinoids to the body, it also delivers harmful substances, including most of those found in tobacco smoke. In addi- tion, plants contain a variable mixture of biologically active compounds and cannot be expected to provide a precisely defined drug effect. For these reasons, this report concludes that the future of cannabinoid drugs lies not in smoked marijuana, but in chemically defined drugs that act on the cannabinoid systems that are a natural compo- nent of human physiology.53
In response to the report, however, the federal Office of National Drug Control Strategy emphasized the potential health risks of marijuana smoking and the imprecision of its administration as a justification for the continued prohibition of marijuana for medical purposes. Largely ignored was one of the report’s main conclusions within the report itself.
Until a nonsmoked, rapid-onset cannabinoid drug deliv- ery system becomes available, we acknowledge that there is no clear alternative for people suffering from chronic conditions that might be relieved by smoking marijuana, such as pain or AIDS wasting.54
intraocular (within the eye) pressure and dilate bronchioles in the lungs suggested uses as a possible therapy for glaucoma and asthma, respectively. However, new prescription medi- cations have been shown to be as effective as marijuana in the treatment of these disorders. Today, the focus has turned toward the treatment of chronic pain, muscle spasticity, nau- sea, and weight loss.
Treating Muscle Spasticity and Chronic Pain Evidence that marijuana is useful in the treatment of muscle spasticity and lack of mobility associated with neu- rological diseases such as multiple sclerosis (MS) comes largely from subjective reports. In a randomized placebo- controlled study of MS patients taking oral capsules of THC or whole cannabis extract, no significant improve- ments were observed through objective measures of mobil- ity but about two-thirds of the patients reported that they felt significant relief from muscle spasticity and associated chronic pain. In addition, patients frequently report relief from cancer-related pain as well as phantom limb pain (a phenomenon in which pain is experienced as coming from a limb that had been amputated). In many cases, they cite the superiority of smoked marijuana to any other form of treatment.50
Treating Nausea and Weight Loss Chemotherapy in the course of cancer treatment produces an extreme and debilitating nausea, lack of appetite, and loss of body weight, symptoms that are clearly counterproductive in helping an individual contend with an ongoing fight against cancer. AIDS patients suffer from similar symp- toms, as do those diagnosed with the gastrointestinal ail- ment Crohn’s disease. Under these circumstances, standard antiemetic (antivomiting) drugs are frequently ineffective. The beneficial effect of marijuana, specifically THC, as an antiemetic drug when treatment by traditional anti- emetic medications have failed, is an important therapeutic application.51
At the same time, the use of marijuana per se as a therapeutic agent has distinct disadvantages. First, the typi- cal administration through smoking presents a significant health risk to the lungs. Second, because marijuana is insol- uble in water, suspensions in an injectable form cannot be prepared. Since 1985, however, two legal prescription drugs
nabilone (NAB-ih-lone): A prescription drug containing a synthetic variation of delta-9-tetrahydrocannabinol (THC). Brand name is Cesamet.
dronabinol (droh-NAB-ih-nol): A prescription drug con- taining delta-9-tetrahydrocannabinol (THC). Brand name is Marinol.
Chapter 12 Marijuana ■ 245
would remove the present conflict that exists with respect to medical marijuana, it would not remove the conflict with respect to nonmedical (recreational) marijuana in those states that have approved such use.
Medical Cannabinoids
In recent years, investigations seeking new cannabis- related treatments for a variety of diseases have turned away from medications containing marijuana or THC to other cannabinoids extracted from cannabis. The most promi- nent cannabinoid with potential for medical applications is CBD. Twelve U.S. states currently have authorized limited medical CBD treatment.
Research into medical benefits of CBD is at an early stage, but so far there are signs of future applications for treating epileptic seizures among children and a wide range of pain conditions including spasticity-related pain in multiple sclerosis, peripheral pain, intractable can- cer pain, and rheumatoid arthritis pain. A prescription drug called Sativex, containing a combination of THC and CBD extracts, holds promise as a useful treatment for spasticity and pain conditions of various kinds. Since it contains both THC and CBD, Sativex stimulates both CB1 and CB2 receptors (see pages 236–237). Importantly, Sativex is administered as a mouth spray rather than a cig- arette, avoiding the pulmonary problems that are associ- ated with marijuana smoking. Sativex has been approved as a medication in 24 countries (including Canada, the United Kingdom, Germany, Austria, Sweden, Denmark, and Spain). Final clinical trials leading to FDA approval of Sativex in the United States as a treatment for cancer pain are currently underway.57
Decriminalization and Legalization
What lies ahead with respect to the public stance toward marijuana smoking in the United States? Should there be a decriminalization of marijuana smoking, which would mean that purchase, possession, and use of marijuana would be considered a civil (noncriminal) offense, punishable by a fine rather than imprisonment? Should there be a legalization of marijuana smoking, which would mean that purchase,
In effect, the report had concluded that, although smoked marijuana could not be recommended for long- term use, short-term use appeared to be suitable for treating specific conditions when patients failed to respond well to traditional medications.
Medical Marijuana Today In a relatively short period of time, the status of medical marijuana in the United States has changed dramatically. As of 2014, 23 U.S. states (Alaska, Arizona, California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, Oregon, Rhode Island, Vermont, and Washington) and the District of Columbia have approved marijuana use for the relief of pain and discomfort or the control of nau- sea and weight loss, when prescribed by a physician. There is substantial variation, however, in the disorders for which marijuana treatment has been authorized and the access options for patients seeking medical treatment of this kind. Meanwhile, four of these states and the District of Columbia have approved marijuana for nonmedical use as well.55
Medical Marijuana: Federal versus State Drug Enforcement
Considering the contradictory positions of specific states and the federal government in their statutes regarding medical marijuana, how is drug enforcement carried out? In 2009, in a significant reversal of federal policy on medical mari- juana, the U.S. Attorney General Eric H. Holder, Jr. issued the following statement on behalf of the U.S. Department of Justice:
It will not be a priority to use federal resources to prosecute patients with serious illnesses or their caregivers who are complying with state laws on medical marijuana, but we will not tolerate drug traffickers who hide behind claims of compliance with state law to mask activities that are clearly illegal.56
Notice that the statement did not officially change federal policy with regard to medical marijuana, only that the government would no longer spend time and money to carry out prosecutions in states in which medical mari- juana was legally sanctioned. In effect, the Department of Justice has returned the question of medical marijuana to the jurisdiction of the states without altering its official stance on a federal level that marijuana is a controlled substance without medical use. Recently, proposals in Congress have been made to “reschedule” marijuana as a Schedule II controlled substance. While this change
decriminalization: The policy of making the possession of small amounts of a drug subject to a small fine but not criminal prosecution.
246 ■ Part Three Legally Restricted Drugs and Criminal Justice
Vermont) have decriminalized (but not legalized) the pos- session of marijuana in small amounts (usually less than an ounce or so).
Figure 12.3 shows the current status of marijuana laws state-by-state in the United States.
Legalization by State Referendum As of 2014, voters in four U.S. states (Alaska, Colorado, Oregon, and Washington) as well as the District of Columbia have approved the legalization of recreational marijuana use, with specific regulatory safeguards. In Colorado, adults over 21 can grow up to six marijuana plants in a private secure area and possess up to an ounce of marijuana, although public use is banned. In Washington, adults over 21 can buy and possess up to an ounce of mari- juana from a state-licensed system of marijuana growers, processors, and stores. In 2013, voters in Colorado approved a substantial tax on recreational marijuana sales primarily to pay for the cost of overseeing the marijuana industry in the state. Marijuana legalization has been approved as well by voters in five cities (Detroit, Ferndale, Flint, Jackson, Lansing) and Portland, Maine, while some communities have continued to ban recreational marijuana use even
States with legalized recreational marijuana (4). States with both legal medical and decriminalization laws (10). States with legal medical marijuana (9). States with decriminalized marijuana possession laws (4). States with total marijuana prohibition (23).
F IGurE 12 .3
United States map showing U.S. states that have approved, as of 2014, medical marijuana, decriminalization, medical marijuana and decriminalization, or legalization. Limited CBD medical treatment has been authorized in Alabama, Florida, Iowa, Kentucky, Mississippi, Missouri, North Carolina, South Carolina, Tennessee, Utah, Virginia, and Wisconsin.
possession, or use of marijuana would no longer be an ille- gal act (assuming certain restrictions such as a minimum age requirement, limitations to personal use only, and prohibit- ing drug use while driving)?
In examining these questions, it is important to review how public policy with respect to marijuana regulation began to change in the 1970s. As described earlier in the chapter, the dramatic emergence during the 1960s of mar- ijuana as a major psychoactive drug initiated a slow but steady reassessment of myths that had been attached to it for decades. By 1972, the American Medical Association and the American Bar Association had proposed a liberal- ization of laws regarding the possession of marijuana. In 1972, the National Commission on Marijuana and Drug Abuse, authorized by the Controlled Substances Act of 1970, encouraged state legislators around the country to consider changes in their particular regulatory statutes that related to marijuana.58
Decriminalization by State Referendum Since 1973, 14 U.S. states (California, Connecticut, Maine, Maryland, Massachusetts, Minnesota, Mississippi, Nebraska, Nevada, New York, North Carolina, Ohio, Rhode Island, and
Chapter 12 Marijuana ■ 247
Local Communities in Washington State just Say No After the repeal of Prohibition in 1933 on a nationwide basis and U.S. states eventually repealed prohibition laws of their own, there were localities that retained alcohol prohibition statutes and were entitled to do so. Therefore, there were “dry towns” in “wet states” for a number of years.
A similar phenomenon appears to be occurring now that voters in four U.S. states have approved the legalization of marijuana for one’s personal use. Economically, hundreds of millions of dollars in tax revenue from marijuana sales could be in jeopardy, depending on the extent of local opposition to the newly established state laws.
Prohibition of marijuana use in a state where it is officially legalized has strongest support in rural and conservative
communities but surprisingly bipartisan political backing. Residents of Yakima, Washington (population 93,000), for example, have voted overwhelmingly to prohibit marijuana businesses to be licensed in their city. The Washington State Attorney General issued in 2014 a nonbinding legal opinion that local government could ban recreational marijuana, even though the intent of the state law passed in 2012, according to its supporters, was to make marijuana available to all state residents. It is expected that marijuana business owners will bring legal challenges to the localized marijuana bans. In answer to these future law suits, local communities have argued that they have the legal right to act as along as marijuana remains illegal under federal law.
Source: Johnson, Kirk (2014, January 27). Cannabis legal, localities begin to just say no. New York Times, pp. A1, A13.
Drug Enforcement … in Focus
Pro-marijuana protesters marching through Portland, Oregon on a global day of action calling for marijuana legalization and free- dom to grow cannabis in the United States and around the world. Marijuana legalization was approved in Oregon in 2014.
though they are located in states where it is legally sanc- tioned (Drug Enforcement … in Focus).
In an effort to establish some degree of clarity on the question of federal versus state definitions of marijuana, the U.S. Department of Justice announced in 2013 that it would not sue to reverse state-level legalization laws, even though the official federal position on marijuana would continue. However, the statement also pointed out that the federal government reserved the right to challenge any regulatory structure established by the state if there were “adverse pub- lic health consequences associated with marijuana use.” The situation is more complicated with respect to the District of Columbia. While DC residents voted in favor of marijuana legalization in 2014, the District is technically under federal jurisdiction. Marijuana legalization in this case may be over- ruled by an act of Congress.59
Public Sentiment for a Liberalization of Marijuana Laws In a national AP-CNBC poll conducted in 2010, 60 percent of American adults favored legalizing the possession of small amounts of marijuana for medical purposes, and 74 percent believed that marijuana would have a real medical benefit for some people. There were no significant differences in these poll results due to the region of the country surveyed, nor were there differences due to the type of region (urban, suburban, or rural). In 2013, the percentage favoring medical marijuana had risen to 85 percent, according to a Fox News poll.60
In a Pew Research Center national poll conducted in 2013, 52 percent of Americans favored legalizing marijuana
in general, while 45 percent opposed it, marking the first time that those in favor had gained the majority. In 2014, the percentage favoring legalization had risen to 55 per- cent, with about a quarter of those who were personally opposed to legalization not inclined to be actively seek- ing a repeal of legalization laws if such laws were passed by state voters and state legislators. To put these num- bers in perspective, acceptance of marijuana legalization from the late 1970s to the mid-1990s had never exceeded 25 percent.61
248 ■ Part Three Legally Restricted Drugs and Criminal Justice
A Matter of Terminology ●● Marijuana is one of several products of the Cannabis
sativa, or common hemp plant, grown abundantly throughout the world.
●● Various cannabis products are distinguished in terms of the content of cannabis resin and, in turn, the concentra- tion of THC, the active psychoactive agent.
The History of Marijuana and Hashish ●● The earliest records of marijuana come from Chinese
writings nearly 5,000 years ago; hashish has its origins in North Africa and Persia in the ninth or tenth centuries a.d.
●● In the United States, marijuana was available in patent medicines during the late 1800s, but its popularity did not become extensive until the 1920s.
●● Federal and state regulation of marijuana began in the 1930s; penalties for possessing and selling marijuana esca- lated during the 1940s and 1950s.
●● The emergence of marijuana on American college cam- puses and among American youth in general during the late 1960s, however, forced a reexamination of public pol- icy regarding this drug, leading to a more lenient approach in the 1970s.
Summary
The Ramifications of Decriminalization and Legalization The available evidence indicates that marijuana decriminal- ization laws have not affected prevalence rates of marijuana use. Statistics drawn from states in 1980 that either have or have not decriminalized show little or no difference in the prevalence rate of marijuana smoking. In addition, attitude sur- veys conducted in California before and after the enactment of decriminalization in 2010 indicate that the acceptance of marijuana among college students actually declined. Further studies of this kind need to be undertaken in U.S. states that have taken the further step to marijuana legalization.62
At the present time, states that have approved legaliza- tion have had to wrestle with a number of problems related to law enforcement, given the conflict with federal statutes that define marijuana as a Schedule I controlled substance, as well as problems related to public safety:
●■ In states where recreational marijuana has been legalized, college students over the age of 21 have been met with a significant restriction in marijuana use. Colleges and uni- versities in Colorado and Washington, for example, have announced a prohibition of marijuana possession by students on college property, despite the legal status of marijuana in these states. The argument is that any institution that receives federal funding (as most colleges and universities do) must follow all federal laws, including the law defining marijuana as an illicit drug. Similar policies in other states with mari- juana legalization have not been announced.63
●■ The definition of “driving while impaired” has tradition- ally been a matter of detecting a minimum blood-alcohol concentration (BAC) adopted as the nationwide standard for drunk driving (see Chapter 15). According to popular opinion, driving while high on marijuana is not consid- ered as dangerous as while intoxicated with alcohol, but as indicated earlier in the chapter deficits in driving be- havior do occur as a result of marijuana intoxication, and there is no available information on the equivalence of the two drugs on driving performance at the present time.
Moreover, while a breathalyzer test for BAC levels can be routinely administered easily by law enforcement, there is no comparable on-site system for the detection of mari- juana intoxication.64
●■ Newly established marijuana shop owners in states where marijuana is legally sold have found it difficult to open checking accounts, apply for business loans, or carry out any other financial transaction that is related to their busi- ness. Banks are reluctant to be associated with a marijuana business, despite its legal status within the state, because of the potential for jeopardizing their federal deposit in- surance (FDIC) eligibility. Their concern is that they would be viewed as being in violation of the Controlled Substances Act and prosecuted under federal money laun- dering statutes. Statements by the U.S. Attorney General on this question have suggested a relaxation of restric- tions, but financial institutions await an official ruling that includes reasonable conditions for the financing of marijuana transactions.65
●■ Meanwhile, the Internal Revenue Service in 2015 reaf- firmed its position that cannabis companies are required to submit payroll taxes electronically or face a 10 percent penalty. The IRS decision came as a request for an excep- tion by a Denver-based cannabis dispensary that pays its taxes promptly in cash but cannot do so electronically because it has been unable to secure a bank account for that purpose. As a result of the IRS position, the cannabis industry currently faces millions of dollars of additional costs.
●■ In Colorado, new marijuana-infused snacks such as chocolate-peppermint Mile High Bars and peanut butter candies infused with hashish oil have appeared on the mar- ket, as legal products. While advertised for customers over the age of 21, these products would be potentially attractive to customers under the age of 21 (the minimum age for pur- chasing any marijuana product). It is interesting that similar concerns have been raised with respect to the availability of alcohol or tobacco products to underage consumers (see Chapters 15 and 16).66
Chapter 12 Marijuana ■ 249
Acute Effects of Marijuana ●● Because marijuana is almost always consumed through
smoking, the acute effects are rapid, but because it is ab- sorbed into fatty tissue, its elimination is slow. It may re- quire days or weeks in the case of extensive exposure to marijuana for THC to leave the body completely.
●● Acute physiological effects include cardiac acceleration and a reddening of the eyes. Acute psychological effects, with typical dosages, include euphoria, giddiness, a per- ception of time elongation, and an increased hunger and sexual desire. There are impairments in attention and memory, which interfere with complex visual–motor skills such as driving an automobile.
●● The acute effects of marijuana are now known to be due to the binding of THC at special receptors in the brain.
Chronic Effects of Marijuana ●● Chronic marijuana use produces tolerance effects; there
is no physical dependence when doses are moderate and only a mild psychological dependence.
●● Carcinogenic effects are suspected because marijuana smoke contains many of the same harmful components that tobacco smoke does, and in the case of marijuana smoking inhalation is deeper and more prolonged.
The Gateway Hypothesis ●● The idea that there exists an amotivational syndrome,
characterized by general apathy and an indifference to long-range planning, as a result of the pharmacological effects of chronic marijuana use has been largely dis- credited. An alternative explanation for the behavioral changes is that chronic marijuana users are involved in a deviant subculture that is directed away from traditional values of school achievement and long-term aspirations.
●● According to the gateway hypothesis, marijuana inherently sets the stage for future patterns of drug abuse. Research
studies have indicated that the use of alcohol and ciga- rettes precedes marijuana use, that marijuana use precedes the use of other illicit drugs, and that marijuana use and subsequent use of other illicit drugs are statistically corre- lated. However, there is little evidence that some inherent property of marijuana exposure itself leads to physical or psychological dependence on other drugs.
Patterns of Marijuana Smoking ●● The current prevalence rate of marijuana smoking among
adolescents and young adults is lower than in the late 1970s. However, in 2013, 36 percent of high school se- niors reported smoking marijuana in the past year and 23 percent in the past month.
●● Other areas of concern are the considerably greater po- tency of marijuana that is now available and the continu- ing risk of marijuana adulteration.
Medical Marijuana, Decriminalization, and Legalization
●● Marijuana has been found to be helpful in the treatment of muscle spasticity, chronic pain, and conditions of nau- sea and weight loss. As of 2014, 23 U.S. states and the District of Columbia have approved medical marijuana.
●● As of 2014, voters in 14 U.S. states have approved decrimi- nalization of marijuana use, and voters in four U.S. states (Alaska, Colorado, Oregon, and Washington) have approved marijuana use for nonmedical (recreational) purposes.
●● While public opinion has become increasingly favorable to medical marijuana, as well as decriminalization or legalization, several difficult issues remain to be resolved, stemming primarily from the continuing conflict between state laws that have liberalized the status of marijuana and the federal position that marijuana is a Schedule I con- trolled substance and therefore an illegal drug.
Key Terms
amotivational syndrome, p. 239 anandamide, p. 236 bhang, p. 230 cannabinoids, p. 229 Cannabis sativa, p. 228
cannabidiol (CBD), p. 229 decriminalization, p. xxx delta-9-tetrahydrocannabinol
(THC), p. 229 dronabinol (Marinol), p. 244
gateway hypothesis, p. 240 hashish, p. 230 hashish oil, p. 230 hashish oil crystals, p. 230 joint, p. 234
marijuana, p. 230 nabilone (Cesamet),
p. 244 reefer, p. 234 sinsemilla, p. 230
1. Explain the characteristics of marijuana, sinsemilla, hashish, and hashish oil in terms of the manner in which they are obtained from the cannabis plant and their respective levels of THC.
2. Explain the social and historical factors that changed the image of marijuana from an obscure psychoactive substance to a drug that was considered dangerous and worthy of extreme prohibi- tory policies.
3. Describe the distinctions between the CB1 and CB2 receptors and how various cannibinoids interact with these two receptor types and produce different behavioral and physiological effects.
4. Discuss the present understanding of the chronic effects of marijuana with respect to cardiovascular and respiratory disease, lung cancer, immunological disease, and sexual functioning.
5. Discuss the basic premises of the gateway hypothesis and present an argument that argues against the inherent property of marijuana to cause a progression to the abuse of more seri- ous drugs.
6. Describe the present-day accepted medical applications of marijuana.
Review Questions
250 ■ Part Three Legally Restricted Drugs and Criminal Justice
You are a bank official in a state in which marijuana has been legalized. A local businessman comes to your bank to apply for a checking account and loan to expand his thriving marijuana shop. He explains that by all standard criteria his credit rating is excellent but for the last several months he has been forced to carry out with all transactions on a cash-only basis, without a checking account. Without a commercial loan, he cannot expand his business. In the
last three weeks, he has been robbed at knifepoint when transporting his cash receipts, the last time being particularly dangerous to him. He nearly lost his life, and fears that next time he may not be so for- tunate. Yet you worry about the FDIC requirements for your bank. If you were to lose FDIC protection for your depositors, you would have to close your doors. Do you approve the loan? What justifica- tions do you provide if you say Yes or if you say No?
Critical Thinking: What Would You Do?
1. Abel, Ernest L. (1980). Marihuana, the first twelve thousand years. New York: Plenum Press, p. ix.
2. Bloomquist, Edward R. (1968). Marijuana. Beverly Hills, CA: Glencoe Press, pp. 4–5.
3. Abel, Marihuana, p. 4. Palfai, Tibor; and Jankiewicz, Henry (1991). Drugs and human behavior. Dubuque, IA: W. C. Brown, p. 452.
4. Abel, Marihuana, pp. x–xi. 5. Goode, Erich (2008). Drugs in American society (7th ed.).
New York: McGraw-Hill Higher Education, p. 239. Hill, Andrew J.; William, Claire M.; Whalley, Benjamin J.; and Stephens, Grey J. (2012). Phytocannabinoids as novel therapeutic agents in CNS disorders. Pharmacology and Therapeutics, 133, 79–97. National Drug Intelligence Cen- ter (2009). Domestic cannabis cultivation assessment 2009. Washington, DC: U.S. Department of Justice, p. 4. National Drug Intelligence Center (2008). National drug threat assessment: 2009. Washington, DC: U.S. Department of Justice, p. 18. Pulse check: Marijuana report. Washington, DC: White House Office of Drug Control Policy.
6. Abel, Marihuana, p. 12. 7. Bonnie, Richard J.; and Whitebread, Charles H. (1974). The
marihuana conviction: A history of marihuana prohibition in the United States. Charlottesville, VA: University Press of Virginia, p. 3. Romos, Ricardo (1999). Responses to Mexican immigration, 1910–1936. In Michael R. Ornelas (Ed.), Beyond 1848: Readings in the modern Chicano historical experience. Dubuque, IA: Kendall Hunt Publishing, p. 115.
8. Abel, Marihuana, pp. 218–222. 9. Bonnie and Whitebread, The marihuana conviction, p. 33.
Polo, Marco (1300/1993). The travels of Marco Polo: The com- plete Yule-Cordier edition. Mineola, NY: Dover Publications. Romos, Responses to Mexican immigration.
10. Anslinger, Harry J.; and Tompkins, William F. (1953). The t raffic in narcotics. New York: Funk & Wagnalls, pp. 37–38. Cited in Inciardi, James A. (2002). The war on drugs III. Boston: Allyn and Bacon, p. 46.
11. Lee, Martin A.; and Shlain, Bruce (1985). Acid dreams: The complete social history of LSD. New York: Grove Weidenfeld.
12. Julien, Robert M. (2005). A primer of drug action (10th ed.). New York: Worth pp. 565–567.
13. Ibid., p. 566. 14. Allen and Hanbury’s athletic drug reference (1992). Research
Triangle Park, NC: Clean Data, p. 33. Wadler, Gary I.; and Hainline, Brian (1989). Drugs and the athlete. Philadelphia: F. A. Davis, pp. 208–209.
15. Grinspoon, Lester; and Bakalar, James B. (1997). Marihuana. In Joyce H. Lowinson; Pedro Ruiz; Robert B. Millman; and John
G. Langrod (Eds.), Substance abuse: A comprehensive textbook (3rd ed.). Baltimore, MD: Williams and Wilkins, pp. 199–206.
16. Jones, Reese T. (1980). Human effects: An overview. In Robert C. Petersen (Ed.), Marijuana research findings: 1980 (NIDA Research Monograph 31). Rockville, MD: National Institute on Drug Abuse, p. 65.
17. Grilly, David; and Salamone, John D. (1998). Drugs, brain, and behavior (6th ed.). Boston: Pearson, p. 337.
18. Center for Behavioral Health Statistics and Quality (2013). Drug Abuse Warning Network, 2011: National estimates of drug-related emergency department visits, 2004–2011. Rockville, MD: Substance Abuse and Mental Health Services Administration, Excel files.
19. Winger, Gail; Hofmann, Frederick G.; and Woods, James H. (1992). A handbook on drug and alcohol abuse (3rd ed.). New York: Oxford University Press, pp. 123–125.
20. Hooker, William D.; and Jones, Reese T. (1987). Increased susceptibility to memory intrusions and the Stroop interference effect during acute marijuana intoxication. Psychopharma- cology, 91, 20–24. Ilan, Aaron B.; Gevins, A.; Coleman, M.; ElSohly, M. A.; and de Wit, H. (2005). Neurophysiological and subjective profile of marijuana with varying concentrations of cannabinoids. Behavioural Pharmacology, 16, 487–496.
21. Delong, Fonya L.; and Levy, Bernard I. (1974). A model of attention describing the cognitive effects of marijuana. In Loren L. Miller (Ed.), Marijuana: Effects on human behavior. New York: Academic Press, pp. 103–117. Gieringer, Dale H. (1988). Marijuana, driving, and accident safety. Journal of Psy- choactive Drugs, 20, 93–101.
22. McKim, William A.; and Hancock, Stephanie D. (2013). Drugs and behavior (7th ed.). Boston: Pearson Education, p. 323.
23. Ramaekers, J. G.; Berghaus, G.; van Laar, M.; and Drummer, O. H. (2004). Dose related risk of motor vehicle crashes after cannabis use. Drugs and Alcohol Dependence, 73, 109–119.
24. Block, Robert I. (1997). Editorial: Does heavy marijuana use impair human cognition and brain function? Journal of the American Medical Association, 275, 560–561. Pope, Harrison G., Jr.; and Yurgelun-Todd, Deborah (1996). The residual cognitive effects of heavy marijuana use in college students. Journal of the American Medical Association, 275, 521–527.
25. Budney; Moore; and Vandrey, Handbook, pp. 261–265. Hall, Wayne.; Degenhardt, Louisa.; and Teesson, Maree (2004). Cannabis use and psychotic disorders: An update. Drug and Alcohol Review, 23, 433–443. Julien, A primer, of drug action, pp. 568–572. McKim and Hancock, Drugs and behavior, p. 328.
26. Ameri, Angela (1999). The effects of cannabinoids on the brain. Progress in Neurobiology, 58, 315–348. Chait, L. D.; and Burke, K. A. (1994). Preference for high- versus low-potency
Endnotes
Chapter 12 Marijuana ■ 251
35. McGothlin, William H.; and West, Louis J. (1968). The marijuana problem: An overview. American Journal of Psychiatry, 125, 372.
36. Goode, Erich (1999). Drugs in American society (5th ed.). New York: McGraw-Hill College, pp. 232–233.
37. Brook, J. S.; Adamas, R. E.; Balka, E. B.; and Johnson, E. (2002). Early adolescent marijuana use: Risks for the transition to young adulthood. Psychological Medicine, 32, 79–91. Goode, Erich (2012). Drugs in American society (8th ed.). New York: McGraw-Hill, pp. 219–220. Roebuck, M. Christopher; French, Michael T.; and Dennis, Michael L. (2004). Adolescent marijuana use and school attendance. Economics of Education Review, 23, 133–141.
38. Goode (1999). Drugs in American society, p. 233. 39. Fried, P. A.; Wilkinson, B.; and Gray, R. (2005).
Neurocognitive consequences of marihuana—A comparison with pre-drug performance. Neurotoxicology and Teratology, 27, 231–239. Pope, Harrison (2002). Cannabis, cognition, and residual confounding. Journal of the American Medical Association, 287, 1172–1174. Solowij, Nadia; Stephens, Robert S.; Roffman, Roger A.; Babor, Thomas; Kadden, Ronald; et al. (2002). Cognitive functioning of long-term heavy cannabis users seeking treatment. Journal of the American Medical Association, 287, 1123–1131.
40. Brook, Judith S.; Zhang, Chenshu; and Brook, David W. (2011). Developmental trajectories of marijuana use from adolescence to adulthood. Archives of Pediatric and Adolescent Medicine, 165, 55–60. Gruber, S. A.; Dahlgren, M. K.; Sagar, K. A.; Gonenc, A.; and Killogre, W. D. (2012). Age of onset of marijuana use impacts inhibitory process- ing. Neuroscience Letters, 511, 89–94. Moore, Abigail S. (2014, November 2). This is your brain on drugs. New York Times, Education Life, p. 17. Yücel, Murat; Solowij, Nadia; Respondek, Colleen; Whittle, Sarah; Fornito, Alex; et al. (2008, June). Regional brain abnormalities associated with long-term heavy cannabis use. Archives of General Psychiatry, 65, 694–701.
41. Kandel, Denise B. (2003). Does marijuana use cause the use of other drugs? Journal of the American Medical Association, 289, 482–483. Kandel, Denise B. (Ed.) (2002). Stages and path- ways of drug involvement: Examining the gateway hypothesis. Cambridge: Cambridge University Press.
42. Cited in Medical marijuana: Editorials debate “gateway” effect (1999, April 12). American Health Line, URL: http:// www.ahl.com.
43. Kandel, Does marijuana use cause the use of other drugs? Lynskey, Michael T.; Hath, Andrew C.; Bucholz, Kathleen K.; Slutske, Wendy S.; Madden, Pamela A. F.; et al. (2003). The escalation of drug use in early-onset cannabis users vs co-twin controls. Journal of the American Medical Associa- tion, 289, 427–433. Martin, Kimberly R. (2001). Adolescent treatment programs reduce drug abuse, produce other improvements. NIDA Notes, 16(1), 11–12. Martin, Kim- berly R. (2001). Television public service announcements decrease marijuana use in targeted teens. NIDA Notes, 16(1), 14.
44. Zimmer, Lynn; and Morgan, John P. (1997). Marijuana myths, marijuana facts: A review of the scientific evidence. New York: Lindesmith Center, p. 37.
45. Goode (2008). Drugs in American society, pp. 250–251. 46. Center for Behavioral Health Statistics and Quality (2014).
Results from the 2013 National Survey on Drug Use and
marijuana. Pharmacology, Biochemistry, and Behavior, 49, 643–647. Tanda, Gianluigi; Pontieri, Francesco E.; and Di Chiara, Gaetano (1997). Cannabinoid and heroin activation of mesolimbic dopamine transmission by a common µ1 opioid receptor mechanism. Science, 276, 2048–2049. Wickelgren, Ingrid (1997). Research news: Marijuana: Harder than thought? Science, 276, 1967–1968.
27. Abood, M.; and Martin, B. (1992). Neurobiology of marijuana abuse. Trends in Pharmacological Sciences, 13, 201–206.
28. Frank, Ira M.; Lessin, Phyllis J.; Tyrrell, Eleanore D.; Hahn, Pierre M.; and Szara, Stephen (1976). Acute and cumula- tive effects of marijuana smoking on hospitalized subjects: A 36-day study. In Monique C. Braude; and Stephen Szara (Eds.), Pharmacology of marijuana, Vol. 2. Orlando, FL: Academic Press, pp. 673–680. Jones, Reese T.; and Benowitz, Neal (1976). The 30-day trip: Clinical studies of cannabis tol- erance and dependence. In Monique C. Braude; and Stephen Szara (Eds.), Pharmacology of marijuana, Vol. 2. Orlando, FL: Academic Press, pp. 627–642.
29. Haney, Margaret; Ward, Amie S.; Comer, Sandra D.; Foltin, Richard W; and Fischman, Marian W. (1999a). Abstinence symptoms following oral THC administration in humans. Psychopharmacology, 141, 385–394. Haney, Margaret; Ward, Amie S.; Comer, Sandra D.; Foltin, Richard W; and Fischman, Marian W. (1999b). Abstinence symptoms following smoked marijuana in humans. Psychopharmacology, 141, 395–404.
30. Duffy, Anne; and Milin, Robert (1996). Case study: Withdrawal syndrome in adolescent chronic cannabis users. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1618–1621. Julien, Robert M. (2001). A primer of drug action (9th ed.). New York: Worth, pp. 320–322.
31. Callaghan, Russell C.; Allebeck, Peter; and Sidorchuk, Anna (2013). Marijuana use and risk of lung cancer: A 40-year cohort study. Cancer, Causes, and Control, 24, 1811–1820. Joshi, Marish; Joshi, Anita; and Bartter, Thaddeus (2014). Review: Marijuana and lung disease. Current Opinion in Pulmonary Medicine, 20, 1–7. Pletcher, Mark J.; Vittinghoff, Eric; Kalhan, Ravi; Richman, Joshua; et al. (2012). Association between mari- juana exposure and pulmonary function over 20 years. Journal of the American Medical Association, 307, 173–181.
32. Committee on Substance Abuse, American Academy of Pediatrics (1999). Marijuana: A continuing concern for pediatricians. Pediatrics, 104, 982–985. Hollister, Leo E. (1988). Marijuana and immunity. Journal of Psychoactive Drugs, 20, 3–7. Petersen, Robert C. (1984). Marijuana over- view. In Meyer D. Glantz (Ed.), Correlates and consequences of marijuana use (Research Issues 34). Rockville, MD: National Institute on Drug Abuse, p. 10.
33. Brands, Bruna; Sproule, Beth; and Marshman, Joan (Eds.) (1998). Drugs and drug abuse: A reference text (3rd ed.). Toronto: Addiction Research Foundation. Committee on Substance Abuse, Marijuana. Grinspoon and Bakalar, Marihuana, pp. 203–204. Male infertility: Sperm from mari- juana smokers move too fast, too early (2003, November 3). Health and Medicine Week, pp. 459–460. Venkatesh L. Hegde; Mitzi Nagarkatti; and Prakash S. Nagarkatti (2010). Cannabinoid receptor activation leads to massive mobilization of myeloid-derived suppressor cells with potent immunosup- pressive properties. European Journal of Immunology, 40(12), 3358–3371, doi: 10.1002/eji.201040667.
34. Grinspoon and Bakalar, Marihuana, p. 203.
252 ■ Part Three Legally Restricted Drugs and Criminal Justice
Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration, Tables 1.1A and 1.1B.
47. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; Schulenberg, John E.; and Miech, Richard A. (2014). Monitoring the future: National survey results on drug use, 1975–2013, Vol. I: Secondary school students. Ann Arbor, MI: Institute for Social Research, University of Michigan, Tables 2-1, 2-2, and 2-3.
48. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; and Schulenberg, John E. (2009, December 14). Teen mari- juana use tilts up, while some drugs decline in use. Ann Arbor, MI: University of Michigan News Service, p. 1, Table 9-8.
49. Johnston; O’Malley; Bachman; Schulenberg; and Miech, Monitoring the future, Table 9-8.
50. Budney; Moore; and Vandrey, Handbook, pp. 278–282. Consroe, Paul; Musty, Rik; Rein, Judith; Tillery, Whitney; and Pertwee, Roger (1997). The perceived effects of smoked cannabis on patients with multiple sclerosis. European Neurology, 38, 44–48. Pertwee, R. (2001). Cannabinoid receptors and pain. Progress in Neurobiology, 63, 165–174. Pertwee, R. (2002). Cannabinoids and multiple sclerosis. Pharmacology and Therapeutics, 95, 165–174. Zajicek, John; Fox, Patrick; Sanders, Hilary; Wright, David; Vickery, Jane; et al. (2003). Cannabinoids for treatment of spasticity and other symptoms related to multiple sclerosis (CAMS study): multicentre randomized placebo-controlled trial. Lancet, 362, 1517–1526.
51. Julien, A primer of drug action, pp. 577–579. Vestag, Brian (2003). Medical marijuana center opens its doors. Journal of the American Medical Association, 290, 877–879.
52. Plasse, T. F.; Gorter, R. W.; Krasnow, S. H.; Lane, M.; Shepard, K. V.; et al. (1991). Recent clinical experience with dronabinol. International conference on cannabis and can- nabinoids, Chania, Greece. Pharmacology, Biochemistry, and Behavior, 40, 695–700.
53. Institute of Medicine (1999). Marijuana and medicine: Assess- ing the science base. Washington, DC: National Academy Press, excerpt on page vii.
54. Institute of Medicine, Marijuana and medicine, excerpt on page 8. Porter, Brenda E.; and Jacobson, Catherine (2013). Report of a parent survey of cannabidiol-enriched cannabis use in pediatric treatment-resistant epilepsy. Epilepsy and Behavior, 29, 574–577.
55. State-by-state information about medical marijuana and decriminalization, courtesy of NORML.org, Washington, DC.
56. U.S. Attorney General Eric Holder Jr. (2009, October 19). Attorney General announces formal medical marijuana guide- lines. Washington, DC: Office of Public Affairs, U.S. Depart- ment of Justice. Stout, David; and Moore, Solomon (2009,
October 20). U.S. won’t prosecute in states that allow medical marijuana. New York Times, pp. A1, A21.
57. Fine, Perry G.; and Rosenfeld, Mark J. (2013). The endocannabinoid system, cannabinoids, and pain. Rambam Maimonides Medical Journal, 4, e0022. Fine, Ethan B.; Cuy, Geoffrey W.; and Robson, Philip J. (2007). Cannabis, pain, and sleep: Lessons from therapeutic clinical trials of Sativex, a cannabis-based medicine. Chemistry and Biodiversity, 4, 1729–1743. Information from GW Pharmaceuticals Web site, http://www.gwpharm.com; Sativex.aspx. Hill; Williams; Whalley; and Stephens, Phytocannabinoids as novel therapeutic agents in CNS disorders. Sharkey, Keith A.; Darman, Dissor A.; and Parker, Linda A. (2014). Regulation of nausea and vomiting by cannabinoids and the endocannabinoid system. European Journal of Pharmacology, 722, 134–146.
58. National Commission on Marihuana and Drug Abuse (1972). Marihuana: A signal of misunderstanding. Washington, DC: Government Printing Office, pp. 151–167.
59. Frosch, Dan (2013, November 7). Measures to legal- ize marijuana are passed. New York Times, pp. A18–A20. Quotation from Southall, Ashley; and Healy, Jack (2013, August 2013). U.S. won’t sue to reverse states’ legalization of marijuana. New York Times, p. A11.
60. AP-CNBC marijuana poll—Complete results and analysis. CNBC.com, accessed April 20, 2010. Responses to question 3. Fox News Network (2013, February 25–27). Poll: 85 percent of voters favor medical marijuana.
61. Majority now supports legalizing marijuana (2013, April 4). News release, Pew Research Center for the People and the Press, Washington, DC. NBC News/Wall Street Journal (2014, January 22–24). Poll: Majority of Americans support efforts to legalize marijuana.
62. AP-CNBC marijuana poll, responses to questions 1 and 10a. Gallup Poll (2009, October 19). Johnston, Lloyd D. (1980, January 16). Marijuana use and the effects of marijuana decriminalization. Unpublished testimony delivered at the hearings on the effects of marijuana held by the Subcommit- tee on Criminal Justice, Judiciary Committee, U.S. Senate, Washington, DC, p. 5.
63. Harvey, Taylor (2014, January 24). Even in Colorado and Washington, pot on campus is ‘not OK.’ Chronicle of Higher Education, p. A18.
64. Koerth-Baker, Maggie (2014, February 18). Marijuana and the sobriety test. New York Times, pp. D1–D2.
65. Healy, Jack; and Apuzzo, Matt (2014, January 24). Legal marijuana business should have access to banks, Holder says. New York Times, p. A20.
66. Healy, Jack (2014, February 1). Snacks laced with marijuana raise concerns. New York Times, pp. A1, A16.
Performance- Enhancing Drugs and Drug Screening Tests
13chapter
My friend Kenny and I had a long talk last September. At the time, just
two years since he had been called up from the minors, Kenny was
enjoying an extraordinary season as a ballplayer on a major league
baseball team that will remain nameless. A game had been can-
celled due to rain, and Kenny had some time on his hands. I asked
him about his achievements and what they meant to him.
“I know you want me to talk about drugs,” Kenny began. “When
I was a little boy growing up, José Canseco and Mark McGwire were
my heroes. Man, their bodies were huge. The power they had in
their bats. When I heard about all the drugs they were taking, I was
mad as hell. I wanted to be another Canseco or another McGwire
on the field. But I knew I couldn’t be like them off the field.”
“Of course, they have all those drug tests now. And I’ve
passed them all, no reason to worry about that, I’m proud to say.
From the start, I was determined that if I made it in the majors
(and I have), it wouldn’t be the way they did it. Yeah, I’m hav-
ing a pretty good season this year. Don’t know about the next
After you have completed this chapter, you should have an understanding of the following:
●● The history of performance- enhancing drugs in sports
●● How anabolic steroids work
●● The health risks of steroid abuse
●● Patterns of steroid abuse
●● Performance-enhancing non- steroid hormones
●● Dietary supplements marketed as performance-enhancing aids
●● Nonmedical use of stimulant medications in baseball
●● Present-day drug screening tests
254 ■ Part Three Legally Restricted Drugs and Criminal Justice
reclassifying anabolic steroids as Schedule III controlled substances. Jurisdiction was transferred from the Food and Drug Administration (FDA) to the Drug Enforcement Administration (DEA). As a result of this legislation, phar- macies are permitted to fill anabolic-steroid prescriptions only up to a maximum of five times. Penalties for violating the law can result in a five-year prison term and a $250,000 fine for illegal nonmedical sales, and a one-year term and a $1,000 fine for nonmedical possession. Penalties are doubled for repeated offenses or for selling these drugs to minors. States are permitted to draft their own laws regard- ing the definition of anabolic steroids and to set sentencing guidelines for steroid offenders. Although most states follow the federally mandated Schedule III classification, New York lists steroids in Schedule II and Alaska schedules steroids in a category equivalent to Schedule IV. In some states, pos- session of small quantities of steroids is regarded as a mis- demeanor; other states regard it as a felony. In most but not all states, first-time offenses do not result in imprisonment, unless there are aggravating circumstances such as posses- sion of large quantities or evidence of intent to sell or distrib- ute the drugs.
Anabolic steroid distribution, like the distribution of other restricted drugs in the United States, has become an enormous black-market enterprise. With their use commonly referred to as being “on the juice,” these drugs are channeled princi- pally through people associated with body-building gyms and through Internet Web sites that frequently change the identity of a company’s location in an effort to stay one step ahead of the law. Some Internet-based suppliers include a warning on their Web sites, “Due to their profound effects and potencies, it is recommended to seek the guidance of a physician prior to use,” to protect themselves from criminal liability, though no customer would voluntarily divulge his or her steroid abuse, much less seek medical guidance. It is estimated that the illicit anabolic steroid market is valued at between $300 and $400 million each year, with the drugs smuggled into the United States from Europe, Canada, and Mexico.2
one, but one thing I do know. I won’t ever have
to apologize to Roger Maris’s widow, like McGwire
did, for using drugs to break Roger’s record. I will
have done it on my own.”
I asked him if he has any regrets. Kenny replied,
looking me straight in the eye, “None whatsoever.”
In a world where running a hundredth of a second faster can mean the difference between a gold medal and a silver, where throwing a javelin a centimeter farther, hitting a base- ball 20 feet farther, or lifting a kilogram more can make you either the champion or an also-ran, temptations abound. In this high-pressure world, athletes are continually on the look- out for a winning edge. The advantage formula may involve a new technique in training, a new attitude toward winning, or a special diet. Or, it could involve the use of performance- enhancing drugs.1
We are used to hearing the (often belated) public confessions of sports celebrities regarding their past use of performance- enhancing drugs, specifically their use of ana- bolic steroids. These public displays of contrition have put the records of their lifetime careers in question forever, along with our respect for their athletic achievements. They are (or were) our heroes.
We tend to view performance-enhancing drug use in sports as simply inappropriate. To most people, their behavior represents a betrayal of our trust in their honesty and society’s assumption of fair play. In fact, on the basis of federal legisla- tion enacted in 1990 and strengthened in 2004, their actions are more than inappropriate; they are illegal. The nonmedi- cal possession of the most potent category of performance- enhancing drugs, namely anabolic steroids and chemical pre- cursors to anabolic steroids, is a criminal offence.
In 1990, as a response to increasing awareness of the abuse of anabolic steroids both in and out of competitive sports, Congress passed the Anabolic Steroid Control Act,
46 Percentage of people in 2009 who believed that Alex Rodriguez was using performance-enhancing drugs for a longer time than he admitted in his 2009 announcement.
25 Highest percentage of Hall of Fame voters approving Mark McGwire for admission into the Baseball Hall of Fame, in four appearances on the ballot. A minimum of 75 percent approval is needed for admission.
$20–$50 The average cost for a drug test reported by the majority of companies engaged in preemployment screening. The cost varies depending on the drugs being tested, collection procedures, and other services.
Sources: Fortner, Neil A.; Martin, David M.; Esen, S. Evren; and Shelton, Laura (2011). Employee drug testing: Study shows improved productivity and attendance and decreased workers’ compensation and turnover. Journal of Global Drug Policy, and Practice, 5, p. 16. Kepner, Tyler (2010, January 12). McGwire admits steroid use in 1990s, his years of magic. New York Times, pp. B10, B14. Perez, A. J. (2009, February 13). Gallup Poll: Nearly half think A-Rod was doping longer. http://www.usatoday.com.
Numbers Talk…
Chapter 13 Performance-Enhancing Drugs and Drug Screening Tests ■ 255
What Are Anabolic Steroids? To understand how testosterone-based steroids produce ergogenic (performance-enhancing) changes, we first have to recognize that testosterone itself has two primary effects on the human body. The first and most obvious effect is androgenic (literally, “man-producing”), in that the hor- mone promotes the development of male sex characteris- tics. As testosterone levels rise during puberty, boys acquire an enlarged larynx (resulting in a deeper voice), body hair, and an increase in body size, as well as genital changes that make them sexually mature adults. The second effect is ana- bolic (upward changing), in that it promotes the develop- ment of protein and, as a result, an increase in muscle tis- sue. Muscles in men are inherently larger than muscles in women because of the anabolic action of testosterone in the male body.
Steroid drugs based on alterations in the testosterone molecule are therefore called anabolic-androgenic steroids. Obviously, with respect to performance enhancement, the goal has been to develop drugs that emphasize the anabolic function while retaining as little of the androgenic function as possible. For that reason, they are most often called simply anabolic steroids. Unfortunately, as we will see, it has not been possible to develop a testosterone-derived drug without at least some androgenic effects (Table 13.1). It is important that anabolic steroids not be confused with adrenocortical steroids, drugs that are patterned after glucocorticoid hor- mones secreted by the adrenal glands. The major drug of this latter type is hydrocortisone (brand name, among others: Hydrocortone injection or tablets). The molecular structure of these drugs qualifies them to belong to the steroid family, but there is no relationship to testosterone or any testosterone- like effects. Adrenocortical steroids are useful in the medical treatment of tissue inflammation; in sports; they reduce the inflammation associated with muscle injuries. Their effects on muscle development can be viewed as catabolic (down- ward changing), in that they produce a weakening of the muscles, an obviously undesirable option for athletes on a long-term basis.4
How did performance-enhancing drugs, particularly ana- bolic steroids, gain such popularity? Far from being a new phenomenon, performance-enhancing drugs have been a factor in competitive sports for centuries, but as we will see, the problem of performance-enhancing drugs goes beyond the world of competitive sports. A growing number of young people use these drugs simply because they want to look bet- ter by developing the musculature of their bodies. The serious dangers in such drug-taking behavior, whether the motivation lies in competitive drive or in personal vanity, are major prob- lems that need to be examined closely.
Performance-Enhancing Drugs in Sports
The first recorded athletic competition, the Olympic Games in ancient Greece, was also the occasion for the first recorded use of drugs in sports. As early as 300 b.c.e., Greek athletes were known to eat hallucinogenic mushrooms, either to improve their performance in the competition or to achieve some kind of mystical connection to the gods. Later, Roman gladiators and charioteers used stimulants to sustain them- selves longer in competition, even when injured.
By the end of the nineteenth century, world-class ath- letes were experimenting with a variety of stimulant and depressant drugs, including cocaine, caffeine, alcohol, nitro- glycerine, opioids, strychnine, and amphetamines. In 1886, while competing in a cross-country race, a Welsh cyclist died of an overdose of a combination of morphine and cocaine (now referred to as a speedball), marking the first drug-related death in sports ever recorded. During the 1904 Olympics, U.S. marathoner Tom Hicks collapsed after win- ning the race and lost consciousness. When he was revived, doctors were told that he had taken a potentially lethal mix- ture of strychnine (a CNS stimulant when administered in low doses) and brandy.3
With the introduction in the 1930s of anabolic steroid drugs specifically patterned after the male sex hormone tes- tosterone, a new element entered the arena of competitive sports. Here was a class of performance-enhancing drugs that did more than alter the behavior or experience of the athlete. These particular drugs actually altered the structure of the athlete’s body.
Anabolic steroid drugs had been studied since the 1930s as a treatment for anemia (low red blood cell count) and for conditions that caused muscles to waste away. Steroid drugs saved many lives in Europe in the months following the end of World War II when people were near death from starva- tion and weight loss, but it quickly became apparent that steroids could be useful when given to otherwise healthy individuals as well. As pharmaceutical companies began to introduce dozens of new body-building drugs based on the testosterone molecule, it was natural that anabolic ste- roids would come to the attention of athletes, as well as their coaches and trainers.
adrenocortical steroids: A group of hormones secreted by the adrenal glands. Their anti-inflammatory action makes them useful for treating arthritis and muscle injuries.
anabolic steroids: Drugs patterned after the testosterone molecule that promote masculine changes in the body and increased muscle development. The full name is “anabolic- androgenic steroids.”
anabolic-androgenic steroids: Drugs that promote masculinizing changes in the body and increase muscle development.
anabolic (AN-ah-BALL-ik): Acting to promote protein growth and muscle development.
androgenic (AN-droh-JEN-ik): Acting to promote masculin- izing changes in the body.
ergogenic (ER-go-JEN-ik): Performance enhancing.
256 ■ Part Three Legally Restricted Drugs and Criminal Justice
the 1956 Olympic Games in Melbourne for both men and women athletes.
Steroid use was clearly out in the open during the 1968 Olympic Games in Mexico City. An estimated one-third of the entire U.S. track and field team, not merely the strength- event and field-event competitors but sprinters and middle- distance runners as well, were using anabolic steroids. Any controversy over their use, however, did not concern the appropriateness or morality of taking steroids, only which particular steroids worked best. Strength-event athletes were taking at least two to five times the therapeutic recommen- dations (based on the original intent of replacing body pro- tein). The following year, an editor of Track and Field News dubbed anabolic steroids “the breakfast of champions.” In 1971, one U.S. weight lifter commented, in reference to his Soviet rival,
Last year the only difference between me and him was I couldn’t afford his drug bill. Now I can. When I hit Munich [in 1972], I’ll weigh in at about 340, or maybe 350. Then we’ll see which is better, his steroids or mine.5
In the meantime, the notable masculine features of many female athletes from eastern European countries in the 1960s and 1970s, not to mention the number of Olympic records that were suddenly broken, prompted many observ- ers to ask whether they were either men disguised as women or genetic “mistakes.” Questions about the unusually deep voices of East German women swimmers prompted their coach, at one point, to respond, “We came here to swim, not to sing.”
From information that subsequently came to light, we now know that the effects were due to large doses of ste- roids. Until the late 1980s, the East German government was conducting a scientific program specifically to develop new steroid formulations that would benefit their national athletes and, at the same time, would be undetectable by standard drug screening procedures. In 2000, the principal physician in the East German Swimming Federation at the time when these steroids were being administered was convicted on charges that from 1975 to 1985 the program caused bodily harm to more than four dozen young female swimmers.6
The 2000 Summer Olympic Games in Sydney, Australia, instituted the strictest drug-testing procedures to date for all competing athletes. For the first time, a specific phrase was inserted into the Olympic Oath, recited by all athletes at the beginning of the games: “… committing ourselves to a sport without doping and without drugs.” Unfortunately, accusations of illegal performance-enhancing drug use and expulsions of athletes continued to plague both Summer and Winter Olympic Games, as they had in previous ones since the 1950s.
Since 2009, the World Anti-Doping Code and Standards for drug testing have been in effect for international sports events. The Code includes an agreed-upon list of prohibited performance-enhancing drugs and performance- enhancing methods in international sports competitions, testing
Anabolic Steroids at the Modern Olympic Games By the time of the 1952 Olympic Games in Helsinki, athletes were well acquainted with performance-enhancing drugs. Legally available amphetamines (see Chapter 10), in particu- lar, were commonplace, particularly in events that empha- sized speed and endurance. Among events requiring strength and size, anabolic steroids were seen to be perfectly suited for gaining a competitive advantage.
It is debatable which country first used anabolic steroids. U.S. athletic officials have claimed that Soviet weight-lifting champions were using steroids in international competitions in 1954; British officials have claimed that a U.S. hammer thrower used steroids prior to 1954. Whoever has the dubi- ous honor of being first, steroid use became the norm by
TABLE 13.1
Anabolic steroids
TYPE OF STEROID GENERIC NAME BRAND NAME
Oral danazol Danocrine
drostanolone Masteron
methandrostenolone Dianabol
methyltestosterone Android, Testred, Virilon
oxyandrolone Oxandrin, Anavar
oxymetholone* Anadrol
stanozolol Winstrol
Intramuscular
Injection
nandrolone decanoate
Deca-Durabolin IM
nandrolone phenpropionate
Durabolin IM
testosterone proprionate*
Testex IM
testosterone enantrate* Delatestryl IM
Transdermal patch
testosterone Androderm transdermal system, Testoderm transdermal system
Note: Anabolic steroids are Schedule III controlled substances. As such, they are considered illicit drugs under federal guidelines when not obtained with a medical prescription and restricted to medical use along with other Schedule III controlled substances. Several “brand names” marketed for performance-enhancing purposes are combinations of various steroids.
* Approved outside the United States.
Sources: Based on information from Julien, R. M. (2005). A primer of drug action (10th ed.). New York: Worth, p. 631. National Institute on Drug Abuse (2000, April). Anabolic steroids. Community drug alert bulletin. Rockville, MD: National Institute on Drug Abuse Physicians’ desk reference (69th ed.) (2015). Montvale, NJ: PDR Network.
Chapter 13 Performance-Enhancing Drugs and Drug Screening Tests ■ 257
procedures for drug screening, and specific penalties for vio- lations. Under the auspices of the World Anti-Doping Agency (WADA), rules and regulations have been formally accepted by Olympic Committees in more than 200 nations, as well as by professional leagues (such as the National Basketball Association and the National Hockey League) representing the United States in the Olympic Games and other interna- tional competitions. The Code has been updated over the years as the development and availability of new drugs of this kind have changed.7
Although the 2012 Summer Olympic Games in London and the 2014 Winter Olympic Games in Sochi, Russia, were the first in recent history to report no specific incidences of performance-enhancing drug use among competing athletes, drug-related scandals in the world of international sports have continued. In 2012, the United States Anti-Doping Agency (USADA) announced that international cycling champion Lance Armstrong would be banned for life from cycling and stripped of his seven Tour de France titles as well as his bronze medal from the 2000 Olympic Games, after finding that Armstrong had used red blood cell booster erythropoietin (EPO), testosterone, corticosteroids, and masking agents, as well as engaged in the trafficking of performance-enhancing drugs and participating in a widespread cover-up of doping activities. In 2013, after years of denials, Armstrong admit- ted using performance-enhancing drugs during his cycling career (Portrait).8
Russian pentathlon champion Nadezhda Tkachenko was one of several world-class female athletes in the 1970s who later tested positive for anabolic steroids.
PORTRAIT Lance Armstrong—From Honor to Dishonor
The athletic and personal record of professional cyclist Lance Armstrong had made him an icon in modern-day sports. He won the Tour de France a record seven con- secutive times between 1999 and 2005. In 1997, barely a year after his diagnosis of testicular cancer that had spread to his brain and lungs, Armstrong had conquered it through surgery and chemo- therapy. He was the founder of the Lance Armstrong Foundation for cancer support and was instrumental in raising more than $500 million for the cause. By 2009, he had returned to competitive cycling, finishing third in the Tour de France of that year. Armstrong himself referred to his life as a “mythic, perfect story.”
It was in 2012 that it came apart. Shortly after his decision to renew his entry in the triathlon competitions (he had been in triathlon competition ear- lier in his life), the USADA charged Armstrong with a long-standing record of having used illicit performance-enhancing
drugs. In other words, the USADA was charging him with doping. Two months
later, the agency imposed a lifetime ban from athletic competition.
Armstrong never appealed the USADA decision that effectively ended his career. Unlike other athletes for whom suspicions of performance- enhancing drug use have made them live only under a shadow of doubt that their achievements were warranted, there would not be an asterisk in the record books for Lance Armstrong; there would be nothing in the official record books to acknowledge his achievements in the first place. The name of the foundation he created would now simply be known as the LIVESTRONG Foundation, sever- ing all ties to Armstrong. Nonetheless, for a time, Armstrong continued to deny the accusations against him, as he had done through most of his career.
In January 2013, in a televised inter- view, Oprah Winfrey asked Armstrong whether during his cycling career he had
used performance-enhancing drugs and blood transfusions (specifically prohibited in competitive sports since 2000). He replied with a simple “yes.” What fol- lowed was a series of measured responses. No details were revealed, no names of teammates or other sports associates were mentioned, nor did he elaborate on the ways he had managed through his career to evade the authorities.
After years of denial, Armstrong’s less-than-complete confession of guilt has been viewed as too little and too late. He is a persona non grata in the world of sports, and he faces the possibility of major lawsuits from the investors in his professional cycling team. It is unclear where it will end.
Sources: Austin, I. (2013, January 19). Armstrong’s critics largely unmoved by interview. New York Times, p. D2. Macur, J. (2013, January 20). As Armstrong decides next move, agencies are watching. New York Times, p. SP4.
258 ■ Part Three Legally Restricted Drugs and Criminal Justice
Fans expressed their opinion on steroid use at Major League Baseball’s All-Star Game in 2002. Between 5 and 7 percent of MLB players tested positive for anabolic steroids when randomized screening was conducted during spring training in 2003. Players involved in steroid use have been dubbed “the syringe generation.”
In 2004, two executives of BALCO, a nutritional supple- ments laboratory in California, and the personal trainer for outfielder Barry Bonds, Greg Anderson, were indicted on charges of illegally distributing steroids and other performance- enhancing drugs to dozens of professional athletes in baseball and other sports. Anderson pled guilty in 2005 to conspiracy to distribute steroids and money laundering and was later sen- tenced to three months in prison and three months of home arrest. The BALCO executives served short prison sentences, as well. In another development, a New York Mets clubhouse assistant pled guilty to having supplied performance- enhancing drugs to dozens of current and former major MLB players and their associates between 1995 and 2005 and subsequently laundering the proceeds from these transactions.
Under intense pressure from public opinion and from government officials, the MLB players union agreed in early 2005 to a policy of steroid testing that was more in line with those of the National Football League and the National Basketball Association. In late 2005, MLB penalties for ste- roid use were stiffened. Testing procedures and penalties for the use of amphetamine and other stimulants, which had been omitted from consideration in the earlier agreement, were added and later extended to minor league players (see Drug Enforcement … in Focus).
Despite changes in policy with regard to performance- enhancing drugs in MLB baseball, it became evident that these kinds of abuses had not ended. In 2007, a major inves- tigation under the direction of former U.S. senator and federal prosecutor George J. Mitchell concluded that MLB policies had reduced the use of steroids but that other, nonsteroid performance-enhancing drugs, particularly human growth hormone, had increased in popularity and were widely used. In 2011, Barry Bonds was convicted of one felony count of obstruction of justice in connection with BALCO investiga- tions. He was sentenced to two years’ probation and 30 days of house arrest, fined $4,000, and asked to complete 250 hours of community service, but he was exonerated on appeal in 2015. In 2012, pitcher Roger Clemens was found not guilty of lying to Congress in 2008, when he testified that he never adminis- tered performance-enhancing drugs during his baseball career.
In 2014, Yankees third baseman Alex Rodriquez was barred for 162 games and the 2014 postseason for using performance-enhancing drugs in previous baseball seasons. It was the longest suspension for doping in baseball history. Shortly before returning to the Yankees in 2015, Rodriguez issued a handwritten letter in which he apologized for his actions. He wrote, “To Major league baseball, the Yankees, the Steinbrenner family, the Players Association and you, the fans, I can only say I’m sorry.”9
The Hazards of Anabolic Steroids
One of the problems in evaluating the adverse effects of steroid abuse is that the dosage levels can vary over an enormous range. Since nonmedical steroid use is illegal, it is virtually
Anabolic Steroids in Professional and Collegiate Sports The widespread use of anabolic steroids in international athletics in the 1960s quickly filtered down to sports closer to home. Trainers in the National Football League (NFL) began to administer anabolic steroids to their players. By the 1970s and 1980s, virtually all the NFL teams were familiar with these drugs. Estimates of how many NFL players were on anabolic steroids varied from 50 to 90 percent. We will never know the full extent of the practice, but it was certainly substantial.
Several professional football players remarked at the time that their steroid use had begun while they were playing on collegiate teams, and indeed, football players in several col- leges and universities during the 1980s were implicated in steroid use. Football players were not alone in this regard. Use of anabolic steroids had found its way into other colle- giate and even high school sports, including track and field, baseball, basketball, gymnastics, lacrosse, swimming, volley- ball, wrestling, and tennis.
Performance-Enhancing Drug Abuse and Baseball Record-breaking home-run performances in the late 1990s and early 2000s raised suspicions that these achievements in baseball were due not solely to athletic prowess but to some pharmacological assistance as well. Matters were made worse by the fact that major league baseball (MLB) had stood apart from other professional sports in the United States and sports organizations around the world by failing to establish regu- latory policies regarding steroid abuse and the use of other performance-enhancing drugs.
Chapter 13 Performance-Enhancing Drugs and Drug Screening Tests ■ 259
in a small number of cases. Paradoxically, the male breasts enlarge (a condition called gynecomastia) because steroids break down eventually into estradiol, the female sex hormone. Other related consequences include frequent, sustained, and often painful penile erections (a condition called priapism) and an enlargement of the prostate gland. Severe acne, par- ticularly on the shoulders and back, results from an increase in the secretions of the sebaceous glands in the skin. Other testosterone-related effects include two changes in hair growth patterns: increased facial hair growth and accelerated balding on the top of the head.
Some athletes have attempted to counter these unde- sirable hormonal effects by combining anabolic steroids
impossible to know the exact dosage levels or even the exact combinations of steroids a particular individual may be tak- ing. It is estimated that a “typical” body builder on anabolic steroids takes in a minimum of 5–29 times the therapeutic doses recommended for the medical use of these drugs, but in some cases, the estimates have gone as high as a hundred to a thousand times the recommended therapeutic dose.10
Effects on Hormonal Systems At these huge dosages, anabolic steroids are literally flooding into the body, upsetting the delicate balance of hormones and other chemicals that are normally controlled by testosterone. The primary effect in men is for the testes gland to react to the newly increased testosterone levels in the blood by pro- ducing less testosterone on its own. In other words, the gland is getting the incorrect message that its services are no longer needed. As a result, the testicles shrink, and a lower sperm count leads to sterility, reversible for most men but irreversible
Suspension Penalties for Performance-Enhancing Drug Use in Sports The 2005 agreement on regulations against performance-enhancing drug use in MLB included a ban on “all substances regarded now, or in the future, by the federal government as steroids,” as well as human growth hormone and steroid precursor hormones such as androstenedione. Suspension penalties for positive-test infractions under these new regulations are shown in comparison to previous MLB regulations and those of other U.S. and international athletic organizations. In 2013, MLB announced an expansion of its drug-testing program, with players required to undergo in-season (as opposed to spring-training and off-season) blood testing for human growth hormone, as well as a new test for synthetic testosterone.
Drug Enforcement … in Focus
Positive Test
First Second Third Fourth Fifth Major League Baseball Pre-2005 counseling 15 days 25 days 50 days 1 year Late 2005 50 games 100 games lifetime suspension, with
right of reinstatement after two years
Minor League Baseball 15 days 30 days 60 days 1 year lifetime National Football League 4 games 6 games 1 year 1 year 1 year National Basketball Association 5 games 10 games 25 games 25 games 25 games
National Hockey League —no testing for steroids— World Anti-Doping Association (Olympic sports)
2 years lifetime
Sources: Curry, Jack (2006, November 16). Baseball lacks stiffer penalties for steroid use. New York Times, pp. A1, D2. Schmidt, Michael S. (2013, January 13). Baseball to expand drug-testing program. New York Times, pp. B13, B17. Schmidt, Michael S. (2010, February 24). Baseball plans to start testing for human growth hormone in minors. New York Times, p. B11. NFL will ban amphetamines as enhancers (2006, June 28). Newsday, p. A53.
priapism (PRY-ah-pih-zem): A condition marked by persistent and frequently painful penile erections.
gynecomastia (GUY-neh-coh-MAST-ee-ah): An enlargement of the breasts.
260 ■ Part Three Legally Restricted Drugs and Criminal Justice
Psychological Problems Stories abound of mood swings and increased aggressive- ness, often referred to by athletes as “roid rage,” when tak- ing anabolic steroids. Numerous anecdotal reports force us to consider the possibility that real psychological changes are going on.13 Yet, it is important to examine more rigorous laboratory investigations into the relationship between ana- bolic steroid use and psychological problems if we are to gain a more thorough understanding of the phenomenon.
In a major study addressing this issue, conducted in 2000, a group of male volunteers were randomly adminis- tered intramuscular injections of either testosterone cypri- onate or a placebo over a period of 25 weeks. All of them were screened for current or prior psychological problems. One subgroup was engaged in weight training but had no prior history of steroid use. A second subgroup had no train- ing experience and had not used steroids. A third group reported a history of steroid use but had refrained from any use for a minimum of three months prior to the beginning of the study.
The results showed that, on average, testosterone signif- icantly increased manic behavior and feelings of aggressive- ness, but the individual reactions were quite variable. Only 8 of the 50 men in the study showed any mood changes at all. Two of them showed marked symptoms. One of these
with human chorionic gonadotropin (HCG), a hormone that ordinarily stimulates the testes to secrete testosterone. In theory, this strategy can work, but the dosages have to be carefully controlled, something that self-medicating ath- letes are unlikely to do. Repeated HCG treatments actually can have the opposite effect from the one that is intended, making matters worse rather than better. In addition, HCG itself has its own adverse effects, including headaches, mood swings, depression, and retention of fluids.11
Among women taking anabolic steroids, the dramatically increased levels of testosterone in bodies that normally have only trace amounts produce major physiological changes, only some of which return to normal when steroids are with- drawn. Table 13.2 lists the major reversible and irreversible effects among women.
Effects on Other Systems of the Body Given the fact that the liver is the primary mechanism for clearing drugs from the body (see Chapter 4), it is not sur- prising that large doses of anabolic steroids take their toll on this organ. The principal result is a greatly increased risk of developing liver tumors. The types of liver tumors that are frequently seen in these circumstances are benign (non- cancerous) blood-filled cysts, with the potential for causing liver failure. In addition, a rupture in these cysts can produce abdominal bleeding, requiring life-saving emergency treat- ment. Fortunately, these liver abnormalities are reversible when steroids are withdrawn from use.
There is evidence from animal studies that increased steroid levels in the body can produce high blood pressure and high cholesterol levels, as well as heart abnormalities. In human studies, chronic steroid abuse has been associ- ated with an increased risk of cardiovascular disease. There are documented cases of heart-related sudden death among athletes who have been steroid users, even though there was no history of illness or any family history that would predis- pose them to heart trouble. Cardiac abnormalities such as enlargement of the left ventricle are not reversible when steroid use is discontinued.12
Whether or not aided by performance-enhancing drugs, massive development of musculature continues to be a prized asset in competitive body building.
Table 13.2
Reported side effects of anabolic steroids in ten women
eFFeCT
NUMbeR RePORTING THe eFFeCT
ReVeRSIble aFTeR eND
OF USe
Lower voice 10 no
Increased facial hair 9 no
Enlarged clitoris 8 no
Increased aggressiveness 8 yes
Increased appetite 8 unknown
Decreased body fat 8 unknown
Diminished or stopped menstruation
7 yes
Increased sexual drive 6 yes
Increased acne 6 yes
Decreased breast size 5 unknown
Increased body hair 5 no
Increased loss of scalp hair 2 no
Note: The ten women were all weight-trained athletes.
Sources: Based on information from Strauss, Richard H.; and Yesalis, Charles E. (1993). Additional effects of anabolic steroids in women. In Charles E. Yesalis (Ed.), Anabolic steroids in sport and exercise. Champaign, IL: Human Kinetics Publishers, pp. 151–160. Strauss, Richard H.; Ligget, M. T.; and Lanese R. R. (1985). Anabolic steroid use and perceived effects in ten weight-trained women athletes. Journal of the American Medical Association, 253, 2871–2873.
Chapter 13 Performance-Enhancing Drugs and Drug Screening Tests ■ 261
Patterns of Anabolic Steroid Abuse
In 1990, as a response to increasing awareness of the abuse of anabolic steroids both in and outside of competitive sports, Congress passed the Anabolic Steroid Control Act, reclassifying anabolic steroids as Schedule III controlled substances. Jurisdiction was transferred from the Food and Drug Administration (FDA) to the Drug Enforcement Administration (DEA). As a result of this legislation, pharma- cies are permitted to fill anabolic-steroid prescriptions only up to a maximum of five times. Penalties for violating the law can result in a five-year prison term and a $250,000 fine for illegal nonmedical sales, and a one-year term and a $1,000 fine for nonmedical possession. Penalties are doubled for repeated offenses or for selling these drugs to minors. States are permitted to draft their own laws regarding the defini- tion of anabolic steroids and to set sentencing guidelines for steroid offenders. Although most states follow the federally mandated Schedule III classification, New York lists steroids in Schedule II, while other states have their own classifica- tion systems. In some states, possession of small quantities of steroids is regarded as a misdemeanor; other states regard it as a felony. In most but not all states, first-time offenses do not result in imprisonment, unless there are aggravating circum- stances, such as possession of large quantities or evidence of intent to sell or distribute the drugs.16
Despite the regulations now in effect, steroid abuse today remains a major problem. Steroid distribution has become an enormous black-market enterprise. With their use commonly referred to as being “on the juice,” these drugs are channeled
men experienced an aggressive outburst at work and, on one occasion, reacted to being cut off in traffic by follow- ing the person in his car for several miles. The other man developed extreme euphoria and reported a decreased need for sleep. Six other study participants showed more moder- ate changes. One man in this category found himself want- ing to beat up his opponent in a college sports competition, even though he had never had such aggressive feelings before in the course of a game. All of the other participants in the study showed minimal or no effects and in no case was there an incident of actual violent behavior. Neither previous steroid use nor regular weight training was associ- ated with the symptoms observed in the men responding to testosterone.
Because the study used a double-blind design, neither the experimenters nor the men being studied knew whether they were being injected with testosterone or a placebo (see Chapter 4); half of the men started with the active drug condition, and half started with the placebo condition. Therefore, in interpreting the results, we can eliminate any possible influences of expectations and preconceptions about what different behaviors and experiences might result from anabolic steroids. On the basis of this information, mood changes and aggressiveness seem genuinely to result from an elevation in testosterone levels, although the reactions of people taking anabolic steroids are far from uniform. It has been estimated, by extrapolating from the available research literature, that somewhere between 2 and 20 percent of men will develop mood-related psychological problems from ana- bolic steroid use.
However, it is important to realize that experimental studies underestimate the extent of the phenomenon in the real world. In the study reported here, ethical considerations required that the dosage of testosterone was no more than 600 milligram per week. In actual practice, steroid abusers often take drugs that boost testosterone to as much as 1,000 to 1,500 milligram per week—levels that far exceed those that can be safely studied in the laboratory. As a consequence, the per- centage of individuals developing significant mood changes and behavioral problems is likely to be much higher, and the changes and problems themselves can be expected to be sub- stantially greater.14
Special Problems for Adolescents During puberty, a particularly crucial process among boys is growth of the long bones of the body, which results in an increase in height. Anabolic steroids suppress growth hor- mones; as a result, muscular development is enhanced but overall body growth is stunted. Among girls, testosterone- related drugs delay the onset of puberty, making the body shorter, lighter, and more “girl-like,” while enhancing the user’s overall strength. On a psychological level, feelings of euphoria and aggression that adolescents experience while using anabolic steroids can be replaced by lethargy, loss of confidence, and depression when these drugs are discontinued.15
Quick Concept Check
Understanding the Effects of Anabolic Steroids Check your understanding of the effects of anabolic steroids by indicating whether the following conditions can be attributed to steroid use.
1. Severe acne on the lower extremities of the body
2. Increased aggressiveness and mood swings
3. Premature balding in men
4. Increased development of the testicles
5. Enlarged breasts (gynecomastia) among women
6. Accelerated growth in adolescents around the time of puberty
Answers: 1. no 2. yes 3. yes 4. no 5. no 6. no
13.1
262 ■ Part Three Legally Restricted Drugs and Criminal Justice
with 1.5-inch needles (called “darts” or “points”), are painful and inevitably leave scars. If these needles are shared, as they frequently are, the risk of hepatitis or HIV contamination is significant.
Steroid abusers often follow a pattern called cycling, in which steroids are taken for periods lasting from 4 to 18 weeks, the “on” periods being separated by “off” periods of abstinence. Unfortunately, when the drugs are withdrawn, the newly devel- oped muscles tend to “shrink up,” throwing the abuser into a panic that his or her body is losing the gains that have been achieved. In addition, abstinence from steroids can lead to signs of depression, such as problems sleeping, lack of appetite, and general moodiness. All these effects encourage a return to steroids, frequently in even larger doses, and generate a craving for the euphoria that the person felt while on them.
A variation of the cycling pattern is the practice of pyramiding. An individual starts with low doses of steroids, gradually increases the doses over several weeks prior to an athletic competition, and then tapers off entirely before the competition itself in an attempt to escape detection during drug testing. However, pyramiding leads to the same problems during abstinence and withdrawal as cycling, except that the symptoms occur during the competition itself.
A major problem associated with steroid abuse is the potential for an individual to believe that his or her physique will forever be imperfect. In a kind of “reverse anorexia” that has been called muscle dysmorphia, some body builders continue to see their bodies as weak and small when they look at themselves in the mirror, despite their greatly enhanced physical development. Peer pressure at the gyms and clubs is a factor in never being satisfied with the size of one’s mus- cles, but it is becoming apparent that societal pressures play a role as well. In the case of males, it is interesting to examine the evolution of the design of G.I. Joe action figures over the years, from the original toy introduced in 1964 to the most recent incarnation introduced in 1998 (Table 13.3). Just as
principally through people associated with body-building gyms and through Internet Web sites that frequently change a company’s name and location in an effort to stay one step ahead of the law. Some Internet-based suppliers include a warning on their Web sites, “Due to their profound effects and potencies, it is recommended to seek the guidance of a physician prior to use,” to protect themselves from liability, although few if any customers would voluntarily divulge their steroid abuse, much less seek medical guidance.
In 2013, the University of Michigan survey reported that between 1 and 2 percent of eighth graders, tenth graders, and high school seniors had used anabolic steroids in their life- time. Less than 1 percent of college students and between 1 and 2 percent of young adults had done the same.17
The Potential for Steroid Dependence
Some anabolic steroids can be taken orally and others through intramuscular injections, but abusers often adminis- ter a combination of both types in a practice called stacking. Hard-core abusers may take a combination of three to five dif- ferent pills and injections simultaneously, or they may con- sume any steroid that is available (“shotgunning”), with the total exceeding a dozen. In addition to the complications that result from so many different types of steroids being taken at the same time, multiple injections into the buttocks or thighs,
muscle dysmorphia (dis-MORF-ee-ah): The perception of one’s own body as small and weak and of one’s musculature as inadequately developed, despite evidence to the contrary. Also known as megorexia, the condition of muscle dysmorphia is a form of body dysmorphic disorder.
TABLE 13.3
Promoting Muscular Development in the Marketing of an Action Figure: The Evolution of G.I. Joe (1964 to 1998) – with a Comparison to Mark McGwire in 1998
YEAR OF INTRODUCTION GENERAL
APPEARANCE
BICEPS CIRCUMFERENCE (ExTRAPOLATED TO A 6-FOOT TALL MAN)
1964 Relatively normal chest and body proportions, no weapon
12.2 inches
1974 Chest and body “bulked up” with a “Kung-fu grip” 15.2 inches
1994 Named Gung-Ho, the ultimate Marine, with mous- tache and tattoo
16.4 inches
1998 Named G.I. Joe Extreme with grenade launcher 26.8 inches
Mark McGwire MLB first-baseman, 70 home runs in 1998, an all-time single-season record (until Barry Bonds hit 73 home runs in 2001)
20.0 inches
Sources: Based on information from As G.I. Joe bulks up, concern for the 98-pound weakling (1999, May 30). New York Times, p. D2.
Chapter 13 Performance-Enhancing Drugs and Drug Screening Tests ■ 263
approach is taken because a failure to acknowledge potential benefits reduces the credibility of the intervention.
Evaluations of the ATLAS program have shown that program participants were better informed than a control group about proper exercise, had a better understanding of the harmful effects of steroids, developed a more negative attitude toward others who used steroids, and were more likely to engage in healthful eating habits. They also showed a 53 percent reduction in new use of anabolic steroids after one year, as well as a 63 percent reduction in the intention to use these drugs in the future. Another prevention and educa- tion program originating at the Oregon Health and Science University, called Athletes Targeting Healthy Exercise and Nutrition Alternatives (ATHENA), is specifically oriented toward female athletes, addressing issues such as the connec- tion between disordered eating behaviors and use of body- shaping and performance-enhancing drugs. The program promotes healthful sports nutrition and strength-training alternatives, as well as the training needed to make healthy choices in sports and throughout their lives.20
Counterfeit Steroids and the Placebo Effect As with many illicit drugs, some products marketed to look like anabolic steroids are not the real thing. The problem here is that athletes are notoriously superstitious and easily
the Barbie doll has been criticized as setting an impossible ideal for the female body among girls, male-oriented action figures can be criticized on the same basis for boys.18
Traditional estimates of substance dependence among steroid users range from 13 to 18 percent, but more recent studies indicate that the prevalence rate may be somewhat higher. In an Internet survey, about one in four weight lifters and body builders using steroids have reported that they were taking larger amounts of steroids over a longer period of time than originally intended, that they needed increased amounts of steroids to achieve the desired effect, or that they experi- enced physical or emotional problems when steroids were discontinued. One in eight admitted that they had resumed steroid use to relieve a problem that occurred when they stopped (Help Line). By the present-day DSM-5 guidelines (see Chapter 4), about one-third of them would meet the cri- teria for moderate to severe substance use disorder.19
In light of the potential for steroid dependence and the adverse effects of acute steroid use, prevention programs have been instituted to address the problems of steroid abuse, par- ticularly among male adolescents involved in sports. The most prominent example, developed by Linn Goldberg at Oregon Health and Science University at Portland, is called the Adolescents Training and Learning to Avoid Steroids (ATLAS) program. Young athletes, team coaches, and team captains receive instruction on both sides of the issue—the desirable effects and the adverse effects of steroid use. This
Help Line The Symptoms of Steroid Abuse
For Both Sexes 1. Rapid increases in strength and/or size beyond what you
would expect in a relatively short time; putting on 10 to 20 pounds of solid muscle within a period of a few weeks or so should be a major warning
2. Involvement in activities in which steroid abuse is known to be condoned or encouraged
3. Sudden increases in appetite and preoccupation with changes in one’s physical condition
4. Recent appearance of acne, particularly on the upper back, shoulders, and arms
5. Premature male-pattern baldness, including a rapidly receding hairline or loss of hair from the top rear of the head
6. A puffy appearance in the face, as if the individual is retaining water
7. An increase in moodiness or unusual shifts in mood 8. A reddening of the face, neck, and upper chest, appearing
as if one is constantly flushed 9. A yellowing of the skin or the whites of the eyes, stemming
from a disturbance in liver function
For Men 1. An enlargement of the breasts, often accompanied by
protruding nipples 2. An increase in sexual interest and a tendency to display
that interest more aggressively
For Women 1. A lowering of the vocal range 2. Smaller or flatter breasts (see Table 12.1)
Where to go for assistance www.nida.nih.gov/Infofacts/Steroids.html www.steroidabuse.gov
The National Institute on Drug Abuse sponsors a vast array of Web sites related to drug use and abuse. The first Web site on steroid abuse includes a comprehensive list of potential adverse effects of anabolic steroids; the second Web site emphasizes issues of prevention and education.
Source: Wright, James E.; and Cowart, Virginia S. (1990). Anabolic steroids: Altered states. Carmel, IN: Benchmark, pp. 71–91.
264 ■ Part Three Legally Restricted Drugs and Criminal Justice
the abuse potential of this hormone in professional sports. It is doubtful, however, that its reputation for performance enhancement is justified, according to a major review of more than 40 studies of hGH in healthy athletes, conducted between 1966 and 2007. The conclusion is that hGH use increases lean body mass, but the increased bulk does not raise levels of strength or endurance. Indeed, hGH produces higher levels of lactate in muscle tissue, leading to fatigue; hGH users are more likely than others to develop joint pain and carpal tunnel syndrome. In the absence of scientific evi- dence of any performance-enhancing effects, it has been sug- gested that reports by athletes that hGH helped to increase their athletic performance are probably due to a placebo effect. Nonetheless, despite hGH’s dubious value, hGH screening, capable of differentiating naturally produced hGH from synthetic hGH, became a fixture of drug testing at the 2008 Summer Olympic Games in Beijing. Because hGH has a relatively short half-life, athletes tested positive only if the drug had been injected in the previous 12–24 hours. No major hGH-related scandals occurred in the 2010 Winter Olympic Games in Vancouver.22
Dietary Supplements as Performance-Enhancing Aids
As recently as 10 years ago, fitness-oriented young people might have taken only basic vitamins and minerals to help them build muscle mass or improve cardiovascular perfor- mance. Today, the fitness market is inundated with a grow- ing number of dietary supplement products with presumed performance-enhancing properties; sales of such products exceed $2 billion each year in the United States. They are sold under short, appealing names such as Adenergy and Lean Stack, alongside impressive before-and-after photo- graphs, or under long, pseudoscientific names like Vaso XP Xtreme Vasodilator and Xenadrine-NRG that are accompa- nied by complex molecular diagrams. An advertisement for Aftermath, for example, promises to help “swell your muscles to grotesque size” and eliminate the chances of “dooming yourself to girly man status.”23
A prominent example of a dietary supplement used for performance-enhancing purposes is androstenedione. Technically, androstenedione is not an anabolic steroid because it is not based on the specific structure of testoster- one itself. Nonetheless, it is testosterone related because it is a naturally occurring metabolic precursor to testosterone. In other words, the body converts androstenedione to tes- tosterone via the action of specific enzymes in the liver. At the recommended daily dose of 300 milligram, androstene- dione has been found to increase testosterone levels by an average of 34 percent above normal. Despite the increase in testosterone, however, no change in body composition or strength is observed when its effect is compared to that of placebo controls. There is no evidence that androstenedione promotes muscle protein synthesis at these dosage levels.24
leave themselves open to placebo effects. On the one hand, in the case of anabolic steroids, the effects on muscle develop- ment are usually so dramatic that it is difficult to mistake the response as simply a result of a placebo effect. On the other hand, some performance-enhancing drugs have far more subtle effects, and psychological factors can end up playing a greater role. In relating his own experience with steroids, MLB superstar Alex Rodriguez spoke of the placebo effect:
I’m not sure what the benefit was … I will say this: when you take any substance, especially in baseball, it’s half mental and half physical. If you take this glass of water and say you’re going to be a better baseball player, if you believe it, you probably will be. I certainly felt more energy, but it’s hard to say.21
Nonsteroid Hormones and Performance-Enhancing Supplements
Certainly anabolic steroids have dominated the performance- enhancing drug scene, but other products have been promoted as having performance-enhancing properties. They include human growth hormone, androstenedione, and creatine.
Human Growth Hormone One illicit alternative, human growth hormone (hGH), has become increasingly popular, according to experts in this field, because it is more widely available and cheaper than in previous years, in contrast to the evermore costly illicit steroids. Those who take this pituitary hormone, however, face the increased risk of developing a significant side effect called acromegaly, a condition resulting in a coarse and misshapen head, enlarged hands and feet, and damage to various internal organs.
Prior to 1985, hGH was obtained from the pituitary glands of human cadavers, but now genetically engineered hGH (brand names: Protropin and Humatrope) is available, having been approved by the FDA for the treatment of rare cases of stunted growth in children. Although the distribution of these drugs is controlled by their manufacturers as care- fully as possible, supplies manage to get diverted for illicit use.
Testimony in 2008 that prominent MLB players had used hGH for performance-enhancing purposes revealed
androstenedione (AN-dro-steen-DYE-own): A dietary supplement, acting as a metabolic precursor to testosterone and used as an ergogenic agent.
acromegaly (A-kroh-MEG-ah-lee): A condition resulting in structural abnormalities of the head, hands, and feet, as well as damage to internal organs.
human growth hormone (hGH): A naturally occurring hormone promoting growth, particularly in the long bones of the body.
Chapter 13 Performance-Enhancing Drugs and Drug Screening Tests ■ 265
were officially banned from MLB in 2005, but before that time, amphetamine use may have been a mainstay for players to stay focused and ward off fatigue in a gru- eling and lengthy competitive season. According to a professional baseball team psychiatrist, testifying in con- gressional hearings in 2008, “Amphetamines are the real performance-enhancing drugs that people should always have been worried about.”
It is therefore not surprising that since 2005, some play- ers have attempted to circumvent the amphetamine ban by taking Adderall (see Chapter 10), a medication for the treat- ment of attention-deficit/hyperactivity disorder (ADHD). In 2007, 103 therapeutic-use exemptions for ADHD were approved for MLB players—a suspiciously high number considering that only 28 players received such approval in 2006. Whether these exemptions reflected a fourfold increase in the incidence of ADHD symptoms over a single year or an effort to benefit from the performance-enhancing effects of stimulant drugs, without violating the amphet- amine ban, continues to be a matter of concern to MLB management as well as baseball fans. From 2007 to 2013, the number of ADHD exemptions for Adderall use was steady at about 110 cases each year. The number of ADHD cases represented about 9 percent of the MLB player community, more than twice the national prevalence for ADHD (4%) among adults in the general population (Drugs … in Focus on page 266).27
Current Drug-Testing Procedures and Policies
Since the mid-1960s, organizers of major athletic com- petitions have attempted to develop effective screening procedures to prevent the use of performance-enhancing drugs from giving one competitor an unfair advantage over another. Needless to say, these procedures have neither proved perfect nor served as an effective deterrent for drug use among athletes. We are used to hearing about cham- pionship events accompanied by reports of an athlete dis- qualified from competing or denied the honor of winning because he or she tested positive for a particular banned substance. Ironically, the present status of drug testing as a fact of life in modern sports has brought with it a new form of contest, pitting the skill and ingenuity of the lab- oratory scientist whose job it is to detect the presence of performance- enhancing drugs against the skill and ingenu- ity of the athlete in devising ways to use them without detec- tion (Drug Enforcement … in Focus on page 267).28
Androstenedione rose to prominence in the late 1990s when it became public that St. Louis Cardinals baseball player Mark McGwire had been taking the supplement during his phenomenal 1998 hitting season (70 home runs, far eclipsing the historic record set by Babe Ruth in 1927). A storm of controversy ensued, with some commentators suggesting that McGwire’s record be disallowed because of his androstenedione use. Although it had been banned by the National Football League and other professional and amateur sports organizations, androstenedione had not yet been banned in MLB at that time, so McGwire’s use of it was not illegal. The publicity surrounding McGwire’s use of androstenedione and its easy availability were blamed for a 30 percent increase among eighth-grade boys and a 75 percent increase among tenth-grade boys in the use of ana- bolic steroids from 1998 to 2000.
In 2005, the FDA banned the over-the-counter sale of androstenedione (Andro) and other testosterone precur- sors. By this time, the Anabolic Steroid Control Act of 2004 had expanded the Schedule III of controlled substances to include androstenedione and other testosterone precursors, along with anabolic steroids themselves. In early 2010, it was disclosed that androstenedione had not been the only performance- enhancing drug in McGwire’s life. He admit- ted what had been suspected for some time: that during the 1990s he had used anabolic steroids, as well. McGwire has denied that his home-run record-breaking achievements could be attributed to steroid use, but it will never be known whether the performance-enhancing drugs he took did indeed enhance his performance.25
Another dietary supplement marketed as a performance- enhancing agent is creatine (brand names: Creatine Fuel, Muscle Power, and many other products), a nonprotein amino acid synthesized in the kidney, liver, and pancreas from l-arginine, glycine, and l-methionine. Ingestion of cre- atine has been found to enhance the retention of water by muscle cells, causing them to expand in size. One hypoth- esis is that water retention might stimulate protein synthesis and increase muscle mass as a result, but there is no evidence from controlled studies that this is the case. Although creatine appears to enhance performance in repetitive bouts of high- intensity cycling and sprints, the weight gain experienced by creatine users makes it undesirable for runners or swimmers. Short-term use of creatine has been found to produce muscle cramping, and its long-term adverse effects have not been fully explored.26
Nonmedical Use of Stimulant Medication in Baseball
Earlier in the chapter, we cited nineteenth-century exam- ples of world-class athletes experimenting with stimulants in attempts to achieve some level of performance enhance- ment in their sport. More than a century later, stimulants have continued to be an attractive option. Amphetamines
creatine (CREE-ah-teen): A dietary supplement available for ergogenic uses.
266 ■ Part Three Legally Restricted Drugs and Criminal Justice
The Forensics of Drug Testing The typical drug-testing process begins with a urine sample from the individual in question. The advantages lie in the ease and noninvasiveness of collecting urine, the ease with which urine can be analyzed for specific factors, and the fact that drugs or their metabolites (by-products) are usually very stable in frozen urine. Therefore, it is possible to provide long-term storage of positive samples, in case the test results are disputed. The disadvantages are that many perceive urine collection to be a humiliating experience, a dehydrated ath- lete may find it difficult to urinate immediately after compet- ing, and there may be ways to tamper with the urine sample prior to testing.
The two major urinalysis methods are the enzyme immunoassay (EIA) technique and a procedure combining gas chromatography and mass spectrometry (GC/MS). In both methods, the collected urine is divided into two sam- ples prior to being sent off to the laboratory so that if the analysis of one sample yields a positive outcome, the analysis can be repeated on the other sample. This reanalysis proce- dure is often required if an individual appeals the original test result.29
With the EIA method, a separate test must be run on each particular drug that is being screened. First, at an earlier
This section looks at drug-testing techniques designed to detect not only performance-enhancing drugs that are rel- evant to sports but also a wider range of illicit drugs, such as amphetamines, heroin, cocaine, and marijuana. Within some sports organizations, such as the National Collegiate Athletic Association (NCAA), drug tests are conducted not only for the presence of performance-enhancing drugs but also for the presence of drugs that have no particular performance-enhancing benefits. In the case of marijuana, for example, the proper description for its effects with regard to athletic competitions might be ergolytic (“performance- reducing”). The policy is defended on the premise that athletes are likely to be exposed to illicit substances, and no collegiate athlete should be permitted to compete while engaging in illegal activity.
ADHD/ADD Exemption Requirements for the Use of Adderall in Sports The following requirements are necessary to be exempt from the ban on Adderall use in competitive sports on the basis of being treated for ADHD or ADD: • National Football League (NFL): A physician must fill out
an exhaustive diagnostic form documenting the presence of lifelong impairments, and childhood history must be confirmed by a physician or health care provider who treated the player as a child. An independent expert in ADHD/ADD is required to confirm the diagnosis. Exemptions must be renewed each year.
• Major League Baseball (MLB): A diagnosis of ADHD or ADD must be made by an MLB-certified clinician. If a diagnosis is not made, the case is referred to the MLB Expert Panel on ADHD/ADD, which can request addition information or tests before issuing the exemption.
• National Basketball Association (NBA): Players can apply for an exemption with the medical director of the NBA Anti-Drug Program.
• National Hockey League (NHL): A player must apply to the NHL Program Committee for a review of the application and approval to grant an exemption. Applications must be renewed annually.
• National Collegiate Athletic Association (NCAA): The student-athlete must show proof of an earlier ADHD/ADD diagnosis and course of treatment, or undergo an assessment through the university in order to receive an exemption The athletic administration maintains the player’s record in the event of a positive drug test.
• United States Anti-Doping Agency/Olympic Sports: The athlete’s physician must submit a sport-specific application and provide supporting documentation of ADHD or ADD. Submissions are received by organizers of the event in which the athlete is preparing to compete.
Source: Swieca, Caitlin (2013, September 10). NFL, other leagues deal with players’ use of amphetamine Adderall. Denver Post. http://denverpost.comn/.
Drugs … in Focus
gas chromatography/mass spectrometry (GC/MS): A drug-testing technique based on the combination of gas chromatography and mass spectrometry.
enzyme immunoassay (EIA): One of the two major drug- testing techniques for detecting banned substances or drugs.
Chapter 13 Performance-Enhancing Drugs and Drug Screening Tests ■ 267
for EMIT, the method I is available on a “generic basis” by several drug testing companies.
With the GC/MS method, the urine is first vaporized and combined with an inert gas and then passed over a number of chemically treated columns. Through the process of gas chro- matography, technicians are able to identify the presence of a banned substance by the different colorations that are left
time, the substance to be tested for (THC or cocaine, for example) has been injected into an animal, eliciting specific immunological antibodies to that substance. The antibodies are then purified into a testing substrate. The combination of the collected urine and the testing substrate will yield a specific reaction if the urine contains the banned substance. A popular commercial testing kit for screening major con- trolled substances (opioids, amphetamines, cocaine, ben- zodiazepines, and marijuana), called enzyme multiplied immunoassay technique (EMIT), has been marketed by Siemens Healthcare since the early 1970s. This kit is rela- tively inexpensive and can be used to screen large numbers of urine samples. Since the expiration of the original patent
Pharmaceutical Companies and Anti-Doping Authorities in Alliance Through the years of scandals involving performance-enhancing drugs, while the World Anti-Doping Agency (WADA) engaged in a continuing and often frustrating game of “cat and mouse” with competitive athletes, major pharmaceutical companies for the most part remained on the sidelines. Now it appears that they are getting increasingly in the game.
A case in point is the medication erythropoietin, marketed in its natural form as Epogen (Amgen Pharmaceuticals) or in synthetic forms as Aranesp (Amgen) and NeoRecorman (Roche Pharmaceuticals). On the one hand, erythropoietin (also known as EPO) is an effective hormonal treatment for millions of anemia patients who suffer from a deficiency in production of red blood cells in bone marrow. On the other hand, the use of EPO for its performance-enhancing (red blood cell– boosting) effect in normal individuals, particularly trained athletes, is clearly a form of cheating, a classic example of “doping.” Prominent headlines regarding accusations and later confirma- tion of EPO use by world champion cyclist Lance Armstrong (see Portrait on page 257) are a public relations nightmare of sorts for those manufacturing EPO-related drugs. Would the public now associate a valuable medicinal agent with the dark world of doping? Even worse, would some people accuse these companies of developing drugs that could be misused by athletes essentially as a way of enhancing sales?
In a major gesture of good “corporate citizenship,” GlaxoSmithKline Pharmaceuticals sponsored the drug-testing laboratories for the 2012 London Summer Olympic Games, carrying the costs for the facilities and the more than 1,000 staff involved in drug screening. It was the first time in Olympic history that an anti-doping operation had a specific corporate sponsor. But the relationship between pharmaceutical com- panies and international anti-doping efforts has gone beyond simply the contribution of financial support. Two major
manufacturers, Glaxo and Hoffman-LaRoche, are now evaluat- ing every new drug candidate in their development pipeline for potential abuse as a performance-enhancing drug. Customarily, when developing a new drug, a number of reagents are also created in company laboratories that react to the molecular structure of the drug. These reagents remain proprietary compounds, and information about them is kept secret. These particular companies took the unusual step of sharing the reagents with WADA, since it is precisely those reagents that can be “markers” for future drug screening tests.
The actions of Glaxo and Roche are not entirely new. Amgen, for example, was asked by WADA officials to help develop a screening test for Aranesp, released for marketing in 2001, in anticipation of possible doping incidents in the 2002 Salt Lake City Winter Olympic Games. However, not all pharmaceutical companies have been as eager to cooperate with anti-doping authorities in this regard. There remains some reluctance on the part of companies in releasing proprietary information in such a highly competitive business as pharma- ceuticals. Nonetheless, there is an increasing awareness that the benefits outweigh the costs.
It must be pointed out that performance-enhancing drugs are also being developed in illicit laboratories around the world, having contacts with athletes in nations that have less strict control over doping than the United States. These laboratories work in the shadows of competitive athletics and have little or no incentive to cooperate with WADA or any other anti-doping agency (see Chapter 2).
Sources: Salyer, Kirsten (2012, July 18). At London Games, a new record for doping tests. Bloomberg Businessweek, http://www .businessweek.com/articles/2012-07-18/at-london-games-a-new- record-for-doping-tests#p2. Thomas, Katie (2013, February 19). An unexpected drug reaction. Manufacturers increasing join the fight against doping. New York Times, pp. B1, B4.
Drug Enforcement … in Focus
EMIT (enzyme multiplied immunoassay technique): A commercial testing kit for screening for major controlled substances, based on enzyme immunoassay analysis.
268 ■ Part Three Legally Restricted Drugs and Criminal Justice
on the columns. After this has been done, the gas is ionized (converted into an electrically active form) and sent through an electric current and magnetic field that separates out each of the different ions (electrically charged particles) in the gas. Through the process of mass spectrometry, a particular “fin- gerprint,” or “signature,” of each chemical substance can be detected and measured. The GC/MS technique is considered more definitive than the EIA technique, but it is considerably more expensive and time consuming. It is also the only testing procedure that adequately screens for anabolic steroids.30
Until the late 1990s, urinalysis was the sole means for drug testing. Since then, there has been increasing interest in oral fluid testing. In this procedure, a collection pad is placed between the lower cheek and gum for two to five min- utes. The collection pad is then sealed and later analyzed by EIA. The sensitivity and specificity of the results (see the next section) are comparable to those obtained through urinalysis. As with positive urinalysis tests, a confirmation of positive oral fluid results is made by GC/MS.
Currently available FDA-approved drug-testing sys- tems using oral fluid samples can now provide test results in approximately 15 minutes. The advantages over traditional urinalysis are obvious. Samples are analyzed on-site rather than having to be sent to laboratories. Specimen collection can be performed face-to-face (literally) with the donor, with little risk of sample substitution, dilution, or adulteration. Embarrassment on the part of the donor is eliminated, as are privacy concerns.31
Sensitivity and Specificity in Drug Testing For any drug-testing procedure to be valid for the detection of a performance-enhancing drug, two essential questions need to be asked:
●■ What is the sensitivity of the test? The sensitivity is deter- mined by the likelihood that a specimen containing drugs (or drug metabolites) will test positive. This outcome is re- ferred to as a “true positive.” If a drug test has a high degree of sensitivity, then there will be very few “false negatives.” If a test is sensitive, the subject will seldom test negative when drug-taking behavior has actually occurred.
●■ What is the specificity of the test? The specificity is determined by the likelihood that a drug-free (or drug metabolite-free) specimen will test negative. This out- come is referred to as a “true negative.” If a drug test has a high degree of specificity, then there will be very few “false positives.”
In other words, sensitivity indicates the ability of the test to correctly report the presence of drugs. Specificity indicates the ability of the test to correctly report the absence of drugs. In this regard, the GC/MS test is more sensitive and specific than the EIA test (Drugs … in Focus).
As mentioned earlier, a GC/MS analysis is typically performed as a confirmation of a positive EIA test result.
Typical Urine Specimen Drug Screening Tests
Drugs … in Focus
9-Panel Testing
Drug Class Examples EIA Screen Cutoff GC/MS Confirmation Cutoff
Amphetamines Amphetamine 1,000 ng/ml** 500 ng/ml Methamphetamine
Cocaine metabolite 300 ng/ml 150 ng/ml
Marijuana metabolite 50 ng/ml 15 ng/ml
Opioids Morphine 2,000 ng/ml 2,000 ng/ml Oxycodone
Phencyclidine (PCP) 25 ng/ml 25 ng/ml
Barbiturates Phenobarbital 300 ng/ml 300 ng/ml
Amobarbital
Benzodiazepines Xanax 300 ng/ml 200 ng/ml Ativan
Methadone 300 ng/ml 200 ng/ml
Propoxyphene Darvon 300 ng/ml 200 ng/ml Darvocet
Chapter 13 Performance-Enhancing Drugs and Drug Screening Tests ■ 269
false-negative result in drug testing. However, suspiciously high levels of epitestosterone can now be detected by GC/ MS techniques, so this form of manipulation is no longer successful.33
Pinpointing the Time of Drug Use It is important to remember that a positive result in a drug test indicates merely that the test has detected a minimal level of a drug or its metabolite. It is difficult to determine when that drug was introduced into the body or how long the drug- taking behavior continued. In the case of urinalysis testing, the time it takes for the body to get rid of the metabolites of a particular drug varies considerably, from a few hours to a few weeks (Table 13.4). In the case of oral fluid (saliva) drug testing, the window of detection may be different, depend- ing on the drug of interest. Opioids and cocaine are detected within two to three days of ingestion; THC in marijuana is detected within a period ranging from 1 hour after ingestion to 14 hours later. Because THC metabolites are excreted into the urine for several days or in some cases for several weeks, oral fluid testing for marijuana is better suited for determin- ing when marijuana has been last used. In effect, the “win- dow of detection” is narrower. If the interval between use and testing has been longer than 14 hours or so but shorter than a few days, urinalysis would pick up a positive result, but oral fluid testing would not.34
Owing to the expense of randomized drug-testing pro- grams, not every institution can afford the costs. Large corpo- rations may be able to budget for potentially thousands of tests for preemployment screening purposes, but relatively few col- leges and considerably fewer high schools are able to estab- lish the level of funding needed to test their student popula- tions. Even if the costs were lower, it is questionable whether illicit drug-taking behavior would be reduced in the long run
Nonetheless, false positives can occur even with the GC/MS test. Eating a poppy seed roll prior to drug testing or taking quinolone antibiotic medications such as ofloxacin (brand name: Floxin) and ciprofloxacin (brand name: Cipro), for example, has resulted in false-positive indications of opiate use. Therapeutic levels of ibuprofen (brand names: Advil, Motrin, and Nuprin, among others) have resulted in false- positive indications of marijuana smoking. In addition, the passive inhalation of marijuana smoke can leave sufficient levels of THC metabolites to result in false-positive indica- tions of marijuana smoking, although the density of smoke that needs to be present for this to happen makes it unlikely that individuals would be completely unaware that they were being exposed to marijuana.32
Masking Drugs and Chemical Manipulations Historically, two specific tactics have been employed to disguise the prior use of anabolic steroids so that the out- come of a drug test becomes, in effect, a false negative. The first strategy was to take the anti-gout drug probenecid (brand name: Benemid). Available since 1987, it masks the presence of anabolic steroids, but it is now on the list of banned substances for competitive athletes and is easily detected by GC/MS techniques. The second strategy was to increase the level of epitestosterone in the body. The standard procedure for determining the present or prior use of anabolic steroids is to calculate the ratio of testoster- one against the level of epitestosterone, a naturally occur- ring hormone that is usually stable at relatively low levels in the body. International athletic organizations now use the standard of a 4:1 ratio (formerly 6:1) or higher as indi- cating steroid use. If epitestosterone is artificially elevated, the ratio can be manipulated downward so as to indicate a
5-Panel Testing*
Drug Class Examples EIA Screen Cutoff GC/MS Confirmation Cutoff
Amphetamines Amphetamine 1,000 ng/ml 500 ng/ml Methamphetamine
Cocaine metabolite 300 ng/ml 150 ng/ml
Marijuana metabolite 50 ng/ml 15 ng/ml
Opioids Morphine 2,000 ng/ml 2,000 ng/ml Oxycodone
Phencyclidine (PCP) 25 ng/ml 25 ng/ml
*5-Panel Testing is federally mandated for employees in the U.S. government. The drugs screened are sometimes referred to as the “federal-five.”
**nanograms of metabolite per milliliter of urine.
Note: Special screening tests are available for other drugs, such as anabolic steroids, synthetic cathinones (so-called bath salts), and synthetic cannabinoids (so-called Spice or K2).
Source: Based on data from Quest Diagnostics, Madison, NJ, and Aegis Sciences Corporation, Nashville, TN.
270 ■ Part Three Legally Restricted Drugs and Criminal Justice
drugs: Individuals who are no longer students in a public institution or participants in an organized athletic program do not need to fear a positive drug test because they will never be required to undergo any form of drug testing, ran- dom or otherwise.
Drug Screening Testing in the Workplace
The workplace has been recognized as an important focus for substance-abuse prevention. According to statistics from the 2013 National Survey on Drug Use and Health, approxi- mately 69 percent of current illicit drug users 18 years or older were employed either full time or part time, as were 76 percent of persons reporting heavy alcohol use (see Chapter 15).36
The 1988 Drug-Free Workplace Act requires that all com- panies and businesses receiving any U.S. federal contracts or grants provide a drug-free workplace and specifically to estab- lish employee assistance programs (EAPs) in order to identify and counsel workers who have personal problems associated with substance abuse or dependence and to provide refer- rals to community agencies where these individuals can get further help. In addition, organizations must initiate a com- prehensive and continuing program of drug education and awareness. Employees must also be notified that the distribu- tion, possession, or unauthorized use of controlled substances is prohibited in that workplace and that action will be taken
as a result. Interestingly, recent evidence indicates that the prospect of randomized drug testing in schools fails to act as a deterrent among students. University of Michigan research- ers in 2003 found virtually identical rates of illicit drug use in schools that had drug-testing programs and schools that did not. This general finding was replicated in a study reported in 2008. The deterrent effect of drug testing on illicit drug use in schools clearly has not been demonstrated.35
It is also worth considering the following fact regard- ing abusers of steroids and related performance-enhancing
TABLE 13.4
Detection periods for various drugs in urinalysis testing
DRUG DETECTION PERIOD Alcohol 1–12 hours
Amphetamines in general 1–2 hours
Barbiturates
Short acting 2 days
Long acting 1–3 weeks
Benzodiazepines
Therapeutic use 3 days
Chronic use (>1 year) 4–6 weeks
Cocaine 2–4 days
Marijuana (THC)
Single use 2–7 days
Chronic, heavy use 1–2 months
MDMA (Ecstasy) 1–2 days
Methamphetamine 1–2 hours
Opioids
Codeine 2 days
Heroin or morphine 2 days
Darvon, Darvocet 6 hours to 2 days
Phencyclidine (PCP)
Casual use 14 days
Chronic, heavy use up to 30 days
Note: The detection periods for urinalysis purposes listed here are general guidelines, which might vary according to the sensitivity of the test or the subject’s physical condition, fluid balance, and state of hydration. Detection periods for hair samples are relatively longer and detection periods for blood or saliva samples are relatively shorter than for urine samples.
Sources: Based on information from Drugs of Abuse Reference Guide (2007). Occupational testing services, LabCorp, Research Triangle Park, NC. Verstraete, A. G. (2004). Detection times of drugs of abuse in blood, urine, and oral fluid. The Drug Monitor, 26, 200–205.
Quick Concept Check
Understanding Drug Testing Check your understanding of present-day drug-testing results by indicating whether the following statements are true.
1. EIA results are more sensitive than GC/MS results.
□ yes □ no
2. The anti-gout drug probenecid (Benemid) is an effective way of achieving a false-positive result.
□ yes □ no
3. The time of marijuana smoking is one conclusion that drug testing has great difficulty in determining.
□ yes □ no
4. Athletes are generally very cooperative in achieving the least number of false- negative outcomes.
□ yes □ no
5. Anabolic steroid screening is presently mandated by the International Olympic Committee for winners of Olympic events.
□ yes □ no
Answers: 1. no 2. no 3. yes 4. no 5. yes
13.2
employee assistance programs (EAPs): Corporate-based services designed to identify and counsel employees with personal problems that are connected to substance abuse or dependence and to provide referrals to community agencies where these individuals can get further help.
Chapter 13 Performance-Enhancing Drugs and Drug Screening Tests ■ 271
and reporting were carried out in an unreliable manner, or if it could not be shown that the presence of any one of the screened substances had a relationship to job impairment. In general, screening methods are not perfectly reliable, the handling of drug tests is not perfectly controlled, and the rela- tionship between drug use and a decline in job performance is not perfectly clear, but drug tests have nonetheless been judged to have met reasonable standards, and the practice is allowed. The bottom line is that drug testing, despite its obvi- ous infringements on individual privacy, has become a fact of life in corporate America.38
Nonetheless, despite the increasing acceptance of drug testing as a tool for drug-abuse prevention in the workplace, there will always be questions about the impact on workers themselves. For example, the possibility of false positives and false negatives can have unfortunate consequences, beyond the potential consequences of a competitive athlete. Consider this possible preemployment screening scenario:
Suppose that the EMIT test were 100 percent effective in spotting drug users (it is not) and that it has a false- positive rate of 3 percent (which is not unreasonable). In a group of 100 prospective employees, one person has recently taken an illegal drug. Since the test is 100 percent effective, that person will be caught, but three other peo- ple (the 3 percent false-positive rate) will also. Therefore, 75 percent of those who fail the test are innocent parties.39
Another problem is that companies are not required to fol- low up a positive EIA test result with another, more sensitive method, such as one using the GC/MS analysis. Some compa- nies allow for retesting in general, but most do not. Nonetheless, drug testing has been defended on the grounds that it functions as an effective deterrent among workers, because the likelihood is strong that illicit drug use will be detected.
The Social Context of Performance-Enhancing Drugs
Anabolic steroids and other performance-enhancing agents are quite different from many of the abused drugs covered in previous chapters in that they affect the way we look and how we compare to others, rather than the way we feel. Charles E. Yesalis, one of the leading experts in steroid abuse, has put it this way:
If you were stranded on a desert island, you might use cocaine if it were available, but nobody would use steroids. On a desert island, nobody cares what you look like and there is nothing to win. We are the ones who have made the deter- mination that appearance and winning are all important.
against any employee who violates these rules. Supervisors are advised to be especially alert to changes in a worker that might signal early or progressive stages in the abuse of alcohol and/ or other drugs. These signals include chronic absenteeism, a sudden change in physical appearance or behavior, spasmodic work pace, unexpectedly lower quantity or quality of work, partial or unexplained absences, a pattern of excuse making or lying, the avoidance of supervisors or coworkers, and on-the- job accidents or lost time from such accidents.
Nongovernmental organizations have since been encour- aged (but not required) by the Drug-Free Workplace Act of 1988 to establish EAP services as well. Thus, though they are not technically required to do so, steadily increasing numbers of American businesses have set up EAPs and are becoming committed to treatment as well as prevention. Traditionally, the emphasis in EAPs, as well as in union-supported member assistance programs (MAPs), has been on problems result- ing from alcohol abuse; this is understandable, given that alcohol abuse represents such a large proportion of substance abuse in general (Chapter 15). In recent years, EAPs and MAPs have expanded their services to focus on psychological problems that do not necessarily concern substance abuse.
By executive order of President Reagan in 1986, preem- ployment drug screening was mandated for all federal employ- ees, along with periodic, random drug testing afterward. (It is not known whether President Reagan or subsequent presidents have been included in this requirement.) However, federal statutes have not required drug testing for employees other than those working for the federal government. Nonetheless, about three out of four U.S. companies surveyed in 2011 reported that they conducted some form of preemployment drug testing. In 84 percent of cases in which drug testing was carried out, urine tests were employed. A majority of compa- nies with drug-testing programs reported some perceived ben- efits in reduced absenteeism, workers’ compensation claims, and increased worker productivity or performance.37
Although it is not difficult to understand the rationale for drug testing in the workplace, the procedure has raised a number of important issues regarding individual rights. Does taking a urine sample violate a person’s freedom from “unrea- sonable search and seizure” as guaranteed by the Fourth Amendment to the U.S. Constitution? It turns out that if the government requires it, the decision rests on the ques- tion of whether there is reasonable or unreasonable cause for the drug testing to occur. In cases in which a threat to public safety is involved, the cause has been ruled reason- able. However, if a private business requires it, the legal rights of employees are somewhat murky. An employee typically accepts his or her job offer with the assumption and agree- ment that periodic monitoring of drug use will take place, but whether this understanding is a form of implied coercion is an open question.
If a worker loses his or her job as a result of testing posi- tive in a drug test, has there been a violation of that individu- al’s to “due process” as guaranteed by the Fifth Amendment? The courts have ruled that this right would be violated only if the method of drug screening were unreliable, if the analysis
member assistance programs (MAPs): Corporate-based services similar to employee assistance programs (EAPs) that are sponsored and supervised by labor unions.
272 ■ Part Three Legally Restricted Drugs and Criminal Justice
As usual, Internet Web sites deliver mixed messages, pro- moting anabolic steroids as well as steroid precursors such as androstenedione with the promise “You’ll get huge!” while saying on the labels of their products that people younger than 18 should not take them or that they should consult a physician first.
We’re telling kids in our society that sports is more than a game. Until we change those signals, for the most part, we might as well tell people to get used to drug use.40
Unfortunately, there seems to be little reason to believe that the temptations to indulge in performance-enhancing drugs will go away anytime soon. Numerous surveys taken among young athletes and nonathletes alike indicate that the social signals are crystal clear, and they are more than willing to take up the challenge, despite the risks. Variations of the following question have been asked of them: “If you had a magic drug that was so fantastic that if you took it once you would win every competition you would enter, from the Olympic decathlon to Mr. Universe, for the next five years, but it had one minor drawback—it would kill you five years after you took it—would you still take the drug?” More than half of those polled have answered “yes” to this question.41
There is a more general sense of competition that goes beyond dreams of athletic achievement. It is apparent that an idealized body image is part of today’s standard for a sense of sexuality and social acceptance. This standard will not be news at all to women, but it is a fairly recent development in men. Anabolic steroids as a way of accelerating the effects of weight training are increasing in our culture. One high school senior has said, “The majority now are guys that don’t do it for sports. They do it for girls. For the look.” Another senior has remarked on a different kind of lifter in weight rooms and gyms: the vanity body builder. As he expressed it, “We notice a lot of kids now; they just want this certain type of body—with the abs and the ripped chest—and they want it quick.”42 Exercise physiologist David Pearson has remarked on the social pressures involved:
The teenage years are the skinniest and most awkward, and the idea of being the skinniest kid in the locker room is absolutely terrifying to a teenage boy.43
The pressure to be number one exists in all areas of athletic compe- tition. The intensity of competition in our culture, however, extends beyond the world of sports. Temptations to secure a competitive edge in the corporate world have led to a growing and disturbing acceptance of stimulant abuse as a means of keeping pace with increasingly rapid technologies for communication and business transactions.
Drug-Taking Behavior in Sports ●● The use of performance-enhancing (ergogenic) drugs in
athletic competition has a long history, dating from the original Olympic Games in ancient Greece.
●● In the modern era, the principal type of performance- enhancing drugs has been anabolic steroids. These syn- thetic drugs are all based on variations of the testosterone molecule.
●● Since the late 1980s, anabolic steroids have been popular with body builders as well as competitive athletes. This lat- ter group typically takes steroids in enormous quantities and administers them in a largely unsupervised fashion.
●● Recently, great concerns have been raised about the use of anabolic steroids, as well as other performance-enhancing drugs, in major league baseball.
The Hazards of Anabolic Steroids ●● The hazards of steroid use include liver tumors, mood
swings, and increased aggressiveness. ●● For men, the effects include lower sperm count, enlarge-
ment of the breasts, atrophy of the testicles, baldness, and severe acne. For women, masculinizing changes occur, some of which are reversible when steroids are withdrawn.
Patterns of Anabolic Steroid Abuse ●● Since 1990, anabolic steroids have been classified as
Schedule III controlled substances, making their posses- sion and sale without a specific medical prescription ille- gal. In 2004, steroid precursors were added to the category of Schedule III controlled substances. These drugs are now distributed through illicit black-market channels.
Summary
Chapter 13 Performance-Enhancing Drugs and Drug Screening Tests ■ 273
of exemption cases in MLB from 2007 to 2013 have been fairly steady at approximately 110 cases per year.
Current Drug-Testing Procedures and Policies ●● Drug-testing procedures, chiefly for those in organized
athletics, have become increasingly sophisticated in their ability to detect the presence of banned substances.
●● Two major techniques, based either on urine or on oral- fluid (saliva) samples, are enzyme immunoassay (EIA) and a combination of gas chromatography and mass spectrom- etry (GC/MS).
●● The ultimate goal of drug-testing procedures is to make it impossible to yield either a false-negative or false-positive result. A sensitive test yields few false negatives, and a spe- cific test yields few false positives.
●● Since 1986, the federal government has required pre- employment drug screening for all federal employees. About three out of four U.S. companies have preemploy- ment drug screening requirements, with the vast majority employing a urinalysis procedure
●● About 13–18 percent of individuals taking large doses of ste- roids develop both physical and psychological dependence.
Nonsteroid Hormones and Performance-Enhancing Supplements
●● Human growth hormone (hGH) is a nonsteroid hormone that has been used for performance-enhancing purposes.
●● Two dietary supplements, androstenedione and creatine, have been prominent recently as performance-enhancing aids.
Nonmedical Use of Stimulant Medication in Baseball ●● Although amphetamines were officially banned in major
league baseball (MLB) in 2005, for a long time players had been taking amphetamines to stay focused and ward off fatigue.
●● In 2007, an unusually large number of MLB players re- ported taking stimulant medications for ADHD treatment, raising suspicions that this was an effort to circumvent pro- hibitions against nonmedical stimulant use. The number
Key Terms
acromegaly, p. 264 adrenocortical steroids, p. 255 anabolic, p. 255 anabolic-androgenic steroids,
p. 255 anabolic steroids, p. 255 androgenic, p. 255
androstenedione, p. 264 creatine, p. 265 enzyme multiplied
immunoassay technique (EMIT), p. 267
employee assistance programs (EAPs), p. 270
enzyme immunoassay (EIA), p. 266
ergogenic, p. 255 gas chromatography/mass
spectrometry (GC/MS), p. 266
gynecomastia, p. 259
human growth hormone (hGH), p. 264
member assistance programs (MAPs), p. 271
muscle dysmorphia, p. 262
priapism, p. 259
1. Discuss the major events of the Olympic Games with respect to performance-enhancing drug use until the creation of the World Anti-Doping Agency (WADA). What effects has the WADA had on athletic competition in the Olympic Games?
2. Describe the adverse effects of anabolic steroids on (1) physiological systems in the body and (2) behavioral responses.
3. Explain the terms “stacking,” “shotgunning,” “cycling,” and “pyramiding” as practices involved in anabolic steroid abuse.
4. Explain how the phenomenon of muscle dysmorphia poses a great challenge in treating anabolic steroid abuse.
5. What are the adverse effects of taking human growth hormone (hGH)?
6. Describe and distinguish between the techniques of enzyme immunoassay (EIA) and gas chromatography/mass spectrom- etry (GC/MS) in drug testing.
7. Define the terms “sensitivity” and “specificity” in drug testing. What unforeseen consequences might there be with respect to drug testing in preemployment screening?
Review Questions
You are a voting member of the Baseball Hall of Fame, and you are about to cast your vote for the induction of MLB player. XYZ meets all the usual eligibility requirements, but he is on record of using androstendione during the years in which his record would clearly qualify him for the Hall of Fame, XYZ used androstendione.
Androstendione is presently a banned substance in the MLB, but in the years in question, androstendione was not a banned substance nor was it a Schedule III controlled substance. Some of your col- leagues are against his election into the Hall of Fame. What would you do?
Critical Thinking: What Would You Do?
274 ■ Part Three Legally Restricted Drugs and Criminal Justice
1. Canseco, José (2005). Juiced: Wild times, rampant ‘roids, smash hits, and how baseball got big. New York: HarperCollins. Kepner, Tyler (2009, February 18). “We weren’t taking Tic Tac.” As team looks on, Rodriguez details his use of steroids. New York Times, pp. B1, B15. Kepner, Tyler. (2010, January 12). McGwire admits steroid use in 1990s, his years of magic. New York Times, pp. B10, B14.
2. DEA leads largest steroid bust in history (2005, December 15). Drug Enforcement Administration, U.S. Department of Justice. National Institute on Drug Abuse (2000, April). Anabolic steroids. Research report series. Rockvile, MD: National Institute on Drug Abuse. Collins, Rick (2003, January 5). Federal and state steroid laws. Posted on the Web site of Collins, McDonald, and Gann, P. C., Attorneys-at-law, Nassau County and New York, NY, www.steroidlaw.com.3.
3. Dolan, Edward F. (1986). Drugs in sports (rev. ed.). New York: Franklin Watts, pp. 17–18. Meer, Jeff (1987). Drugs and sports. New York: Chelsea House, pp. 2, 61–75. Taylor, William N. (1991). Macho medicine: The history of the anabolic steroid epidemic. Jefferson, NC: McFarland and Co., pp. 3–16. Wadler, Gary I.; and Hainline, Brian (1989). Drugs and the athlete. Philadelphia: F. A. Davis, pp. 3–17.
4. Bhasin, Shalender; Storer, Thomas W.; Berman, Nancy; Callegari, Carlos; Clevenger, Brenda; et al. (1996). The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men. New England Journal of Medicine, 335, 1–7. Lombardo, John (1993). The efficacy and mechanisms of action of anabolic steroids. In Charles E. Yesalis (Ed.), Anabolic steroids in sport and exercise. Champaign, IL: Human Kinetics Publishers, p. 100.
5. Scott, Jack (1971, October 17). It’s not how you play the game, but what pill you take. New York Times Magazine, p. 41.
6. Maimon, Alan (2000, February 6). Doping’s sad toll: One athlete’s tale from East Germany. New York Times, pp. A1, A6. Yesalis, Charles E.; Courson, Stephen P.; and Wright, James (1993). History of anabolic steroid use in sport and exercise. In Yesalis (Ed.), Anabolic steroids, pp. 1–33.
7. Longman, Jere (2003, October 24). Steroid is reportedly found in top runner’s urine test. New York Times, p. D2. Macur Juliet (2008, October 9). Beijing Games blood samples to be retested for new drug. New York Times, pp. B17, B20. Vecsey, George (2002, March 1). More curious material in skiing’s closet. New York Times, pp. D1, D4. World Anti-Doping Agency (2013, September 11). The 2014 Prohibited List, International Standard, effective 1 January 2014. Montreal: World Anti- Doping Agency. World Anti-Doping Agency (2012, January). International Standard for Testing. Montreal: World Anti-Doping Agency.
8. Macur, Juliet (2012, October 11). Details of doping scheme paint Armstrong as leader. New York Times, pp. A1, B15. Macur, Juliet (2013, January 5). In reversal, Armstrong is said to weigh admitting drug use. New York Times, pp. A1, D4.
9. Curry, Jack (2005, November 16). Baseball backs stiffer penal- ties for steroid use. New York Times, pp. A1, D2. Eder, Steve (2014, January 12). Rodriguez out for all of 2014, arbitrator says. New York Times, pp. A1, SP7. Fainaru-Wada, Mark and Williams, Lance (2006). Game of shadows: Barry Bonds, Balco and the steroids scandal that rocked professional sports. New York: Gotham Books. Kepner, Tyler (2009, July 31). A stain
keeps spreading. New York Times, pp. B10, B11. Schmidt, Michael S.; and Macur, Juliet (2010, August 30). Clemens enters not guilty plea. New York Times, p. B14. Vecsey, George (2008, January 16). Spring training and the syringe genera- tion. New York Times, pp. D1, D3. Waldstein, David (2015, February 18). Exchanging sword for pen, Rodriguez apologizes to Yankees and fans. New York Times, p. B11.
10. Council on Scientific Affairs (1990). Medical and nonmedical uses of anabolic-androgenic steroids. Journal of the American Medical Association, 264, 2923–2927. Hartgens, Fred; and Kuipers, Harm (2004). Effects of androgenic-anabolic steroids in athletes. Sports Medicine, 34, 513–554. Perry, Paul J.; Lund, Brian C.; Deninger, Michael J.; Kutscher, Eric C.; and Schneider, Justin (2005). Anabolic steroid use in weightlifters and bodybuilders: An Internet survey of drug utilization. Clinical Journal of Sport Medicine, 15, 326–330.
11. Neri, M.; Bello, S.; Bonsignore, A.; Cantatore, S.; Riezzo, I.; et al. (2011). Anabolic androgenic steroids and liver toxicity. Mini Reviews in Medicinal Chemistry, 11, 430–437. Van Amsterdam, J.; Opperhuizen, A.; and Hartens, F. (2010). Adverse health effects of anabolic-androgenic steroids. Regulatory Toxicology and Pharmacology, 57, 117–123.
12. DiPaolo, Marco; Agozzino, Manuela; Toni, Chiara; Luciani, Allesandro Bassi; et al. (2005). Sudden anabolic steroid abuse– related death in athletes. International Journal of Cardiology, 114, 114–117. Karch, Steven B. (2009). Pathology of drug abuse (4th ed.). Boca Raton, FL: CRC Press, pp. 617–623. Maravelias, C.; Dona, A.; Stefanidou, M.; and Spiliopoulou, C. (2005). Adverse effects of anabolic steroids in athletes: A constant threat. Toxicology Letters, 158, 167–175. Urhausen, A.; Albers, T.; and Kindermann, W. (2004). Are the cardiac effects of anabolic steroid abuse in strength athletes reversible? Heart, 90, 496–501.
13. Greenberg, Alan (1991, June 29). Alzado has a serious message to kids about steroids: Don’t use them. Hartford (CT) Courant, cited in Jim Ferstle (1993). Evolution and politics of drug testing. In Charles E. Yesalis (Ed.), Anabolic steroids, p. 276. Su, Tung-Ping; Pagliaro, Michael; Schmidt, Peter J.; Pickar, David; Wolkowitz, Owen; et al. (1993). Neuropsychiatric effects of anabolic steroids in male normal volunteers. Journal of the American Medical Association, 269, 2760–2764.
14. Pope, Harrison G., Jr.; Kouri, Elena M.; and Hudson, James I. (2000). Effects of supraphysiologic doses of testosterone on mood and aggressiveness in normal men: A randomized controlled trial. Archives of General Psychiatry, 57, 133–140. Stocker, Steven (2000). Study provides additional evidence that high steroid doses elicit psychiatric symptoms in some men. NIDA Notes, 15(4), 8–9. Trenton, Adam J.; and Currier, Glenn W. (2005). Behavioural manifestations of anabolic steroid use. CNS Drugs, 19, 571–595.
15. Adler, Jerry (2004, December 20). Toxic strength. Newsweek, pp. 45–52. Bahrke, Michael S. (1993). Psychological effects of endogenous testosterone and anabolic-androgenic steroids. In Charles E. Yesalis (Ed.), Anabolic steroids in sport and exercise. Champaign, IL: Human Kinetics Publishers, pp. 161–192. Doff, Wilson (2005, March 10). After a young athlete’s sui- cide, steroids called the culprit. New York Times, pp. A1, D8. Estrada, Manuel; Varshney, Anurag; and Ehrlich, Barbara E. (2006). Elevated testosterone induces apoptosis in neuronal
Endnotes
Chapter 13 Performance-Enhancing Drugs and Drug Screening Tests ■ 275
24. Juhn, Popular sports supplements and ergogenic aids. Leder, Benjamin Z.; Longcope, Christopher; Catlin, Don H.; Ahrens, Brian; and Schoenfeld, Joel S. (2000). Oral androstenedione administration and serum testosterone concentrations in young men. Journal of the American Medical Association, 283, 779–782.
25. Denham, Bryan E. (2006). The Anabolic Steroid Control Act of 2004: A study in the political economy of drug policy. Journal of Health and Social Policy, 22, 51–78. Kepner, McGwire admits steroid use in 1990s, his years of magic. Mravic, Mark (2000, February 21). Ban it, bud. Sports Illustrated, pp. 24, 26.
26. Buford, Thomas W.; Kreider, Richard B.; Stout, Jeffrey R.; et al. (2007). International Society of Sports Nutrition position stand: Creatine supplementation and exercise. Journal of the International Society of Sports Nutrition, 4, 6. Freeman, Mike (2003, October 21). Scientist fears athletes are using unsafe drugs: Discovery of an undetected steroid confirms suspicions. New York Times, p. D2. Gregory, Andrew J. M.; and Fitch, Robert W. (2007). Sports medicine: Performance- enhancing drugs. Pediatric Clinics of North America, 54, 797–806.
27. Schmidt, Michael S. (2008, January 16). Baseball is challenged on rise in stimulant use. New York Times, pp. A1, A16. Quotation on page A16. Schmidt, Michael S. (2009, January 10). Baseball officials give report on amphetamine use among players. New York Times, p. D5. Swieca, Catlin (2013, September 10). NFL, other leagues deal with players’ use of amphetamine Adderall, http://www.denverpost.com/broncos/ ci_24055922/.
28. Hamilton, Martha McNeil (2003, February 23). Beating drug screening builds cottage industry. Evaders change faster than testing technology. Houston Chronicle, p. 2.
29. Wadler and Hainline, Drugs and the athlete, pp. 201–202. 30. Hatton, Caroline K. (2007). Beyond sports-doping headlines:
The science of laboratory tests for performance-enhancing drugs. Pediatric Clinics of North America, 54, 713–733. Meer, Drugs and sports, pp. 92–95.
31. Alternate specimen testing policies may be set soon (2005, September). Occupational Health and Safety, p. 26. Cone, Edward J.; Presley, Lance; Lehrer, Michael; Seiter, William; Smith, Melissa; et al. (2002). Oral fluid testing for drugs of abuse: Positive prevalence rates by Intercept immunoassay screening and GC-MS-MS confirmation and suggested cutoff concentrations. Journal of Analytical Toxicology, 26, 540–546.
32. Allen and Hanbury’s athletic drug reference (1992). Durham, NC: Clean Data, pp. 65–66. Baden, Lindsey R.; Horowitz, Gary; Jacoby, Helen; and Eliopoulos, George M. (2001). Quinolones and false-positive urine screening for opiates by immunoassay technology. Journal of the American Medical Association, 286, 3115–3119. Struempler, Richard E. (1987, May/June). Excretion of codeine and morphine following ingestion of poppy seeds. Journal of Analytical Toxicology, 11, 97–99. Wadler and Hainline, Drugs and the athlete, pp. 208–209.
33. Catlin, Don; Wright, Jim; Pope, Harrison; and Liggett, Mariah (1993). Assessing the threat of anabolic steroids: Sportsmedi- cine update. The Physician and Sportsmedicine, 21, 37–44.
34. Rosenberg, Ronald (2000, October 12). Citgo to use Avitar drug tests, job applicants to undergo new saliva-based exam. Boston Globe, p. C3.
35. Brookman, Richard R. (2008). Unintended consequences of drug and alcohol testing in student athletes. AAP (American
cells. Journal of Biological Chemistry, 281, 25492–25501. Longman, Jere (2003, November 26). An athlete’s dangerous experiment: Using steroids enhanced his physique, but he died trying to stop. New York Times, pp. D1, D4.
16. National Institute on Drug Abuse (2000, April). Anabolic steroids. Research report series. Rockvile, MD: National Institute on Drug Abuse. Collins, Rick (2003, January 5). Federal and state steroid laws. Posted on the Web site of Collins, McDonald, and Gann, P. C., Attorneys-at-law, Nassau County and New York, NY, www.steroidlaw.com.
17. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; Schulenberg, John E.; and Miech, Richard A. (2014). Monitor- ing the future: National survey results on drug use, 1975–2013, Vol. II: College students and adults ages 19-55. Ann Arbor, MI: Institute for Social Research, University of Michigan, Table 2-1.
18. Pope, Harrison G.; Gruber, Amanda J.; Choi, Priscilla; Olivardia, Roberto; and Phillips, Katherine A. (1997). Muscle dysmorphia: An underrecognized form of body dysmorphic disorder. Psychosomatics, 38, 548–557. Wroblewska, Anna-M. (1997). Androgenic-anabolic steroids and body dysmorphia in young men. Journal of Psychosomatic Research, 42, 225–234.
19. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing, pp. 483–490. Bahrke, Michael S.; Yesalis, Charles E.; and Brower, Kirk J. (1998). Anabolic-androgenic steroid abuse and performance-enhancing drugs among adolescents. Sport Psychiatry, 7, 821–838. Beel, Andrea; Maycock, Bruce; and McLean, Neil (1998). Current perspectives on anabolic steroids. Drug and Alcohol Review, 17, 87–103. Kashkin, Kenneth B.; and Kleber, Herbert D. (1989). Hooked on hormones? An anabolic steroid addiction hypothesis. Journal of the American Medical Association, 262, 3166–3169. Monaghan, Lee F. (2000). Bodybuilding, drugs, and risk. New York: Routledge. Perry; Lund; Deninger; Kutscher; and Schneider, Anabolic steroid use in weightlifters and bodybuilders. Schrof, Joanne M. (1992, June 1). Pumped up. U.S. News and World Report, pp. 55–63.
20. Goldberg, Linn; Mackinnon, David P.; Elliot, Diane L.; Moe, Esther L.; Clarke, Greg; and Cheong, JeeWon (2000). The adolescents training and learning to avoid steroids program. Archives of Pediatrics and Adolescent Medicine, 154, 332–338. Information courtesy of the Oregon Health and Science University, Portland, OR, 2008. Moe, Esther L.; Goldberg, Linn D.; MacKinnon, David P.; and Cheong, JeeWon (1999). Reducing drug use and promoting healthy behaviors among athletes: The ATLAS program. Medical Science Sports Exercise, 31(5), S122.
21. Kepner, “We weren’t taking Tic Tac.” Quotation from Alex Rodriguez on p. B15.
22. Interlandi, Jeneen (2008, February 25). Myth meets science. Newsweek, p. 48. Juhn, Mark S. (2003). Popular sports supplements and ergogenic aids. Sports Medicine, 33, 921–939. Liu, Hau; Bravata, Dena M.; Olkin, Ingram; Friedlander, Anne; et al. (2008). Systematic review: The effects of growth hormone on athletic performance. Annals of Internal Medicine, 148, 747–748. Macur, Juliet (2008, June). Who has the horse tranquilizers? Play, p. 18. Macur, Juliet (2008, October 9). Olympic blood samples to be retested. New York Times, p. B17. Macur, Juliet (2010, February 28). No doping scandals at Games, but time will tell. New York Times, Sports p. 9.
23. Tuller, David (2005, January 18). For sale: “muscles” in a bottle. New York Times, pp. F5, F10. Quotation on p. F5.
276 ■ Part Three Legally Restricted Drugs and Criminal Justice
39. Avis, Harry (1996). Drugs and life (3rd ed.). Dubuque, IA: Brown and Benchmark. Quotation on, p. 256.
40. Quotation from Charles E. Yesalis. In Wright, James E; and Cowart, Virginia S. (1990). Anabolic steroids: Altered States. Traverse City, MI: Cooper Publishing, p. 196. Schwerin, Michael J.; Corcoran, Kevin J.; Fisher, Leslee; Patterson, David; et al. (1996). Social physique anxiety, body esteem, and social anxiety in bodybuilders and self-reported anabolic steroid users. Addictive Behaviors, 21, 1–8.
41. Goldman, Bob; and Klatz, Ronald (1992). Death in the locker room II: Drugs and sports. Chicago: Elite Sports Medicine Publications, pp. 23–24. McHenry, Christopher R. (2007, December). Presidential address to the American Association of Endocrine Surgeons: The illicit use of hormones for enhance- ment of athletic performance: A major threat to the integrity of organized athletic competition. Surgery, pp. 785–792. Shermer, Michael (2008, April). The doping dilemma. Scientific American, pp. 82–89.
42. Egan, Timothy (2002, November 22). Body-conscious boys adopt athlete’s taste for steroids. New York Times, pp. A1, A24. Quotation on p. A24. Kolata, Gina; Longman, Jere; Weiner, Tim; and Egan, Timothy (2002, December 2). With no answers on risks, steroid users still say “yes.” New York Times, pp. A1, A19. Morgan, R. (2002). The men in the mirror. Chronicle of Higher Education, 49, A53–A54. Pope, Harrison G., Jr., Phillips, Katherine A.; and Olivardia, Roberto (2002). The Adonis complex: How to identify, treat, and prevent body obsession in men and boys. New York: Simon and Schuster. Roosevelt, Max (2010, January 14). When the gym isn’t enough. New York Times, pp. E1, E8.
43. Egan, Body-conscious boys. Quotation on p. A24.
Academy of Pediatrics) Grand Rounds, 19, 15–16. Yamaguchi, Ryoko; Johnston, Lloyd D.; and O’Malley, Patrick M. (2003). Relationship between student illicit drug use and school drug-testing policies. Journal of School Health, 73, 159–164.
36. Center for Behavioral Health Statistics and Quality (2014). Results from the 2013 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration, Tables 1.23A, 1.23B, 2.46A, and 2.46B. Larson, Sharon L.; Eyerman, Joe; Foster, Misty S.; and Gfroerer, Joseph C. (2011, June). Worker substance use and workplace policies and programs. Analytic Studies, A-29. Rockville, MD: Substance Abuse and Mental Health Services Administration, pp. 12, 16. Lehman, Wayne E. K.; Farabee, David J.; and Bennett, Joel B. (1998). Perceptions and correlates of co-worker substance use. Employee Assistance Quarterly, 13, 1–22.
37. American Management Association (2004). AMA 2004 workplace testing survey: Medical testing. New York: American Management Association, p. 3. Fortner, Neil A.; Martin, David M.; Esen, S. Evren; and Shelton, Laura (2011). Employee drug testing: Study shows improved productivity and attendance and decreased workers’ compensation and turnover. Journal of Global Drug Policy, and Practice, 5, pp. 6, 18. Substance Abuse and Mental Health Services Administration (2008, March 15). Mak- ing your workplace drug-free: A kit for employers. Rockville, MD: Substance Abuse and Mental Health Services Administration.
38. Comerford, Anthony W. (1999). Work dysfunction and addiction. Journal of Substance Abuse Treatment, 16, 247–253. Normand, J.; Lempert, R.; and O’Brien, C. (Eds.) (1994). Under the influence? Drugs and the American work force. Washington, DC: National Academy Press.
Depressants and Inhalants
14 chapter
“I remember,” Julio said to me, taking quick, nervous puffs from his
cigarette, “when I was a little kid, maybe eight or nine, and I used to
take the garbage out for my mother, I’d always see tubes from air-
plane glue under the stairwell in our apartment house and in the alley
out back. At first, glue just meant building models to me.”
“But I’d see people sniffing it, under the stairwell. I was curi-
ous, and one day I tried it. It made me feel like I was in a trance. It
wasn’t really exciting, but I did it again and again until we moved,
and in the new neighborhood people weren’t into glue and I
didn’t see the empty tubes to remind me anymore.”
“Besides, I guess I just grew out of it,” Julio said with a grin.
After you have completed this chapter, you should have an understanding of the following:
●● The acute and chronic effects of barbiturates as sedative-hypnotic drugs
●● The development of benzodiazepines as anxiolytic (antianxiety) medications
●● Nonbenzodiazepine sedative-hypnotics and anxiolytic (antianxiety) medications
●● The acute effects and dangers of glue, solvent, or aerosol spray inhalation
●● Patterns of inhalant abuse and its chronic effects
●● The abuse of amyl nitrite and butyl nitrite
●● Rohypnol, gamma- hydroxybutyrate (GHB), and other depressants in drug-facilitated sexual assaults
278 ■ Part Three Legally Restricted Drugs and Criminal Justice
Just as cocaine, amphetamines, and other stimulants bring us up, depressants bring us down. Just as people desire to be stronger, faster, and more attuned to the world, they also desire to move apart from that world, reduce the stress and anxiety of their lives, and fall asleep more easily. We learned in Chapter 9 that the powerful effects of opioids not only relieved pain but also allowed people to retreat from the world around them. In Chapter 15, we will examine the age-old allure of alcohol to relax our mind and body.
In the first section of this chapter, we will focus on a group of nonopioid, nonalcoholic depressant drugs called sedative-hypnotics, so named because they calm us down (from the Latin verb, sedare, meaning “to calm or be quiet”) and produce sleep (from the Greek noun, hypnos, meaning “sleep”). Several types of sedative-hypnotic drugs exist, rang- ing from drugs that were introduced more than 200 years ago to others that have become available only recently.
The second section concerns prescription medica- tions that provide specific relief from stress and anxiety without sedating us. These drugs have often been referred to as tranquilizers by virtue of their ability to make us feel peaceful or tranquil, but we will call them by their more cur- rently accepted name, antianxiety drugs or anxiolytic drugs. Unfortunately, sedative-hypnotics and antianxiety drugs have been subject not only to legitimate medical use but to misuse
and abuse as well. Many of them can be obtained through illicit sources as street drugs and are consumed for recre- ational purposes.
The third section examines a category of depressant drugs known as inhalants, a group of chemicals that emit breathable vapors and produce intoxicating effects. These chemicals do not need to be acquired in a pharmacy, a con- venience store, a liquor store, or even on the street. They can be found under the sink, in kitchen or bathroom cabinets, in the basement, or in the garage. Ordinary household prod- ucts frequently have the potential for intoxication if they are sniffed or inhaled. When you consider that these substances are readily available to anyone in a family, including its youngest members, the consequences of their abuse become especially troubling.1
In the final section of this chapter, the important issue of drug-facilitated sexual assault will be examined, with a spe- cific focus on so-called date-rape drugs such as Rohypnol and gamma-hydroxybutyrate (GHB), as well as alcohol.
Barbiturates
In 1864, the German chemist Adolf von Baeyer combined a waste product in urine called urea and an apple extract called malonic acid to form a new chemical compound called barbituric acid. There are two often-told stories about how this compound got its name. One story has it that von Baeyer had gone to a local tavern to celebrate his discovery and encountered a number of artillery officers celebrating the feast day of St. Barbara, the patron saint of explosives handlers. Inspired by their celebration, the name “barbituric acid” came to mind. The other story attributes the name to a relationship with a certain barmaid (perhaps at the same tavern) whose name was Barbara.2
Whichever story is true (if either is), von Baeyer’s dis- covery of barbituric acid set the stage for the development of a class of drugs called barbiturates. Barbituric acid itself has no behavioral effects, but if additional molecular groups
50 Percent reduction ordered by the FDA in 2013 in the recommended dosage of zolpidem (brand name: Ambien) due to adverse side effects.
1 in 5 Proportion of female undergraduates admitted to a hospital-based sexual assault treatment center in Ontario, Canada, between 2005 and 2007 who suspected that they had been drugged.
65–96 Depending on the study, the range of percentages of drug-facilitated sexual assaults during which alcohol had been consumed by the victim prior to the attack.
Sources: Du Mont, Janice; Macdonald, Sheila; Rotbard, Nomi; Asllani, Erioa; Bainbridge, Deidre; et al. (2009). Factors associated with suspected drug-facilitated sexual assault. Canadian Medical Journal, 180, 513–519. Lawyer, Steven; Resnick, Heidi; Bakanic, Von; Burkett, Tracy; and Kilpatrick, Dean (2010). Forcible, drug-facilitated, and incapacitated rape and sexual assault among undergradu- ate women. Journal of American College Health, 58, 453–460.
Numbers Talk…
barbiturate (bar-BIT-chur-rit): A drug within a family of depressants derived from barbituric acid and used as a sedative-hypnotic and antiepileptic medication.
inhalants: Chemicals that emit breathable vapors, producing euphoriant and depressant effects when sniffed or inhaled.
antianxiety drugs: Medications that make the user feel more peaceful or tranquil; also called anxiolytic medications.
anxiolytic drugs: Medications that reduce anxiety; also called antianxiety medications.
sedative-hypnotics: A category of depressant drugs that provide a sense of calm and sleep.
Chapter 14 Depressants and Inhalants ■ 279
they are referred to as ultra-short-acting bar- biturates. Because these features are undesir- able to a person seeking a recreational drug, ultra-short-acting barbiturates are not com- monly abused.
Acute Effects of Barbiturates At very low doses, the primary result of oral administrations of a barbiturate is relaxation and, paradoxically, a sense of euphoria. These effects derive chiefly from a disinhibition of the cerebral cor- tex, in which normal inhibitory influ- ences from the cortex are reduced. These symptoms are similar to the inebriating or intoxicating effects that result from low to moderate doses of alcohol (Drug Enforcement … in Focus).
As the dose level increases, lower regions of the brain concerned with gen- eral arousal become affected. At therapeu- tic doses (one 100 mg capsule of secobar- bital, for example), barbiturates make you feel sedated and drowsy. For this reason,
patients are typically warned that barbiturates can impair the performance of driving a car or operating machinery. At higher doses, a hypnotic (sleep-inducing) effect will be achieved.
Barbiturates tend to suppress rapid eye movement (REM) sleep, a phase of everyone’s sleep that represents about 20 percent of the total sleep time each night. REM sleep is associated with dreaming and general relaxation of the body. If barbiturates are consumed over many evenings and then stopped, the CNS will attempt to catch up for the lost REM sleep by producing longer REM periods on subse- quent nights. This REM-sleep rebound effect produces vivid and upsetting nightmares, along with a barbiturate hangover the next day, during which the user feels groggy and out of sorts. In other words, barbiturates may induce sleep, but a refreshing sleep it definitely is not.3
The most serious acute risks of barbiturate use involve the possibility of a lethal overdose either from taking too
combine with the acid, depressant effects are observed. In 1903, the first true barbiturate, diethylbarbituric acid, was created and marketed under the name Veronal. Over the next 30 years, several barbiturate drugs were introduced: phenobarbital (marketed in generic form), amobarbital (brand name: Amytal), pentobarbital (brand name: Nembutal), and secobarbital (brand name: Seconal). Major barbiturates currently available are listed in Table 14.1.
Categories of Barbiturates Barbiturates all share a number of common features. They are relatively tasteless and odorless, and at sufficient dosages, they reliably induce sleep, although the quality of sleep is a matter that will be discussed later. Because they slow down the activity of the central nervous system (CNS), the princi- pal therapeutic application of barbiturates has been in the treatment of seizure disorders (epilepsy).
The principal difference among them lies in how long the depressant effects will last; a rough classification of barbi- turates is based upon this factor. Barbiturates are categorized as long acting (six or more hours), intermediate acting (four to six hours), or short acting (less than four hours). Bear in mind, however, that these groups are relative only to one another. All other factors being equal, injectable forms of barbiturates are shorter acting than orally administered forms of the same drug, since it takes longer for the drug to be absorbed when taken by mouth and longer for it to be eliminated from the body (see Chapter 4).
The barbiturates used in surgical anesthesia, such as thio- pental (brand name: Pentothal), take effect extremely rapidly (within seconds) and last only a few minutes. For this reason,
TABle 14.1
Major barbiturates
GenerIc nAme BrAnd nAme durATIon of AcTIon
relATIve PoTenTIAl for ABuse
phenobarbital generic* long low
mephobarbital Mebaral long low
butalbarbital Pheniline Forte** intermediate moderate
amobarbital Amytal intermediate high
secobarbital and amobarbital
Tuinal short, intermediate
high
pentobarbital Nembutal short high
secobarbital Seconal short high
Note: Short-acting barbiturates begin to take effect in about 15 minutes, intermediate- acting barbiturates in 30 minutes, and long-acting barbiturates in one hour.
*Phenobarbital is also available in combination with hyoscyamine, atropine, and scopolamine under the brand name Donnatal.
**Several brands combine butalbarbital with acetaminophen.
Sources: Henningfield, Jack E.; and Ator, Nancy A. (1986). Barbiturates: Sleeping potion or intoxicant? New York: Chelsea House, p. 24. Physicians’ desk reference (69th ed.) (2015). Montvale, NJ: PDR Network.
rem-sleep rebound: A phenomenon associated with the withdrawal of barbiturate drugs in which the quantity of rapid eye movement (REM) sleep increases, resulting in disturbed sleep and nightmares.
secobarbital (sec-oh-BAr-bih-tall): A short-acting barbitu- rate drug. Brand name is Seconal.
pentobarbital (Pen-toh-BAr-bih-tall): A short-acting barbiturate drug. Brand name is Nembutal.
amobarbital (AY-moh-BAr-bih-tall): An intermediate- acting barbiturate drug. Brand name is Amytal.
phenobarbital (feen-oh-BAr-bih-tall): A long-acting barbi- turate drug, usually marketed in generic form.
280 ■ Part Three Legally Restricted Drugs and Criminal Justice
Chronic Effects of Barbiturates Even after brief use of barbiturates, anxiety may be tempo- rarily increased during the day, and there may be an even greater degree of insomnia than before. In addition, because a barbiturate-induced sleep typically leaves a person feeling groggy the next morning, it is tempting to take a stimulant drug during the day to feel completely alert. At bedtime, the person still feels the stimulant effects and is inclined to continue taking a barbiturate to achieve any sleep at all.
Withdrawal symptoms, observed when barbiturates are discontinued, indicate a strong physical dependence on the drug. A person may experience a combination of trem- ors (the “shakes”), nausea and vomiting, intense perspiring, general confusion, convulsions, hallucinations, high fever, and increased heart rate. Not surprisingly, considering the parallels with alcohol, the barbiturate withdrawal syndrome closely resembles that of withdrawal after chronic alcohol abuse (see Chapter 15).
Professionals in the treatment of drug dependence often view the effects of barbiturate withdrawal as the most distress- ing as well as the most dangerous type of drug withdrawal. From a medical perspective, the withdrawal process is life- threatening unless it is carried out in gradual fashion in a hospital setting. Without medical supervision, abrupt with- drawal from barbiturates carries approximately a 5 percent chance of death.5
high a dose level of the drug alone or from taking the drug in combination with alcohol, such as when a barbiturate is taken after an evening of drinking. In these instances, sleep can all too easily slip into coma and death, since an excessive dose produces an inhibition of the respiratory control cen- ters in the brain. The mixture of barbiturates with alcohol produces a synergistic effect (see Chapter 4) in which the combined result is greater than the sum of the effects of each drug alone.4
Barbiturates and alcohol have frequently been combined in attempts to commit suicide.
Is There Any Truth regarding “Truth serum”? The idea that a sedative-hypnotic drug such as amobarbital (Amytal, or “sodium amytal”) may function as a “truth serum” is not at all new. It has been known for centuries that depressants can produce remarkable candor and freedom from inhibition. The oldest example is simple alcohol, whose effect on loosening the tongue has led to the Latin proverb in vino veritas (“in wine, there is truth”).
Whether we are guaranteed truthfulness under any of these circumstances, however, is another matter entirely. Courts have ruled that expert opinion in criminal cases based solely on drug- assisted testimony cannot be admitted as evidence. Controlled laboratory studies have shown that individuals under the influ- ence of Amytal, when pressed by questioners, are as likely to give convincing renditions of fabrications (outright lies) or fantasies as they are to tell the truth. So, perhaps, Amytal might be better described as a “tell anything serum.”
Recently, the question of whether Amytal or other depres- sant drugs should be used to gain information has come up
with regard to the interrogation of captured al Qaeda prisoners following the September 11, 2001, attacks. The United States has determined that such individuals are unlawful combatants, a designation that excludes them from protection under the Geneva Convention guidelines prohibiting such practices for prisoners of war. Officially, U.S. officials deny that depressant drugs are being used to gain information from captives under American jurisdiction. It is possible that this practice is in effect in other countries to which captives have been transferred.
The lack of evidence that truthful information may be gained through the use of depressant drugs has not changed, however. Nonetheless, military and intelligence experts point to the potential for gaining some relevant information that might be buried in drug-induced ramblings.
Sources: CBS News (2003, April 23). Truth serum: A possible weapon. www.cbsnews.com. Lillienfeld, Scott O.; and Landfield, Kristin (2008). Science and pseudoscience in law enforcement. Criminal Justice and Behavior, 35, 1215–1230. Michaelis, James I. (1966). Quaere, whether “in vino veritas”: An analysis of the truth serum cases. Issues in Criminology, 2(2), 245–267.
Drug Enforcement … in Focus
Chapter 14 Depressants and Inhalants ■ 281
undesirable side effects. Unfortunately, these objectives were not realized.
One such drug, chloral hydrate, had been synthesized as early as 1832. As a depressant for the treatment of insomnia, it has the advantage of not producing the REM-sleep rebound effect or bringing on the typical barbiturate hangover. A major disadvantage, however, is that it can severely irritate the stom- ach. Like other depressants, it is also highly reactive when combined with alcohol. In the nineteenth century, a few drops of chloral hydrate in a glass of whiskey became the infamous “Mickey Finn,” a concoction that left many an unsuspecting sailor unconscious and eventually “shanghaied” onto a boat for China. You might say that chloral hydrate was an early pre- cursor to a modern-day “date-rape” drug (see pages 290–294).
The development of methaqualone (brand names: Quaalude, Sopor), first introduced in the United States in 1965, was a further attempt toward achieving the perfect sleeping pill. In 1972, methaqualone had become the sixth-best- selling drug for the treatment of insomnia. During the early 1970s, recre- ational use of methaqualone (popularly known as “ludes” or “sopors”) was rapidly spreading across the country, aided by the unfounded reputation that it had aphrodisiac properties.
The problem with methaqualone was compounded by the extensive number of prescriptions written by physi- cians who mistakenly saw the drug as a desirable alternative to barbiturates. On the street, quantities of methaqualone were obtained from medical prescriptions or stolen from pharmacies. Methaqualone-related deaths started to be promi- nent “ED-mentions” in the DAWN reports of the period. In 1984, this drug’s legal status changed to that of a Schedule I drug, the most restricted classification, which indicates a high potential for abuse and no medical benefits. While no longer manufactured by any pharmaceutical company, methaqua- lone is still available as an illicit drug. It is either manufactured in domestic underground laboratories or smuggled into the country from underground laboratories abroad.
The Development of Anxiolytic Drugs
If social historians consider the 1950s “the age of anxiety,” then it is appropriate that this period also would be marked by the development of drugs specifically intended to com- bat that anxiety. These drugs were originally called minor tranquilizers, to distinguish them from other drugs regarded as major tranquilizers and developed at about the same time to relieve symptoms of schizophrenia. This terminology
Barbiturate Use and Abuse Barbiturate abuse reached its peak in the 1950s and 1960s, later to be overshadowed by abuses of heroin, hallucino- gens, nonbarbiturate depressants, amphetamines, and more recently, abuses of cocaine, crack, and various stimulants and hallucinogens (Table 14.2). The principal reason was that barbiturates became less widely available as prescription drugs. Stricter controls were placed on obtaining excessive amounts of barbiturates from pharmacies, whereas physi- cians, concerned with the potential of barbiturates as ways of committing suicide, became reluctant to prescribe them on a routine basis.
Despite their decline as major drugs of abuse, however, barbiturates are still being abused. The 2013 University of Michigan survey of high school seniors found that 5 percent had taken them within the past year, down from 11 percent in 1975.6
Nonbarbiturate Sedative-Hypnotics
As the hazards of barbiturate use became increasingly evi- dent, the search was on for sedative-hypnotic drugs that were not derivatives of barbituric acid and, it was hoped, had fewer
TABle 14.2
Street names for various barbiturates
TYPe of BArBITurATe sTreeT nAme
Pentobarbital (Nembutal)
abbotts, blockbusters, nebbies, nembies, nemmies, yellow bullets, yellow dolls, yellow jackets, yellows
Amobarbital (Amytal)
blue angels, bluebirds, blue bullets, blue devils, blue dolls, blue heavens, blues
Secobarbital (Seconal)
F-40s, Mexican reds, R.D.s, redbirds, red bullets, red devils, red dolls, reds, seccies, seggies, pinks
Secobarbital and amobarbital (Tuinal)
Christmas trees, double trouble, gorilla pills, rainbows, tootsies, trees, tuies
Barbiturates in general
downers, down, goofballs, G.B.s, goofers, idiot pills, King Kong pills, peanuts, pink ladies, sleepers, softballs, stumblers
Note: Like any other street drug, illicit barbiturate capsules often contain an unknown array of other substances, including strychnine, arsenic, laxatives, or milk sugars. Any yellow capsule may be “marketed” as Nembutal, any blue capsule as Amytal, or any red capsule as Seconal.
Source: Updated from Henningfield, Jack E.; and Ator, Nancy A. (1986). Barbiturates: Sleeping potion or intoxicant? New York: Chelsea House, p. 82.
methaqualone (meH-tha-QuAY-lone): A nonbarbiturate depressant drug once used as a sedative. Brand name is Quaalude.
chloral hydrate: A depressant drug once used for the treat- ment of insomnia. It is highly reactive with alcohol and can severely irritate the stomach.
282 ■ Part Three Legally Restricted Drugs and Criminal Justice
Benzodiazepines
The introduction of a new group of drugs, called benzodiaz- epines, was a dramatic departure from all earlier attempts to treat anxiety. On the one hand, for the first time, there now were drugs that had a selective effect on anxiety itself, instead of producing a generalized reduction in the body’s overall level of functioning. It was their “tranquilizing” effects, rather than their sedative effects, that made benzodiazepines so appealing to mental health professionals. On the other hand, it is important to distinguish between the well-publicized vir- tues of benzodiazepines when they were first introduced in the 1960s and the data that accumulated during the 1970s as millions of people experienced these new drugs. Although certainly very useful in the treatment of anxiety and other stress-related problems, long-acting benzodiazepines are no longer recognized as the miracle drugs they were promoted to be when they first entered the market.
Medical Uses of Benzodiazepines The first marketed benzodiazepine, chlordiazepoxide (brand name: Librium), was introduced in 1960, followed by diazepam (brand name: Valium) in 1963. Table 14.3
is no longer used today, for we now know that the phar- macological differences between the two drug categories are more than simply a matter of degree. Anxious people (or even people who are not bothered by anxiety) are not affected by drugs designed to treat schizophrenia. The cur- rent, and more logical, practice is to refer to drugs in terms of a specific action and purpose. The minor tranquilizers are now called anxiolytic (anxiety-reducing) drugs or anti- anxiety medications.
The first antianxiety medication to be developed was meprobamate (brand name: Miltown), named in 1955 for a New Jersey town near the headquarters of the pharmaceutical company that first introduced it. It was the first psychoactive drug in history to be marketed specifically as an antianxiety medication.
Meprobamate had advantages and disadvantages. On the positive side, the toxic dose was relatively high, mak- ing the possibility of suicide more remote than with alco- hol, barbiturates, and other depressants. In addition, judg- ing from the reduction in autonomic responses to stressors, there were genuine signs that people on this medication were actually less anxious. On the negative side, motor reflexes were diminished, making driving more hazard- ous. People often complained of drowsiness, even at dose levels that should have only been calming them down. Meprobamate also produced both physical and psychologi- cal dependence.7
diazepam (dye-AZ-eh-pam): A major benzodiazepine drug for the treatment of anxiety. Brand name is Valium.
chlordiazepoxide (cHlor-dye-az-eh-PoX-ide): A major benzodiazepine drug for the treatment of anxiety. Brand name is Librium.
benzodiazepines (Ben-zoh-dye-AZ-eh-pins): A family of antianxiety drugs. Examples are diazepam (Valium), chlordiazepoxide (Librium), and triazolam (Halcion).
meprobamate (meH-pro-BAYm-ate): A nonbarbiturate antianxiety drug and sedative. Brand name is Miltown.
A person’s job and other aspects of living are often sources of enormous stress and anxiety.
TABle 14.3
The leading benzodiazepines on the market
TrAde nAme GenerIc nAme elImInATIon
HAlf-lIfe (In Hours)
long-acting benzodiazepines
Valium diazepam 20–100
Librium chlordiazepoxide 8–100
Limbitrol chlordiazepoxide and amitriptyline (an antidepressant)
8–100
Dalmane flurazepam 70–160
Tranxene clorazepate 50–100
Intermediate-acting benzodiazepines
Ativan lorazepam 10–24
Klonopin clonazepam 18–50
Restoril temazepam 8–35
ProSom estazolam 13–35
short-acting benzodiazepines
Versed midazolam 2–5
Halcion triazolam 2–5
Xanax alprazolam 11–18
Note: Klonopin is available in orally disintegrating wafers for panic-attack patients who need the medication in an easily administered form.
Sources: Julien, Robert M. (1998). A primer of drug action (8th ed.). New York: Freeman, p. 99. Physicians’ desk reference (69th ed.) (2015). Montvale, NJ: PDR Network.
Chapter 14 Depressants and Inhalants ■ 283
onset of Alzheimer’s disease. An additional problem with benzodiazepines is the increased risk of falls and bone fractures. It is for these reasons that long-acting benzodi- azepines are no longer recommended for this age group, and those who are currently taking these drugs are being encouraged to switch to shorter-acting forms or alternative antianxiety therapies.9
Chronic Effects of Benzodiazepines The benzodiazepines were viewed originally as having few, if any, problems relating to a tolerance effect or an acquired dependence. We now know that the anxiety-relieving aspects of benzodiazepines show little or no tolerance effects when the drugs are taken at prescribed dosages, but there is a tol- erance to the sedative effects. In other words, if the drugs are taken for the purpose of relieving anxiety, there is no problem with tolerance, but if they are taken for insomnia, more of the drug may be required in later administrations to induce sleep.10
We also now know that physiological symptoms appear when benzodiazepines are withdrawn, an indication of ben- zodiazepine dependence. In the case of long-acting benzodi- azepines, the slow rate of elimination delays the appearance of withdrawal symptoms until between the third and sixth day following drug withdrawal. The first signs include an anxiety level that may be worse than the level for which the drug was originally prescribed. Later, there are symptoms of insomnia, restlessness, and agitation. In general, however, withdrawal symptoms are less severe than those observed after barbitu- rate withdrawal, occur only after long-term use, and are gone in one to four weeks.11
Benzodiazepine abuse has since declined substantially in psychiatric practice as newer approaches to anxiety dis- orders have been pursued. Nonetheless, benzodiazepines remain widely prescribed drugs throughout the world, par- ticularly for people over the age of 65 years, to treat problems of insomnia and anxiety. While they are useful for short-term use, unfortunate adverse side effects can arise when benzodi- azepines are taken over a long period of time. The potential for cognitive impairment among elderly people and adverse effects when combined with alcohol were discussed earlier in this chapter. These possibilities have been a particular problem in European countries where wine is consumed on a regular basis.12
Nonbenzodiazepine Medications
Just as benzodiazepines represented a great advance over bar- biturates, the development of new nonbenzodiazepine drugs has provided better opportunities to treat sleep disorders and anxiety. Prominent examples of this new generation of medi- cations are zolpidem, eszopiclone, buspirone, beta blockers, and, strangely enough, antidepressants.
lists the major benzodiazepine drugs currently on the mar- ket. Although they are all chemically related, there are variations in their time course or action and, as a result, different recommendations for their medical use. Oral administrations of the relatively long-acting benzodiaz- epines, in general, are recommended for relief from gen- eral anxiety, with the effects beginning 30 minutes to four hours after ingestion. When a very quick effect is desired, an injectable form of diazepam is used either to reduce the symptoms of agitation that follow alcohol withdrawal (delirium tremens, or the DTs), as an anticonvulsant for epileptic patients, or as a pre-anesthetic drug to relax the patient just prior to surgery. In contrast, shorter-acting oral benzodiazepines are recommended for sleeping problems because their effects begin more quickly and wear off well before morning.
Acute Effects of Benzodiazepines In general, benzodiazepines are absorbed relatively slowly into the bloodstream, so their relaxant effects last lon- ger and are more gradual than those of barbiturates. The primary reason for these differences lies in the fact that benzodiazepines are absorbed from the small intestine rather than the stomach, as is the case with barbiturates. The relatively greater water solubility and, by implication, the relatively lower fat solubility of benzodiazepines also are factors.
The major advantage that benzodiazepines have over barbiturates and other drugs previously used to control anxiety is their higher level of safety. Respiratory centers in the brain are not affected by benzodiazepines, so it is rare that a person will die of respiratory failure from an accidental or intentional overdose. Even after taking 50 or 60 times the therapeutic dose, the person will still not stop breathing. It is almost always possible to arouse a person from the stupor that such a drug quantity would produce. In contrast, doses of barbiturates or nonbarbiturate seda- tives that are 10–20 times the therapeutic dose are lethal. Yet we should understand that this higher level of safety assumes that no alcohol or other depressant drugs are being taken at the same time.8
Nonetheless, despite the relative safety of benzodiaz- epines, these medications pose a number of serious risks for special populations. For elderly patients, for example, the rate of elimination of these drugs is slowed down significantly, resulting in the risk of a dangerously high buildup of ben- zodiazepines after several doses. In the case of a long- acting benzodiazepine such as Valium or Librium, the elimination half-life is for them as long as 10 days. An elderly patient with this rate of elimination would not be essentially drug-free until two months had passed.
The continued accumulation of benzodiazepines in the elderly can produce a form of drug-induced demen- tia in which the patient suffers from confusion and loss of memory. Without understanding the patient’s medica- tion history, these symptoms easily can be mistaken for the
284 ■ Part Three Legally Restricted Drugs and Criminal Justice
publicized cases. In 2013, Sanofi-Aventis, manufacturer of Ambien, issued the caution that “After taking Ambien, you may get up out of bed while not being fully awake and do an activity that you do not know you are doing. The next morning, you may not remember that you did anything during the night.”14
Buspirone Since 1986, a new type of antianxiety medication has been available called buspirone (brand name: BuSpar), with a number of remarkable features. It has been found to be equivalent to benzodiazepines in its ability to relieve anxi- ety, but, unlike benzodiazepines, buspirone shows no cross- tolerance effects when combined with alcohol or other depressants and no withdrawal symptoms when discontin- ued after chronic use. When compared with benzodiaz- epines, side effects are observed less frequently and are less troublesome to the patient; approximately 9 percent report dizziness, and 7 percent report headaches. Animals do not self-administer buspirone in laboratory studies, and human volunteers indicate no feelings of euphoria. Buspirone also fails to show the impairments in motor skills that are char- acteristic of benzodiazepines. In other words, the relief of anxiety is attainable without the accompanying feelings and behavioral consequences of sedation.
Despite its virtues, however, buspirone has a distinct disadvantage: a very long delay before anxiety relief is felt. It may take weeks for the drug to become completely effective. While this feature makes buspirone clearly inappropriate for relieving acute anxiety conditions, patients suffering from long-term generalized anxiety disorder find it helpful as a therapeutic drug. An extra benefit of the delay in the action of buspirone is that it becomes highly undesirable as a drug of abuse. Do not expect to see news headlines in the future warning of an epidemic of buspirone abuse.15
Beta Blockers The traditional medical uses of beta-adrenergic-blocking drugs, commonly known as beta blockers, include slowing the heart rate, relaxing pressure on the walls of blood vessels, and decreasing the force of heart contractions. The combination of a beta-blocker drug and a diuretic is a frequent treatment for the control of high blood pressure. These drugs are also prescribed for individuals facing an anxiety-producing event, such as performing on the stage or giving a speech. Examples of beta blockers include atenolol (brand name: Tenormin), metoprolol (brand name: Lopressor), and propanolol (brand name: Inderal).16
Antidepressants A recent development in the treatment of panic disorder, posttraumatic stress disorder, and social anxiety disorder has been the use of antidepressant medications—specifically,
Zolpidem and Eszopiclone Zolpidem (brand name: Ambien) is not a benzodiazepine drug, but it produces some of the effects usually associated with benzodiazepines. As a result, zolpidem is particularly useful in the short-term treatment of insomnia. Its strong but transient sedative effects (with a half-life of about two hours) have led to the marketing of zolpidem, since its introduction in 1993, as a sedative-hypnotic rather than an antianxiety medication. While little or no muscle relaxation is experi- enced with recommended dosages, there are health risks when combined with other drugs (particularly alcohol) or when exceeding the recommended dosage.
Introduced in 2004, eszopiclone(brand name: Lunesta, formerly known as Estorra) is also a nonbenzodiazepine drug that is prescribed for the treatment of insomnia. As a result of successful clinical trials lasting six months, the FDA has approved Lunesta for an interval of treatment that is longer than the recommended treatment with Ambien. Because its half-life of six hours is longer than that of Ambien, Lunesta has been helpful for people who have dif- ficulty in staying asleep during the night as well as difficulty in falling asleep.13
In cases of both zolpidem and eszopiclone, high dos- age levels have been found to produce in some patients an impairment in activities that requires full alertness, such as driving, even if they feel fully awake. As a result, the FDA required in 2014 manufacturers to include new caution- ary information on the drug label and to lower the recom- mended starting dose. In addition, a relatively uncommon but disturbing set of side effects have been observed with these medications. Some patients have reported unusual reactions ranging from sleepwalking episodes to sensory hal- lucinations, binge eating during the night, and even driving while asleep. In these instances, there is no recollection of the events that occurred during the night. Although these side effects are rare from a percentage standpoint, the large number of prescriptions issued for these medications (par- ticularly for the continuous-release form of zolpidem, mar- keted as Ambien CR) have resulted in a number of widely
zolpidem (Zol-pih-dem): A nonbenzodiazepine sedative- hypnotic drug, first introduced in 1993, for the treatment of insomnia. Brand name is Ambien.
eszopiclone (es-ZoP-eh-clone): A nonbenzodiazepine sedative-hypnotic, first introduced in 2005, for the treatment of insomnia. Brand name is Lunesta.
beta blockers: Medicinal drugs that are traditionally used to treat cardiac and blood pressure disorders. They are also prescribed for individuals who suffer from “stage fright” or anxiety regarding a specific event. Examples include at- enolol (brand name: Tenormin), metoprolol (brand name: Lopressor), and propanolol (brand name: Inderal).
buspirone (BYoo-spir-rone): A nonbenzodiazepine anti- anxiety drug, first introduced in 1986. Brand name is BuSpar.
Chapter 14 Depressants and Inhalants ■ 285
Nitrous Oxide The British chemist Sir Humphrey Davy synthesized the gas nitrous oxide in 1798 at the precocious age of 19. He immediately observed the pleasant effects of this “laughing gas” and proceeded to give nitrous oxide parties for his liter- ary and artistic friends. By the early 1800s, recreational use of nitrous oxide became widespread both in England and the United States as a nonalcoholic avenue to drunkenness. In the 1840s, public demonstrations were held in cities and towns, as a traveling show, by entrepreneurs eager to market the drug commercially.
It was at such an exhibition in Hartford, Connecticut, that a young dentist, Horace Wells, got the idea for using nitrous oxide as an anesthetic. One of the intoxicated par- ticipants in the demonstration had stumbled and fallen, receiving in the process a severe wound to the leg. Seeing that the man showed no evidence of pain despite his injury,
selective serotonin reuptake inhibitors (SSRIs) such as ser- traline (brand name: Zoloft) and paroxetine (brand names: Paxil, Asima).17
Inhalants through History
The mind-altering effects of substances inhaled into the lungs have been known since the beginnings of recorded history. Burnt spices and aromatic gums were used in acts of worship in many parts of the ancient world; exotic per- fumes were inhaled during Egyptian worship as well as in Babylonian rituals. Inhalation effects also figured promi- nently in the famous rites of the oracle at Delphi in ancient Greece, where trances induced by the inhaling of vapors led to mysterious utterances that were interpreted as prophecies. We know now, from archeological studies, that limestone faults underneath the temple at Delphi once caused petro- chemical fumes to rise to the surface. The oracle was prob- ably inhaling ethylene, a sweet-smelling gas that produces an out-of-body sense of euphoria.18
It was not until the latter part of the eighteenth century that reports about the inhalation of specific drugs began to appear. The two most prominent examples were cases involving nitrous oxide and ether. These anesthetic drugs were first used as surgical analgesics in the 1840s, but they had been synthesized decades earlier. From the very start, the word had spread of recreational possibilities.
Quick Concept Check
Understanding the Abuse Potential in Drugs Each of the following statements describes a particular at- tribute of a new drug. Based on material in this chapter, judge whether each description, when taken by itself, either increases or decreases the abuse potential of the drug.
1. Drug fails to produce euphoria at any dose levels.
2. Drug acts very quickly.
3. Drug is cross-tolerant to barbiturates and alcohol.
4. Drug is not available to the public.
5. There are tolerance effects when taking this drug.
6. The drug can be used without the need for medical super- vision of dose or dosage schedule.
Answers: 1. decreases 2. increases 3. increases 4. decreases 5. increases 6. increases
14.1
Public demonstrations of nitrous oxide (“laughing gas”) inhalation were popular entertainments in the first half of the nineteenth century.
nitrous oxide (nIGH-trus oX-ide): An analgesic gas commonly used in modern dentistry. It is also referred to as laughing gas.
286 ■ Part Three Legally Restricted Drugs and Criminal Justice
alcoholic beverages, both ether drinking and ether inhala- tion became quite popular. It was used for the same pur- pose later in the United States during the Prohibition years and in Germany during World War II when alcohol was rationed. Ether’s flammability, however, made its recre- ational use highly dangerous.21
Glue, Solvent, and Aerosol Inhalation
Some of the common products that have been subject to abuse include glues, paint thinners, lighter fluid, and stain removers. In addition, many aerosol products are inhalable: hair sprays, deodorants, vegetable lubricants for cooking, and spray paints. Unfortunately, new products are continually being introduced for genuinely practical uses, with little awareness of the conse- quences should someone inhale their ingredients on a recre- ational basis (Table 14.4). There are also significant problems associated with occupational exposure to solvent vapors. In a study reported in 1999, 125 pregnant women who had been exposed to solvent products at the workplace were studied
Wells was sufficiently impressed to try out the anesthetic possibilities himself. The next day, he underwent a tooth extraction while under the influence of nitrous oxide. He felt no pain during the procedure, and nitrous oxide became a part of dental practice for quite a while. Today, however, its role has diminished in favor of local anesthetics such as lidocaine (brand name: Xylocaine).19
During the 1960s, nitrous oxide inhalation reappeared as a recreational drug. Tanks of compressed nitrous oxide were diverted for illicit use, and health professionals, like their counterparts 100 years earlier, were reportedly hosting nitrous oxide parties. Small cartridges of nitrous oxide called whippets, generally used by restaurants to dispense whipped cream, became available through college campus “head shops” and mail-order catalogs. The customary pattern of nitrous oxide abuse was to fill a balloon from these cylinders and inhale the gas from the balloon. The result was a mild euphoric high that lasted for a few minutes and a sense of well-being that lingered for several hours. Sometimes, there would be a loss of consciousness for a few seconds and an experience of “flying.” Once consciousness returned, there was the possibility of sensory distortions, nausea, or vomit- ing. Ordinary cans of commercial whipped cream, in which nitrous oxide is the propellant gas, currently provide easy access to this inhalant.
Nitrous oxide itself is a nontoxic gas, but its inhalation presents serious risks. As with any euphoriant drug, the recre- ational use of nitrous oxide can be extremely dangerous when a person is driving under its influence. In addition, if nitrous oxide is inhaled through an anesthetic mask and the mask is worn over the mouth and nose, without the combination of oxygen, the consequences can be lethal. Nitrous oxide dilutes the air that a person breathes. Unless there is a minimum of 21 percent oxygen in the mixture, reproducing the 21 percent oxygen content in the air, a lack of oxygen (called hypoxia) will produce suffocation or irreversible brain damage.20
Ether As was true of nitrous oxide, ether came into use well before its anesthetic effects were appreciated by the medi- cal profession. It was introduced by Friedrich Hoffmann at the beginning of the 1700s, under the name Anodyne, as a liquid “nerve tonic” for intestinal cramps, toothaches, and other pains. Whether it was swallowed or inhaled (it evaporated very quickly), ether also produced effects that resembled intoxication from alcohol. In fact, during the mid-1800s, when the combination of a heavy tax on alco- hol and an antialcohol temperance campaign in England and Ireland forced people to consider alternatives to
whippets: Small canisters containing pressurized nitrous oxide.
ether (ee-ther): An anesthetic drug, first introduced to surgical practice by William T. Morton in the 1840s. It is highly flammable.
hypoxia (high-PoX-ee-ah): A deficiency in oxygen intake.
TABle 14.4
Household products with abuse potential and their ingredients
HouseHold ProducT PossIBle InGredIenTs
Glues, plastic cements, and rubber cements
Acetates, acetone, benzene, hexane, methyl chloride, toluene, trichloroethylene
Cleaning solutions Carbon tetrachloride, petroleum products, trichloroethylene
Nail polish removers Acetone
Lighter fluids Butane, isopropane
Paint sprays, paint thinners, and paint removers
Acetone, butylacetate, methanol, toluene, methyl chloride
Other petroleum products Acetone, benzene, ether, gasoline, hexane, petroleum, tetraethyl lead, toluene
Typewriter correction fluid
Trichloroethylene, trichloroethane
Hair sprays Butane, propane
Deodorants, air fresheners Butane, propane
Whipped cream propellants Nitrous oxide
Sources: Based on information in Schuckit, Marc A. (2000). Drug and alcohol abuse: A clinical guide to diagnosis and treatment. New York: Kluwer Academic/Plenum, p. 222. Sharp, Charles W.; and Rosenberg, Neil L. (1997). Inhalants. In Joyce H. Lowinson; Pedro Ruiz; Robert B. Millman; and John G. Langrod (Eds.), Substance abuse: A comprehensive textbook (3rd ed.). Baltimore: Williams and Wilkins, p. 248.
Chapter 14 Depressants and Inhalants ■ 287
feel intoxicated within minutes after inhalation. The most immediate effects include giddiness, euphoria, dizziness, and slurred speech, lasting for 15–45 minutes. This state is followed by one to two hours of drowsiness and sometimes a loss of consciousness. Along with these effects are occasional experiences of double vision, ringing in the ears, and halluci- nations. We should realize that inhalant abuse often involves concentrations of glue and solvent products that are usually 50 to a 100 times greater than the maximum allowable con- centration of exposure in industry. The health of the inhalant abuser, therefore, is obviously at risk (Help Line).25
The dangers of inhalant abuse lie not only in the toxic effects of the inhaled compound on body organs but also in the behavioral effects of the intoxication itself. Inhalant- produced feelings of euphoria include feelings of reckless- ness and omnipotence. There have been instances of young inhalant abusers leaping off roof tops in an effort to fly, run- ning into traffic, lying on railroad tracks, or incurring severe lacerations when pushing their hand through a glass window that has been perceived as open. The hallucinations that are sometimes experienced carry their own personal risks. Walls may appear to be closing in, or the sky may seem to be fall- ing. Ordinary objects may be perceived to be changing their shape, size, or color. Any one of these delusions easily can lead to impulsive and potentially destructive behavior.26
There are also significant hazards that are related to the ways in which inhalants are administered. While solvents are sometimes inhaled from a handkerchief or from the container in which they were originally acquired (“huffing”), glues and similar vaporous compounds are often squeezed into a plas- tic bag and inhaled while the bag is held tightly over the nose and mouth (“bagging”). Potentially, a loss of consciousness can result in hypoxia and asphyxiation. Choking can occur if there is vomiting while the inhaler is unconscious. Another
over a nine-year period. There was a 13 times greater risk of birth defects among the exposed group, relative to controls. Occupations of these women included factory workers, labo- ratory technicians, artists, printing industry workers, chemists, and painters.22
Commercial glues, solvents, and aerosol sprays are prime candidates for drug abuse for a number of reasons. First, because they are inhaled into the lungs, the feeling of intoxica- tion occurs more rapidly than with orally administered alcohol. “It’s a quicker drunk,” in the words of one solvent abuser.23 The feeling is often described as a “floating euphoria,” similar to the effect of alcohol but with a shorter course of intoxication. The high is over in an hour or so, and the hangover is consid- ered less unpleasant than that following alcohol consumption. Second, the typical packaging of inhalant products makes them easy to carry around and conceal from others. Even if they are discovered, many of the products are so common that it is not difficult to invent an excuse for having them on hand.
Finally, most inhalants are easily available in hardware stores, pharmacies, and supermarkets, where they can be bought cheaply or stolen. Among some inhalant abusers, shoplifting these products from open shelves is not just rou- tine but expected. Inhalants are even more widely available than alcohol in poor households; liquor may be in short supply but gasoline, paints, or aerosol products are usually around the house or garage.24 As we will see, all these factors contribute to the considerable potential for inhalant abuse.
Acute Effects of Glues, Solvents, and Aerosols The fumes from commercial inhalant products fall into the general category of depressant drugs, in that the central ner- vous system is inhibited after they are inhaled. Individuals
Help Line The signs of Possible Inhalant Abuse
• Headaches and dizziness • Light sensitivity (from dilation of the pupils) • Reddened, irritated eyes and rash around the mouth • Double vision • Ringing in the ears (tinnitus) • Sneezing and sniffling • Coughing and bad breath • Nausea, vomiting, and loss of appetite • Diarrhea • Chest pains • Abnormal heart rhythm (cardiac arrhythmia) • Muscle and joint aches • Slurred speech and unsteady muscle coordination
• Chemical odor or stains on clothing or body • Rags, empty aerosol cans and other containers • Plastic and paper bags found in closets and other hidden
places
Where to go for assistance www.inhalant.org
The Web site is sponsored by the National Inhalant Prevention Coalition, Austin, Texas.
Sources: Fox, C. Lynn; and Forbing, Shirley E. (1992). Creating drug-free schools and communities. New York: HarperCollins, p. 37. Schuckit, Marc A. (1995). Drug and alcohol abuse: A clinical guide to diagnosis and treatment (4th ed.). New York: Plenum Medical Book Co., p. 219.
288 ■ Part Three Legally Restricted Drugs and Criminal Justice
that are mixed in the fuel. The additive triorthocresyl phosphate (TCP), in particular, has been associated with spastic muscle disorders and liver problems. Lead content in gasoline is generally linked to long-term CNS degen- eration, but fortunately leaded gasoline is no longer com- monly available in the United States. On the other hand, present-day gasoline mixtures contain large amounts of toluene, acetone, and hexane to help achieve the “anti- knock” property that lead had previously provided.27
Patterns of Inhalant Abuse
Among all the psychoactive drugs, inhalants are associated most closely with the young and often the very young. For those who engage in inhalant abuse, these compounds fre- quently represent the first experience with a psychoactive drug, preceding even alcohol or tobacco. Overall, inhalant abuse ranks as the fourth highest incidence of drug experi- mentation among secondary school students, surpassed only by alcohol, tobacco, and marijuana (in that order). Most of these drug abusers, however, are younger than secondary school age; often they are between 11 and 13 years old. The University of Michigan survey in 2013 found that about one out of nine eighth-grade students (11%) had used inhalants at some previous time. About 5 percent reported that they had used inhalants within the past year, and 2 percent within the past month. Inhalants are the only class of drugs for which the incidence of usage in the eighth grade significantly exceeds the incidence in the tenth and twelfth grades.28
In other cultures and under different circumstances, inhal- ant abuse affects even younger children and a wider proportion of them. In Mexico City, among street children as young as eight or nine who live without families in abandoned build- ings, rates of inhalant abuse are extremely high, with 22 percent
danger lies in the inhalation of Freon, a refrigerant gas so cold that the larynx and throat can be frozen upon contact.
The toxic effects of inhalant drugs themselves depend on the specific compound, but the picture is complicated by the fact that most products subject to inhalant abuse contain a variety of compounds, and in some cases, the list of ingredi- ents on the product label is incomplete. Therefore, often we do not know if the medical symptoms resulted from a particu- lar chemical or its interaction with others. Nonetheless, there are specific chemicals that have known health risks. The most serious concern involves sudden-death cases, brought on by cardiac dysrhythmia, that have been reported following the inhalation of propane and butane, commonly used as a propellant for many commercial products.
Besides butane and propane, other inhalant ingredients that present specific hazards are acetone, benzene, hexane, toluene, and gasoline.
●■ Acetone: Acetone inhalation causes significant damage to the mucous membranes of the respiratory tract.
●■ Benzene: Prolonged exposure to benzene has been associated with carcinogenic (cancer-producing) disorders, specifically leukemia, as well as anemia. Benzene is generally used as a solvent in waxes, resins, lacquers, paints, and paint removers.
●■ Hexane: The inhalation of hexane, primarily in glues and other adhesive products, has been associated with periph- eral nerve damage leading to muscular weakness and mus- cle atrophy. There is a latency period of a few weeks before the symptoms appear.
●■ Toluene: Toluene inhalation through glue sniffing has been associated with a reduction in short-term memory, anemia, and a loss of hearing, as well as dysfunctions in parts of the brain that result in difficulties in movement and coordination. Toluene also has been implicated as a principal factor in cases of lethal inhalation of spray paints and lacquers, though it is difficult to exclude the contribu- tion of other solvents in these products.
●■ Gasoline: Concentrated vapors from gasoline can be lethal when inhaled. Medical symptoms from gasoline inhala- tion are also frequently attributed to gasoline additives
triorthocresyl phosphate (TcP) (tri-or-thoh-creH-sil fos-fate): A gasoline additive. Inhalation of TCP-containing gasoline has been linked to spastic muscle disorders and liver problems.
toluene (Tol-yoo-ene): A compound in glues, cements, and other adhesive products. Inhalation of these products results in behavioral and neurological impairments.
hexane: A dangerous compound present in many glues and adhesive products. Inhalation of these products has been associated with muscular weakness and atrophy.
benzene: A carcinogenic (cancer-producing) compound found in many solvent products, representing a serious health risk when inhaled.
acetone (Ass-eh-tone): A chemical found in nail polish removers and other products.
A group of abandoned Brazilian children inhale glue from bags in Rio de Janeiro. The dazed expression is a typical sign of inhalant intoxication.
Chapter 14 Depressants and Inhalants ■ 289
that are involved with these tolerance effects, it appears that individuals exposed only to low concentrations for brief periods of time or high levels on an occasional basis fail to show tolerance to the inhalants.
Inhalant dependence occurs frequently. Inhalant abusers have been reported as feeling restless, irritable, and anxious when prevented from inhaling glues, solvents, or aerosols. Physiological withdrawal symptoms are only rarely observed among inhalant abusers but are frequently observed among animals in laboratory studies, so the question of whether phys- ical dependence exists has yet to be definitively answered.31
The young age at which inhalant abuse occurs leads to the question of whether there is a causal link between inhal- ant abuse and later abuse of other drugs. Without a doubt, some youths will subsequently replace inhalants with alcohol, marijuana, and other recreational drugs, but the experience of inhalants cannot be considered to lead on a pharmacologi- cal level to other drug experimentation or long-term abuse. A similar “gateway argument” with respect to marijuana was reviewed in Chapter 12.
Responses of Society to Inhalant Abuse
Certainly, the concern about inhalant abuse takes a backseat to more widely publicized concerns about cocaine, metham- phetamine, and heroin abuse or the abuse of hallucinogenic
reporting some form of solvent inhalation on a daily basis. Inhalant abuse is reported to be commonplace among street children in Rio de Janeiro and other major cities in Central and South America as well as Asia (Drugs . . . in Focus).29
Inhalant abuse, on an experimental basis, is not restricted by social or geographic boundaries. Chronic inhalant abuse, however, is overrepresented among the poor and those youths suffering emotional challenges in their lives and seek- ing some form of escape. Studies of young inhalant abusers show high rates of delinquency, poor school performance, and emotional difficulties. They often come from disorga- nized, multiproblem homes in which parents are actually or effectively absent or else engage themselves in abuse of alcohol or some other substance. The diversity of ethnic subgroups showing high prevalence rates for inhalant abuse include such disparate groups as Latino children in a rural community in the Southwest, Native American children on U.S. reservations, and white children in an economically dis- advantaged neighborhood in Philadelphia.30
Dependence Potential of Chronic Inhalant Abuse The long-term effects of inhalant abuse are not well docu- mented, owing to the fact that inhalant abuse frequently does not extend over more than a year or two in a person’s life and may occur only sporadically. There have been reports of cases showing a tolerance to the intoxicating effects of glues and gasoline. Although it is difficult to determine the dosages
resistol and Resistoleros in latin America In the cities of Central and South America, the street children are referred to as resistoleros, a name derived from their fre- quent habit of sniffing a commercial brand of shoemaker’s glue called Resistol. Granted, many cases of inhalant abuse among the hundreds of thousands of children in Latin America do not specifically involve Resistol; nevertheless, the frequency of Resistol abuse and the fact that Resistol dominates the market in commercial solvent-based adhesives have focused attention on the company that manufactures it, the H. B. Fuller Company of St. Paul, Minnesota.
Concern for the welfare of these children also has spotlighted a thorny ethical issue: Should a corporation accept the social re- sponsibility when widespread abuse of its product exists, either in the United States or elsewhere in the world? Testor Corporation in 1969 added a noxious ingredient to discourage abuse of its
model glue; in 1994, a German chemical company marketing a Resistol rival stopped its distribution in this region. For its part, Fuller did modify the formulation of Resistol in 1992, replac- ing the sweet-smelling but highly toxic toluene with a slightly less toxic chemical, cyclohexane. However, it continues to sell Resistol, claiming that its legitimate uses benefit the economies of regions where it is marketed. Moreover, the company has funded community programs for homeless children throughout Central America and has limited its Resistol marketing efforts to large industrial customers rather than small retailers. Unappeased, foes continue to press Fuller to discontinue the product entirely.
Note: There is no association between Resistol glue and Resistol Western Hats or any corporation-related sponsorships such as the Resistol Arena in Mesquite, Texas.
Source: Henriques, Diana B. (1995, November 26). Black mark for a “good citizen.” Critics say H. B. Fuller isn’t doing enough to curb glue-sniffing. New York Times, Section 3, pp. 1, 11.
Drugs … in Focus
290 ■ Part Three Legally Restricted Drugs and Criminal Justice
products. Like nitrous oxide and ether, these nitrites have been around for some time, but their abuse has been rela- tively recent.
Amyl and butyl nitrites were first identified in the nineteenth century. When inhaled, they produce an intense vasodilation, a relaxation of smooth muscle, a fall in blood pressure, and an increase in heart rate. Since 1867, amyl nitrite has been used medically, on a prescription basis, in the treatment of angina pain in heart patients and as an antidote to cyanide poisoning. Butyl nitrite produces similar therapeutic effects but has never been used on a clinical basis.
News of the recreational potential of nitrite inhala- tion began to spread in the 1960s and reached a peak in the 1970s, particularly within the gay community, as it was recognized that the vasodilation of cerebral blood vessels produced a euphoric high, anal sphincter muscles were relaxed, and vasodilation of genital blood vessels enhanced sexual pleasure (Table 14.5). By 1979, more than 5 million people in the United States were using amyl or butyl nitrites more than once a week. Since then, there has been a sub- stantial decline in their popularity.34 Amyl nitrite is often referred to as “poppers” or “snappers” because it is com- monly available in a mesh-covered glass ampule and there is a popping sound as the ampule is broken and the vapors of the nitrite are inhaled as they are released into the air. It is quick- acting, with vasodilatory effects appearing within 30 seconds. Light-headedness, a flushing sensation, blurred vision, and euphoria last for about five minutes, followed by headache and nausea. Butyl nitrite follows a similar time course in its effects and is available in pornography shops and mail-order catalogs.
Cases of nitrite inhalation have also been found among both heterosexual and gay adolescents, for whom the primary attraction is a feeling of general euphoria. The University of Michigan survey began looking at prevalence rates for nitrite inhalation in 1979. In that year, approxi- mately 11 percent of high school seniors reported having tried nitrite inhalants at least once in their lifetime. By 2003, the rate had dropped substantially and has remained steady at about 1 percent.35
Depressants and Drug-Facilitated Sexual Assault
Undoubtedly, the incidence of sexual assault has become a significant social as well as personal issue, and, in many cases, occurrences of this type have been associated with the voluntary or involuntary consumption of depressant drugs. This is not to say, however, that depressants covered in this chapter are typically involved in sexual assault cases. In fact, the “classic” depressant drug in sexual assault is
drugs. Despite the relatively low priority given to inhalant abuse, however, steps have been taken to reduce some of its hazards. One major approach has been to restrict the availabil- ity and sales of glues to young people, a strategy that, as you might predict, has met with mixed success. Some U.S. cities have restricted sales of plastic cement unless it is purchased with a model kit, but such legislation is largely ineffective when model kits themselves are relatively inexpensive. As with the official restriction of sales of alcohol and tobacco to minors, young people can find a way around these laws.
In a more direct approach, Testor Corporation, a lead- ing manufacturer of plastic cement for models, has incorpo- rated oil of mustard into the formula. This additive produces severe nasal irritation similar to the effect of horseradish while not affecting its use as a glue or the effect on the user who does not inhale it directly. Other brands of glues and adhesives, however, may not contain oil of mustard and as a result could still be available for abuse, and additives in general would not be desirable for certain products that are used for cosmetic purposes. Meanwhile, concentrations of benzene in many household products sold in the United States have been reduced or eliminated, though it is difficult to determine the exact composition of solutions merely by inspecting the label. Standards for products manufactured and sold in foreign countries are typically far less stringent.32
Ultimately, an educational strategy needs to be coordi- nated that is targeted at children in the elementary grades in school and their parents at home. Different countries have differing educational approaches, ranging from nonalarmist, low-key programs to those urging absolute abstinence, and it is not clear which strategy is most effective in controlling inhalant abuse. A National Inhalants and Poisons Awareness Week is currently held each year in March to promote greater efforts to inform the public about this problem. A 2002 sur- vey conducted by the Partnership for a Drug-Free America has shown that only a small fraction of the parents of teens who have tried inhalants are aware of that fact.33
Amyl Nitrite and Butyl Nitrite
The incidence of inhalant abuse with respect to amyl nitrite and butyl nitrite involves a different population from the one traditionally associated with glue, solvent, or aerosol
butyl nitrite (BYoo-til nIGH-trite): An inhalant drug, similar in its effects to amyl nitrite. It is commonly abused as it induces feelings of euphoria.
amyl nitrite (AY-mil nIGH-trite): An inhalant drug that relaxes smooth muscle and produces euphoria. Clinically useful in treating angina pain in cardiac patients, it is also subject to abuse.
oil of mustard: An additive in Testor brand hobby-kit glues that produces nasal irritation when inhaled, thus reducing the potential for inhalant abuse.
Chapter 14 Depressants and Inhalants ■ 291
simple alcohol (see Chapter 15). Nonetheless, it is impor- tant to examine here the role of specific “nonalcoholic” depressant drugs, either consumed alone or in combina- tion with alcohol (Portrait).
The Scope of the Problem Drug-facilitated sexual assault (DFSA) is defined as an instance in which alcohol or other drugs are used to compro- mise an individual’s ability to consent to sexual activity. In addition, drugs and alcohol are often used to minimize the resistance and memory of the victim of a sexual assault. In a national survey in 2011, about 18 percent of women in the United States reported being a victim of sexual violence at some time in their lives. In a survey of female undergraduates admitted to a hospital-based sexual assault treatment center in Ontario, Canada, between 2005 and 2007, 21 percent sus- pected that they were drugged. Studies vary in their reported incidences of alcohol intoxication among DFSA victims, but the numbers are very high. Between 65 and 96 percent of victims, depending on the study, report alcohol consump- tion on a voluntary basis prior to the assault. From police records of sexual assault cases, however, it is not often clear as to whether the perpetrator was intoxicated at the time of the crime (Figure 14.1).36
Quick Concept Check
Understanding the History of Inhalants Check your understanding of the history of inhalant drugs by indicating whether a particular substance was used (a) first recreationally, then as an application in medicine; (b) first as an application in medicine, then recreationally; or (c) recreationally, with no known application in medicine.
1. Amyl nitrite
2. Hexane
3. Nitrous oxide
4. Toluene
5. Ether
6. Benzene
7. Amyl nitrite
8. Butyl nitrite
Answers: 1. b 2. c 3. a 4. c 5. a 6. c 7. b 8. c
14.2
TABle 14.5
A chronology of nitrite inhalation abuse
dATe evenT dATe evenT
1859
1867
1880s
1960
1963
1960s
1969
1970
1974
1976
Flushing of skin with amyl nitrite first described
First therapeutic use of amyl nitrite for angina pain
Butyl nitrite studied but not used clinically
Amyl nitrite prescription requirement eliminated by FDA
First reports of recreational use of nitrites
Widespread recreational use of nitrites among young adults
Amyl nitrite prescription requirement reinstated
Street brands of butyl nitrite begin- ning to be widely available
Popper craze beginning
$50 million sales reported in nitrites in one U.S. city
1977
1979
1980
1981
1985
1990s to present
Nitrite inhalation predominant among gay men
More than 5 million people estimated to have used nitrites more than once per week
19 cases of Kaposi’s sarcoma found in retrospect
56 cases of Kaposi’s sarcoma reported
Increased suspicions of a link between nitrite use and Kaposi’s sarcoma
Concerns about AIDS and HIV infection beginning to receive widespread media attention
Association between nitrite inhalation and Kaposi’s sarcoma is discredited
Nitrite inhalation abuse greatly reduced among hetero- sexual populations
Source: Updated from Newell, Guy R.; Spitz, Margaret R.; and Wilson, Michael B. (1988). Nitrite inhalants: Historical perspective. In Harry W. Haverkos; and John A. Dougherty (Eds.), Health hazards of nitrite inhalants (NIDA Research Monograph 83). Rockville, MD: National Institute of Drug Abuse, p. 6.
292 ■ Part Three Legally Restricted Drugs and Criminal Justice
may feel extreme relaxation and sensitivity toward others, as well as an increased sensitivity to touch. While under influence, individuals may be less likely to be aware of danger or protect themselves from attack. In the case of ketamine (street names: Vitamin K, Special K), DSFA victims may feel detached from their bodies and their surroundings and experience subsequent amnesia.37
●■ Rohypnol is a long-acting benzodiazepine, not unlike diazepam (Valium), except that it is approximately 10 times stronger. Since it is highly synergistic with
Involvement of Drugs Other Than Alcohol There are several drugs other than alcohol that have been implicated in DFSA cases. They include Ecstasy and ket- amine, flunitrazepam (brand name: Rohypnol), and gamma- hydroxybutyrate (abbreviated GHB).
●■ Although Ecstasy and ketamine are traditionally classi- fied as hallucinogens (see Chapter 11), they have depres- sant-like properties. In the case of Ecstasy, DFSA victims
PorTrAIT Patricia White—GHB and Drug-Facilitated Sexual Assault
Patricia White, a 47-year- old mother of three, was at a party celebrating the birthday of her boss, Lorenzo Feal. According to testimony later given by White, as she was about to leave the party, Feal handed her a bottle of water. She took a gulp. A few hours later, White woke up in Feal’s bed, naked and nauseated. She had been drugged and raped. Doctors at the emer- gency department of the local hospital found traces of GHB in her system, and Feal was eventually convicted of using an anesthetic substance in carrying out White’s rape.
A prosecuting attorney has called GHB “ideal for predators and tough for prosecutors” because it is so easily
concealed in a drink. Without toxi- cological evidence, it is difficult to
prove that the rape victim had not given consent to sex. Perhaps GHB should really be called an “acquaintance- and date-rape drug.”
In 1994, when GHB was relatively new, only 56 GHB-related emergency department “mentions” were reported through the DAWN system (see Chapter 1). By 2002, that number had grown to 3,300. Colleges and universi- ties, as well as commercial bars, became justifiably alarmed. Since then, the Drug Enforcement Administration (DEA) has collaborated with the Rape, Abuse, and Incest National Network (RAINN) in an effort to provide a heightened awareness
of GHB and other “predatory” drugs such as Rohypnol.
Patricia White now counsels GHB rape victims and speaks out publicly about her personal story. In the case of GHB, the more you know about this drug, the safer you are.
Sources: Smalley, Suzanne (2003, February 3). “The perfect crime”: GHB is colorless, odorless, leaves the body within hours—and is fueling a growing number of rapes. Newsweek, p. 52. Substance Abuse and Mental Health Services Administration (2003). Emergency department trends from the drug abuse warning network, final estimates 1995–2002. Rockville, MD: Substance Abuse and Mental Health Services, Table 3.30.
44%
26%
13%
9%
8%
<1%
Perceived to be under influence of alcohol
Perceived to be under the influence of alcohol and drugs Perceived to be under the influence but not sure if alcohol or drugs
Perceived to be under influence of drugs
Don’t know or not ascertained Not on alcohol or drugs
f IGure 14 .1
Perceptions of victims of rape, sexual assault, verbal threats of rape, or verbal threats of sexual assault with regard to alcohol and/or drug use by the perpetrator.
Source: Based on data from the Bureau of Justice Statistics (2011, May). Criminal victimiza- tion in the United States, 2010, Statistical tables. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice.
Chapter 14 Depressants and Inhalants ■ 293
steroid-enhancing and growth-hormone-stimulating effects, leading to interest among bodybuilders. Other promotions focused on GHB as a sedative. By 1990, however, numerous reports of GHB-related seizures and comas led to its removal from the legitimate drug market. Reports of GHB in DFSA cases are uncommon (the incidence rate varies between 1% and 4%). Nonetheless, the fact that it is virtually undetectable makes it poten- tially dangerous in these circumstances.39
Efforts to Reduce Drug-Facilitated Sexual Assaults It is difficult to ascertain the relative involvement of various depressants (other than alcohol) in DFSA cases for a number of reasons. Victims of sexual assault are frequently amnesic to the circumstances prior to their attack or may be reluctant to reveal details of events leading up to the attack, particularly if voluntary drug-taking behavior had occurred. They may not acknowledge that drugs played a role.
Recent developments in target screening for drugs through hair samples (see Chapter 13) have been useful in forensic studies carried out to identify specific drugs that may have been implicated in DFSA cases. In these circum- stances, urine or blood samples are frequently unavailable. However, since there are only small-sample reports of hair analyses in DFSA cases, it is not possible to say which depres- sant drugs are most frequently involved.40
In some cases, the manufacturers of depressant drugs have taken steps to reduce the involvement of their product in sexual assault. Hoffmann–La Roche, the manufacturer
alcohol (see Chapter 4), it is particularly dangerous in DFSA situations. In one study, 9 percent of DFSA victims reported having consumed Rohypnol.38 Street names for Rohypnol include “roofies,” “rope,” “wolfies,” “roches,” and “R2.” Although it is not legally available in the United States, Rohypnol is approved for medical use in Europe and South America, where it is marketed by Hoffmann–La Roche Pharmaceuticals as a treatment for sleep disorders and as a surgical anesthetic. The U.S. supply of Rohypnol is smuggled into the country from Mexico and South America and sold for recre- ational use, frequently in its original bubble packaging (Drugs . . . in Focus).
●■ Gamma-hydroxybutyrate (GHB) is a colorless, odor- less, and virtually tasteless depressant drug, easily slipped into an alcoholic beverage without the knowledge of the drinker. It produces euphoria, and an “out-of- body” high with an accompanying lowering of inhibi- tions. At one time, GHB was sold in health-food stores and similar establishments. It was considered to have
gamma-hydroxybutyrate (GHB) (GAm-ma heye-droX- ee-BYoo-tih-rate): A powerful depressant, often abused to induce euphoria and sedation. When slipped in an alcoholic beverage without the knowledge of the drinker, GHB has been used as a date-rape drug.
rohypnol (ro-HIP-nol): The brand name for a benzodi- azepine drug, illegal in the United States but available for medical use in Europe and South America. It has been implicated in instances of drug-facilitated sexual assault. The generic name is flunitrazepam.
rohypnol and sexual Assaults The abuse potential of Rohypnol (generic name: flunitraz- epam) surfaced in the mid-1990s, when the number of pills identified in seizures by the DEA and other federal agencies increased by 400 percent from 1994 to 1995 alone. Drug en- forcement authorities have drastically reduced the availability of Rohypnol in the United States, though the drug remains a matter of concern, particularly in cases of drug-facilitated sexual assault.
Under such street names as “roofies,” “rope,” “wolfies,” “roches,” “R2,” and “Mexican Valium,” Rohypnol has been promoted not only as an alcohol enhancer but also as a strategy for getting drunk without having a blood-alcohol concentration level that would be defined as legal intoxication. Prior to the
time in which Hoffman–La Roche, manufacturer of Rohypnol, reformulated the drug, Rohypnol was odorless, colorless, and tasteless, making it easy to combine with any alcoholic beverage without detection.
Since 1996, U.S. federal law provides for a 20-year sentence for the use of Rohypnol in connection with rape or other violent crime.
Sources: Community Epidemiology Work Group (1996). Epidemiologic trends in drug abuse, Vol. 1: Highlights and executive summary. Rockville, MD: National Institute on Drug Abuse, pp. 8, 64. Office of National Drug Control Policy (2003, February). ONDCP Drug Policy Clearing-house fact sheet: Rohypnol. Washington, DC: Executive Office of the President.
Drugs … in Focus
294 ■ Part Three Legally Restricted Drugs and Criminal Justice
of Rohypnol, has reformulated the drug so that it turns blue when dissolved in a clear liquid. This helps to make Rohypnol somewhat more noticeable to an unsuspecting drinker, but it is important to realize that it is difficult to notice discernible changes in beverage color under the dim illumination conditions of a typical bar. Besides, blue dye in blue tropical drinks and punches produces no color change at all. A test strip developed by Drink Safe Technologies is available for the detection of GHB and ketamine (but not for Rohypnol). A straw can be used to place a few drops of one’s drink on the test strip. If the liquid turns blue, there is a positive result. Unfortunately, when the drink contains dairy products, an accurate detection cannot be made. Bar coasters have been developed that incorporate this particular test strip (see Help Line).41
This commercially available bar coaster is used to test for the presence of GHB and ketamine in an alcoholic beverage.
Help Line drug-facilitated sexual Assault: Protective strategies
There are several protective strategies to reduce the possibility of a drug-facilitated sexual assault. They include the following: • Watch the person who pours you a drink, even if he or she
is a friend or a bartender. Even better, do not drink what you cannot open or pour yourself. Avoid punch bowls and shared containers. Never accept a drink offered to you by a stranger.
• Do not leave a drink alone—not while you are dancing, using the restroom, or making a telephone call. If you have left it alone, it is better to toss the beverage.
• Appoint a designated “sober” friend to check up on you at parties, bars, clubs, and other social gatherings.
• If a friend seems extremely drunk or sick after a drink and has trouble breathing, call 911 immediately.
• If you have been slipped GHB, the drug will take effect within 10–30 minutes. Initially, you will feel dizzy or
nauseous, or develop a severe headache. You can be incapacitated rapidly. This is the time when having a nondrinking friend nearby is crucial.
• If you wake up in a strange place and believe that you have been sexually assaulted while under the influence of GHB, do not urinate until you have been admitted to a hospital. There is an approximately 12-hour window of opportunity to detect GHB through urinalysis.
Where to go for assistance www.4woman.gov/faq/rohypnol.htm
This Web site is sponsored by the National Woman’s Health Information Center, a service of the U.S. Department of Health and Human Services dedicated to women’s health issues.
Source: Information courtesy of the Rape, Abuse, and Incest National Network (RAINN), Washington, DC.
Barbiturates ●● Until approximately 1960, the primary sedative-hypnotics
(drugs that produce sedation and sleep) belonged to the barbiturate family of drugs.
●● Barbiturates are typically classified by virtue of how long their depressant effects are felt, from long acting (example: phenobarbital) to intermediate acting (examples: butalbar- bital and amobarbital) to short acting (examples: pentobar- bital and secobarbital).
●● A major disadvantage of barbiturates is the potential of a lethal overdose, particularly when combined with
other depressants such as alcohol. In addition, barbitu- rate withdrawal symptoms are very severe and require careful medical attention.
nonbarbiturate sedative-Hypnotics ●● Methaqualone (Quaalude) was introduced in the 1960s
as an alternative to barbiturates for sedation and sleep. Unfortunately, this drug produced undesirable side effects and became subject to widespread abuse. It is no longer available as a licit drug.
Summary
Chapter 14 Depressants and Inhalants ■ 295
household cleaning compounds, aerosol sprays, and solvents of all kinds.
●● These products are usually cheap, readily available, and easily concealable, and their intoxicating effects when inhaled are rapid. All these factors make inhalants prime candidates for abuse.
●● The principal dangers of inhalant abuse lie in the behav- ioral consequences of intoxication and in the possibility of asphyxiation when inhalants are administered by an air- proof bag held over the nose and mouth.
●● Specific toxic substances contained in inhalant products include acetone, benzene, hexane, toluene, and gasoline.
Patterns of Inhalant Abuse ●● Inhalant abuse respects no social or geographic boundar-
ies, though prevalence rates are particularly high among poor and disadvantaged populations.
●● Research studies indicate the presence of psychological dependence rather than physical dependence in inhalant abuse behavior.
●● Tolerance effects are seen for chronic inhalant abusers when the inhalant concentration is high and exposure is frequent.
responses of society to Inhalant Abuse ●● Concern about the dangers of inhalant abuse has led to
restriction of the sale of model-kit glues to minors and a modification of the formulas for model-kit glue in an attempt to lessen the possibility of abuse.
●● There are so many products currently on the open market that contain volatile chemicals that a universal restriction of abusable inhalants is practically impossible. Therefore, prevention efforts regarding inhalant abuse are critical ele- ments in reducing this form of drug-taking behavior.
Amyl nitrite and Butyl nitrite Inhalation ●● Two types of inhalants, amyl nitrite and butyl nitrite,
appeared on the scene in the 1960s, reaching a peak in the late 1970s. Although they are often identified with gay men, populations of heterosexual adolescents and young adults have also engaged in this form of inhalant abuse.
depressants and drug-facilitated sexual Assaults ●● Although alcohol is clearly the most prominent depres-
sant drug implicated in drug-facilitated sexual assaults, other depressants have also been identified, either sin- gly or in combination with alcohol. These depressants include Ecstasy and ketamine, Rohypnol, and gamma- hydroxybutyrate (GHB).
●● Efforts have been made to reformulate Rohypnol to make it somewhat more noticeable to an unsuspecting drinker that Rohypnol and alcohol has been combined. Special bar coasters containing test strips are commercially available to aid in identifying depressant drugs that might have been slipped into an alcoholic drink.
●● A number of protective strategies have been promoted to minimize the risk of drug-facilitated sexual assault.
The development of Antianxiety drugs ●● Beginning in the 1950s, a major effort was made by the
pharmaceutical industry to develop a drug that would relieve anxiety (tranquilize) rather than merely depress the CNS (sedate).
●● Meprobamate (Miltown) was introduced in 1955 for this purpose, though it is now understood that the effects of this drug result more from its sedative properties than its ability to relieve anxiety.
Benzodiazepines ●● The introduction of benzodiazepines, specifically diaz-
epam (Valium) and chlordiazepoxide (Librium), in the early 1960s, was a significant breakthrough in the develop- ment of antianxiety drugs. These drugs selectively affect specific receptors in the brain instead of acting as general depressants of the nervous system.
●● In general, benzodiazepines are safer drugs than barbitu- rates, when taken alone. When taken in combination with alcohol, however, dangerous synergistic effects are observed.
●● Social problems concerning the taking of benzodiazepine drugs during the 1970s centered on the widespread misuse of the drug. Prescriptions were written too frequently and for excessive dosages.
nonbenzodiazepine depressants ●● Recently developed nonbenzodiazepines have provided
better opportunities to treat sleep disorders and anxiety. Two examples are zolpidem and buspirone.
●● Zolpidem (brand name: Ambien) and eszopiclone (Lunesta) have been useful as a sedative-hypnotic in the treatment of insomnia. They have strong but transient sedative effects and produce little or no muscle relaxation.
●● Buspirone (brand name: BuSpar) has been useful as an antianxiety medication that does not cause sedation.
●● Beta blockers, traditionally used to treat cardiac and blood pressure disorders, have been prescribed for individuals who are facing an anxiety-producing event, such as per- forming on the stage or speaking in public.
●● Certain antidepressants called selective serotonin reuptake inhibitors (SSRIs) have been successful in treating a vari- ety of anxiety disorders.
Inhalants through History ●● Nitrous oxide was discovered in 1798 and became a major
recreational drug in the 1880s. It is still used recreation- ally, but its primary application is for routine anesthesia in dentistry.
●● Ether is another anesthetic drug, first introduced in the 1840s. It has also been used as a recreational drug, partic- ularly in times when alcohol availability has been severely reduced.
Glue, solvent, and Aerosol Inhalation ●● Present-day inhalant abuse involves a wide range of com-
mercial products: gasoline, glues and other adhesives,
296 ■ Part Three Legally Restricted Drugs and Criminal Justice
Key Terms
acetone, p. 288 amobarbital, p. 279 amyl nitrite, p. 290 antianxiety drugs, p. 278 anxiolytic drugs, p. 278 barbiturate, p. 278 benzene, p. 288 benzodiazepines, p. 282 beta blockers, p. 284
buspirone, p. 284 butyl nitrite, p. 290 chloral hydrate, p. 281 chlordiazepoxide, p. 282 diazepam, p. 282 ether, p. 286 eszopiclone, p. 284 gamma hydroxybutyrate
(GHB), p. 293
hexane, p. 288 hypoxia, p. 286 inhalants, p. 278 meprobamate, p. 282 methaqualone, p. 281 nitrous oxide, p. 285 oil of mustard, p. 290 pentobarbital, p. 279 phenobarbital, p. 279
REM-sleep rebound, p. 279 Rohypnol, p. 292 secobarbital, p. 279 sedative-hypnotics, p. 278 toluene, p. 288 triorthocresyl phosphate
(TCP), p. 288 whippets, p. 286 zolpidem, p. 284
1. Identify four barbiturate drugs, including one that is long- acting, one that is intermediate-acting, one that is short-acting, and one that is ultra-short-acting. What are the principal medical applications for each of these types?
2. What have been the advantages of benzodiazepines as antianxiety medications in comparison to barbiturates and other sedative-hypnotics?
3. What are the advantages and disadvantages of using xolpidem (Ambien) or eszopiclone (Lunesta) for treating insomnia? What are the advantages and disadvantages of using buspirone (BuSpar) for the treatment of anxiety?
4. Why are inhalants of particular concern for individuals who are too young to have access to other psychoactive drugs?
5. Identify five ingredients in household products that would be particularly toxic in the course of inhalant abuse.
6. Describe the scope of the problem of drug-facilitated sexual assault and identify four depressant drugs (other than alcohol) that have been implicated in cases of this type.
7. Describe at least three strategies that can reduce the risk of drug-facilitated sexual assault.
Review Questions
You are on a jury in a trial in which a man is accused of rape. The female victim testifies that she had voluntarily consumed a large amount of alcohol prior to the attack. Nonetheless, she also testi- fies that she did not have consensual sex with the man in question,
despite her inebriated state at the time. She claims that she was forcibly raped. In the jury deliberations, a number of fellow jury members have voiced their inclination to be lenient toward the accused, given the woman’s testimony. What would you do?
Critical Thinking: What Would You Do?
1. Silverstein, Alvin; Silverstein, Virginia; and Silverstein, Robert (1991). The addictions handbook. Hillside, NJ: Enslow Publish- ers, p. 51.
2. Palfai, Tibor; and Jankiewicz, Henry (1991). Drugs and human behavior. Dubuque, IA: W. C. Brown, p. 203.
3. Julien, Robert M. (2005). A primer of drug action (10th ed.). New York: Worth, pp. 147–148.
4. Julien, A primer of drug action, p. 148. 5. Kauffman, Janice F.; Shaffer, Howard; and Burglass, Milton
E. (1985). The biological basics: Drugs and their effects. In Thomas E. Bratter; and Gary G. Forrest (Eds.), Alcoholism and substance abuse: Strategies for clinical intervention. New York: Free Press, pp. 107–136.
6. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; Schulenberg, John E.; and Miech, Richard A. (2014). Monitor- ing the future: National survey results on drug use, 1975–2013, Vol. I: Secondary school students 2013. Ann Arbor, MI: Institute for Social Research, University of Michigan, Table 5-2.
7. Julien, A primer of drug action, pp. 149–150. 8. Substance Abuse and Mental Health Services Administration.
Benzodiazepines in drug abuse-related emergency department visits: 1995–2002 (2004, April). The DAWN Reports. Rockville,
MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, pp. 1–4. Lickey, Marvin E.; and Gordon, Barbara (1991). Medicine and mental illness. New York: Freeman, p. 280. Tanaka, Einosuke (2002). Toxicological interactions between alcohol and benzodiaz- epines. Journal of Toxicology—Clinical Toxicology, 40, 69–75.
9. Cumming, Robert G.; and LeCouteur, David G. (2003). Ben- zodiazepines and risk of hip fractures in older people: A review of the evidence. CNS Drugs, 17, 825–837. Salzman, Carl (1999). An 87-year-old woman taking a benzodiazepine. Jour- nal of the American Medical Association, 281, 1121–1125.
10. Rickels, Karl; Case, W. George; Downing, Robert W.; and Winokur, Andrew (1983). Long-term diazepam therapy and clinical outcome. Journal of the American Medical Association, 250, 767–771.
11. Longo, Lance P.; and Johnson, Brian (2000). Addiction: Part I. Benzodiazepines—Side effects, abuse risk and alternatives. American Family Physician, 61, 2121–2128.
12. Lagnaouli, Rajaa; Moore, Nicholas; Dartigues, Jean François; Fourrier, Annie; and Bégaud, Bernard (2001). Benzodiazepine use and wine consumption in the French elderly. British Jour- nal of Clinical Pharmacology, 52, 455–456. Pimlott, Nicholas
Endnotes
Chapter 14 Depressants and Inhalants ■ 297
aromatic hydrocarbons. In Charles W. Sharp and Mary L. Brehm (Eds.), Review of inhalants: Euphoria to dysfunction (NIDA Research Monograph 15). Rockville, MD: National Institute on Drug Abuse, pp. 124–163. Garriott, James C. (1992). Death among inhalant abusers. In Charles W. Sharp; Fred Beauvais; and Richard Spence (Eds.), Inhalant abuse: A volatile research agenda (NIDA Research Monograph 129). Rockville, MD: National Institute on Drug Abuse, pp. 171–193.
28. Edwards, Ruth W.; and Oetting, E. R. (1995). Inhalant use in the United States. In Nicholas Kozel; Zili Sloboda; and Mario De La Rosa (Eds.), Epidemiology of inhalant abuse: An interna- tional perspective (NIDA Research Monograph 148). Rockville, MD: National Institute on Drug Abuse, pp. 8–28. Johnston; O’Malley; Bachman; Schulenberg; and Miech, Monitoring the Future, Vol. I: Tables 5-5a, 5-5b, and 5-5c.
29. Howard, Matthew O.; Walker, R. Dale; Walker, Patricia S.; Cottler, Linda B.; and Compton, Wilson M. (1999). Inhal- ant use among urban American Indian youth. Addiction, 94, 83–95. Kin, Foong; and Navaratnam, Vis (1995). An overview of inhalant abuse in selected countries of Asia and the Pacific region. In Nicholas Kozel; Zili Sloboda; and Mario De La Rosa (Eds.), Epidemiology of inhalant abuse: An international perspective (NIDA Research Monograph 148). Rockville, MD: National Institute on Drug Abuse, pp. 29–49. Leal, Hermán; Mejía, Laura; Gómez, Lucila; and Salina de Valle, Olga (1978). Naturalistic study on the phenomenon of inhalant use in a group of children in Mexico City. In Charles W. Sharp and L. T. Carroll (Eds.), Voluntary inhalation of industrial solvents. Rockville, MD: National Institute on Drug Abuse, pp. 95–108. Medina-Mora; María Elena; and Berenzon, Shoshana (1995). Epidemiology of inhalant abuse in Mexico. In Nicho- las Kozel; Zili Sloboda; and Mario De La Rosa (Eds.), Epide- miology of inhalant abuse: An international perspective (NIDA Research Monograph 148). Rockville, MD: National Institute on Drug Abuse, pp. 136–174. Surratt, Hilary L.; and Inciardi, James A. (1996). Drug use, HIV risks, and prevention/interven- tion strategies among street youths in Rio de Janeiro, Brazil. In Clyde B. McCoy; Lisa R. Metsch; and James A. Inciardi (Eds.), Intervening with drug-involved youth. Thousand Oaks, MI: Sage Publications, pp. 173–190.
30. Howard, Matthew O.; and Jenson, Jeffrey M. (1998). Inhalant use among antisocial youth: Prevalence and correlates. Addic- tive Behaviors, 24, 59–74. Mackesy-Amiti; Mary Ellen; and Fendrich, Michaeal (1999). Inhalant abuse and delinquent behavior among adolescents: A comparison of inhalant users and other drug users. Addiction, 94, 555–564.
31. Korman, Maurice (1977). Clinical evaluation of psychologi- cal factors. In Charles W. Sharp and Mary Lee Brehm (Eds.), Review of inhalants: Euphoria to dysfunction (NIDA Research Monograph 15). Rockville, MD: National Institute on Drug Abuse, pp. 30–53.
32. Sharp, Charles W. (1977). Approaches to the problem. In Charles W. Sharp and Mary Lee Brehm (Eds.), Review of inhalants: Euphoria to dysfunction (NIDA Research Monograph 15). Rockville, MD: National Institute on Drug Abuse, pp. 226–242.
33. Office of National Drug Control Policy (2003, February). Inhalants: Drug Policy Information Clearinghouse fact sheet. Washington, DC: White House Office of National Drug Control Policy. Substance Abuse and Mental Health Services Administration (2003). Inhalants: Substance abuse treat-
J. G.; Hux, Janet E.; Wilson, Lynn M.; Kahan, Meldon; Li, Cindy; and Rosser, Walter W. (2003). Educating physicians to reduce benzodiazepine use by elderly patients: A randomized controlled trial. Canadian Medical Association Journal, 168, 835–839.
13. Emergency department visits linked to zolpidem overmedi- cation nearly doubled (2014, August 11). SAMHSA News Release. Substance Abuse and Mental Health Services Administration, Rockville, MD. Gershell, Leland (2006). From the analyst’s couch: Insomnia market. Nature Reviews and Drug Discovery, 5, 15–16.
14. FDA requiring lower starting dose for sleep drug Lunesta (2014, May 15). FDA News Release, U.S. Food and Drug Administration, Washington, DC. Medication Guide for Ambien. Sanofi-Aventis, U.S., L.L.C., Bridgewater, NJ.
15. Julien, A primer of drug action, pp. 181–182. 16. Naftel, K. A.; Adler, R. H.; Kappeli, L.; Rossi, M.; Dolder, M.;
et al. (1982). Stage fright in musicians: A model illustrating the effect of beta blockers. Psychosomatic Medicine, 44, 461–469.
17. Kent, J. M.; Coplan, J. D.; and Gorman, J. M. (1998). Clinical utility of the selective serotonin reuptake inhibitors in the spectrum of anxiety. Biological Psychiatry, 44, 812–824.
18. Broad, William J. (2002, March 19). For Delphic oracle, fumes and visions. New York Times, pp. F1, F4. Preble, Edward; and Laury, Gabriel V. (1967). Plastic cement: The ten cent halluci- nogen. International Journal of the Addictions, 2, 271–281.
19. Gillman, Mark A.; and Lichtigfeld, Frederick J. (1997). Clini- cal role and mechanisms of action of analgesic nitrous oxide. International Journal of Neuroscience, 93, 55–62. Nagle, David R. (1968). Anesthetic addiction and drunkenness. International Journal of the Addictions, 3, 33.
20. Layzer, Robert B. (1985). Nitrous oxide abuse. In Edmond I. Eger (Ed.), Nitrous oxide/N2O. New York: Elsevier, pp. 249–257.
21. Nagle, Anesthetic addiction and drunkenness, pp. 26–30. 22. Khattak, Sohail; K-Moghtader, Guiti; McMartin, Kristen;
Barrera, Maru; Kennedy, Debbie; and Koren, Gideon (1999). Pregnancy outcome following gestational exposure to organic solvents. Journal of the American Medical Association, 281, 1106–1109.
23. Cohen, Sidney (1977). Inhalant abuse: An overview of the problem. In Charles W. Sharp and Mary Lee Brehm (Eds.), Review of inhalants: Euphoria to dysfunction (NIDA Research Monograph 15). Rockville, MD: National Institute on Drug Abuse, p. 7.
24. Cohen, Inhalant abuse, pp. 6–8. 25. Schuckit, Marc A. (2006). Drug and alcohol abuse: A clinical
guide to diagnosis and treatment (6th ed.). New York: Springer, pp. 46–48. Sharp, Charles W.; and Rosenberg, Neil L. (1997). Inhalants. In Joyce H. Lowinson; Pedro Ruiz; Robert B. Millman; and John G. Langrod (Eds.), Substance abuse: A comprehensive textbook. Baltimore: Williams and Wilkins, pp. 246–264.
26. Abramovitz, Melissa (2003, October). The dangers of inhal- ants. Current Health, 2, 19–21. Winger, Gail; Hofmann, Frederick G.; and Woods, James H. (1992). A handbook on drug and alcohol abuse: The biomedical aspects (3rd ed.). New York: Oxford University Press, pp. 90–91.
27. Brands, Bruna; Sproule, Beth; and Marshman, Joan (1998). Drugs and drug abuse: A reference text. Toronto: Addiction Research Foundation, pp. 469–471. Bruckner, James V.; and Peterson, Richard G. (1977). Toxicology of aliphatic and
298 ■ Part Three Legally Restricted Drugs and Criminal Justice
Forcible, drug-facilitated, and incapacitated rape and sexual assault among undergraduate women. Journal of American College Health, 58, 453–460.
37. Rape, Abuse, and Incest National Network (RAINN). 38. Lawyer; Resnick; Bakanic; Burkett; and Kilpatrick, Forcible
drug-facilitated and incapacitated rape, p. 457. 39. Dyer, J. E. (2000). Evolving abuse of GHB in California:
Bodybuilding drug to date-rape drug. Journal of Toxicology— Clinical Toxicology, 38, 184. Lawyer; Resnick; Bakanic; Burkett; and Kilpatrick, Forcible drug-facilitated and incapacitated rape, p. 457. Németh, Zsófia; Kun, Bernadette; and Demetrovics, Zsolt (2010). The involvement of gamma- hydrobutyrate in reported sexual assaults: A systematic review. Journal of Psychopharmacology, 24, 1281–1287. Office of National Drug Control Policy (1998, October). ONDCP Drug Policy Information Clearinghouse fact sheet: Gamma hydroxybutyrate (GHB). Washington, DC: Executive Office of the President.
40. Staikos, Voula; Beyer, Jochem; Gerostamoulos, Deimitri; and Drummer, Olaf H. (2010). Targeted screening for common drugs of abuse in hair samples. Pathology, 42, p. S28.
41. Information regarding bar coasters courtesy of Drink Safe Technologies, Wellington, FL.
ment advisory. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration.
34. Newell, Guy R.; Spitz, Margaret R.; and Wilson, Michael B. (1988). Nitrite inhalants: Historical perspective. In Harry W. Haverkos and John A. Dougherty (Eds.), Health hazards of nitrite inhalants (NIDA Research Monograph 83). Rockville, MD: National Institute on Drug Abuse, pp. 1–14.
35. Johnston; O’Malley; Bachman; Schulenberg; and Miech, Monitoring the Future, Vol. I, Table 5-2.
36. Definition courtesy of the Rape, Abuse, and Incest National Network (RAINN), Washington, DC. Du Mont, Janice; Mac- donald, Sheila; Rotbard, Nomi; Asllani, Erioa; Bainbridge, Deidre; et al. (2009). Factors associated with suspected drug- facilitated sexual assault. Canadian Medical Journal, 180, 513–519. The National Center for Injury Prevention and Con- trol (2011, November). Executive Summary of the National Intimate Partner and Sexual Violence Survey. Atlanta, GA: Centers for Disease Control and Prevention. Hurley, Michael; Parker, Helen; and Wells, David L. (2006). The epidemiology of drug facilitated sexual assault. Journal of Clinical Foren- sic Medicine, 13, 181–185. Lawyer, Steven; Resnick, Heidi; Bakanic, Von; Burkett, Tracy; and Kilpatrick, Dean (2010).
Alcohol Use and Chronic
Alcohol Abuse “It’s funny but at the same time, really sad,” a friend and colleague
of mine said to me. “People don’t understand that alcohol is a drug,
a psychoactive drug.”
“They might say something like ‘Bob drinks a little too much,
but at least he’s not doing drugs.’ It’s incredible that here we have
a legal commodity in America that causes so many problems for
millions of Americans. It has devastating effects on family life, on
workplace productivity. Think of the innocent children born with
fetal alcohol syndrome; think of the tens of thousands of people
who die from car accidents every year. And yet, we don’t call it
drug abuse, when it really is. It’s like talking about the drug prob-
lem in America today—over a six-pack.”
“I couldn’t agree with you more,” I replied, “By the way,
I teach a course that deals with drug abuse and its effect on
society. The course is called ‘Drugs and Alcohol.’ I would like to
know how many of my students would expect to cover the effects
of alcohol in a course that was simply called ‘Drugs.’ I would
predict, not many.”
After you have completed this chapter, you should have an understanding of the following:
●● How alcoholic beverages are made
●● Patterns of alcohol consumption
●● Acute physiological and behavioral effects of alcohol
●● Strategies for responsible alcohol consumption
●● Patterns of chronic alcohol abuse
●● Physiological and behavioral aspects of chronic alcohol abuse
●● Treatment options for chronic alcohol abuse
15chapter
PA r t F o u r
On the Margins of Criminal Justice:
Regulating Legal Drugs
300 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
The Making of an Alcoholic Beverage
Creating ethyl alcohol, through a process known as fermentation, is a remarkably easy thing to do. Almost every culture in the world, at one time or another, has stumbled on the basic recipe. All you need is organic material with a sugar content (honey, grapes, berries, molasses, rye, apples, corn, sugar cane, rice, pumpkins, to name some examples) left undisturbed in a warm container for a time, and nature does the work. Microscopic yeast cells, floating through the air, land on this material and literally consume the sugar in it, so that, for every one sugar molecule consumed, two molecules of alcohol and two molecules of carbon dioxide are left behind as waste. The carbon dioxide bubbles out, and what remains is an alcoholic beverage, less sweet than the substance that began it all but with a new, noticeable kick. Basic fermentation results in a beverage with an alcohol content of between 12 and 16 percent, best exemplified by standard grape wine.2
The process of fermenting starchy grains such as barley to produce beer, called brewing, is somewhat more complicated. The barley is first soaked in water until it sprouts, producing an enzyme that is capable of breaking down the starch into sugar. It is then slowly dried, the sprouts are removed, and the remainder (now called barley malt) is crushed into a powder. The barley malt is combined with water, corn, and rice to form a mixture called a mash. The water activates the enzyme so that the starches convert into sugars. The addition of yeast to the mash starts the fermentation process and produces an alco- hol content of approximately 4.5–6 percent. The dried blos- soms of the hop plant, called hops, are then added to the brew for the characteristic pungent flavoring and aroma.
Relying on fermentation alone yields an alcohol con- centration level of about 15–16 percent at best. When the alcohol content exceeds this level, the alcohol starts to kill the yeast and, in doing so, stops the fermentation process. To obtain a higher alcoholic content, another process, called distillation, must occur.
For the record, my friend and I were having this con-
versation over a cup of coffee, not beer. This is not to say
we weren’t engaging in a form of drug-taking behavior.
The caffeine in our coffee is another psychoactive drug,
although fortunately much more benign than alcohol.
Alcohol consumption is so tightly woven into the social fabric of our lives that it is easy to forget about the pos- sible consequences of drinking too much too often.1 An alco- holic drink is often regarded as simply a social beverage, when in actuality it is a social drug. This chapter deals with the psychoactive properties of alcohol and its psychological and social consequences. In the first section, we will examine the acute effects of alcohol consumption, particularly with regard to the consequences of drinking in excessive amounts. In the second section, we will examine the chronic effects of alcohol consumption, focusing on the consequences of drinking over an extended period of time. At the end, we will review the treatment options available for chronic alcohol abuse.
We begin by asking a basic question: What makes a bever- age alcoholic in the first place?
23 Percentage of male college students in the United States (about one in four) reporting in 2013 as having 10 or more drinks in a row at least once in the prior two weeks.
9.4 Percentage of male college students in the United States (about one in eleven) reporting in 2013 as having 15 or more drinks in a row at least once in the prior two weeks.
2.1 million Estimated number of American adults who report that they have worked under the influence of alcohol in the past 12 months.
Sources: Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; Schulenberg, John E.; and Miech, Richard A. (2014). Monitoring the future: National survey results on drug use, 1975–2013, Vol. II: College students and adults ages 19–55, 2013. Ann Arbor, MI: Institute for Social Research, University of Michigan, p. 369. Frone, Michael R. (2006). Prevalence and distribution of alcohol use and impair- ment in the workplace: A U.S. survey. Journal of Studies on Alcohol and Drugs, 67, 147–156.
Numbers Talk…
barley malt: Barley after it has been soaked in water, sprouts have grown, sprouts have been removed, and the mixture has been dried and crushed to a powder.
brewing: The process of producing beer from barley grain.
fermentation: The process of converting natural sugars into ethyl alcohol by the action of yeast.
ethyl alcohol: The product of fermentation of natural sugars. It is generally referred to simply as alcohol, though several types of nonethyl alcohol exist.
distillation: A process by which fermented liquid is boiled and then cooled, so that the condensed product contains a higher concentration of alcohol than before.
mash: Fermented barley malt, following liquefaction and combination with yeast.
Chapter 15 Alcohol Use and Chronic Alcohol Abuse ■ 301
Processing of Alcohol in the Body
Alcohol is a very small molecule that is moderately soluble in fat and highly soluble in water—all characteristics that make it easily absorbed through the gastrointestinal tract once it is ingested, without needing any digestion. About 20 percent of it is absorbed into the bloodstream directly from the stom- ach, whereas the remaining 80 percent is absorbed from the upper portion of the small intestine.
Because the small intestine assumes the lion’s share of the responsibilities and acts extremely rapidly (more rapidly than the stomach), the rate of total alcohol absorption is based largely on the condition of the stomach when the alcohol arrives and the time required for the stomach to empty its contents into the small intestine. If the stomach is empty, an intoxicating
Distillation involves heating a container of some fer- mented mixture until it boils. Because alcohol has a lower boil- ing temperature than water, the vapor produced has a higher alcohol-to-water ratio than the original mixture. This alcohol- laden vapor is then drawn off into a special coiled apparatus (often referred to as a still), cooled until it condenses back to a liquid, and poured drop by drop into a second container. This new liquid, referred to as distilled spirits or simply liquor, has an alcohol content considerably higher than 15 percent, generally in the neighborhood of 40–50 percent. It is possible through further distillations to achieve an alcohol content of up to 95 percent.
The alcohol content of distilled spirits, however, is commonly described not by percentage but rather by the designation “proof.” Any proof is twice the percentage of alcohol: An 80-proof whiskey contains 40 percent alcohol; a 190-proof vodka contains 95 percent alcohol.
The three basic forms of alcoholic beverages are wine, beer, and distilled spirits. Table 15.1 shows the sources of some well-known examples.
distilled spirits: The liquid product of distillation, also known as liquor.
tAble 15.1
Prominent alcoholic beverages and their sources
beverAge Source beverAge Source
Distilled spirits Wines
Brandy Distilled from grape wine, cherries, or peaches
Red table wine
White table wine
Champagne
Sparkling wine
Fortified wines
Winelike variations
Hard cider
Sake
beers
Draft beer
Lager beer
Ale
Malt liquor
Fermented red grapes with skins
Fermented skinless grapes
White wine bottled before yeast is gone so that remaining carbon dioxide produces a carbonated effect
Red wine prepared like champagne or with c arbonation added
Wines whose alcohol content is raised or fortified to 20% by the addition of brandy—for example, sherry, port, Marsala, and Madeira
Fermented apples
Fermented rice
Types of beer vary depending on brewing procedures.
Contains 3–6% alcohol
Contains 3–6% alcohol
Contains 3–6% alcohol
Contains up to 8% alcohol
Liqueur or cordial Brandy or gin, flavored with blackberry, cherry, chocolate, peppermint, licorice, etc. Alcohol content ranges from 20% to 55%
Rum Distilled from the syrup of sugar cane or from molasses
Scotch whiskey
Rye whiskey
Blended whiskey
Bourbon whiskey
Gin
Vodka
Tequila
Grain neutral spirits
Distilled from fermented corn and barley malt
Distilled from rye and barley malt
A mixture of two or more types of whiskey
Distilled primarily from fermented corn
Distilled from barley, potato, corn, wheat, or rye, and flavored with juniper berries
Approximately 95% pure alcohol, distilled from grains or potatoes and diluted by mixing with water
Distilled from the fermented juice of the maguey plant
Approximately 95% pure alcohol, used either for medicinal purposes or diluted and mixed in less- concentrated distilled spirits
Source: Adapted from Becker, Charles E.; Roe, Robert L.; and Scott, Robert A. (1979). Alcohol as a drug: A curriculum on pharmacology, neurology, and toxicology. Huntington, NY: Robert Krieger Publishing, pp. 10–12.
302 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
biotransformation process consists of two basic steps. First, an enzyme, alcohol dehydrogenase, breaks down alcohol into acetaldehyde. This enzyme is present in the stomach, where about 20 percent of alcohol is broken down prior to absorption into the bloodstream, and in the liver, where the remaining 80 percent is broken down from accumulations in the blood. Second, another enzyme, acetaldehyde dehy- drogenase, breaks down acetaldehyde in the liver into acetic acid. From there, further oxidation results in oxygen, carbon dioxide, and calories of energy.
The entire process is determined by the speed with which alcohol dehydrogenase does its work, and for a given individual, it works at a constant rate, no matter how much alcohol needs to be broken down. Imagine a bank at which only one teller window stays open, no matter how long the line of customers grows, and you will understand the limitations under which the body is operating.
A number of factors, however, can alter the oxidation process. For example, women have 60 percent less alcohol dehydrogenase than men, making their oxidation of alcohol relatively slower, even when different body weights have been taken into account. Aspirin reduces enzyme levels by one-half, causing more alcohol to accumulate in the blood. Among women, aspirin has a greater inhibiting effect than among men, so it is possible that alcohol oxidation will be drastically reduced if a woman is taking aspirin prior to drinking alco- holic beverages. Gastric ulcer medications also inhibit alcohol dehydrogenase and thus increase the physiological impact of alcohol. As mentioned in Chapter 4, about 50 percent of all people of Asian descent have a genetically imposed lower level of acetaldehyde dehydrogenase in the liver. As a consequence, acetaldehyde builds up, causing nausea, itching, facial flush- ing, and cardiac acceleration. The combination of these symp- toms, often referred to as fast-flushing, makes alcohol con- sumption very unpleasant for many Asians.5
In general, the oxidation rate for adults in general is approximately one-third to one-half ounce of pure alcohol an hour. If you sipped (not gulped) slightly less than the contents of one 12-ounce bottle of beer, one 5-ounce glass of wine, or any equivalent portion of alcohol (see Drugs . . . in Focus, page 304) very slowly over an hour’s time, the enzymes in the stomach and liver would keep up, and you would not feel intoxicated. Naturally, if you consume larger amounts of alcohol at faster rates of consumption, all bets are off.6
It is no secret that alcohol consumption is conducive to the accumulation of body fat, most noticeably in the form of the notorious beer belly. It turns out that alcohol does not have significant effects on the biotransformation of dietary carbohydrates and proteins, so a drinking individual who consumes a healthy diet does not have to worry about getting enough nutrients. Alcohol does, however, reduce the breakdown of fat, so dietary fat has a greater chance of being stored rather than expended. Over time, the accu- mulation of fat in the liver is particularly serious because it eventually interferes with normal liver function. This potentially life-threatening medical condition involving the
effect (the “buzz”) will be felt very quickly. If the stomach is full, absorption will be delayed as the alcohol is retained by the stomach along with the food being digested, and the passage of alcohol into the small intestine will slow down.
Besides the condition of the stomach, there are other fac- tors related to the alcohol itself and the behavior of the drinker that influence the rate of alcohol absorption. The principal factor is the concentration of alcohol in the beverage being ingested. An ounce of 80-proof liquor (equivalent to an alco- hol content of 40%) will be felt more quickly than an ounce of wine containing 12 percent alcohol, and of course the level of alcohol in the blood will be higher as well. Also, if the alco- holic beverage is carbonated, as are champagne and other sparkling wines, the stomach will empty its contents faster and effects will be felt sooner. Finally, if the alcohol enters the body at a rapid pace, such as when drinks are consumed in quick succession, the level of alcohol in the blood will be higher because the liver cannot eliminate it fast enough. All other factors being equal, a bigger person requires a larger quantity of alcohol to have equivalent levels accumulating in the blood, simply because there are more body fluids to absorb the alcohol, thus diluting the overall effect.3
The Breakdown and Elimination of Alcohol Its solubility in water helps alcohol to be distributed to all bodily tissues, with those tissues having greater water con- tent receiving a relatively greater proportion of alcohol. The excretion of alcohol is accomplished in two basic ways. About 5 percent will be eliminated by the lungs through exhalation, causing the characteristic “alcohol breath” of heavy drinkers. Breathalyzers, designed to test for alcohol concentrations in the body and used frequently by law enforcement officials to test for drunkenness, work on this principle. The remaining 95 percent is eliminated in the urine, after the alcohol has been biotransformed into carbon dioxide and water.4
The body recognizes alcohol as a visitor with no real biological purpose. It contains calories but no vitamins, min- erals, or other components that have any nutritional value. Therefore, the primary bodily response is to break it down for eventual removal, through a process called oxidation. This
acetic acid (a-See-tik ASS-id): A by-product of alcohol metabolism, produced through the action of acetaldehyde dehydrogenase.
acetaldehyde dehydrogenase (ASS-ee-tAl-duh-hide Dee- high-DrAW-juh-nays): An enzyme in the liver that converts acetaldehyde to acetic acid in alcohol metabolism.
acetaldehyde (ASS-ee-tAl-duh-hide): A by-product of alcohol metabolism, produced through the action of alcohol dehydrogenase.
alcohol dehydrogenase (Al-co-haul Dee-high-DrAW- juh-nays): An enzyme in the stomach and liver that converts alcohol into acetaldehyde.
oxidation: A chemical process in alcohol metabolism.
Chapter 15 Alcohol Use and Chronic Alcohol Abuse ■ 303
of alcohol in the blood relative to 100 milliliters of blood, expressed as a percentage. For example, 0.1 gram (100 milli- grams) of alcohol in 100 milliliters of blood is represented by a BAC of 0.10 percent. As shown in Table 15.2, BAC levels are calculated in terms of four factors: (1) gender, (2) one’s body weight, (3) the amount of alcohol consumed, and (4) the num- ber of hours elapsed since starting the first drink. In order to calculate your BAC, choose the correct chart (male or female), find the column corresponding to your approximate weight in pounds and the row corresponding the number of “standard drinks” consumed (see page 304), then subtract 0.015 for every hour since drinking began.
In all U.S. states, a BAC level of 0.08 percent and higher is the standard for “legal intoxication.” In some cases, the standards are more stringent. According to regulations of the U.S. Department of Transportation, truck drivers are tested and prevented from driving at a BAC level of 0.04 percent and airline pilots are prevented from flying at a BAC level of 0.02 percent (after 24 hours of abstinence).9
liver will be examined later in the chapter as one of the major adverse consequences of chronic alcohol abuse.7
Alcohol on the Brain Alcohol is clearly a CNS-depressant drug, though it is often misidentified as a stimulant. The reason for this confusion is that alcohol, at low doses, first releases the cerebral cor- tex from its inhibitory control over subcortical systems in the brain, a kind of double-negative effect. In other words, alco- hol is depressing an area of the brain that normally would be an inhibitor, and the result is the illusion of stimulation. The impairment in judgment and thinking (the classic features of being drunk) stems from a loosening of social inhibitions that enable us, under nonalcoholic circumstances, to be rela- tively thoughtful about the consequences of our actions, as well as relatively civil and well behaved.8
Measuring Alcohol Levels in the Blood The degree of alcohol intoxication is directly related to alco- hol levels in the blood. Therefore, it is important to consider how these levels are measured.
The blood alcohol concentration (BAC) of an individ- ual who has consumed alcohol refers to the number of grams
tAble 15.2
blood alcohol concentration (bAc): The number of grams of alcohol in the blood relative to 100 milliliters of blood, expressed as a percentage. An alternate term is blood-alcohol level (BAL).
MeN WoMeN Approximate blood alcohol concentration (BAC) Approximate blood alcohol concentration (BAC)
Drinks Body weight (pounds) Drinks Body weight (pounds)
100 120 140 160 180 200 220 240 90 100 120 140 160 180 200 220 240
0
.00
.00
.00
.00
.00
.00
.00
.00 Only safe
driving limit
0
.00
.00
.00
.00
.00
.00
.00
.00
.00
Only safe driving
limit
1 .04 .03 .03 .02 .02 .02 .02 .02 Caution 1 .05 .05 .04 .03 .03 .03 .02 .02 .02 Caution
2 .08 .06 .05 .05 .04 .04 .03 .03 2 .10 .09 .08 .07 .06 .05 .05 .04 .04
3 .11 .09 .08 .07 .06 .06 .05 .05 3 .15 .14 .11 .10 .09 .08 .07 .06 .06
4 .15 .12 .11 .09 .08 .08 .07 .06 Driving impaired
4 .20 .18 .15 .13 .11 .10 .09 .08 .08 Driving impaired
5 .19 .16 .13 .12 .11 .09 .09 .08 5 .25 .23 .19 .16 .14 .13 .11 .10 .09
6 .23 .19 .16 .14 .13 .11 .10 .09 6 .30 .27 .23 .19 .17 .15 .14 .12 .11
7 .26 .22 .19 .16 .15 .13 .12 .11 Legally intoxicated
7 .35 .32 .27 .23 .20 .18 .16 .14 .13 Legally intoxicated
8 .30 .25 .21 .19 .17 .15 .14 .13 8 .40 .36 .30 .26 .23 .20 .18 .17 .15
9 .34 .28 .24 .21 .19 .17 .15 .14 9 .45 .41 .34 .29 .26 .23 .20 .19 .17
10 .38 .31 .27 .23 .21 .19 .17 .16 10 .51 .45 .38 .32 .28 .25 .23 .21 .19
Alcohol is “burned up” by your body at .015% per hour, as follows:
Hours since starting first drink 1 2 3 4 5 6 Percent alcohol burned up .015 .030 .045 .060 .075 .090
To calculate your BAC level correctly, you must consider the number of standard drinks you have consumed, your gender and body weight, and how much time has passed since the first drink. All U.S. states have now adopted the .08% standard for drunk driving.
Source: Based on information from Julien, Robert M. (2001). A primer of drug action (9th ed.). New York: Worth, p. 317, and the Pennsylvania State Liquor Control Board, Harrisburg, PA.
304 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
How many alcoholic drinks does this estimated daily amount add up to? To answer this question, it is impor- tant first to consider the amount of pure alcohol that is contained in each of four basic types of alcoholic bever- ages (Drugs . . . in Focus). A single half-ounce of alcohol is
Measuring Alcohol Consumption The estimated annual per capita consumption of pure alco- hol for adults in the United States is approximately 2.3 gal- lons (8.7 liters). This level of consumption amounts to about three-fourths of an ounce of pure alcohol per day.10
Multiple Ways of getting a Standard Drink A standard alcoholic drink is any drink that contains about 14 grams of pure alcohol (about 0.5 fluid ounce). All of the following seven alcoholic drinks should be considered equivalently as a standard drink.
Drugs . . . in Focus
There are so many variations in the quantity of an alcoholic beverage being served that it can be confusing to determine as to how many standard drinks are actually being consumed. Here are some examples of how the number of standard drinks can multiply when quantities increase:
●■ For beer or wine cooler, the approximate number of standard drinks in • 12 oz = 1 • 16 oz = 1.3 • 22 oz = 2 • 40 oz = 3.3
●■ For malt liquor, the approximate number of standard drinks in • 12 oz = 1.5 • 16 oz = 2 • 22 oz = 2.5 • 40 oz = 4.5
●■ For table wine, the approximate number of standard drinks in • a standard 750 mL (25 oz) bottle = 5
●■ For 80-proof spirits, or “hard liquor,” the approximate number of standard drinks in • a mixed drink = 1 or more** • a pint (16 oz) = 11 • a fifth (25 oz) = 17 • 1.75 L (59 oz) = 39
*In recent years it has been common for wines to contain an alcohol concentration of 16 percent. In these instances, 5 ounces of wine would be equivalent to 0.80 ounces of alcohol, which is 33 percent higher than when a 12 percent wine is considered. Another way of thinking about this is that for a drink of wine with 16 percent alcohol concentration to be equivalent to a 12-ounce can of beer or a typical shot of liquor, the quantity of wine consumed should be reduced to approximately 4 ounces. In this chapter, however, we will retain the concept of 5 ounces of wine as representing a standard drink, since it is traditional that alcohol equivalencies are calculated on this basis.
**It can be difficult to estimate the number of standard drinks served in a single mixed drink made with hard liquor. Depending on factors such as the type of spirits and the recipe, one mixed drink can contain from one to three or more standard drinks.
Source: National Institute on Alcohol Abuse and Alcoholism (2005). Helping patients who drink too much: A clinician’s guide. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism, p. 12.
12 oz 8.5 oz 5 oz 3.5 oz 2.5 oz 1.5 oz 1.5 oz
1.5 oz of spirits
(a single jigger of 80-proof gin, vodka,
whiskey, etc.) Shown straight and in a highball glass with ice to show
level before adding mixer
2–3 oz of cordial,
liqueur, or aperitif
2.5 oz shown
3–4 oz of fortified wine
(such as sherry or
port) 3.5 oz shown
5 oz of table wine*
8–9 oz of malt liquor 8.5 oz shown in
a 12-oz glass that, if full, would hold
about 1.5 standard drinks of
malt liquor
12 oz of beer or
wine cooler
1.5 oz of brandy
(a single jigger)
Chapter 15 Alcohol Use and Chronic Alcohol Abuse ■ 305
12 ounces in capacity. A mixed drink in a bar might con- tain a quantity of liquor that exceeds a standard amount, if the bartender is particularly generous. In either of these circumstances, an individual can be misled into believ- ing that he or she is consuming an “average” amount (in terms of drinks) when, in fact, the quantity of alcohol being consumed is considerably larger.
It is useful to look at average statistics when considering alcohol consumption, but it is obvious that not everyone is “average.” There is an enormous disparity in terms of how much alcohol each person actually consumes during a given year. Some people drink no alcohol at all, whereas others drink heavily. In fact, 80 percent of the total amount of alco- hol consumed in the United States each year is consumed by only the 30 percent of Americans who drink and only 20 per- cent of the population in general. Drugs . . . in Focus provides a graphic demonstration of the lop-sided distribution in alcohol consumption in the United States today.
consumed when drinking any of the following alcoholic beverages in the amounts indicated:
●■ One 5-ounce glass of wine ●■ One 12-ounce bottle or can of beer ●■ One 12-ounce bottle of wine cooler ●■ One shot (1.5-ounce size) of 80-proof liquor
All these quantities are approximately equal to about one- half ounce in terms of pure alcohol, and they are often referred to as “standard drinks.”
Based on these equivalencies, the average alcohol consumption in the United States can be approximated as about 1.5 “standard drinks” per day. Bear in mind, how- ever, that a “standard drink” may not be the drink you typi- cally consume. You have to be careful in computing your own personal level of alcohol consumption. Draft beer, for example, is typically dispensed in large glasses that exceed
visualizing the Pattern of Alcohol consumption in the united States To appreciate the uneven pattern of alcohol consumption in the population, try the following demonstration:
Assemble ten people and ten bottles of beer (preferably empty).
Separate three people who hold nothing. They represent the 30 percent of the population that does not drink alcohol at all.
Separate five people; together they hold two bottles. They represent the 50 percent of the population that drinks 20 percent of the total alcohol supply.
Separate the ninth person; this person holds two bottles. This individual represents the 10 percent of the popu- lation that drinks another 20 percent of the total alcohol supply.
Separate the tenth person; this person holds a six-pack of bottles. This individual represents the 10 percent of the population that drinks 60 percent of the total alcohol supply.
the Moral of the Story Twenty percent of the entire population (the ninth and tenth persons in this demonstration) drink 80 percent of the total alcohol consumed in the United States each year. Of those who drink some alcohol, two-sevenths (roughly 30%) of them drink 80 percent of the total alcohol consumed each year, while five-sevenths (roughly 70%) of them drink the remaining 20 percent. These figures correspond to those expressed in the text.
Drugs . . . in Focus
Source: Kinney, G. Jean (2006). Loosening the grip: A handbook of alcohol information, 8th ed. New York: McGraw-Hill, p. 30.
306 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
Patterns of Alcohol Consumption
Historians point out that fermented honey, called mead, was probably the original alcoholic beverage, dating from approximately 8000 b.c. Beer, requiring more effort than simple fermentation, came on the scene much later; the Egyptians established the first official brewery in about 3700 b.c. At that time, beer was quite different from the watery forms we know today. It more closely resembled bread than a beverage, and the process of producing beer was closer to baking than to brewing.11
Evidence of the development of wine comes from references to its sale in the Code of Hammurabi, King of Babylonia, recorded about 1700 b.c. Wine making itself, however, appears to have begun more than 3,000 years before that. Excavations of an ancient village in modern-day Iran have revealed the remains of wine-stained pottery dating back to as early as 5400 b.c.12
The first documented distillation of alcohol was the conversion of wine into brandy during the Middle Ages, at a medical school in Salerno, Italy. With an emphasis on its medicinal applications, the new beverage became known in Latin as aqua vitae (“the water of life”). People quickly caught on to its inebriating possibilities, and brandy was the primary distilled liquor in Europe until the middle of the seventeenth century. At that time the Dutch perfected the process of distilling liquor and flavoring it with juniper berries. A new alcoholic beverage was born: gin.
The enormous popularity of gin throughout Europe marked a crucial point in the history of alcohol’s effect on European society. Because it was easily produced, cheaper than brandy, and faster acting than wine, gin became attractive to all levels of society, particularly the poorer classes of people. By the mid-1700s, alcohol abuse was being condemned as a major societal problem, and concerns about drunkenness had become a public issue.
Consumption of other distilled spirits introduced during this period, such as rum and whiskey, added to the overall problem, but gin was undoubtedly the prime culprit. The epidemic of gin drinking in England during the first half of the eighteenth century illustrates how destructive the intro- duction of a potent and easily available psychoactive drug into an urban society already suffering from social dislocation and instability can be. The consequences in many ways mirrored the introduction of crack cocaine into the urban communi- ties of the United States during the 1980s.13
It has been theorized that the earliest systems of agriculture in human history were born of the desire to secure a depend- able supply of beer. If this is so, then alcohol, commercializa- tion, and economics have been linked from the very beginning. Today, of course, alcohol is not merely a big business, but an
aqua vitae (AH-kwa veYe-tee): A brandy, the first distilled liquor in recorded history.
The social chaos of “Gin Lane” in London, as interpreted in this engraving by William Hogarth (1697–1764). Notice the falling baby in the foreground as a symbol of rampant child neglect during this time.
enormous business. Americans spend more than $140 billion on the purchase of alcoholic beverages each year, and the alcohol industry spends about $1.4 billion advertising its prod- ucts. More than one-third of this advertising budget is typically devoted to television commercials for beer.14
The stainless steel tanks of the world’s largest winemaker, the Ernest and Julio Gallo Winery, are located in Modesto, California. Nearly 900 million gallons of wine are produced by E. & J. Gallo each year, accounting for approximately one of every three bottles of wine sold annually in the United States.
Chapter 15 Alcohol Use and Chronic Alcohol Abuse ■ 307
■■ Among first-semester freshman students, roughly one in five males reported having consumed more than 10 drinks, and 1 in 10 females reported having consumed more than eight drinks at least once in the previous two weeks. This pattern of alcohol use is referred to as extreme binge drink- ing. In these cases, the level of alcohol consumption was more than twice the consumption level defined as the threshold for binge drinking.
■■ College students who drank alcohol at some time over the past year frequently report alcohol-related problems while at college. One in four students report that their drinking had a negative impact on their academic performance. Problems included missing a class, failing behind on course assignments, doing poorly on exams or papers, and receiving lower grades overall.
■■ One in five students report that, while intoxicated, they engaged in unplanned sexual activity or engaged in unpro- tected sex. One in three students report that they had done something they regretted while intoxicated.
The surveys have also shed light on the negative impact of alcohol consumption among college students on nondrink- ers (defined as either abstainers or nonbinge drinkers). These situations, called secondhand effects (because the individuals themselves were not intoxicated but were affected by those who were), are analogous to the problems of secondhand smoking, which will be examined in Chapter 16. Three in 10 college students (29%) report that they were insulted or humil- iated by another student who had been drinking. One in five students (19%) report having experienced an unwanted sexual advance.15
Alcohol Consumption among Underage Drinkers Looking at the early years of teenage drinking, we find that alcohol use has been extensive by the eighth grade. In fact, among young people who report some alcohol consumption
Alcohol Consumption among College Students Not surprisingly, the prevalence of moderate alcohol con- sumption in college (assessed in terms of those having a drink in the last 30 days) is substantially higher than levels encoun- tered in high school, although the establishment of 21 as the mandated legal drinking age in all U.S. states has delayed the occurrence of peak consumption levels to the junior or senior year. Among young adults, binge drinking—defined for men as having five or more alcoholic drinks and for women as having four or more alcoholic drinks over a period of two hours—rises sharply from age 18, peaks at ages 21–22, and then steadily declines over the next 10 years. The prevalence of daily drinking also rises from levels encountered in high school but remains relatively stable afterward, through age 32.
An extensive series of surveys conducted from 1993 to 2005 on American college campuses have shown a fairly consistent picture of the drinking patterns of college students in the United States over this period of time. Here are the general findings:
■■ Overall, approximately 44 percent of college students report having engaged in binge drinking during the two weeks prior to the administration of the survey—41 percent of the women and 49 percent of the men. About one in five students abstain from alcohol, whereas one in four is a fre- quent binge drinker. About half of college students (48%) report that drinking to get drunk is an important reason for drinking. Three students in 10 (29%) report being intoxi- cated three or more times in a month.
Quick Concept Check
Understanding Alcoholic Beverages Check your understanding of the alcohol content of various types of alcoholic beverages by rank ordering the alcohol content of the following five “bar orders,” with “1” represent- ing the largest amount and “5” the smallest. Are there any ties?
______ A. Three 1-shot servings of liquor and one 5-oz glass of wine
______ B. Two 1-shot servings of liquor
______ C. One 1-shot serving of liquor, one 5-oz glass of wine, and three 12-oz beers
______ D. Three 5-oz glasses of wine
______ E. One 1-shot serving of liquor, one 5-oz glass of wine, and one 12-oz beer
Answers: 1 ∙ C 2 ∙ A 3 ∙ D and E (tie) 5 ∙ B
15.1
Binge drinking among college students and young adults is both a social ritual and a social concern.
308 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
by establishing workplace programs specifically designed for employees who need help. Two major efforts address this problem. The first is employer- sponsored employee assistance programs (EAPs), and the second is union-supported member assistance programs (MAPs). EAPs have been established as a way of increasing the productivity of the organization, whereas MAPs are oriented toward enhancing the welfare of the individual worker.
In either case, a major thrust of workplace interven- tions has been to change the culture of drinking within the organization. For example, problems arise because employ- ees tend to drink heavily in order to conform to workplace drinking norms. Within a heavy drinking culture, employees are more likely to use alcohol to cope with stress and feelings of alienation. Gender harassment, characterized by behaviors directed at female employees that convey hostile and degrad- ing attitudes toward women, is associated with the proportion of male employees identified as heavy or “at-risk” drinkers, and the association is stronger when alcohol consumption is considered a common pattern of behavior during lunch or other meal breaks. In other words, a permissive, alcohol- oriented culture at work exacerbates an already serious work- place problem. Workplace issues with regard to substance abuse in general will be taken up in Chapter 17.
Acute Physiological Effects of Alcohol
Alcohol can produce a number of immediate physiological effects; they will be examined here. The physiological effects resulting from chronic alcohol consumption will be covered later in the chapter.
Toxic Reactions First and foremost, we have to be aware that potential death by asphyxiation can happen if BAC levels are elevated, gener- ally when they reach 0.50 percent. In general, the therapeutic index for alcohol, as measured by the LD50/ED50 ratio (see Chapter 1), is approximately 6. This figure is not very high, and caution is strongly advised; the risks of being the “big win- ner” in a drinking contest should be weighed very carefully.
On the one hand, to achieve a lethal BAC level of 0.50 percent, a 160-pound man needs to have consumed approximately 23 drinks over a four-hour period.18 On the other hand, consuming 10 drinks in one hour, a drinking schedule that achieves a BAC level of 0.23 percent, puts a person in dangerous territory (see Table 15.2). We need to remember that LD50 is the average dose for a lethal effect; there is no way to predict where a particular person might be located on the normal curve!
Fortunately, two mechanisms are designed to protect us to a degree. First, alcohol acts as a gastric irritant so the drinker feels nauseated and vomits. Second, the drinker may simply pass out, and the potential from further drinking
between the ages of 12 and 20, the average age when drinking began is 14 years. In the University of Michigan survey, 28 percent of eighth graders reported in 2013 that they had consumed alcohol, and 12 percent reported that they had been drunk sometime in their lives. Fortunately, these figures are down significantly from those found in earlier surveys. Approximately 5 percent of students at this age reported consuming more than five drinks on a single occasion in the previous two weeks, a prevalence rate that is one-half the level in 1991.
Although the downward trend in underage drinking is encouraging, the major challenge in reducing underage alco- hol use still further lies in the continuing access that underage drinkers have to alcoholic beverages, despite the legal restric- tions on alcohol sales. Studies show that among the estimated 8.6 million underage drinkers, defined as persons aged 12–22 who drank in the past 30 days, 45 percent reported in 2013 that the alcohol had been provided free by an adult aged 21 or older. About 18 percent of underage drinkers were given alcohol free by a parent, guardian, or another family member in the past month. About one-half (52%) reported drinking alcohol in someone else’s home, and about one-third (34%) drank in their own home.16
Alcohol Consumption in the Workplace It has been estimated that about 10 percent of the people in the American work force (12.8 million workers) have been at work either under the influence of alcohol or with a hangover at least once in the previous 12 months. The prevalence rates of alcohol impairment at the workplace are higher among men than women, higher for white employ- ees than nonwhite employees, higher for younger than older employees, and higher for unmarried than married employ- ees. Alcohol impairment is also most frequently reported by individuals in the arts/entertainment/sports/media industries, food preparation and service jobs, and building and grounds maintenance occupations. Individuals with jobs that would be seriously affected if alcohol impairment was present, such as workers in the construction/extraction and transporta- tion/material-moving industries, do not show a significantly higher prevalence rate of alcohol impairment at work than the workforce at large.17
Given the adverse impact of alcohol abuse on a range of workplace behaviors, it makes sense that corporations, hospitals, the armed services, and other large organizations should benefit
member assistance programs (MAPs): Institutional programs for workers or employees to help them with alcohol or other drug-abuse problems, set up by established unions within the organization and tailored to meet the needs of union members.
employee assistance programs (eAPs): Corporate or institutional programs for workers or employees to help them with alcohol or other drug-abuse problems.
Chapter 15 Alcohol Use and Chronic Alcohol Abuse ■ 309
pronounced if salty foods (peanuts or pretzels, for example) were eaten along with the alcohol.
The inhibition of ADH during the drinking of alcoholic beverages can be a serious concern, particularly following vigorous exercise when the body is already suffering from a loss of water and fluid levels are low. Therefore, the advice to the marathoner, whose body may lose more than a gallon of water over the course of a warm three-hour run, is to celebrate the end of the race not with a beer but with nonintoxicating liquids such as Gatorade or similar mineral-rich drinks.19
Effects on Sleep It might seem tempting to induce sleep with a relaxing “night- cap,” but in fact the resulting sleep patterns are adversely affected. Alcohol reduces the duration of a phase of sleep called rapid eye movement (REM) sleep, in the same way as do barbiturates (see Chapter 14). Depending on the amount of alcohol consumed, REM sleep can be either partially or completely suppressed during the night. When alcohol is withdrawn, REM sleep rebounds and represents a higher per- centage of total sleep time than before alcohol consumption began. As a result, individuals sleep poorly and experience nightmares.20
becomes irrelevant. Nonetheless, there are residual dangers in becoming unconscious; vomiting while in this state can prevent breathing, and death can occur from asphyxiation (Help Line).
Heat Loss and the Saint Bernard Myth Alcohol is a peripheral dilator, which means that blood ves- sels near the skin surface enlarge, leading to a greater amount of blood shunted to the skin. The effect gives you the feeling that your skin is warm, which is most likely the basis for the myth that alcohol can keep you warm in freezing weather. In truth, peripheral dilation causes core body temperature to decrease. In other words, alcohol produces a greater loss in body heat than would occur without it. So if you are marooned in the snow and you see an approaching Saint Bernard with a cask of brandy strapped to its neck, politely refuse the offer. It will not help and could very well do you harm. (But feel free to hug the dog! That will certainly help.)
Diuretic Effects As concentration levels rise in the blood, alcohol begins to inhibit the secretion of antidiuretic hormone (ADH), a hor- mone that normally acts to reabsorb water in the kidneys prior to elimination in the urine. As a result, urine is more diluted and, because large amounts of liquid are typically being con- sumed at the time, more copious. Once blood alcohol con- centrations have peaked, however, the reverse occurs. Water is now retained in a condition called antidiuresis, result- ing in swollen fingers, hands, and feet. This effect is more
Help Line emergency Signs and Procedures in Acute Alcohol Intoxication
emergency Signs
• Stupor or unconsciousness • Cool or damp skin • Weak, rapid pulse (more than 100 beats per minute) • Shallow and irregular breathing rate, averaging around one
breath every three or four seconds • Pale or bluish skin
Note: Among African Americans, color changes will be apparent in the fingernail beds, mucous membranes inside the mouth, or underneath the eyelids.
emergency Procedures
• Seek medical help immediately. • Drinker should lie on his or her side, with the head slightly
lower than the rest of the body. This will prevent blockage of the airway and possible asphyxiation if the drinker starts to vomit.
• If drinker is put to bed, maintain some system of monitoring until he or she regains consciousness.
Note: There is no evidence that home remedies for “sobering up,” such as cold showers, strong coffee, forced activity, or induction of vomiting, have any effect in reducing the level of intoxication. The only factors that help are the passage of time, rest, and perhaps an analgesic if there is a headache.
Where to go for assistance www.postgradmed.com/issues/2002/12_02/yost1.htm.
This Web site is adapted from Yost, David A. (2002). Acute care for alcohol intoxication: Be prepared to consider clinical dilemmas. Postgraduate Medicine Online.
Source: Victor, Maurice (1976). Treatment of alcohol intoxication and the withdrawal syndrome: A critical analysis of the use of drugs and other forms of therapy. In Peter G. Bourne (Ed.), Acute drug abuse emergencies: A treatment manual. New York: Academic Press, pp. 197–228.
antidiuresis: A condition resulting from excessive reabsorption of water in the kidneys.
antidiuretic hormone (ADH): A hormone that acts to reab- sorb water in the kidneys prior to excretion from the body.
310 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
Table 15.3 shows a partial listing of major therapeutic drugs that interact with alcohol and have undesirable, if not danger- ous, outcomes. The complete list is so long that it is fair to say that, whenever any medication is taken, the individual should inquire about possible interactions with alcohol.
Hangovers About 4–12 hours after heavy consumption of alcohol, usu- ally the next day, unpleasant symptoms of headache, nausea, fatigue, and thirst may occur; these are collectively known as a hangover. At least one such experience has been undergone by 40 percent of all men and 27 percent of all women over the age of 18.22
The probable explanations at present focus on individual aspects of a hangover, though it is likely that several factors contribute to the total phenomenon. One factor, beyond the simple fact of drinking too much, is the type of alcohol that has been consumed. Among distilled spirits, for example, vodka has a lower probability of inducing hangovers than whiskey. A possible reason is the relatively lower amount of congeners.
Effects on Pregnancy As will be seen in a later section of the chapter, the con- sumption of alcohol during pregnancy, even in moderation, greatly increases the risk of retardation in the development of the fetus, and reducing the incidence of this behavior has been a major public health objective since the mid-1990s. From data averaged over 2012 and 2013, it has been esti- mated that about 9 percent of pregnant women consume alcohol, exposing approximately 1 in 11 fetuses to alcohol in utero.21
Interactions with Other Drugs A major concern in alcohol drinking is the complex interac- tion of alcohol with many drugs. As noted in Chapter 1, the DAWN reports of emergency department admissions show an extremely high incidence of medical crises arising from the combination of alcohol not only with prescribed medica- tions but also with virtually all the illicit drugs on the street. Opioids, marijuana, and many prescription medications inter- act with alcohol such that the resulting combination produces effects that are either the sum of the parts or greater than the sum of the parts. In other cases, the ingestion of medications with alcohol significantly lessens the medication’s benefits. Anticoagulants, anticonvulsants, and MAO-inhibitors (used as antidepressant medications) fit into this second category.
tAble 15.3
A partial listing of possible drug–alcohol interactions
geNerIc Drug (brAND NAMe or tYPe)
coNDItIoN beINg treAteD
eFFect oF INterActIoN
chloral hydrate (Noctec) Insomnia Excessive sedation that can be fatal; irregular heartbeat; flushing
glutethimide (Doriden) Insomnia Excessive sedation; reduced driving and machine-operating skills
antihypertensives (Apresoline, Diuril) High blood pressure Exaggeration of blood pressure–lowering effect; dizziness on rising
diuretics (Aldactone) High blood pressure Exaggeration of blood pressure–lowering effect; dizziness on rising
antibiotics (penicillin) Bacterial infections Reduced therapeutic effectiveness
nitroglycerin (Nitro-bid) Angina pain Severe decrease in blood pressure; intense flushing; headache; dizziness on rising
warfarin (Coumadin) Blood clot Decreased anti–blood clotting effect, easy bruising
insulin Diabetes Excessive low blood sugar; nausea; flushing
disulfiram (Antabuse) Alcoholic drinking Intense flushing; severe headache; vomiting; heart palpitations; could be fatal
methotrexate Various cancers Increased risk of liver damage
phenytoin (Dilantin) Epileptic seizures Reduced drug effectiveness in preventing seizures; drowsiness
prednisone (Deltasone) Inflammatory conditions (arthritis, bursitis)
Stomach irritation
various antihistamines Nasal congestion Excessive sedation that could be fatal
acetaminophen (Tylenol) Pain Increased risk of liver damage
Sources: National Institute on Alcohol Abuse and Alcoholism (1995, January). Alcohol alert: Alcohol–medication interactions. No. 27, PH355. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism. Office of Substance Abuse Prevention (1988). The fact is . . . It’s dangerous to drink alcohol while taking certain medications. Rockville, MD: National Institute on Drug Abuse. Parker, Christy (1985). Simple facts about combinations with other drugs. Phoenix, AZ: Do It Now Foundation.
congeners (KoN-jen-ers): Nonethyl alcohols, oils, and other organic substances found in trace amounts in some distilled spirits.
Chapter 15 Alcohol Use and Chronic Alcohol Abuse ■ 311
Driving Skills There is no question that alcohol consumption significantly impairs the ability to drive or deal with automobile traffic. Among the 32,700 traffic fatalities that occurred in the United States in 2013, approximately 10,000 of them (about 31%) were alcohol related. To put this statistic in perspective, there were approximately 28 alcohol-related fatalities every day during that year (one instance every 52 minutes).25
Most of these alcohol-related fatalities resulted from conditions in which drivers had a BAC of 0.08 percent or higher, the minimum standard for legal intoxication in all U.S. states, but there were also a number of fatalities associ- ated with the driver having a BAC less than 0.08 percent. It is important to recognize that driving can be impaired with BAC levels as low as 0.02–.0.04 percent, which are well below the “driving while intoxicated” (DWI) threshold.
All these statistics could be viewed as correlational and not necessarily proof of a causal relationship between alco- hol and automobile accidents, were it not for the data from laboratory-based experiments showing a clear deterioration of sensorimotor skills following the ingestion of alcohol. Reaction times are slower, the coordination necessary to steer a car steadily is hampered, and the ability to stay awake when fatigued is impaired, but the major way that alcohol impairs driving ability is the reduction in the drinker’s awareness of peripheral events and stimuli.26
Violence and Aggression In Chapter 14, it was pointed out that alcohol consumption is a significant factor in drug-facilitated sexual assaults. In many cases, however, both perpetrator and victim have been
These substances in alcoholic beverages, including trace amounts of nonethyl alcohol, oils, and other organic matter, are by- products of the fermentation and distillation processes and give the drinks their distinctive smell, taste, and color. A com- mon congener is the tannin found in red wines. Although no harm is caused by congeners in minute concentrations, they are still toxic substances, and they probably contribute to hang- over symptoms.
Other possible factors include traces of nonoxidized acetaldehyde in the blood, residual irritation in the stomach, and a low blood sugar level rebounding from the high levels induced by the previous ingestion of alcohol. The feeling of swollenness from the antidiuresis, discussed earlier, may contribute to the headache pain. The thirst may be due to the dehydration that occurred the night before.23
Acute Behavioral Effects of Alcohol
The consumption of alcoholic beverages is so pervasive in the world that it seems almost unnecessary to comment on how it feels to be intoxicated by alcohol. The behavioral effects of consuming alcohol in more than very moderate quantities range from the relatively harmless effects of exhilaration and excitement, talkativeness, slurred speech, and irritability to behaviors that have the potential for causing great harm: unco- ordinated movement, drowsiness, sensorimotor difficulties, and stupor. Some of the prominent behavioral problems asso- ciated with acute alcohol intoxication will be examined in this section.
Blackouts A blackout is an inability to remember events that occurred during the period of intoxication, even though the individual was conscious at the time. For example, a drinker having too much to drink at a party drives home, parks the car on a nearby street, and goes to bed. The next morning, he or she has no memory of having driven home and cannot locate the car. This phenomenon is different from “passing out,” which is a loss of consciousness from alcoholic intoxication. In the case of blackouts, conscious- ness is never lost.
Owing to the possibility of blackouts, drinkers can be easily misled into thinking that because they can understand some information given to them during drinking, they will remember it later. The risk of blackouts is greatest when alco- hol is consumed very quickly, forcing the BAC to rise rapidly. In an e-mail survey of college students, conducted in 2002, to learn more about their experiences with blackouts, approxi- mately half of those who had ever consumed alcohol reported having experienced a blackout at some point in their lives and 40 percent reported having had at least one experience in the 12 months prior to the survey.24
blackout: Amnesia concerning events occurring during the period of alcoholic intoxication, even though consciousness had been maintained at that time.
Every community has its tragic stories of preventable deaths due to drunk driving. Alcohol is also recognized as a major factor in more than 800 boating fatalities in the United States each year.
312 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
or she will commit some form of violence on another person or property.29
Researchers have advanced two principal ways of accounting for the linkage between alcohol intoxication and violent behavior. The disinhibition theory holds that ingest- ing alcohol on a pharmacological level impairs normal corti- cal mechanisms responsible for inhibiting the expression of innate or suppressed aggressive inclinations. The cognitive- expectation theory holds that learned beliefs or expectations about alcohol’s effects can facilitate aggressive behaviors. The implication is that violence is induced by the act of drinking in combination with one’s personal view of how a person is “supposed to respond” rather than by the pharmacological effects of alcohol itself (Drug Enforcement . . . in Focus).30
Sex and Sexual Desire If they were asked, most people would say that alcohol has an enhancing or aphrodisiac effect on sexual desire and performance. The actual effect of alcohol, however, is more complex than what we commonly believe. In fact, it
drinking alcohol.27 Therefore, it is difficult to examine the unique effects of alcohol intoxication on the perpetrator alone in these situations.
Nonetheless, the link between alcohol intoxication and violent behavior in general is well documented. In all vio- lent offenses committed in the United States, 28 percent of victims report that the offender had been drinking prior to the offense. In studies of criminal homicide, 50–60 percent of the perpetrators were found to be under the influence of alcohol when the murder took place. From 60 to 70 percent of male-instigated domestic violence occur when the offender has been drunk; more than 60 percent of all acts of child molestation involve drunkenness. About one-third of con- victed offenders on parole or probation report that they had been drinking at the time of their offense.28
Yet, it is important to emphasize the well-known fact that violent behavior occurs only rarely in everyday situa- tions in which alcohol is consumed. However, a consistent finding is the relationship between the quantity of alcohol consumed and violent behavior. The greater the quantity of alcohol that is consumed, the greater is the likelihood that he
Alcohol, Security, and Spectator Sports In 2005, the National Basketball Association (NBA) issued a set of security guidelines that included “Fan Code of Conduct” specifying that “guests will enjoy the basketball experience free from disruptive behavior, including foul or abusive language or obscene gestures.” In the words of NBA Commissioner David Stern, “We look at this as an opportunity to remind people that coming to an arena is an opportunity to share an experience of rooting a home team on to victory and booing the opposition, but not doing it in an antisocial way that goes against our civil society.”
Acknowledging the connection between disruptive behavior and alcohol, the NBA bans alcohol sales during the fourth quarter of every game and imposes a 24-ounce limit on the size of alcoholic drinks sold in an arena, with a maximum of two alcoholic drinks per customer. Increased security measures and restrictions on alcohol sales came about after basketball players and fans brawled in the stands and on the court at the end of a game in November 2004 between the Indiana Pacers and the Detroit Pistons. Indiana’s Ron Artest went into the seats after being hit by a full cup of beer that had been tossed by a spectator. As a result of the melee, considered to be one of the most vio- lent episodes in NBA history, Artest was suspended for the rest of the 2004–2005 season, and other players were given suspensions of as many as 30 games. All told, ten players and fans were charged with fighting.
Alcohol consumption has also come under scrutiny during college and professional football games, where binge drinking at tailgating parties and after-game celebrations frequently results in property damage and sometimes leads to injuries or deaths. At the University of Virginia, a tradition that began in the 1980s has seniors individually drinking a fifth of liquor by kickoff time at the final game of the football season (the so-called Fourth-Year Fifth). This practice was associated with the deaths of 18 students between 1990 and 2002. Since 1999, a university organization, Fourth-years Acting Responsibly (FAR), has coordinated an annual pledge drive to reduce abusive drinking at the final home game, as part of a campuswide alcohol-abuse prevention program.
It should be noted that the NCAA does not permit alcohol sales at any of the 89 championship basketball games it adminis- ters. College football evidently is another matter. Beer, wine, and spirits were available for spectators at all bowl games in the 2015 inaugural playoff college football championships. The Football Bowl Subdivision in charge of the playoff games is the only NCAA-sanctioned group whose championship events are not governed by the NCAA.
Sources: Eskenazi, Gerald (2005, December 21). For Patriots and Jets, a sobering experience. New York Times, p. D3. Football, tailgating parties, and alcohol safety (2005, October 1). The NCADI Reporter. Bethesda, MD: National Clearinghouse for Drug Information. NBA issuing sterner security, beer guidelines. USA Today.com, accessed May 8, 2005. Tracy, Marc (2015, January 11). College football is powerful: The proof is in the alcohol. New York Times Sports Sunday, pp. 1, 6.
Drug Enforcement . . . in Focus
Chapter 15 Alcohol Use and Chronic Alcohol Abuse ■ 313
Whether or not restricted access reduces alcohol consumption and alcohol-related problems is a complex question. When “dry” jurisdictions are compared to “wet” jurisdictions with respect to alcohol-related accidents, the sta- tistics on alcohol-related accidents show a higher incidence in “dry” locales, largely due to the fact that drinkers drive to nearby “wet” locales to consume alcohol and then drive home!32
According to the National Highway Traffic Safety Admin- istration, more than 700 lives of persons aged 18, 19, or 20 have been saved each year as a result of laws setting 21 as the mini- mum drinking age. Since 1998, a nationwide minimum BAC level defining “driving while intoxicated” for drivers younger than 21 years of age has been set at 0.02 percent.33
Present-Day Alcohol Regulation by Taxation One immediate benefit when 13 years of Prohibition ended in 1933 (see Chapter 3) was the return of federal revenue from taxes on alcohol. In fact, the positive impact on a strug- gling national economy hard hit by the Depression had been one of the arguments advanced by the repeal movement. In 1933 alone, such excise taxes brought in $500 million, a significant windfall that was put to use in financing social programs of the New Deal.
The concept of collecting taxes on the basis of alco- hol consumption dates back to the very beginning of the United States as a nation. In 1794, the newly established U.S. Congress passed a law imposing an excise tax on the sale of whiskey. After a short-lived Whiskey Rebellion in which President Washington had to order federal militia to subdue Appalachian farmers who had refused to pay the new tax, the practice of taxing alcohol was accepted and has continued to the present day as a legal way of raising tax money. Currently, more than $9 billion each year is col- lected from federal excise taxes on alcohol. Total annual revenues exceed $18 billion, when additional excise taxes imposed by all U.S. states and some local communities are included.
Taxes on alcohol sales (so-called sin taxes) have been an indirect mechanism for regulating the consumption of alcohol by increasing its price, not unlike present-day taxes on tobacco products (see Chapter 16). Numerous studies have indicated that increases in the price of alcohol bev- erages lead to reduced alcohol consumption, both in the general population and in certain high-risk populations (heavy drinkers, adolescents, and young adults).34 On the basis of these analyses, it has been proposed that a further step be taken, setting alcohol taxes high enough to begin to offset the total societal costs resulting from alcohol abuse. This approach would place a form of “user fee” on the con- sumption of alcohol. However, it has been argued that rais- ing alcohol prices by additional taxation might lead to the development of a black market for alcohol purchases, little change in alcohol consumption, and a net decline in tax revenues.35
is because of these beliefs that people are frequently more susceptible to the expectations of what alcohol should do for them than they are to the actual physiological effects of alcohol.
To examine the complex relationship between alcohol and sex, we need to separate the possible pharmacological effects of alcohol and the possible expectations about what alcohol is supposed to do (see Chapter 4). It turns out that the general results of studies of this kind are quite different for men and women.
Among men, those who expected to be receiving low levels of alcohol had greater penile responses, reported greater subjective arousal, and spent more time watching erotic pic- tures, regardless of whether they did indeed receive alcohol. When alcohol concentrations rose to levels that reflected genuine intoxication, however, the pharmacological actions outweighed the expectations. The overall effect was definitely inhibitory. Men who are drunk had less sexual desire and a decreased capacity to perform sexually.
In contrast, expectations among women played a lesser role. They were more inclined to react to the pharmaco- logical properties of alcohol itself, but the direction of their response depended on whether the measures being studied are subjective or physiological. For women receiving increas- ing alcohol concentrations, measures of subjective arousal increased but measures of vaginal arousal decreased. The pat- tern of their responses mirrors Shakespeare’s observation in Macbeth that alcohol “provokes the desire, but it takes away the performance,” a comment originally intended to reflect only the male point of view. Evidently, in the case of males, alcohol takes away both the desire and the performance.31
Strategies for Regulating Alcohol Consumption
In light of the adverse personal and social consequences of excessive alcohol consumption, it has been important to develop over the years a number of regulatory controls. Obviously, the total prohibition of alcohol, as instituted dur- ing the Prohibition Era (see Chapter 3), did not work. What other measures could be employed?
Present-Day Alcohol Regulation by Restricted Access Regulations regarding the circumstances under which alco- hol can be purchased or consumed fall under the jurisdic- tion of individual U.S. states or local communities. Some jurisdictions have virtually no restrictions, other than the nationwide minimum age requirement that an individual must be 21 years old or older. In these locales, alcohol can be purchased 24 hours a day, seven days a week, and alcoholic beverages can be consumed by passengers in vehicles. At the other extreme, more than half of U.S. states have cities or counties that are “dry.”
314 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
accomplishments, and aspirations of MADD, specifically with respect to tighter regulations on drinking and driving.
Regulations Based on Ignition Interlock Technology A major goal in reducing alcohol-related fatalities on the road is to prevent an intoxicated individual from getting behind the wheel in the first place. We cannot prevent any intoxicated individual from driving a car, but we can at least try to prevent an individual who has had a previous DUI arrest from driv- ing while intoxicated. The most widely used technology for preventing such a situation is known as an ignition interlock device. When activated by the detection of a minimum BAC level in the breath of the driver, the ignition interlock will prevent the car from starting. In 2007, New Mexico became the first state to require ignition interlocks to be installed after a first DWI offense; alcohol-related fatalities decreased 11 percent in the first year. When, in 2004, Maryland mandated that the system be installed after several DWI arrests, fatali- ties were reduced by 18 percent. As of 2014, all 50 U.S. states have enacted some form of ignition interlock law, typically during the period of license suspension and/or a specified time before fully relicensing DWI offenders. In 15 U.S. states, ignition interlock devices are mandated even after a first-time DWI offense.
Today, alcoholic beverages are one of the most heavily taxed consumer products. Approximately 45 percent of the retail price of an average bottle of distilled spirits, for exam- ple, is earmarked for federal, state, or local taxes.
Regulations to Reduce Alcohol-Related Traffic Fatalities Another strategy aims not at reducing alcohol consumption itself but rather reducing the incidence of adverse conse- quences of alcohol consumption. In that sense, it is a “harm reduction” approach in alcohol control policy. A prime example of this approach is the effort to reduce alcohol- related traffic fatalities.
With the minimum BAC level for intoxication estab- lished nationwide as 0.08 percent, there has been a signifi- cant reduction in alcohol-related traffic fatalities. According to estimates made by the National Highway Traffic Safety Administration, the reduction of the minimum BAC level to 0.08 percent has saved 500 lives each year.36
In addition, educational programs in schools and com- munities emphasizing the advantage of using “designated drivers” as well as public education and lobbying groups such as Mothers Against Drunk Driving (MADD) and Students Against Drunk Driving (SADD) have had positive effects. This chapter’s Portrait feature highlights the origins,
PortrAIt Candace Lightner—Founder of MADD
In 1980, Candace Lightner’s 13-year-old daughter, Cari, was killed by a hit-and-run intoxi- cated driver in California. The driver had been out of jail on bail for only two days, a consequence of another hit-and-run drunk-driving crash, and he had three previous drunk-driving arrests and two previous convictions. He was allowed to plea bargain to vehicular manslaughter. Although the sentence was to serve two years in prison, the judge allowed him to serve time in a work camp and later a halfway house.
It was appalling to Lightner that drunk drivers, similar to the one who had killed her daughter, were receiving such lenient treatment, with many of them never going to jail for a single day. Lightner quit her job and started an or- ganization that has become a household name: Mothers Against Drunk Driving (MADD).
Since then, MADD has campaigned for stricter laws against drunk driving, and
most of the present DWI legislation around the country is a result of its
intense efforts. In addition, MADD acts as a voice for victims of drunk-driving injuries and the families of those who have been killed. From a single act of courage, despite enormous grief, Lightner has cre- ated an organization that boasts more than 3 million members in the United States, with groups in virtually every state and more than 400 local chapters.
More recently, MADD has set for itself the goal of reducing the number of all traffic fatalities associated with alcohol drinking. These are some of the group’s proposals for change:
1. More effective enforcement of the minimum-drinking-age law
2. A “0.00 percent BAC” criterion for drivers under 21, making it illegal to drive with any measurable level of blood alcohol in any state
3. Driver’s license suspensions for underage persons convicted of
purchasing or possessing alcoholic beverages
4. Alcohol-free zones for youth gatherings
5. Criminal sanctions against adults who provide or allow alcoholic beverages at events for underage participants
6. Mandatory alcohol and drug testing for all drivers in all traffic crashes resulting in fatalities or serious bodily injury
7. Sobriety checkpoints to detect and apprehend alcohol-impaired drivers and to serve as a visible deterrent to drinking and driving
The most recent initiative of MADD has been its campaign to have ignition interlock systems installed in vehicles driven by individuals convicted of drunk driving.
Source: Information courtesy of Mothers Against Drunk Driving, Irving, Texas. Interview with Candace Lightner.
Chapter 15 Alcohol Use and Chronic Alcohol Abuse ■ 315
heart disease. It was estimated that consumption of approxi- mately 8 ounces of wine (a bit less than two standard drinks) per day resulted in a 25 percent reduction in the risk of coro- nary heart disease.
A natural substance in red wine known as resveratrol has been identified as a possible factor in explaining the health benefits of drinking red wine. Mice administered resveratrol in very large quantities were higher in endurance levels, rela- tive to controls, and were less susceptible to the elevations in glucose and insulin that normally result from eating a high-fat diet. However, these animals received a daily dos- age of resveratrol far larger than a human would ingest from drinking wine, so the question of whether this substance is a key factor remains unsettled. Human intake of resveratrol at comparable dosages would have a significant potential for acute toxicity (Chapter 1).38
The benefits evidently extend beyond coronary heart disease. Moderate alcohol intake reduces the risk of diabetes mellitus, reduces the risk of stroke, and reduces the risk of dementia (possibly by reducing the incidence of mini-strokes or by boosting concentrations of vitamin B6, which is essen- tial for the formation of essential brain chemicals). A recent study indicates that moderate alcohol consumption can also lower the risk of rheumatoid arthritis by up to 50 percent.39
Of course, the key to the health benefits of alcohol con- sumption lies in moderation, with moderate drinking being defined as taking no more than one drink per day for women and no more than two drinks per day for men. The newest (2000) Dietary Guidelines for Americans, released by the U.S. Department of Agriculture and the U.S. Department of Health and Human Services, acknowledge the effect of alco- hol in reducing the risk of coronary heart disease but limit the recommendation of moderate drinking to men over age 45 and women over age 55, a subpopulation that carries an elevated risk for the disease.
Despite the weight of evidence tilting toward the poten- tial health benefits of alcohol, the public health officials and medical professionals remain divided on the question of whether to encourage patients who do not drink alcohol to start at a moderate level of consumption. In some cases, moderate intake is not advisable. Even one drink per day slightly increases the risk for breast cancer in women, and in no circumstances should alcohol be consumed during
In general, even though we have reason to be cautiously optimistic about reducing alcohol-related traffic fatalities, it is clear that much work remains to be done. The United States presently has one of the most lenient standards for driving while intoxicated among nations in the world (Table 15.4). The number of alcohol-related accidents, particularly among male drivers, whose involvement exceeds that of female drivers by more than 2:1, is far too high. Meanwhile, the drinking- and-driving phenomenon is widespread throughout the popu- lation. It has been estimated that more than 28 million adults were under the influence of alcohol while driving in 2013 at least once in the past year. It should not be surprising that the peak age of drinking and driving was between 21 and 25, dur- ing which one in five reported being intoxicated on the road at least once in the past year.37
On the Other Hand: Alcohol and Health Benefits
The documented health benefits of moderate levels of alco- hol consumption over the last 30 years of research have pre- sented a major dilemma among medical and public health professionals. The crux of the dilemma is that moderate amounts of alcohol can possibly save your life, while immod- erate amounts can possibly destroy it.
It started as an observation that did not seem to make sense. Epidemiological studies of French and other European populations who consumed large amounts of butter, cheese, liver, and other animal fats—a diet associated with elevated cholesterol and an elevated risk for coronary failure—found that these populations had a remarkably low incidence of coronary heart disease. The answer seemed to be that rela- tively more alcohol was consumed along with their dietary food. The “French paradox” was resolved when later research showed that alcohol increases high-density lipoprotein (HDL) cholesterol (the so-called good cholesterol) levels in the blood, with HDL acting as a protective mechanism against a possible restriction of blood flow through arteries. The greatest benefit was seen in those individuals who had high concentrations of low-density lipoprotein (LDL) cholesterol (the so-called bad cholesterol) and therefore had the greatest risk for coronary
tAble 15.4
Blood alcohol concentrations at which drivers in different nations are legally drunk
bA c 0.00+ 0.02 0.03 0.05 0.08
c o
u N
tr Y Czech Republic,
Slovakia, Hungary
Norway, Poland, Sweden
Japan, China
Argentina, Australia, Costa Rica, Denmark, Finland, France, Italy, Germany,
Greece, The Netherlands, Peru, Russia, South Africa,
Spain, Thailand
Brazil, Britain, Canada, Chile, Ecuador, Ireland, Jamaica, New Zealand,
Singapore, United States
Source: Based on information from Valenti, John (2005, July 13). U.S. lags others in DWI toughness. Newsday, p. A15.
316 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
At the same time, it is important to remember that alco- hol remains a drug with significant potential for dependence. Unfortunately, it is easy to get hooked. As it has been said, people may plan to get drunk, but no one plans to be an alco- holic. The problems surrounding chronic alcohol abuse and alcoholism are reviewed in the next sections.
Chronic Alcohol Abuse and Alcoholism
Chronic abuse of alcohol has been called the hidden addic- tion. There is no need to get out on the street and find a drug dealer; for many people, it is remarkably easy to conceal their
pregnancy. Some public health researchers are concerned that an endorsement of moderate alcohol drinking may open up a range of possible risks, in effect giving alcohol a kind of “halo effect” that might be confusing to the public. Even so, an argument can be made that moderate alcohol drinking is simply a behavior that coincides with a healthful lifestyle in the first place, rather than a behavior that actually makes you healthy (Help Line).40
It can be argued that moderate alcohol consumption can have health benefits, but there is no argument that immoder- ate alcohol consumption has none. Yet, millions of people drink on occasion, enjoy the experience, and have never engaged in any violent or aggressive acts. They avoid situa- tions in which alcohol consumption would endanger their lives and the lives of others.
Help Line guidelines for responsible Drinking
The following guidelines can be useful in avoiding the numerous adverse consequences of alcohol consumption. Responsible drinking is not always an easy matter, but certain considerations can make it easier to accomplish. • Know how much you are drinking. Measure your drinks. Beer
is often premeasured (unless you are drinking draft beer from a keg), but wine and liquor drinks frequently are not. Learn what a 5-ounce quantity of wine or a 1½-ounce shot of liquor looks like and use these measures to guide your drinking.
• Choose beer or wine over liquor. Beer especially will make you feel fuller more quickly, with a smaller intake of alco- hol. But be careful. A 12-ounce beer is equivalent in alcohol content to a 5-ounce glass of wine or a 1-shot drink of liquor.
• Drink slowly. One drink an hour stays relatively even with your body’s metabolism of the alcohol you consume. Sipping your drinks is a good strategy for slowing down your consumption. If you are a man, you’ll look cool; if you are a woman, you’ll look refined.
• Don’t cluster your drinking. If you are going to have seven drinks during a week, don’t drink them all on the weekend.
• Don’t combine alcohol with energy drinks. Caffeinated drinks combined with alcoholic beverages have been found to lead to increased alcohol consumption (in terms of the number of alcoholic drinks) and tends to increase the hours with an elevated BAC. Controlling for BAC levels, the com- bination increases the number of negative consequences.
• Eat something substantial while you are drinking. Protein is an excellent accompaniment to alcohol. Avoid salty foods because they will make you thirstier and more inclined to have another drink.
• Drink only when you are already relaxed. Chronic alcohol abuse occurs more easily when alcohol is viewed as a way to relax. If you have a problem, seek some nondrug alternative.
• When you drink, savor the experience. If you focus on the quality of what you drink rather than the quantity you are drinking, you will avoid drinking too much.
• Never drink alone. Drinking is never an appropriate answer to social isolation. Besides, when there are people around, there is someone to look out for you.
• Beware of unfamiliar drinks. Some drinks, such as zombies and other fruit and rum drinks, are deceptively high in types of alcohol that are not easily detected by taste.
• Never drive a car after having had a drink. Driving impairment begins after consumption of very low quantities of alcohol.
• Be a good host or hostess. If you are serving alcohol at a party, do not make drinking the focus of activity. Do not refill your guests’ glasses. Discourage intoxication and do not condone drunkenness. Provide transportation options for those who drink at your party. Present nonalcoholic beverages as prominently as alcoholic ones. Prior to the end of the party, stop serving alcohol and offer coffee or other warm nonalcoholic beverages and a substantial snack, pro- viding an interval of nondrinking time before people leave.
Where to go for assistance www.indiana.edu/~engs/hints/holiday.html
This Web site on sensible, moderate, and responsible alcohol consumption and party hosting is adapted from Engs, R. C. (1987). Alcohol and other drugs: Self responsibility. Bloomington, IN: Tichenor Publishing.
Sources: Based on information in Gross, Leonard (1983). How much is too much? The effects of social drinking. New York: Random House, pp. 149–152. Hanson, David J.; and Engs, Ruth C. (1994). Drinking behavior: Taking per- sonal responsibility. In Peter J. Venturelli (Ed.), Drug use in America: Social, cultural, and political perspectives. Boston: Jones and Bartlett, pp. 175–181. Steele, Donald W. (1986). Managing alcohol in your life. Mansfield, MA: Steele Publishing and Consulting. Patrick, Megan E; and Maggs, Jennifer L. (2014). Energy drinks and alcohol: Links to alcohol behaviors and consequences across 56 days. Journal of Adolescent Health, 54, 454–459.
Chapter 15 Alcohol Use and Chronic Alcohol Abuse ■ 317
Problems Associated with a Preoccupation with Drinking The dominant characteristic of alcoholics is their preoccupa- tion with the act of drinking and their incorporation of drink- ing into their everyday lives. An alcoholic may need a drink prior to a social occasion to feel “fortified.” With increasing frequency, such a person sees alcohol as a way of dealing with stress and anxiety. Drinking itself becomes a routine, no longer a purely social behavior. There are two aspects to a preoccupation with drinking.
●■ The habit of taking a few drinks upon arriving home from work each day is an example of symptomatic drinking, in which alcohol is viewed specifically as a way of relieving tension. Also increasing is the incidence of unintentional states of severe intoxication and blackouts of events sur- rounding the time of drinking, a condition quite different from “passing out” from a high BAC level. One such oc- currence may not be a particularly critical sign, but recur- rences definitely are.
●■ Another feature often attributed to alcoholics is a loss of control over their drinking. The alcoholic typically craves a drink and frequently engages in compulsive behavior related to alcohol. There may be a stockpiling of liquor, taking a drink or two before going to a party, or feeling u ncomfortable unless alcohol is present. The alcoholic may be sneaking drinks or having drinks that others do not know about, such as surreptitiously having an extra drink or two in the kitchen out of the sight of party guests. Particularly when the alcoholic is trying to totally refrain from drinking (in other words, engage in absolute abstinence) or to re- duce the quantity of alcohol consumed, his or her thoughts become focused on the possibility of drinking in the future or on ways to rationalize it if it happens.
Emotional Problems Given that alcohol is a depressant drug on the central nervous system, it should not be surprising that chronic alcohol intake produces depressive symptoms. Serious depressions and thoughts of suicide frequently occur in the midst of heavy drinking. However, relatively few chronic alcohol abusers have experienced major depression either before the onset of their alcoholic condition or during extended periods of abstinence. Therefore, it is reasonable to conclude that the depressive symptoms are alcohol induced. Alcoholics are no more likely than others in the general population to have suffered an episode of major depression.42
problem (at least in the beginning) from family and friends. But eventually the effects on family and friends become all too evident. In the following sections, we will review the multilayered difficulties that are encountered under these circumstances.
Alcoholism: Stereotypes, Definitions, and Criteria First of all, we need to examine the preconceptions you may have about alcoholism itself.
Close your eyes and try to imagine what an alcoholic looks like. Some of you might be forming an image of an individual, probably male, possibly homeless and dishev- eled in appearance, possibly in a state of deteriorating health, possibly alone in the world with no one caring about him.
If that is so, you would be imagining less than 5 percent of all alcoholics; more than 95 percent of them look quite different. They are neatly dressed and have jobs, a home, and a family. The demographics of alcoholism include every pos- sible category. Alcoholics can be 14 or 84 years of age, male or female, professional or blue-collar. They can be urbanites, suburbanites, or rural residents in any community.
There is also diversity in the pattern of their drinking. Although the hallmark of alcoholism is the excessive quan- tity of alcohol that is consumed, there are significant dif- ferences in the way alcoholics consume their alcohol. Not all of them drink alone or begin every day with a drink. Many of them drink on a daily basis, but others are spree or binge alcoholics who might become grossly intoxicated on occasion and totally abstain from drinking the rest of the time.41
What aspects of their behavior tie them all together? Owing to the wide diversity of characteristics, it has been difficult to come up with one encompassing definition of alcoholism. Instead, we rely on a set of criteria—basically, a collection of signs, symptoms, and behaviors that help us make the diagnosis. A single individual may not meet all of these criteria, but if he or she fulfills enough of them, we decide that the standard has been met.
The criteria adopted here focus on four basic life problems that are tied to the consumption of alcohol: (1) problems associated with a preoccupation with drinking, (2) emotional problems, (3) vocational, social, and family problems, and (4) problems associated with physical health. Notice that these criteria make no mention of the cause or causes of alcohol- ism but instead reflect only its behavioral, social, and physical consequences. In short, we are recognizing that alcoholism is a complex phenomenon with psychological-behavioral com- ponents (criteria 1 and 2), social components (criterion 3), and a physical component (criterion 4).
All these consequences stem from a long-term pattern of alcohol consumption that we refer to as chronic alcohol abuse. For the sake of simplicity, the terms “chronic alcohol abuse” and “alcoholism” will be used interchangeably in the rest of this chapter.
abstinence: The avoidance of some consumable item or behavior.
symptomatic drinking: A pattern of alcohol consumption aimed at reducing stress and anxiety.
alcoholism: A condition in which the consumption of alcohol has produced major psychological, physical, social, or occupational problems.
318 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
Alcoholism affects such a diverse group of people that it is virtually impossible to make generalizations about the typical profile of an alcoholic. This poster shows 16 examples of individuals with whom many people might not have immediately associated the term “alcoholic.” Note the example in the extreme upper right corner.
Chapter 15 Alcohol Use and Chronic Alcohol Abuse ■ 319
Vocational, Social, and Family Problems No one questions the potential problems that chronic alco- hol abuse can bring to the maintenance of a job or career, social relationships, and a stable family life. These three areas frequently intertwine, and trouble in one usually exacerbates trouble in the others. A job loss puts stress on marital and family relationships, just as marital and family difficulties put stress on occupational performance.43
Physical Problems There is also no question that chronic alcohol consump- tion has a destructive effect on the body. Not surprisingly, a principal site of damage is the brain. Neuroimaging proce- dures, such as CT and MRI brain scans, reveal a consistent link between heavy drinking and physical shrinkage of brain matter, particularly in the cerebral cortex, cerebellum, and regions associated with memory and other cognitive func- tions. These neurological changes are observed even in the absence of other alcohol-related medical conditions such as chronic liver disease and cancer.
Overall, chronic alcohol consumption accounts for one in ten working-age deaths in the United States, principally among men. In other countries, the death toll to alcohol is much higher. The risk of dying before age 55 for Russian men who said they drank three or more half-liter bottles of vodka a week was 35 percent. A quarter of Russian men die before reaching 55, as compared with 7 percent of men in the United Kingdom and less than 1 percent in the United States.44
The Interpersonal Dynamics of Alcoholism
The major life problems that serve as rough criteria for deter- mining the condition of alcoholism are often not recognized by alcoholics themselves because of their tendency to deny that their drinking has any influence on their lives or the lives of people around them. When in denial, the alcoholic can be extremely sensitive to any mention of problems associated with drinking. A hangover the next day, for example, is sel- dom discussed because it would draw attention to the fact that drinking has occurred.45
Denial can also manifest among the people around the alcoholic. Members of an alcoholic’s family, for example, may try to function as if life were normal. Through their excuse making and efforts to undo or cover up the frequent physical and psychological damage the alcoholic causes, they inadvertently prevent the alcoholic from seeking treat- ment or delay that treatment until the alcoholism is more severe. These people are referred to as enablers because
enablers: Individuals whose behavior consciously or uncon- sciously encourages another person’s continuation in a pat- tern of alcohol or other drug abuse.
they enable the alcoholic to function as an alcoholic (as opposed to a sober person). Both processes of denial and enabling present major difficulties not only in establish- ing problem-oriented criteria for diagnosing alcoholism but also in introducing necessary interventions. Denial and enabling are clearly relevant processes in the area of alcoholism, but it is not difficult to see that they present problems with regard to any form of substance abuse problem.
Alcohol Use Disorder: The Health Care Professional’s View
The American Psychiatric Association, through its Diagnostic and Statistical Manual, Fifth Edition (known as DSM-5), has established a set of 11 behavioral criteria for a diagnosis of
Quick Concept Check
Understanding the Psychology of Alcoholism Check your understanding of the psychological aspects of alcoholism by matching each quotation or behavioral descrip- tion (on the left) with the appropriate term (on the right).
15.2
1. Brad tries to call his estranged wife on the telephone. She hangs up on him. Now angry and frustrated, Brad takes a drink.
2. Mary stays sober during the work- week, but on the weekend she downs at least two quarts of vodka.
3. “Despite what my family says, I am convinced I am not an alcoholic.”
4. “If I’m with her when she’s drinking, I can make sure she doesn’t overdo her drinking.”
5. “I’m going to the theater later. I don’t think there will be any li- quor there, so I had better have a couple of drinks before I go.”
a. denial
b. enabling
c. out-of-control drinking
d. spree or binge drinking
e. symptomatic drinking
Answers: 1. e 2. d 3. a 4. b 5. c
320 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
treatment for alcoholism and of medical intervention for alcohol-related diseases, lost productivity from absentee- ism and decreases in worker performance, treatment for alcohol-related injuries, and the lost value of future earnings of individuals who die prematurely because of alcohol- ism. The total costs in the United States are estimated to be about $200 billion annually, even without taking into consideration the incalculable costs of human suffering that are associated with an estimated 83,000 alcohol-related deaths.47
As mentioned earlier, alcoholics can be found in every age, gender, racial, ethnic, and religious group and in all socioeconomic levels and geographic regions of the country. Nonetheless, large differences in prevalence exist within these categories. For example, men outnumber women in the incidence of alcoholism by about six to one, with men tending to be steadier from day to day in their consumption of alcohol and women tending to abstain from drinking for lengths of time and to binge once they start drinking again. Overall, women are more vulnerable to alcohol-related organ damage. Whether this higher risk results from differences in the pattern of drinking or from differences in the way alcohol is processed in a woman’s body is at present unknown.
Figure 15.1 shows the levels of per capita consumption of alcohol in the United States on a state-by-state basis. Differences in the prevalence of alcohol-related problems are presumed to be correlated with consumption levels.
alcohol use disorder (see Drugs . . . in Focus). While the terms “alcoholism” and “chronic alcohol abuse” are not used in this diagnosis, the criteria encompass the psychological-behavioral, social, and physical components discussed earlier.
The severity of alcohol use disorder is based on the num- ber of criteria that apply. Mild alcohol use disorder is indicated when two to three behaviors are observed; moderate alcohol use disorder when four to five behaviors are observed, and severe alcohol use disorder when six or more behaviors are observed.
On the basis of an observation of these behaviors over a 12-month period, the prevalence in the United States of alcohol use disorder is estimated to be 4.6 percent among 12–17-year- olds and 8.5 percent among adults aged 18 years or older. Peak prevalence rates are observed for individuals of ages 18–29 years.46
Patterns of Chronic Alcohol Abuse
When we consider the range of direct and indirect costs to society that result from chronic abuse of alcohol, the price we pay is enormous. These costs include the expense of
alcohol use disorder: A diagnosis in the DSM-5 classification of mental disorders, based upon a set of behavioral criteria that reflect the psychological-behavioral, social, and physical components of chronic alcohol abuse.
behavioral criteria for Alcohol use Disorder The American Psychiatric Association considers 11 behaviors as criteria as the basis for the diagnosis of alcohol use disorder in the DSM-5 classification system. They are presented here as a useful means for a self-evaluation of problems that might be due to chronic alcohol abuse, but a formal diagnosis can only be made through the services of a health care professional. The behaviors are as follows:
1. Drinking alcohol in larger amounts or over a longer interval than was intended.
2. A persistent desire or unsuccessful efforts to cut down on alcohol use.
3. A great deal of time spent on activities to obtain alcohol, use it or recover from its effects.
4. Craving or a strong urge to use alcohol. 5. Failure to fulfill major obligations at work, school, or home
due to recurrent alcohol use.
6. Continuing alcohol use despite social or interpersonal problems related to the effects of alcohol.
7. Social, occupational, or recreational activities given up or reduced due to alcohol use.
8. Recurrent alcohol use when a physical hazardous situation may result.
9. Continued alcohol use despite knowing that physical or psychological problems might be caused or made worse by alcohol consumption.
10. Tolerance to the pharmacological properties of alcohol, needing increased amounts to achieve intoxication or diminished intoxication with the same amount of alcohol.
11. Withdrawal symptoms when alcohol use is diminished or stopped.
Source: Based upon information from the American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (DSM-5) (5th ed.). Washington, DC: American Psychiatric Publishing, pp. 490–497.
Drugs . . . in Focus
Chapter 15 Alcohol Use and Chronic Alcohol Abuse ■ 321
Physiological Effects of Chronic Alcohol Use
Let’s look at what we know about the consequences of long- term (chronic) consumption of alcohol over and above the acute effects that were discussed in earlier in the chapter.
Tolerance and Withdrawal As with other CNS depressants, alcohol consumption over a period of time will result in a tolerance effect. On a meta- bolic level, alcohol dehydrogenase activity during tolerance becomes higher in the stomach and liver, allowing the alco- hol to leave the body somewhat faster; on a neural level, the brain is less responsive to alcohol’s depressive effects.48 Therefore, if the level of alcohol consumption remains steady, an individual feels less of an effect.
As a result of tolerance and the tendency to compensate for it in terms of drinking a greater quantity, the chronic alcohol abuser is subject to increased physical risks. There are serious behavioral risks as well; for example, an alcohol- tolerant drinker may consider driving with a BAC level that exceeds the standard for drunk driving, thinking that he or
she is not intoxicated and hence not impaired. A person’s driving ability, under these circumstances, will be substan- tially overestimated.
An alcohol-dependent person’s abrupt withdrawal from alcohol can result in a range of serious physical symptoms beginning from 6 to 48 hours after the last drink, but esti- mates of as to how many people are typically affected vary. Among hospitalized patients, only 5 percent appear to show withdrawal symptoms, whereas studies of alcoholics using outpatient facilities have estimated the percentage to be as high as 18. Although the exact incidence may be somewhat unclear, there is less disagreement about what takes place. Physical withdrawal effects are classified in two clusters of symptoms.
●■ The first cluster, called the alcohol withdrawal syndrome, is the more common of the two. It begins with insomnia, vivid dreaming, and a severe hangover; these discomforts
1.99 or below (9) 2.00 — 2.24 (7) 2.25 — 2.49 (14) 2.50 or over (21)
U.S. Total = 2.33
DC
F Igure 15 .1
Annual per capita alcohol consumption in gallons for the U.S. population 14 years and older by state in 2012.
Source: LaVallee, Robin A.; Kim, Trinh; and Yi, Hsiao-ye (2014, April). Surveillance report #98: Apparent per capita a lcohol consumption: National, state, and regional trends, 1977–2012. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism, Figure 4.
alcohol withdrawal syndrome: The more common of two general reactions to the cessation of alcohol consump- tion in an alcoholic. It is characterized by physiological discomfort, seizures, and sleep disturbances.
322 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
of the skin), and abdominal pain, resulting at least in part from a lower functioning level of the immune system. It is also reversible with abstinence, though some residual scarring may remain.
●■ The third and most serious liver condition is alcoholic cirrhosis, characterized by the progressive development of scar tissue that chokes off blood vessels in the liver and destroys liver cells by interfering with the cell’s utilization of oxygen. At an early stage, the liver is enlarged from the accumulation of fats, but at later stages it is shrunken as liver cells begin to degenerate (Figure 15.2). Though ab- stinence helps to prevent further liver degeneration when cirrhosis is diagnosed, the condition is not reversible ex- cept by liver transplantation surgery.
Cirrhosis and other forms of chronic liver disease are collectively ranked as the twelfth leading cause of death in the United States, claiming more than 27,000 lives each year. Most deaths occur in people of ages 40–65 years. Daily drinkers are at a higher risk of developing cirrhosis than binge drinkers, though this risk may be the result of the rela- tively larger quantity of alcohol consumed over a long period of time. Generally, patients showing liver damage have been
are followed by tremors (the “shakes”), sweating, mild agitation, anxiety (the “jitters”), nausea, and vomiting, as well as increased heart rate and blood pressure. In some patients, there are also brief tonic-clonic (grand mal) seizures, as the nervous system rebounds from the chronic depression induced by alcohol. The alcohol withdrawal syndrome usually reaches a peak from 24 to 36 hours after the last drink and is over after 48 hours.
●■ The second cluster, called delirium tremens (DTs), is much more dangerous and is fortunately less common. The symptoms include extreme disorientation and confu- sion, profuse sweating, fever, and disturbing nightmares. Typically, there are also periods of frightening hallucina- tions, when the individual might see snakes or insects on the walls, ceiling, or his or her skin. These effects generally reach a peak three to four days after the last drink. During this time, there is the possibility of life-threatening events such as heart failure, dehydration, or suicide, so it is criti- cal for the individual to be hospitalized and under medical supervision at all times. The current medical practice for treating individuals undergoing withdrawal is to admin- ister antianxiety medication (see Chapter 14) to relieve the symptoms. After the withdrawal period has ended, the dose levels of the medication are gradually reduced and discontinued.49
Liver Disease Chronic consumption of alcohol produces three forms of liver disease. The following conditions are presented in ascending order of severity:
●■ The first of these is a fatty liver, resulting from an abnormal concentration of fatty deposits inside liver cells. Normally, the liver breaks down fats adequately, but when alcohol is in the body, the liver breaks down the alcohol at the ex- pense of fats. As a result, fats accumulate and ultimately interfere with the functioning of the liver. The condition is fortunately reversible, if the drinker abstains. The accumu- lated fats are gradually metabolized, and the liver returns to normal.
●■ The second condition is alcoholic hepatitis, an inflam- mation of liver tissue causing fever, jaundice (a yellowing
alcoholic cirrhosis (Al-co-HAul-ik seer-oH-sis): A disease involving scarring and deterioration of liver cells as a result of chronic alcohol abuse.
alcoholic hepatitis (Al-co-HAul-ik hep-ah-tIe-tus): A disease involving inflammation of the liver as a result of chronic alcohol abuse.
fatty liver: A condition in which fat deposits accumulate in the liver as a result of chronic alcohol abuse.
delirium tremens (Dts): The less common of two general reactions to the cessation of drinking in an alcoholic. It is characterized by extreme disorientation and confusion, fever, hallucinations, and disturbing nightmares.
F Igure 15 .2
The dramatic difference between a healthy liver (top) and a cirrhotic liver (bottom).
Chapter 15 Alcohol Use and Chronic Alcohol Abuse ■ 323
hospitals show signs of alcohol-related dementia. Through abstinence, it is possible to reverse some of the cognitive defi- cits and even some of the abnormalities in the brain, depend- ing on the age of the alcoholic when treatment begins. As you might suspect, younger alcoholics respond better than older ones.53
A more severe form of cognitive impairment related to chronic alcohol consumption is a two-part disease referred to as Wernicke-Korsakoff syndrome. In Wernicke’s enceph- alopathy or simply Wernicke’s disease, the patient shows confusion and disorientation, abnormal eye movements, and difficulties in movement and body coordination. These neurological problems arise from a deficiency in vitamin B1 (thiamine), a nutrient required for neurons in the brain to consume glucose. Extreme alcoholics may go days or weeks at a time eating practically nothing and receiving calories exclusively from drinking alcoholic beverages. As a result of thiamine deficiency, large numbers of neurons die in areas of the brain specifically concerned with thinking and move- ment. About 15 percent of patients with Wernicke’s disease, however, respond favorably to large amounts of thiamine supplements in combination with abstinence from alcohol, restoring their previous level of orientation, eye movements, and coordination.
In some cases, Wernicke’s disease patients, whether or not they recover from confusion and motor impair- ments, also display a severe form of chronic amnesia and general apathy called Korsakoff’s psychosis. Such patients cannot remember information that has just been presented to them and have only a patchy memory for distant events that occurred prior to their alcoholic state. They frequently attempt, through a behavior called confabulation, to com- pensate for their gaps in memory by telling elaborate sto- ries of imagined past events, as if trying to fool others into thinking that they remember more than they actually do. Thiamine deficiency is linked to Korsakoff’s psychosis as well. After being treated with thiamine supplements, about 20 percent of patients completely recover their memory and 60 percent partially recover it. Yet, the remaining 20 percent, generally the most severely impaired patients and those with the longest history of alcohol consump- tion, show little or no improvement and require chronic institutionalization.54
drinking for 10 to 20 years. Only 10–20 percent of all heavy drinkers develop cirrhosis, however, in contrast to 90–100 percent, who show evidence of either fatty liver or hepatitis. There may be a genetic predisposition to cirrhosis that puts a subgroup of alcoholics at increased risk.50
Cardiovascular Problems About one in every four alcoholics develops cardiovascular problems owing to the chronic consumption of alcohol. The effects include inflammation and enlargement of the heart muscle, poor blood circulation to the heart, irregular heart contractions, fatty accumulations in the heart and arteries, high blood pressure, and stroke.51
Cancer Chronic alcohol abuse is associated with the increased risk of several types of cancers—in particular, cancers of the pharynx and larynx. Nearly 50 percent of all such cancers are associated with heavy drinking. If alcohol abusers also smoke cigarettes, the increased risk is even more dramatic. An increased risk of liver cancer is also linked to chronic alcoholic abuse, whether or not cirrhosis is present as well. In addition, alcohol consumption is associated with breast cancer in women. There is either a weaker association or no association at all with cancers of the stomach, colon, pancreas, or rectum.
Alcohol is not technically considered a carcinogen (a direct producer of cancer), so why the risks are increased in certain cancer types is at present unknown. It is possible that the increased risk is a combined result of alcohol enhanc- ing the carcinogenic effects of other chemicals and, as is true with the development of hepatitis, alcohol depressing the immune system. With a reduced immune response, the alcoholic may have a lowered resistance to the development of cancerous tumors.52
Dementia and Wernicke-Korsakoff Syndrome Chronic alcohol consumption can produce longer-lasting deficits in the way an individual solves problems, remembers information, and organizes facts about his or her identity and surroundings. These cognitive deficits are commonly referred to collectively as alcoholic dementia and are associated with structural changes in brain tissue. Specifically, there is an enlargement of brain ventricles (the interior fluid-filled spaces within the brain), a widening of fissures separating sec- tions of cerebral cortex, and a loss of acetylcholine- sensitive receptors. The combination of these effects results in a net decrease in brain mass, as indicated in CT and MRI brain scans, and a decline in overall intelligence, verbal learn- ing and retention, and short-term memory, particularly for middle-aged and elderly alcoholics.
Some 50–75 percent of all detoxified alcoholics and nearly 20 percent of all individuals admitted to state mental
confabulation: The tendency to make up elaborate past histories to cover the fact that long-term memory has been impaired.
thiamine (tHY-ah-meen or tHY-ah-min): Vitamin B1.
Wernicke-Korsakoff syndrome (verN-ih-kee Kor-sa-kof SIN-drohm): A condition resulting from chronic alcohol consumption, characterized by disorientation, cognitive deficits, amnesia, and motor difficulty.
alcoholic dementia (Al-co-HAul-ik dih-MeN-chee-ah): A condition in which chronic alcohol abuse produces cogni- tive deficits such as difficulties in problem solving and memory.
324 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
Present-day diagnoses of FAS are made on the basis of three groups of observations: (1) prenatal or postnatal growth retardation in which the child’s weight or length is below the tenth percentile, (2) evidence of CNS abnormalities or mental retardation, and (3) a characteristic skull and facial appearance that includes a smaller-than-normal head, small wide-set eyes, drooping eyelids, a flattening of the vertical groove between the mouth and nose, a thin upper lip, and a short upturned nose.
The incidence of FAS is approximately 0.5–3 cases per thousand live births in the general U.S. population. Risks are greatly increased when excessive drinking is taking place. Although an occasional drink may have minimal effects, no one has determined a “safe” level of drinking during pregnancy that would make this behavior risk free. The objective of prevention, therefore, is to educate women to the dangers of drinking at any level and to encourage com- plete abstinence from alcohol (as well as other psychoactive drugs) during pregnancy.56 Since 1989, all containers of alcoholic beverages must contain two warning messages, one of which is that “according to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects.”
Fortunately, the public is aware of the problem and the number of women who consume alcohol during pregnancy has declined over the last 25 years. The bad news, however, is that the rates of alcohol consumption among several other high-risk populations in the United States, such as pregnant smokers, unmarried women, women under the age of 25, and women with the fewest years of education, remain sub- stantial despite the fact that about 90 percent of women are aware of the potential harm. Ten percent of pregnant women nationwide continue to consume alcohol. Unfortunately, FAS continues to be the third leading cause of mental retardation not only in the United States but in the entire Western world, exceeded only by Down syndrome and spina bifida. The fact that the development of alcohol-related fetal defects is entirely preventable makes the incidence of these conditions all the more tragic.57
The Family Dynamics of Alcoholism
Alcoholism, like any form of drug abuse, is an especially traumatizing experience for the families involved. For every one person who has a problem with alcohol, there are, on average, at least four others who are directly affected on a day-to-day basis. It is therefore important to examine some of these effects on particular family members. Since the 1950s, a systems approach has advocated looking at how the alcoholic and other members of the family interact. We discussed one of these aspects earlier in the chapter in con- nection with the adverse effects of enabling behavior on the alcoholic. Another important aspect related to an alcoholic’s family is the possibility of codependency.
Fetal Alcohol Syndrome (FAS) The disorders just reviewed generally have been associated with consumption of large quantities of alcohol over a long period of time. In the case of the adverse effects of alcohol during pregnancy on unborn children, we are dealing with a unique situation. First of all, we need to recognize the extreme susceptibility of a developing fetus to conditions in the mother’s bloodstream. In short, if the mother takes a drink, the fetus takes one, too. And to make matters worse, the fetus does not have sufficient levels of alcohol dehydrogenase to break down the alcohol properly; thus, the alcohol stays in the fetus’s system longer than in the mother’s. In addition, the presence of alcohol coincides with a period of time in prena- tal development when critical processes are occurring that are essential for the development of a healthy, alert child.
Although it has long been suspected that alcohol abuse among pregnant women might present serious risks to the fetus, a specific syndrome was not established until 1973, when Kenneth L. Jones and David W. Smith described a cluster of characteristic features in children of alcoholic mothers that is now referred to as fetal alcohol syndrome (FAS).55 Their studies, and research conducted since then, have shown clearly that alcohol is teratogenic; that is, it produces specific birth defects in offspring by disrupting fetal development during pregnancy, even when differences in prenatal nutrition have been accounted for. Later in life, FAS children show deficits in short-term memory, problem solving, and attentiveness.
The face of a child with fetal alcohol syndrome, showing the wide- set eyes and other features that are characteristic of this condition.
systems approach: A way of understanding a phenom- enon in terms of complex interacting relationships among individuals, family, friends, and community.
teratogenic (ter-ah-tuh-JeN-ik): Capable of producing specific birth defects.
fetal alcohol syndrome (FAS): A serious condition involving mental retardation and facial-cranial malformations in the offspring of an alcoholic mother.
Chapter 15 Alcohol Use and Chronic Alcohol Abuse ■ 325
Whether or not risk factor of family history is genetically based (through the transmission of genes from the parents) or environmentally based (through the living conditions in which the offspring have been brought up) is often a complex question. One way of teasing apart the influences of “nature” and “nurture” is to examine cases of adopted children and compare their behavior to behaviors of either their biologi- cal or adoptive parents. In 1981, an extensive research study in Sweden examined the adoption records of approximately 3,000 children who had alcoholic biological parents but lived with nonalcoholic adoptive parents. The results showed that, overall, a larger percentage of these children become alcohol- ics than would be seen in the general population. The greater incidence was present even when the children had been raised by their adoptive parents immediately after being born, indicating that a strong genetic component was operating.
There were, however, two subgroups among those chil- dren who eventually became alcoholics. One subgroup, called Type 1 alcoholics, developed problem drinking later in life and generally functioned well in society. In addi- tion to a genetic predisposition toward alcoholism, there was for this subgroup a strong environmental factor as well. Whether the child was placed in a middle-class or a poor adoptive family influenced the final outcome. A second sub- group, called Type 2 alcoholics, developed alcoholism ear- lier in life and had significant antisocial patterns of behavior. A strong genetic component was operating in this subgroup, and because the socioeconomic status of the adoptive family made no difference in the outcome, we can conclude that environmental factors played a negligible role. Table 15.5 (on page 326) gives a more complete picture of the charac- teristics associated with Type 1 and Type 2 alcoholics.60
Diagnosis, Treatment, and Legal Responsibility
Since 1957, the American Medical Association has defined alcoholism as a disease, and numerous other health organiza- tions have adopted a similar position. As reasonable as this position might sound, the disease concept has created some- thing of a dilemma among professionals concerned with the treatment of alcohol use disorders, as defined by the DSM-5 diagnostic system. It places the burden on physicians to deal with the alcoholic through medical interventions, and unfor- tunately the medical profession is frequently ill-equipped to help. A study in 2000, for example, found that 94 percent of a group of primary care physicians failed to make a correct
Since the early 1980s, the concept of codependency has gained widespread attention as a way of understanding people who live on a day-to-day basis with an alcoholic or any individual with a drug dependence. Definitions vary but most identify four essential features. In members of the family of an alcoholic, therapists have observed (1) an over- involvement with the alcoholic, (2) obsessive attempts to control the alcoholic’s behavior, (3) a strong reliance upon external sources of self-worth, through the approval of others, and (4) an attempt to make personal sacrifices in an effort to improve the alcoholic’s condition.
If people in a relationship with a codependent act badly, the codependent believes that he or she is responsible for their behavior. Because codependency is considered to be a learned pattern of thinking rather than an innate trait, the goal of therapy is to teach the codependent person to detach himself or herself from the alcoholic and begin to meet his or her own needs rather than being controlled by the value judgments of others.58
Risk Factors for Developing Alcoholism
Given the dysfunctional family dynamics that exist when one parent or both parents are chronic alcohol abusers, it is understandable that there should be negative conse- quences on the psychological development of the children. It is not surprising, therefore, that children of alcoholics (COAs) have a higher statistical risk of becoming alcoholics themselves than do children of nonalcoholics. Therefore, having an alcoholic parent or having both parents as alco- holics is a significant risk factor for the later development of alcoholism.
An equally important risk factor is related to a charac- teristic pattern of alcohol consumption itself. Men who, at age 20, have a relatively low response to alcohol, in that they need to drink more than other people to feel intoxicated, carry a higher risk of becoming alcoholic by the time they are 30, regardless of their pattern of drinking at an earlier age and regardless of their parents’ drinking. Sons of alcoholics having a low response to alcohol have a 60 percent chance of becoming alcoholics, compared with a 42 percent chance for sons of alcoholics in general. Sons of nonalcoholics having a low response to alcohol have a 22 percent chance of becom- ing alcoholics, compared with an 8 to 9 percent chance for sons of nonalcoholics in general.
The combination of these two risk factors—family his- tory and a low response to alcohol—is obviously the worst scenario for a development of alcoholism, at least in males. Nonetheless, we should remember that a large proportion of people still do not become alcoholics, even with both risk factors present. The question of what protective fac- tors may account for the resilience of high-risk individu- als with regard to alcoholism is a major subject of current research.59
children of alcoholics (coAs): Individuals who grew up in a family with either one or two alcoholic parents.
codependency: The concept that individuals who live with a person who has an alcohol (or other drug) dependence suffer themselves from difficulties of self-image and impaired social independence.
326 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
goal is a serious obstacle to their success in rehabilitation. The organization Moderation Management (MM) and SMART Recovery are two examples of treatment organizations holding this position.
Research studies using carefully randomized assignment of alcoholic subjects to either an abstinence-oriented treat- ment or a controlled-drinking one have shown that long-term results are comparable for either group. This is not to say that the prospects are wonderful for either of them; the odds are still higher against long-term recovery from alcoholism than for it, no matter what the treatment. But it does appear that controlled drinking can occur.
How many alcoholics can manage to achieve a contin- ued level of nonproblem drinking? Percentages vary from 2 to 10 to 15, though the lower figure is probably more accu- rate for those individuals with severe alcoholic difficulties. Perhaps a more important point is that no one knows how to predict whether an alcohol abuser will be one of that small number of successful controlled drinkers. Obviously, most alcoholics are convinced that they will be the lucky ones.62
Questions surrounding “controlled drinking” for indi- viduals in treatment for chronic alcohol abuse and the appro- priateness of labeling alcoholism as a physical disease have important legal ramifications in situations in which a crimi- nal offence might be committed. The justification for using alcohol intoxication as a legal defense in these circumstances is a complex issue in present-day criminal law.63
Treatment Options
Treatment options for alcohol use disorder are classified as either biologically based interventions, which involve medi- cations, or psychosocial interventions, which involve self- help programs such as Alcoholics Anonymous and SMART Recovery. As we will see, programs employing a psychosocial intervention have different philosophies as to the nature of problem drinking
Biologically Based Treatments The use of disulfiram (brand name: Antabuse) as a treat- ment for alcohol use disorders is based on the idea that if aversive physiological reaction is induced when alcohol is consumed, then consumption will be avoided and the problems of alcoholism will be reduced. Disulfiram, taken orally as a pill once each day, inhibits alcohol dehydro- genase, allowing acetaldehyde to build up in the blood- stream. As a result, individuals who consume alcohol in combination with disulfiram experience a flushing of the face, rapid heart rate and palpitations, nausea, and vom- iting. These effects are brought on not only by consum- ing alcoholic beverages but also by ingesting alcohol in
diagnosis of early-stage alcohol abuse when presented with symptoms typical of this condition. Only a small percentage, approximately one out of five, considered themselves “very prepared” to make a diagnosis in the first place.61
Another difficult issue related to the treatment for alco- holism is whether it is possible for alcoholics in the course of treatment to achieve a level of “controlled drinking” without relapsing. As we will see, well-entrenched organizations such as Alcoholics Anonymous (AA) and the National Institute on Alcohol Abuse and Alcoholism have a strong position that alcoholism is a disease, that abstinence from alcohol is the only answer, and that even the slightest level of alcohol con- sumption will trigger a cascade of problems that the alcoholic is constitutionally incapable of handling. Other treatment organizations, represented in greater numbers in Canada and Europe than in the United States, believe that uncontrolled drinking is a reversible behavioral disorder and that for many alcoholics the promotion of total abstinence as a treatment
disulfiram (dye-Sull-fih-ram): A medication that causes severe physical reactions and discomfort when combined with alcohol. Brand name is Antabuse.
tAble 15.5
Two types of alcoholics
cHArActerIStIcS tYPe 1 tYPe 2
Usual age at onset (late onset) after 25
(early onset) before 25
Inability to abstain infrequent frequent
Fights and arrests when drinking
infrequent frequent
Psychological dependence (loss of control)
infrequent frequent
Guilt and fear about alcoholism
frequent infrequent
Novelty-seeking personality low high
Tendency to use alcohol to escape negative feelings
high low
Tendency to use alcohol to achieve positive feelings
low high
Gender male and female
male only
Extent of genetic influences moderate high
Extent of environmental influences
high low
Serotonin abnormalities in the brain
absent present
Source: Based on updated information from Cloninger, C. Robert (1987). Neurogenetic adaptive mechanisms in alcohol- ism. Science, 236, 410–416.
Chapter 15 Alcohol Use and Chronic Alcohol Abuse ■ 327
of alcoholic individuals. Researchers concluded that to prevent one person from returning to drinking the num- ber of people needed to treat for acamprosate was 12 and for naltrexone was 20. While these numbers may appear to be quite high, it is worth comparing the results to large- scale studies that have found that from 25 to more than 100 people need treatment of widely used cholesterol-lowering statin medications to prevent one cardiovascular event such as a heart attack. Yet, only a small proportion of individuals with alcohol problems receive treatment of any kind, and a still smaller proportion are prescribed medications (see Chapter 17).65
Alcoholics Anonymous The best-known treatment program for alcoholism is Alcoholics Anonymous (AA). Founded in 1935, this orga- nization was conceived as a fellowship of individuals, who wished to rid themselves of their problem drinking by help- ing one another maintain sobriety. The philosophy of AA is expressed in the famous Twelve Steps. Members must have acknowledged that they were “powerless over alcohol” and that their lives had become unmanageable, and so must have turned their will and their lives over “to the care of God as we understood Him.” As the steps indicate, there is a strong spiritual component to the AA program, although the organization vigorously denies that any religious doctrine prevails.
AA functions as a type of group therapy with each mem- ber oriented toward a common goal: the maintenance of abstinence from alcohol despite a powerful and continu- ing craving for it. All meetings are completely anonymous (only first names are used in all communications), and the proceedings are dominated by members recounting their personal struggles with alcohol, their efforts to stop drinking, and their support for fellow alcoholics in their own struggles. New members are encouraged to pair up with a sponsor,
other forms such as mouthwashes and cough mixtures, and even by the absorption of aftershave lotions and shampoos through the skin.
Studies in which disulfiram has been administered to large numbers of alcoholics indicate that it is not effective when it is the sole treatment. One major problem is that alco- holics must take the drug regularly every day, and because disulfiram does nothing to reduce the alcoholic’s craving for alcohol, compliance rates are low. The consensus among professionals in this field is that disulfiram can be useful in a subgroup of higher-functioning alcoholics with exception- ally high motivation to quit drinking; for others, disulfiram can be useful as a transitional treatment until other support programs are in place.64
A more direct approach to treatment than aversion therapy is to reduce the actual craving for alcohol on a physi- ological level. As noted in Chapter 5, the craving for alcohol is related to neurochemical activity in the same dopamine- releasing receptors in the nucleus accumbens that have been implicated in craving for opioids such as heroin as well as in craving for cocaine and nicotine. Medications that interfere with dopamine activity in the nucleus accumbens, such as naltrexone (brand name as an alcoholism treatment: ReVia) and nalmefene (brand name: Revex), should be useful in treatment
An extended-release injectable form of naltrexone (brand name: Vivitrol), administered on a monthly basis, was FDA approved in 2006. The obvious advantage is that individuals do not have to remember to take their medication on a daily basis. Problems associated with individuals skipping their medication are eliminated, and there can be a more intensive concentra- tion on the counseling component of recovery. The advantage of an extended-release naltrexone parallels that of extended- release formulations of buprenorphine (brand names: Subutex, Subuxone) for treating heroin abuse (see Chapter 9).
Other neurochemical approaches have focused on other neurotransmitter systems in the brain (see Drugs . . . in Focus, page 87).
●■ FDA approved in 2004, acamprosate (brand name: Campral) works on the basis of regulating the neurotrans- mitter, GABA.
●■ Topiramate (brand name: Topamax) also works on the basis of regulating GABA. Other therapeutic applications include topiramate as an antiepileptic and migraine- alleviating medication.
●■ An antinausea medication that reduces serotonin levels such as ondansetron (brand name: Zofran) has been use- ful for early-onset (Type 2) alcoholics, owing to the associ- ation between this subgroup and serotonin abnormalities in the brain (see Table 15.5).
In a recent study, medications based on naltrexone (ReVia, Revex, and Vivitrol) and acamprosate (Campral) were found to be effective treatments for at least a portion
Alcoholics Anonymous (AA): A worldwide devoted to the treatment of alcoholism through self-help groups and adherence to its principles, which include absolute abstinence from alcohol.
ondansetron (on-DANS-eh-tron): A serotonin-related drug for the treatment of alcoholism. Brand name is Zofran.
acamprosate (A-cam-Pro-sate): A GABA-related drug for the treatment of alcoholism. Brand name is Campral.
nalmefene (nal-MeH-feen): A long-lasting opioid antagonist for the treatment of alcoholism. Brand name is Revex.
naltrexone (nal-treX-ohn): A long-lasting opioid antagonist for the treatment of alcoholism. Brand name is ReVia. Brand name for an extended-release injectable form is Vivitrol
328 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
not required to call himself or herself an alcoholic to achieve success in recovery. The strategy is based on rational emotive behavior therapy (REBT), an approach developed by the psy- chologist Albert Ellis that emphasizes rooting out irrational thoughts, emotions, and beliefs that prevent the achievement of personal goals.
Another major difference is that SMART Recovery insists on professional involvement in its program, with a professional adviser (often a clinical psychologist) helping members learn the fundamentals of REBT. No reference is made to God or a higher power; the objective is “NHP (no higher power) sobriety.” The goal is that within a year and a half members will be able to maintain sobriety without going to meetings. In contrast, AA members are encouraged to continue going to meetings for the rest of their lives.
Since 1990, there has been increased interest in secu- lar (nonreligious) approaches to self-help alcoholism treat- ment such as that practiced by SMART Recovery. Other examples include Men for Sobriety (MFS), Women for Sobriety (WFS), Moderation Management (MM), and Secular Organization for Sobriety (SOS). Nonetheless, recent research has indicated that alcoholics benefit from participation in AA programs, regardless of their religious beliefs (Drugs . . . in Focus).67
typically a more experienced AA member, who has success- fully completed the Twelve Steps and can serve as a personal source of support on a day-to-day basis. According to AA, no alcoholic is ever cured but is only recovering, and the process of recovery continues throughout that person’s life. In this view, alcoholism is a disease, and relapse from sobriety can occur at any moment.
AA has grown to more than 114,000 groups and more than 2 million members worldwide, although it is difficult to get a precise count because the organization is delib- erately structured very loosely. Perhaps more important than its size is the powerful impact AA has had not only on the way we deal with alcoholism but also on the way we consider treatment for any compulsive behavior in gen- eral. Over the years, the Twelve-Step program has become a generic concept, as the precepts and philosophy of AA have been widely imitated. There are chapters of Gamblers Anonymous, Nicotine Anonymous, Narcotics or Cocaine Anonymous, and Overeaters Anonymous, all based on the AA model. In addition, there are two specialized fellowship organizations: Al-Anon for relatives and friends of alcohol- ics and Alateen for teenagers living with an alcoholic family member. These programs adopt a Twelve-Step approach to identifying and dealing with the dysfunctionality of an alco- holic family.
AA is widely regarded in the field of alcohol reha- bilitation as a beneficial self-help approach, particularly when it is combined with other treatments such as indi- vidual counseling and medical interventions. It has been pointed out that AA employs four factors that have been shown to be effective in preventing relapse in alcohol use disorder: (1) the imposition of external supervision, (2) the substitution of dependence on a group activity for depen- dence on drug-taking behavior, (3) the development of caring relationships, and (4) a heightened sense of spiri- tuality. Nonetheless, the inherent anonymity of Alcoholics Anonymous remains a significant barrier to the precise scientific assessment of its effectiveness as an intervention program.66
SMART Recovery In contrast to AA, the self-help program SMART Recovery holds the position that people do not need to believe that they are “powerless over alcohol” or have to submit to “a Power greater than ourselves” (phrases taken from the Twelve Steps) to recover from alcoholism. Instead, the domi- nant philosophy is that individuals have the power them- selves to overcome anything, including drinking. Unlike AA, Smart Recovery discourages labeling in general; a person is
Quick Concept Check
Understanding Alcoholics Anonymous Check your understanding of the principles and philosophy of Alcoholics Anonymous by indicating whether each of the following statements would be subscribed to by Alcoholics Anonymous.
1. I have always had the power □ yes □ no to control my drinking.
2. I must put myself in the □ yes □ no hands of a Higher Power if I am to be sober for the rest of my life.
3. It is possible to be □ yes □ no cured of alcoholism.
4. I am capable of having □ yes □ no a drink once in a great while without slipping back into alcoholism.
5. The more meetings □ yes □ no I attend, the better chance I have of remaining sober.
Answers: 1. no 2. yes 3. no 4. no 5. yes
15.3
SMArt recovery: A treatment program for abuse of alcohol and other drugs that emphasizes a nonspiritual philosophy and a greater sense of personal control in the abuser. SMART stands for “Self-Management and Recovery Training.”
Chapter 15 Alcohol Use and Chronic Alcohol Abuse ■ 329
the Nondisease Model of Alcoholism Despite the “official” description of alcoholism as a disease by the American Medical Association and many international health organizations, the concept of alcoholism as a disease remains con- troversial and continues to attract vigorous criticism among health care professionals. Nondisease theorists assert that alcoholics (as well as other substance abusers) are not sick in the technical sense of the word and that the labeling of “sickness” encourages the alcoholic to assume a passive stance, relying upon advances of modern medicine to save the day, and permitting a pattern of making excuses for one’s behavior rather than changing it.
The “disease versus nondisease” debate has inevitable consequences for the ways in which we choose to respond to the problem. Nondisease theorists view the prevailing majority opinion as unfortunately leading to a marginalization of alco- holics, reducing them to a small group of afflicted, biologically predestined individuals, rather than seeing these people in the
context of the way all of us behave to one degree or another. In the words of nondisease advocate Stanton Peele, this attitude fosters a “one-size-fits-all” approach to treatment that might be simpler to administer on a large-scale basis but ends up ignoring the diversity of needs within the alcoholic population. Peele views the disease model as leading to the assumption that all drinking must cease (a position held by AA), instead of to the encouragement of controlled levels of drinking, as advocated by Moderation Management (MM).
Sources: Goode, Erich (1999). Drugs in American society (5th ed.). New York: McGraw-Hill College. Quotation on p. 350. Kinney, Jean (2003). Loosening the grip: A handbook of alcohol informa- tion (7th ed.). St. Louis: Mosby, pp. 318–322. Peele, Stanton (1995). Assumptions about drugs and the marketing of drug policies. In W. K. Bickel and R. J. DeGrandpre (Eds.), Drug policy and human nature. New York: Plenum, pp. 199–220. Peele, Stanton; and Brodsky, Archie (1975). Love and addiction. New York: Taplinger Publishing.
Drugs . . . in Focus
What Makes an Alcoholic beverage? ●● Drinkable alcohol is obtained from the fermentation of
sugar in some natural fruits (grapes, apples, honey, etc. in the case of wines) or grains (in the case of beer).
●● To obtain very strong alcoholic beverages, it is necessary to boil the fermented liquid and condense it later by cool- ing, in a process called distillation. The results are prod- ucts known as distilled spirits or liquors.
●● Absorption of alcohol into the bloodstream is extremely rapid. The breakdown of alcohol is handled by two special enzymes in the stomach and liver.
●● Generally, the neural effect of alcohol proceeds down- ward, beginning with inhibition of the cerebral cortex, fol- lowed by that of lower brain regions.
●● The effective level of alcohol in the body is measured by the blood alcohol concentration (BAC) level in the bloodstream.
●● There is a great disparity in the drinking habits in the U.S. population. About a third of the population do not drink at all, and only 30 percent of those who drink account for 80 percent of total alcohol consumption.
Patterns of Alcohol consumption ●● Peak alcohol consumption occurs at ages 21–22. Alcohol
problems among college students are a continuing social concern.
●● Other areas of concern with respect to problematic drink- ing include access to alcohol beverages by underage drinkers and loss of productivity among individuals in the workplace.
Acute Physiological effects ●● Alcohol at very high levels produces a number of acute
physiological effects, some of them being life threaten- ing. Potential death by asphyxiation can occur with BAC levels reaching 0.50 percent. At moderate levels, acute effects include a loss of body heat, increased excretion of water, an increase in heart rate and constriction of coronary arteries, disturbed patterns of sleep, and serious interactions with other drugs.
●● Consumption of alcohol, even in moderate amounts, dur- ing pregnancy greatly increases the risk of retardation in the development of the fetus.
Acute behavioral effects ●● On a behavioral level, serious adverse effects include
blackouts, significant impairment in sensorimotor skills such as driving an automobile, and an increased potential for aggressive or violent acts.
●● The relationship between alcohol consumption and sex- ual desire and performance is a complex one, with differ- ences being observed for men and women. Expectations can play a significant role in some circumstances.
Summary
330 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
Physiological effects of chronic Alcohol Abuse ●● Physiological effects of chronic alcohol abuse include toler-
ance and withdrawal, liver disease, cardiovascular disease, cancer, and neurological disorders such as Wernicke- Korsakoff syndrome.
●● A particular concern is the development of fetal alcohol syndrome (FAS) in the offspring of alcoholic mothers.
the Family Dynamics in Alcoholism ●● A systems approach to alcoholism examines the complex
interacting relationships among individuals, family, friends, and community.
●● The concept of codependency has helped shed light on the specific effects of alcoholism on spouses and other family members.
risk Factors for Developing Alcoholism ●● The children of alcoholics (COAs) carry an increased risk of
becoming alcoholic as a result of a vulnerability toward alco- holism that is genetically or environmentally based, or both.
●● One risk factor is having an elevated threshold for alcohol intoxication.
●● The increased risk of developing alcoholism for an alcoholic having drinking problems early in life (a Type 2 alcoholic) has been shown to be generically based, rather than environ- mentally based.
Diagnosis and treatment of Alcoholism ●● The standard position among health care professional with
respect to alcoholism is that it should be considered a dis- ease. The American Medical Association has supported this view.
●● The question of the likelihood for an alcoholic to sustain a moderate level of controlled drinking is controversial within the alcoholism treatment profession.
treatment options ●● Treatment options for alcohol use disorder are classified
as biologically based treatments, using specific medica- tions, or psychosocial treatments.
●● Psychosocial treatment programs include Alcoholics Anonymous (AA), Moderation Management (MM), and SMART Recovery. The position of AA is that the alcoholic can never be cured and that a zero tolerance for alcohol consumption has to be sustained. The position of MM and SMART Recovery is that the alcoholic can success- fully overcome problem drinking through rational-emotive behavioral therapy.
Strategies for regulating Alcohol consumption ●● One approach to regulating alcohol consumption is to
restrict access. Twenty-one years has been set nationwide as the minimum age requirement for the purchase of alcoholic beverages.
●● A principal strategy for regulation has been the imposition of taxes, either at the federal or local level.
●● The reduction in alcohol-related traffic fatalities has been made through a nationwide standard 0.08 percent for “driving while intoxicated” among adult drivers and 0.02 percent for drivers younger than 21 years. Anti-ignition interlock systems in automobiles have also been useful for drivers with a record of driving while intoxicated.
Alcohol and Health benefits ●● There is a reduced risk for coronary heart disease and
stroke with moderate consumption of alcohol. Other pos- sible health benefits include a reduction of risk for diabe- tes, dementia, and rheumatoid arthritis.
●● Moderate alcohol consumption has been defined as no more than one drink per day for women and no more than two drinks per day for men. There should be zero tolerance for alcohol consumption among pregnant women.
chronic Alcohol Abuse and Alcoholism ●● Alcoholism is a multidimensional condition that is typi-
cally defined in terms of four major criteria: (1) prob- lems associated with a preoccupation with drinking, (2) emotional problems, (3) vocational, social, and family problems, and (4) physical problems. Dysfunctionality is a typical feature of an individual’s family dynamics when one or both parents in the family are chronic alcohol abusers.
●● According to health professionals, alcohol use disorder is diagnosed through a set of behavioral criteria that in- clude uncontrolled alcohol intake, unsuccessful efforts to reduce alcohol use, life problems, and alcohol tolerance and withdrawal.
Patterns of chronic Alcohol Abuse ●● An estimated 83,000 alcohol-related deaths occur in the
United States each year. ●● Men outnumber women in the incidence of alcoholism
by about six to one, although women are more vulnerable to alcohol-related organ damage.
Key Terms
abstinence, p. 317 acamprosate, p. 327 acetaldehyde, p. 302 acetaldehyde dehydrogenase,
p. 302
acetic acid, p. 302 alcohol dehydrogenase, p. 302 alcohol use disorder, p. 320 alcoholic cirrhosis, p. 322 alcoholic dementia, p. 323
alcoholic hepatitis, p. 322
Alcoholics Anonymous (AA), p. 327
alcoholism, p. 317
alcohol withdrawal syndrome, p. 321
antidiuresis, p. 309 antidiuretic hormone
(ADH), p. 309
Chapter 15 Alcohol Use and Chronic Alcohol Abuse ■ 331
1. Describe the process of fermentation and distillation in the making of wine, beer, and liquor.
2. Describe the factors that determine the BAC level of an individual after a period of alcohol drinking.
3. Briefly describe the acute physiological effects of alcohol consumption, with reference to toxic reactions, heat and water retention, cardiovascular condition, and patterns of sleep.
4. Briefly describe the acute behavioral effects of alcohol consumption with reference to memory, driving skills, and aggressive behavior.
5. In what way would taxation designed to reduce alcohol consumption have the totally opposite effect?
6. Briefly describe the potential health benefits from moderate alcohol consumption.
7. Summarize the behavioral criteria for alcohol use disorder, as established by the DSM-5 classification of diagnoses.
8. Briefly describe the physiological effects of chronic alcohol abuse, with respect to tolerance and withdrawal, liver and car- diovascular disease, cancer, and certain neurological disorders.
9. Distinguish between a Type 1 and Type 2 alcoholic. What are the ramifications for treatment?
10. Contrast Alcoholics Anonymous (AA) and SMART Recovery with respect to their philosophies and general approaches toward treatment.
Review Questions
You are the presiding judge in a trial in which John Doe is charged with assaulting and injuring a man while outside a local fast-food establishment. The defense attorney has argued that Mr. Doe is a recovering alcoholic, having been treated in the SMART Recovery program. Mr. Doe has been engaged in controlled drinking for the past eight months, without incident.
On the night of the offense, Mr. Doe returned home and fell asleep; in the morning, he had no memory of the offense for which he is charged or any aspect of the incident in question. Evidence that the offense was committed has not been contested. Would you reduce the sentence of Mr. Doe on the basis of the argument that there were mitigating circumstances?
Critical Thinking: What Would You Do?
1. Pinel, John P. J. (2003). Biopsychology (5th ed.). Boston: Allyn and Bacon, p. 381.
2. Gibbons, Boyd (1992, February). Alcohol: The legal drug. National Geographic Magazine, pp. 2–35.
3. U.S. Department of Health and Human Services (2000). Alco- hol and health (Tenth Special Report to the U.S. Congress). Bethesda, MD: National Institute on Alcohol Abuse and Alco- holism, p. 370.
4. Dubowski, Kurt M. (1991). The technology of breath-alcohol analysis. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism.
5. Frezza, Mario; DiPadova, Carlo; Pozzato, Gabrielle; Ter- pin, Maddalena; Baraona, Enrique; and Lieber, Charles S. (1990). High blood alcohol levels in women: The role of decreased gastric alcohol dehydrogenase activity and first- pass metabolism. New England Journal of Medicine, 322, 95–99. Nakawatase, Tomoko V.; Yamamoto, Joe; and Sasao, Toshiaki (1993). The association between fast-flushing response and alcohol use among Japanese Americans. Journal of Studies on Alcohol, 54, 48–53. Roine, Risto; Gentry, Thomas; Hernandez-Muñoz, Rolando; Baraona,
Enrique; and Lieber, Charles S. (1990). Aspirin increases blood alcohol concentrations in humans after ingestion of ethanol. Journal of the American Medical Association, 264, 2406–2408.
6. Julien, Robert M. (2005). A primer of drug action (10th ed.). New York: Worth, pp. 96–98. National Institute on Alcohol Abuse and Alcoholism (2007, April). Alcohol alert: Alcohol metabolism: An update. No. 72. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism.
7. Suter, Paolo M.; Schutz, Yves; and Jequier, Eric (1992). The effect of ethanol on fat storage in healthy subjects. New Eng- land Journal of Medicine, 326, 983–987.
8. Levinthal, Charles F. (1990). Introduction to physiological psychology (3rd ed.). Englewood Cliffs, NJ: Prentice Hall, pp. 181–184.
9. Julien, A primer of drug action, p. 97. 10. LaVallee, Robin A.; Kim, Trinh; and Yi, Hsiao-ye (2014,
April). Surveillance report #98: Apparent per capita alcohol consumption: National, state, and regional trends, 1977–2012. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism, Figure 4.
Endnotes
aqua vitae, p. 306 barley malt, p. 300 blackout, p. 311 blood alcohol concentration
(BAC), p. 303 brewing, p. 300 children of alcoholics
(COAs), p. 325 codependency, p. 325 confabulation, p. 323
congeners, p. 310 delirium tremens (DTs), p. 322 distillation, p. 300 distilled spirits, p. 301 disulfiram, p. 326 employee assistance programs
(EAPs), p. 308 enablers, p. 319 ethyl alcohol, p. 300
fatty liver, p. 322 fermentation, p. 300 fetal alcohol syndrome
(FAS), p. 324 mash, p. 300 member assistance programs
(MAPs), p. 308 nalmefene, p. 327 naltrexone, p. 327
ondansetron, p. 327 oxidation, p. 302 SMART Recovery, p. 328 symptomatic drinking, p. 317 systems approach, p. 324 teratogenic, p. 324 thiamine, p. 323 Wernicke-Korsakoff
syndrome, p. 323
332 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
17. Frone, Michael R. (2006). Prevalence and distribution of alcohol use and impairment in the workplace: A U.S. national survey. Journal of Studies on Alcohol and Drugs, 67, 147–156.
18. Grilly, David M.; and Salamone, John (2012). Drugs, brain and behavior (6th ed.). Boston: Pearson Education, p. 238.
19. Luks, Allan and Barbato, Joseph (1989). You are what you drink. New York: Villiard, pp. 42–43.
20. National Institute on Alcohol Abuse and Alcoholism (1998, July). Alcohol alert: Alcohol and sleep. No. 41. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism.
21. Center for Behavior Health Statistics and Quality, Results from the 2013 National Survey, p. 33.
22. Schuckit, Marc A. (2006). Drug and alcohol abuse: A clinical guide to diagnosis and treatment (6th ed.). New York: Plenum, p. 88.
23. Wiese, Jeffrey G.; Shlipak, Michael G.; and Browner, Warren S. (2000). The alcohol hangover. Annals of Internal Medicine, 232, 897–902.
24. White, Aaron M.; Jamieson-Drake, David W.; and Swartzwelder, H. Scott (2002). Prevalence and correlates of alcohol-induced blackouts among college students: Results of an e-mail survey. Journal of American College Health, 51, 117–131.
25. National Highway Traffic Safety Administration (2014, December). Alcohol-impaired driving. Traffic safety facts: 2013 data. Washington, DC: National Center for Statistics and Analysis, National Highway Traffic Safety Administration.
26. Hoyer, William J.; Semenec, Silvie C.; and Buchler, Norbou E. G. (2007). Acute alcohol intoxication impairs controlled search across the visual field. Journal of Studies on Alcohol and Drugs, 68, 748–758.
27. Abbey, Antonia (2002). Alcohol-related sexual assault: A common problem among college students. Journal of Stud- ies of Alcohol and Drugs (Supplement No. 14), 118–128. Abbey, Antonia; Zawacki, Tina; Buck, Philip O.; Clinton, A. Monique; and McAuslan, Pam (2004). Sexual assault and alcohol consumption: What do we know about their relationship and what types of research are still needed? Aggression and Violent Behavior, 9, 271–303.
28. Collins, James J.; and Messerschmidt, Pamela M. (1993). Epidemiology of alcohol-related violence. Alcohol Health and Research World, 17, 93–100. Goode, Erich (2012). Drugs in American society (8th ed.). New York: McGraw- Hill, pp. 184–188. Bureau of Justice Statistics (2011, May). Criminal victimization in the United States, 2008. Statistical tables. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice, Table 32.
29. Goode (2012), Drugs in American society, p. 368. 30. Giancola, Peter R. (2000). Executive functioning: A concep-
tual framework for alcohol-related aggression. Experimental and Clinical Psychopharmacology, 8, 576–597. Giancola, Peter R. (2002). Alcohol-related aggression in men and women: The influence of dispositional aggressivity. Journal of Studies on Alcohol, 63, 696–708.
31. Abel, Ernest L. (1985). Psychoactive drugs and sex. New York: Plenum Press, pp. 19–54. Cooper, M. Lynne (2006). Does drinking promote risky sexual behavior? A complex answer to a simple question. Current Directions in Psychological Science, 15, 19–23.
32. Mosher, Clayton J.; and Akins, Scott. M. Drugs and drug policy: The control of consciousness alteration. Los Angeles: Sage Publications, p. 370.
11. Gibbons, Alcohol, p.7. 12. McGovern, Patrick E.; Glusker, Donald L.; Exner, Lawrence
J.; and Voigt, Mary M. (1996). Neolithic resinated wine. Nature, 381, 480–481. Roueché, Berton (1963). Alcohol in human culture. In Salvatore P. Lucia (Ed.), Alcohol and civilization. New York: McGraw-Hill, pp. 167–182. Vallee, Bert L. (1998, June). Alcohol in the western world. Scientific American, pp. 80–85.
13. Sournia, Jean-Charles (1990). A history of alcoholism. Cambridge, MA: Basil Blackwell, pp. 14–50.
14. Garfield, Craig F.; Chung, Paul J.; and Rathouz, Paul J. (2003). Alcohol advertising in magazines and adolescent readership. Journal of the American Medical Association, 289, 2424–2429. Hanson, Glen R.; and Li, Ting-Kai (2003). Public health implications of excessive alcohol consumption. Journal of the American Medical Association, 289, 1031–1032. National Association of Convenience Stores (2008). That’s the spirit—U.S. alcohol sales growing. www.nacsonline.com. US top five beer companies ranked by prime-time network television advertising outlays in dollars with the top three network TV programs ranked by beer ad expenditures. Adweek (2003, April 21), p. SR14.
15. Heeren, Timothy; Zakocs, Ronda C.; and Kopstein, Andrea (2002). Age of first intoxication, heavy drinking, driving after drinking and risk of unintentional injury among U.S. col- lege students. Journal of Studies on Alcohol, 63, 136–144. Hingson, Ralph W.; Zha, Wenxing; and Weitzman, Elissa R. (2009). Magnitude of and trends in alcohol-related mortality and morbidity among U.S. college students ages 18–24, 1998–2005. Journal of Studies on Alcohol and Drugs (Supplement No. 16), 12–20. National Institute on Alcohol and Alcohol Abuse (2010). Statistical snapshot of college drinking. Bethesda, MD: National Institute on Alcohol and Alcohol Abuse. Wechsler, Henry; and Nelson, Toben F. (2008). What we have learned from the Harvard School of Public Health College Alcohol Study: Focusing attention on college student alcohol consumption and the environmental conditions that promote it. Journal of Studies on Alcohol and Drugs, 69, 1–10. Wechsler, Henry; Lee, Jae Eun; Kuo, Meic- hun; Seibring, Mark; Nelson, Toben F.; et al. (2002). Trends in college binge drinking during a period of increased pre- vention efforts: Findings from four Harvard School of Public Health College Alcohol Study Surveys: 1993–2001. Journal of American College Health, 50, 203–217. White, Aaron M.; Kraus, Courtney L.; and Swartzwelder, Harry. S. (2006). Many college freshmen drink at levels far beyond the binge threshold. Alcoholism: Clinical and Experimental Research, 30, 1006–1010.
16. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; Schulenberg, John E.; and Miech, Richard A. (2014). Monitoring the future: National survey results on drug use, 1975–2013, Vol. I: Secondary school students 2013. Ann Arbor, MI: Institute for Social Research, University of Michigan, Tables 2-1 and 2-4. Center for Behavioral Health Statistics and Quality (2014). Results of the 2013 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Admin- istration, Tables 6-68A, 6-68B, 6-69A, and 6-69B. Windle, Michael; and Zucker, Robert A. (2010). Reducing underage and young adult drinking: How to address critical drinking problems during this developmental period. Alcohol Research and Health, 33, 29–44.
Chapter 15 Alcohol Use and Chronic Alcohol Abuse ■ 333
33. National Highway Traffic Safety Administration (2009, June). Lives saved in 2008 by restraint use and minimum drinking age laws. Traffic Safety Facts. Washington, DC: National Center for Statistics and Analysis, National Highway Traffic Safety Administration.
34. Xu, Xin; and Chaloupka, Frank J. (2012). The effects of prices on alcohol use and its consequences. Alcohol Research and Health, 34, 236–245.
35. National Institute on Alcohol Abuse and Alcoholism (2001, April). Alcohol alert: Alcohol and transportation safety. No. 52. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism. Wagenaar, Alexander C.; O’Malley, Patrick M.; and LaFond, Colette (2001). Lowered legal blood alcohol limits for young drivers: Effects on drinking, driving, and driving-after-drinking behaviors in 30 states. American Journal of Public Health, 91, 801–803.
36. National Highway Traffic Safety Administration (2009, June). Lives saved in 2008 by restraint use and minimum drinking age laws. Traffic Safety Facts. Washington, DC: National Center for Statistics and Analysis, National Highway Traffic Safety Administration.
37. Center for Behavioral Health Statistics and Quality, Results from the 2013 National Survey, Tables 6.94B and 6.95A.
38. Rimm, Eric B. (2000). Moderate alcohol intake and lower risk of coronary heart disease: Meta-analysis of effects on lipids and haemostatic factors. Journal of the American Medical Associa- tion, 283, 1269. Wade, Nicholas (2006, November 2). Yes, red wine holds answer. Check dosage. Zuger, Abigail (2002, December 31). The case for drinking (all together now: in moderation). New York Times, pp. F1, F6. Quotation on p. F1.
39. Howard, Andrea A.; Arnsten, Julia H.; and Gourevitch, Marc N. (2004). Effect of alcohol consumption on diabetes mellitus: A systematic review. Annals of Internal Medicine, 140, 211–219. Källberg, Henrik; Jacobsen, Soren; Bengts- son, Camilla; Pdersen, Merete; Padyukov, Leonid; et al. (2009). Alcohol consumption is associated with decreased risk of rheumatoid arthritis: Results from two Scandinavian case-control studies. Annals of the Rheumatic Diseases, 68, 222–227. Mukamal, Kenneth J.; Conigrave, Katherine M.; Mittleman, Murray A.; Carmargo, Carlos A., Jr.; Stampfer, Meir J.; et al. (2003). Roles of drinking pattern and type of alcohol consumed in coronary heart disease in men. New Eng- land Journal of Medicine, 348, 109–118. Mukamal, Kenneth J.; Kuller, Lewis H.; Longstreth, W. T.; Mittleman, Murray A.; and Siscovick, David S. (2003). Prospective study of alcohol consumption and risk of dementia in older adults. Journal of the American Medical Association, 289, 1405–1413. Reynold, Kristi; Lewis, L. Brian; Nolen, John David L.; Kinney, Gregory L.; Sathya, Bhavani; et al. (2003). Alcohol consumption and risk of stroke: A meta-analysis. Journal of the American Medical Association, 289, 579–588.
40. Alcohol Policies Project, Center for Science in the Public Interest (2000). Victory for public health: New U.S. guide- lines on alcohol consumption drop positive spin on drinking. Washington, DC: Center for Science in the Public Inter- est. Darby, William; and Heinz, Agnes (1991, January). The responsible use of alcohol: Defining the parameters of modera- tion. New York: American Council on Science and Health, pp. 1–26. The Gallup Organization (2005, July 22). Fewer young adults drinking to excess. Princeton, NJ: Gallup Orga- nization. Goldberg, Ira (2003). To drink or not to drink. New England Journal of Medicine, 348, 163–164. Klatsky, Arthur
(2003, February). Drink to your health? Scientific American, pp. 75–81. Rabin, Roni Caryn (2009, June 19). Alcohol’s good for you? Some scientists doubt it. New York Times, pp. D1, D6.
41. Hofmann, Frederick G. (1983). A handbook on drug and alcohol abuse (2nd ed.). New York: Oxford University Press, p. 99.
42. Conner, Kenneth R.; Yue, Li; Meldrum, Sean; Duberstein, Paul R.; and Conwell, Y. (2003). The role of drinking in sui- cidal ideation: Analysis of Project MATCH data. Journal of Studies on Alcohol, 64, 402–408. Schuckit, Marc A. (2000). Drug and alcohol abuse: A clinical guide to diagnostic and treatment (5th ed.). New York: Kluwer Academic/Plenum, pp. 54–97.
43. Maiden, R. Paul (1997). Alcohol dependence and domestic violence: Incidence and treatment implications. Alcohol Treatment Quarterly, 15, 31–50. U.S. Department of Health and Human Services (1990). Alcohol and health (Seventh Special Report to the U.S. Congress). Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism, p. 174.
44. Centers for Disease Control and Prevention (2014, August 19). Fact sheets—Alcohol use and your health. Atlanta, GA: Centers for Disease Control and Prevention. National Insti- tute on Alcohol Abuse and Alcoholism (2000, April). Alcohol Alert: Imaging and alcoholism: A window on the brain. No. 47. Bethesda, MD: National Institute on Alcohol Abuse and Alco- holism. Zeridze, David; Lewington, Sarah; Borode, Alexander; Scelo, Ghislaine; Karpov, Rostislav; et al. (2014). Alcohol and mortality in Russia: Prospective observational study of 151,000 adults. Lancet, 383, 1465–1473.
45. Fishbein, Diana H.; and Pease, Susan E. (1996). The dynamics of drug abuse. Needham Heights, MA: Allyn and Bacon, pp. 122–124.
46. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). DSM-5. Washington, DC: American Psychiatric Publishing, pp. 490–497.
47. Harwood, Henrick (2011, October 23). Recent findings on the economic impacts of substance abuse. Presented at the American Psychological Association 2011 Science Leadership Conference, Psychological Science and Substance Abuse, Washington, DC, Slide 12. Mokdad, A. H.; Marks, J. S.; Stroup, D. F.; and Gerberding, J. L. (2004). Actual causes of death in the United States, 2000. Journal of the American Medical Association, 291, 1238–1245.
48. Julien, A primer of drug action, pp. 106–109. 49. Becker, Howard (2008). Alcohol dependence, withdrawal, and
relapse. Alcohol Research and Health, 31, 348–361. 50. Centers for Disease Control and Prevention (2009, April 17).
Deaths: Final data for 2006. National Vital Statistics Reports, 57, 1, Table 13. Lieber, Charles S. (2001). Alcohol and hepatitis C. Alcohol Research and Health, 25, 245–254. Szabo, Gyongyi; and Mandrekar, Pranoti (2010). Alcohol and the liver. Alcohol Research and Health, 33, 87–96.
51. Mukamal, Kenneth J.; Tolstrup, Janne S.; Friberg, Jens; Jensen, Gorm; and Gronbaek, Morton (2005). Alcohol consumption and risk of atrial fibrillation in men and women. Circulation, 112, 1736–1742.
52. Bagnardi, Vincenzo; Blangliardo, Marta; and LaVecchia, Carlo (2001). Alcohol consumption and the risk of cancer: A meta-analysis. Alcohol Research and Health, 25, 263–270. Molina, Patricia E.; Happel, Kyle I.; Zhang, Ping; Kolls, Jay K.; and Nelson, Steve (2010). Alcohol and the immune system. Alcohol Research and Health, 33, 97–108. Smith-Warner, Stephanie A.; Spiegelman, Donna; Shiaw-Shyuan, Yuan; Van
334 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
61. Maltzman, Irving (1994). Why alcoholism is a disease. Journal of Psychoactive Drugs, 26, 13–31. National Center on Addiction and Substance Abuse at Columbia University (2000, May). Missed opportunity: National survey of primary care physicians and patients on substance abuse. New York: National Center on Addiction and Substance Abuse at Columbia University.
62. Hester, Reid K.; and Miller, William R. (1989). Self-control training. In Reid K. Hester and William R. Miller (Eds.), Handbook of alcoholism treatment approaches. New York: Pergamon Press, pp. 141–149. Miller, William R. (1989). Increasing motivation for change. In Reid K. Hester and William R. Miller (Eds.), Handbook of alcoholism treatment approaches. New York: Pergamon Press, pp. 67–80. Sobell, Mark B.; and Sobell, Linda C. (1978). Behavioral treatment of alcohol problems: Individualized therapy and controlled drinking. New York: Plenum.
63. Carter-Yamauchi, Charolotte (1998). Drugs, alcohol, and the insanity defense: The debate over “settled” insanity. Report No. 7, 1998. Honolulu, HI: Legislative Reference Bureau, Hawaii State Capital. Herald, John E. (1970, Fall–Winter). Criminal law: Alcoholism as a defense. Marquette Law Review, 53, 445–450. Weinstock, Robert (1999, January). Drug and alco- hol intoxication: mens rea defenses. AAPL Newsletter, Ameri- can Academy of Psychiatry and the Law, 24, 1–3.
64. Banys, Peter (1988). The clinical use of disulfiram (Antabuse): A review. Journal of Psychoactive Drugs, 20, 243–261.
65. Jonas, Daniel E.; Halle, R. Amick; Felmer, Cynthia; Bobaschev, Georgly; Thomas, Kathleen; et al. (2014). Pharmacotherapy for adults with alcohol use disorders in out- patient settings: A systematic review and meta-analysis. Journal of the American Medical Association, 311, I889–1900.
66. Dodes, Lance and Dodes, Zachary (2014). The sober truth: Debunking the bad science behind 12-step programs and the rehab industry. Boston: Beacon Press. Hopson, Ronald E.; and Beaird-Spiller, Bethany (1995). Why AA works: A psycho- logical analysis of the addictive experience and the efficacy of Alcoholics Anonymous. Alcoholism Treatment Quarterly, 12, 1–17. Morgenstern, Jon; Bux, Donald; LaBouvie, Erich; Blanchard, Kimberly A.; and Morgan, Thomas J. (2002). Examining mechanisms of action in a 12-step treatment: The role of 12-step cognitions. Journal of Studies on Alcohol, 63, 665–672. White, William H. (1998). Slaying the dragon: The history of addiction treatment and recovery in America. Bloomington, IL: Chestnut Health Systems, pp. 127–177.
67. Ellis, Albert and Velten, Emmett (1992). When AA doesn’t work for you: Rational steps to quitting alcohol. Fort Lee, NJ: Barricade Press. Kaskutas, Lee A. (1996). A road less traveled: Choosing the “Women for Sobriety” program. Journal of Drug Issues, 26, 77–94. Schmidt, Eric (1996). Rational recovery: Finding an alternative for addiction treatment. Alcoholism Treatment Quarterly, 14, 47–57. SMART Recovery (2004). SMART Recovery handbook. Mentor, OH: SMART Recov- ery®. Winzelberg, Andrew; and Humphreys, Keith (1999). Should patients’ religiosity influence clinicians’ referral to 12-step self-help groups? Evidence from a study of 3,018 male substance abuse patients. Journal of Consulting and Clinical Psychology, 67, 790–794.
den Brandt, Piet A.; Folsom, Aaron R.; et al. (1998). Alcohol and breast cancer in women: A pooled analysis of cohort studies. Journal of the American Medical Association, 279, 535–540.
53. National Institute on Alcohol Abuse and Alcoholism (2001, July). Alcohol Alert: Cognitive impairment and recovery from alcoholism. No. 53. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism. U.S. Department of Health and Human Services (1990). Alcohol and health, pp. 123–124.
54. McEvoy, Joseph P. (1982). The chronic neuropsychiatric disorders associated with alcoholism. In E. Mansell Pattison and Edward Kaufman (Eds.), Encyclopedic handbook of alcoholism. New York: Gardner Press, pp. 167–179.
55. Golden, Janet (2005). Message in a bottle: The making of fetal alcohol syndrome. Cambridge, MA: Harvard University Press. Jones, Kenneth L.; and Smith, David W. (1973). Recogni- tion of the fetal alcohol syndrome in early infancy. Lancet, 2, 999–1001. Sokol, Robert J.; Delaney-Black, Virginia; and Nordstrom, Beth (2003). Fetal alcohol spectrum disorder. Journal of the American Medical Association, 290, 2996–2999. Thomas, Jennifer; Warren, Kenneth; and Hewitt, Brenda G. (2010). Fetal alcohol spectrum disorders: From research to policy. Alcohol Research and Health, 33, 118–126.
56. Genetics of Alcohol Use Disorders. National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD. http://niaaa. nih.gov/alcohol-health/overview-alcohol-consumption/ (accessed on March 23, 2014).
57. Carroll, Linda (2003, November 4). Alcohol’s toll on fetuses: Even worse than thought. New York Times, pp. F1, F6. Centers for Disease Control and Prevention (2004, December 24). Alcohol consumption among women who are pregnant or who might become pregnant—United States, 2002. Morbidity and Mortality Weekly Report, 1178–1181. Floyd, R. Louise; O’Connor, Mary J.; Sokol, Robert J.; Bertrand, Jacquelyn; and Cordero, José F. (2005). Recognition and prevention of fetal alcohol syndrome. Obstetrics and Gynecology, 106, 1059–1064.
58. Beattie, Melody (2009). The new codependency. New York: Simon and Schuster.
59. Erblich, Joel; and Earleywine, Mitchell (1999). Children of alcoholics exhibit attenuated cognitive impairment during an ethanol challenge. Alcoholism: Clinical and Experimen- tal Research, 23, 476–482. Hussong, Andrea M.; Curran, Patrick J.; and Chassin, Laurie (1998). Pathways of risk for accelerated heavy alcohol use among adolescent children of alcoholic parents. Journal of Abnormal Child Psychology, 26, 453–466.
60. Cloninger, C. Robert (1987). Neurogenetic adaptive mechanisms in alcoholism. Science, 236, 410–416. Cloninger, C. Robert; Gohman, M.; and Sigvardsson, S. (1981). Inheri- tance of alcohol abuse: Cross fostering analysis of adopted men. Archives of General Psychiatry, 38, 861–868. Devor, E. J.; and Clooninger, C. Robert (1989). Genetics of alcoholism. Annual Review of Genetics, 23, 18–26. National Institute on Alcohol Abuse and Alcoholism (2008). Genetics of alcohol use disorders. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism.
Nicotine and Tobacco Use
16 chapter
I’m told Mark Twain once said that quitting smoking was easy and
that he should know because he had done it a thousand times.
Well, I should know too. It seems that I’ve tried to quit a million
times.
I realize it’s not good for me; I’m no fool. But you have to know
that when I wake up in the morning, all I can think about is that
first cigarette. I think about smoking my next cigarette all day long.
Somehow I’m willing to suffer the indignity and inconvenience of
sneaking out of the office and standing out there in the rain and
the cold, not to mention the disapproving glances of a lot of my
friends and people I work with, just to have a cigarette. It’s so hard
to stop.
—Anonymous
After you have completed this chapter, you should have an understanding of the following:
●● The history of tobacco from 1492 to the present day
●● Public health perspectives and tobacco control policy since 1990
●● The components of tobacco smoke: carbon monoxide, tar, and nicotine
●● The dependence potential of nicotine
●● The adverse health conse- quences of tobacco use
●● Patterns of tobacco use in the United States
●● Current regulatory policy for tobacco control
●● Smokeless tobacco, cigars, and e-cigarettes
●● Global issues in tobacco use and tobacco control
●● Strategies for people who want to stop smoking
336 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
But increasingly, there is public outcry for some kind of regulation, especially when young people are involved. As we will see, the recent introduction of smokeless “e-cigarettes” and their popularity among young people has raised particu- lar concerns. In the end, our society is in a “harm-reduction” mode of thinking with respect to a public policy toward nico- tine and tobacco use. What lies ahead in terms of regulatory policy? How did we arrive at this point?
This chapter will explore what we know about the effects of tobacco smoking and other forms of nicotine consumption, the impact these behaviors have had on American society and the world, and the ways in which the United States has dealt with the issue of tobacco over the years. Also, the chapter will examine current regulatory strategies as well as the law enforcement efforts that are directed toward those who violate these regulations. Finally, the chapter will examine current treatment approaches toward helping people who choose to stop smoking.
Tobacco Use through History
Shortly after setting foot on the small Caribbean island of San Salvador on October 12, 1492, Christopher Columbus received from the inhabitants a welcoming gift of large, green, sweet-smelling tobacco leaves. Never having seen tobacco before, Columbus didn’t know what to make of this curious offering, except to observe in his journal that the leaves were greatly prized by the “Indians.” In the first week of November, two members of the expedition ventured to the shores of Cuba, searching at Columbus’s insistence for the great khan of Cathay (China). They found no evidence of the khan but did return with reports of natives who appar- ently were “drinking smoke.”
Before long, some of Columbus’s men were “tobacco drinking” as well. One sailor in particular, Rodrigo de Jerez, became quite fond of the practice. He was, in fact, history’s
In the sixteenth century, when tobacco was first intro- duced to the Western world, smoking behavior was met with mixed reviews. Many people were captivated by it (literally), while others considered it personally objectionable. No one could deny that it was strangely alluring. The same is true today. We are drawn to it even when we know that our health is at risk in doing so. And judging from the opening quotation, people in the twenty-first century have as much difficulty quitting as they did in Mark Twain’s time.
Until the mid-1960s, lighting up and smoking a cigarette was an unquestioned sign of sophistication. There was little or no public awareness that harm would come of it, a possibility that was concealed for decades by the major tobacco compa- nies. It was an era before surgeon general’s reports, National Smoke-out Days, and smoke-free restaurants, hotels, and pub- lic buildings. Cigarette lighters were standard features on the dashboard of our cars.
The times have definitely changed. Today, it is no lon- ger a matter of debate that tobacco smoking is a major health hazard, both to the person doing the smoking and to other people nearby and to society at large. These concerns are based not on public attitudes that can shift over time but on solid scientific fact. It is also no longer a matter of debate that the main psychoactive ingredient in tobacco, nico- tine, is a major dependence-producing psychoactive drug. Even tobacco companies now concede that their product is dangerous.
Yet, at the same time, the reality is that tobacco prod- ucts are legally sanctioned commodities with considerable economic significance, both to the United States and to the world. Tobacco companies argue that it is a matter of personal freedom for adults to engage in the consumption of a legal product, even if it may lead to premature death. Most people will agree that banning tobacco products by governmental legislation would lead us into a Prohibition era comparable to or perhaps exceeding in social upheaval the one experienced with respect to alcohol in the last century (see Chapter 3).
>300 million The estimated number of men in China who are regular tobacco smokers, a number exceeding the population of the United States.
5.4 million The estimated number of people worldwide who die each year from tobacco-related lung cancer, heart disease, and other illnesses.
>8 million The estimated number of people worldwide who will die each year by 2030, if present trends continue; 80 percent of these deaths will be in developing nations.
100 million The estimated number of people worldwide in the twentieth century who died prematurely of tobacco-related disease.
Sources: World Health Organization (2010). Tobacco: Key facts. Geneva, Switzerland: World Health Organization. World Health Organization (2009). WHO report on the global tobacco epidemic 2009. Geneva, Switzerland: World Health Organization. World Health Organization (2008). The WHO report on the global tobacco epidemic 2008. Geneva, Switzerland: World Health Organization.
Numbers Talk…
Chapter 16 Nicotine and Tobacco Use ■ 337
Snuffing and Chewing One form of tobacco use observed by the early Spanish ex- plorers was the practice of grinding a mixture of tobacco into a fine powder (snuff), placing or sniffing a pinch of it into the nose, and exhaling it with a sneeze. By the 1700s, this custom, called snuffing, overtook smoking as the dominant form of tobacco use. Among French aristocrats, both men and women, expensive snuffs, perfumed with exotic scents and carried in jeweled and enameled boxes, became part of the daily routine at the court in France and then in the rest of Europe. Sneezing was considered to clear the head of “super- fluous humors,” invigorate the brain, and brighten the eyes. In an era when bad smells were constant features of daily living, snuffing brought some degree of relief, not to mention a highly effective way of sending nicotine to the brain (see Chapter 4).
Because of their dominance in the rapidly expanding tobacco market, the English colonies in America, particu- larly Virginia, enjoyed great prosperity. England benefit- ted from a profitable tobacco trade, but you might say that the development of colonial tobacco growing eventually backfired. In 1777, when Benjamin Franklin was sent as an envoy to France to gain support against the British in the American War for Independence, he was able to close the deal with an offer to deliver prime Virginia tobacco. The French agreed, and the rest is history. Had it not been for American tobacco, there might not have been a United States of America at all.4
In the United States, snuffing was soon replaced by a more rough-and-ready method for using tobacco: chewing. The practice was not totally new; early Spanish explorers had found the natives chewing tobacco as well as smoking it from the earliest days of their conquest, though North American tribes preferred smoking exclusively. Chewing tobacco had the advantage of freeing the hands for work, and its low cost made it a democratic custom befitting a vigorous new nation in the nineteenth century. It also eliminated the fire hazards associated with burning tobacco. However, the need to spit out tobacco juices on a regular basis raised the tobacco habit to unimaginable heights of gross behavior. It was enough to make the objections to smoke and of pos- sible fire fade into insignificance; now the problem was a matter of public health. Tobacco spitting became a major factor behind the spread of infectious diseases such as tuber- culosis. Adding to this unsavory picture was the likelihood that a man’s accuracy in targeting the nearest spittoon was inevitably compromised by his level of alcohol consump- tion, which was setting all-time records during this period (see Chapter 3).
first documented European smoker, though he lived to regret it. When Rodrigo returned to Spain, he volunteered to dem- onstrate the newfound custom to his neighbors, who instead of being impressed thought that anyone who could emit smoke from the nose and mouth without burning had to be possessed by the Devil. A parish priest turned Rodrigo over to the Inquisition, which sentenced him to imprisonment for witchcraft. He spent several years in jail, presumably without a supply of tobacco. Rodrigo therefore also may be remem- bered as the first European smoker to quit cold turkey.1
In 1560, the year historians mark as the year tobacco was officially introduced to Europe, a French diplomat named Jean Nicot presented tobacco seeds to the queen of France, Catherine de Medici, with a letter describing their use for curing her migraine headaches. Later, Nicot was honored by having the botanical name for modern-day tobacco, Nicotiana tabacum, named after him, as well as the psycho- active ingredient in tobacco, nicotine.
It was not long before news about tobacco being enjoyed among members of the French court traveled to royal courts throughout Europe. Smoking tobacco through long, elaborate pipes became a fashionable pastime among European aristocracy. This is not to say that everyone was enthusiastic about this new fad. In fact, King James I of England hated tobacco. In 1604, the king was so outraged by tobacco smoking that he wrote a lengthy treatise enti- tled “A Counter-blaste to Tobacco,” in which he listed his reasons for condemning tobacco use. Predating modern- day surgeon general’s reports by more than 350 years, he referred to tobacco as a “stinking weede,” characterizing tobacco smoking as “a custom loathsome to the eye, hate- ful to the nose, harmful to the brain, [and] dangerous to the lung.” In the first recorded comment on its potential for causing dependence, the king observed that “he that taketh tobacco saith he cannot leave it, it doth bewitch him.” King James was undoubtedly ahead of his time.
Politics, Economics, and Tobacco Elsewhere in the world, during the early seventeenth century, the condemnation of tobacco became extreme. In Russia, off- icials established penalties for smoking that included whip- ping, mutilation, exile to Siberia, and death. Turkey, Japan, and China tried similar tactics, but, not surprisingly, tobacco use continued to spread.2
By the end of the seventeenth century, even the fierc- est opponents of tobacco had to admit that it was here to stay. A sultan of Turkey in 1648 became a smoker himself, and naturally, penalties for tobacco use vanished overnight; Czar Peter the Great in 1689 pledged to open up Russia to the West, and tobacco suddenly became a welcome symbol of modernism; Japan and China stopped trying to enforce a prohibition that citizens obviously did not want. Even King James eventually put aside his personal disgust for tobacco in favor of the attractive prospect of sizable revenue that could come from taxing the sales of this popular new commodity.3
snuffing: The ingestion of snuff either by inhalation or absorption through tissue in the nose.
snuff: A quantity of finely shredded or powdered tobacco. Modern forms of snuff are available in either dry or moist forms.
338 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
The public image of the cigarette eventually would change dramatically; until then, cigarette manufacturers had to rely instead on a powerful marketing advantage: low cost. In 1881, James Bonsack patented a cigarette-making machine that transformed the tobacco industry. Instead of producing at most 300 cigarettes an hour by hand, three machine operators could now turn out 200 a minute, or roughly 120,000 cigarettes a day. This is a snail’s pace com- pared to the present state-of-the-art machines capable of pro- ducing more than 10,000 cigarettes a minute, but in those days, the Bonsack machine was viewed as an industrial mar- vel. Cigarette prices by the end of the 1800s were as cheap as 20 for a nickel.7
Tobacco in the Twentieth Century At the beginning of the twentieth century, Americans could choose from a variety of ways to satisfy their hunger for nicotine through tobacco use. Cigars and pipes were still the dominant form of tobacco use, but the future favored the cigarette for two basic reasons. First, a growing num- ber of women began to challenge the idea of masculine dominance, and smoking tobacco was one of the privi- leges of men that women now wanted to share. Not that women smoking was met with immediate acceptance; in one famous case in 1904, a New York City woman was arrested for smoking in public. Nonetheless, as smoking among women became more common, the mild-tasting, easy-to-hold cigarette was the perfect option for them. By the 1920s, advertising slogans such as “Reach for a Lucky instead of a sweet” (a clever effort to portray cigarette smok- ing as a weight-control aid) as well as endorsements by glamorous celebrities were being designed specifically for the women’s market. A second factor was World War I, dur- ing which time cigarettes were a logical form of tobacco to take along to war. Times of tension have always been times of increased tobacco use. When the war was over, the ciga- rette was, in the words of one historian, “enshrined forever as the weary soldier’s relief, the worried man’s support, and the relaxing man’s companion.”8
Cigarettes really came into their own in the 1920s, with the introduction of heavily advertised brand names and intense competition among American tobacco compa- nies. Cigarette sales in the United States increased from $45 billion in 1920 to $80 billion in 1925 and $180 billion by 1940.9
Health Concerns and Smoking Behavior
A combination of promotion through mass-media advertis- ing and the endorsement of smoking by sports celebrities and glamorous people in the entertainment industry enabled the tobacco industry, now dominated by cigarettes, to increase its
Cigars and Cigarettes By the time of the American Civil War, the fashion in tobacco use began to shift once more, as its overall popularity contin- ued to soar. Although the plug of tobacco suitable for chewing was still a major seller and would remain so until the early twentieth century, two new trends emerged, particularly in the growing industrial cities.
The first trend was the popularity of smoking cigars (commonly known as “seegars”), tight rolls of dried tobacco leaves. New innovations in curing (drying) tobacco leaves had produced a milder and lighter-quality leaf that was more suitable for smoking than the older forms that had been around since the colonial period. North Carolina, with its ideal soil for cultivating this type of tobacco, began to dominate as the tobacco-growing center of the United States; it continues to do so today. With the advent of cigars, tobacco consumers could combine the feeling of chew- ing (since the cigar remained in the mouth for a relatively longer period of time) and the effects of ingesting tobacco smoke. Pioneers heading west could indulge in foot-long cigars called “stogies,” named after the Conestoga wagons that they rode during the long and tedious journey.
The second trend was the introduction of cigarettes, rolls of shredded tobacco wrapped in paper. They had become popular among British soldiers returning from the Crimean War in 1856, who had adopted the practice from the Turks. Europe took to cigarettes immediately, but the United States proved a harder sell. Part of the problem was the opposi- tion of a well-entrenched U.S. cigar industry, which did not look kindly on an upstart competitor. Cigar makers did not discourage the circulation of rumors that the cigarette paper wrapping was actually soaked in arsenic or white lead, that cigarette factory workers were urinating on the tobacco to give it an extra “bite,” or that Egyptian brands were mixed with crushed camel dung.5
An even greater marketing challenge than unsubstanti- ated rumors was the effeminate image of cigarette smoking itself. A cigarette was looked upon as a dainty, sissy version of the he-man cigar; cigars were fat, long, and dark, whereas cigarettes were slender, short, and light. Well into the begin- ning of the twentieth century, this attitude persisted. This is what John L. Sullivan, champion boxer and self-appointed defender of American masculinity, thought of cigarettes in 1904:
Who smokes ’em? Dudes and college stiffs—fellows who’d be wiped out by a single jab or a quick undercut. It isn’t natural to smoke cigarettes. An American ought to smoke cigars. . . . It’s the Dutchmen, Italians, Russians, Turks, and Egyptians who smoke cigarettes and they’re no good anyhow.6
cigarettes: Rolls of shredded tobacco wrapped in paper, today usually fitted at the mouth end with a filter.
cigars: Tightly rolled quantities of dried tobacco leaves.
Chapter 16 Nicotine and Tobacco Use ■ 339
months in 1964 showed a bounce upward, most likely reflecting the fact that many people who tried to quit had only temporary success, the long-term trend in U.S. tobacco consumption from that point on would never be upward again.
●■ As evidence of health risks accumulated, restrictions on public consumption were instituted. In 1971, all television advertising for tobacco was banned, and in 1984, a rotating series of warning labels (already on all packages of tobacco products since 1966) was required on all print advertise- ments and outdoor billboards.
●■ There was a significant change in the type of cigarette smoked by the average smoker. In the 1950s, more and more cigarette smokers began to choose filtered as dis- tinct from unfiltered cigarettes, being persuaded by the tobacco companies that they would be ingesting less of the toxins in tobacco as a result. The surgeon gen- eral’s reports accelerated this trend. By the 1990s, about 95 percent of all smokers were using filtered brands. However, after the introduction of filtered cigarettes, the industry changed the formulation of the tobacco to a stronger blend with an increased tar content. As a result of a stronger “filter blend” formula in the cigarette, sidestream smoke, the smoke directly inhaled by a non- smoker from a burning cigarette, ended up more toxic when originating from a filtered cigarette than it was from an unfiltered one. In principle, a cigarette filter should have allowed a flow of air through small holes in the filter itself. Because a smoker typically held the cigarette with the fingers covering these holes, however, little or no filtering was accomplished. In the meantime, filtered cigarettes increased tobacco company profits. Filters were only paper and therefore cost considerably less than filling the same space with tobacco. The cork- like appearance of the filter was intended to imply that something was being filtered, when actually no filtering was taking place.
●■ As a consequence of the surgeon general’s assertion that tar and nicotine were specifically responsible for increased health risks from smoking, new “light” and “mild” ciga- rette brands were introduced that were low in tar and nico- tine (T/N), and the Federal Trade Commission began to issue a listing of tar and nicotine levels in major commer- cial brands. As later surgeon general’s reports indicated, however, smokers cancelled out the benefits of switch- ing to low T/N brands by varying the manner in which they smoked a low T/N cigarette. Smokers took more puffs, inhaled more deeply, and smoked more of the ciga- rette when it has a lower T/N level so as to maintain the
volume of sales from the 1940s to the 1980s by a steady 9 billion cigarettes each year. The peak in domestic sales was reached in 1981, when approximately 640 billion were sold. Owing to the increase in population, however, per capita consump- tion in the United States had peaked in 1963 at approximately 4,300 cigarettes per year (roughly 12 cigarettes per day).
Beginning in 1964, annual per capita consumption began a steady decline, from 2,076 cigarettes (roughly six per day) in 2000 to 1,232 cigarettes (roughly 3–4 per day) in 2011. According to one forecast, the future average rate of decline is projected to be 3% per year, making the estimated annual per capita consumption rate in 2040 to be 50 percent less than in 2011.
The year of the turnaround in cigarette smoking coin- cided with the U.S. surgeon general’s first report on smoking and health in 1964. For the first time, the federal govern- ment asserted publicly what had been suspected for decades: that tobacco smoking was linked to cancer and other seri- ous diseases. From the standpoint of tobacco use in America, surgeon general’s reports issued from 1964 to the present day have resulted in a number of developments in smoking behavior and tobacco regulation.
●■ In the month or so immediately after the first report was released, there was a dramatic drop (approximately 25%) in per capita consumption levels. Although succeeding
sidestream smoke: Tobacco smoke that is inhaled by nonsmokers from the burning cigarettes of nearby smokers. Also referred to as environmental tobacco smoke.
To encourage female cigarette smokers, advertisements drew heavily on an association with popular Hollywood celebrities, including Ronald Reagan in a Christmas promotion in1949. Other ads were directed at male smokers, featuring prominent baseball players. The most famous and most valuable baseball card, depicting 1909 baseball player Honus Wagner, was actually enclosed in a pack of cigarettes, long before baseball cards became associated with bubble gum.
340 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
The Legacy of the Surgeon General’s Reports, 1964–2014 The first surgeon general’s report on smoking and health, issued in January 1964, has been regarded as one of the most significant documents in American public health history. The reduction in the prevalence rate of tobacco use in the 50 years that have passed has been attributed to the influence of this report and others that followed. The prevalence rate for adults in the United States declined from 42 percent in 1964 to 18 percent in most recent surveys. The consequences have been significant.
●■ An estimated 8 million premature deaths due to tobacco use were avoided during this time.
●■ Tobacco control contributed 2.3 years to the 7.8-year increase in the estimated life expectancy of a male at age 40.
●■ Tobacco control contributed 1.6 years to the 5.4-year increase in the estimated life expectancy of a female at age 40.
same amount of nicotine (the same number of nicotine “hits”). Moreover, a greater number of low T/N cigarettes had to be smoked in order to satisfy the smoker’s needs. In 2010, tobacco companies changed the branding labels to acknowledge that “light” or “mild” brands were no less harmful than regular brands. Marlboro Lights, for exam- ple, became Marlboro Gold, and Marboro Ultra Lights became Marlboro Silver.
●■ In 2007, it was confirmed that cigarette manufacturers had increased the nicotine concentrations in tobacco from 1997 to 2005 by 11 percent and also had modified certain design features of the cigarettes themselves to in- crease the number of puffs per cigarette during smoking. In the “medium/mild” market category, nicotine levels more than doubled from 1998 to 2005 in nonmetholated cigarettes and rose by 22 percent in mentholated cigarettes (Drugs . . . in Focus). Whether tobacco companies will be required to make modifications in their products, bringing nicotine levels back to 1997 levels, under new regulations remains uncertain.10
African Americans, Smoking, and Mentholated Cigarettes It has long been puzzling that African Americans tend to smoke fewer cigarettes than white smokers but carry a higher risk of tobacco-related disorders such as lung cancer and heart disease. One factor that has been used as an explanation is the relatively slower rate of nicotine metabolism among African Americans following cigarette smoking (Chapter 4). African Americans may be taking in and retaining relatively more nicotine per cigarette and, as a result, may not need to smoke as many cigarettes per day to take in an equivalent dose of nicotine.
Recent studies have indicated that a major factor might be the menthol in certain brands of cigarettes. More than 75 per- cent of African American smokers prefer mentholated brands such as Newport and Kool over nonmentholated brands such as Marboro and Camel, almost the complete opposite to the pattern of brand preferences among white smokers. Menthol allows smokers to take in more smoke and possibly hold it in longer, essentially canceling any benefit of choosing a “light” or “ultralight” brand to smoke. Relative to other smokers, African Americans who smoked menthol cigarettes had higher levels in their saliva of a specific nicotine by-product. The finding that smokers of mentholated cigarettes are almost twice as likely to relapse after attempts to quit smoking, compared to smokers of nonmentholated cigarettes, is consistent with the relatively higher levels of nicotine intake likely to occur when one is smoking mentholated brands.
The growing evidence of the effect of menthol content in cigarettes on smoking behavior and the implications with regard to smoking cessation have led to calls for the FDA to require tobacco companies to report how much menthol is contained in various cigarette brands, as they now do for levels of nicotine and tars, or even for mentholated cigarettes to be banned alto- gether. Such actions would be possible under the statutes of the Tobacco Control Act of 2009. In 2013, a study published by the FDA pointed to the unique public health risks of mentholated cigarettes. The FDA concluded that mentholated cigarettes were not more or less toxic than nonmentholated cigarettes but the cooling and anesthetic properties of menthol made cigarette smoke less harsh, increasing the appeal to younger smokers who would be starting out as tobacco users.
Sources: Celebucki, Carolyn C.; Wayne, Geoffrey, F.; Connolly, Gregory N.; Pankow, James F.; and Chang, Elsa I. (2005). Characterization of measured menthol in 48 U.S. cigarette sub- brands. Nicotine and Tobacco Research, 7, 523–531. Mustonen, Tanu K.; Spencer, Stacie M.; Hoskinson, Randall A.; Sachs, David P. L.; and Garvey, Arthur J. (2005). The influence of gender, race, and menthol content on tobacco exposure measures. Nicotine and Tobacco Research, 7, 581–590. Pletcher, Mark J.; Hulley, Benjamin J.; Houston, Thomas; Kiefe, Catarina; Benowitz, Neal; et al. (2006). Menthol cigarettes, smoking cessation, atheroscle- rosis, and pulmonary function. Archives of Internal Medicine, 166, 1915–1922. Substance Abuse and Mental Health Services Administration (2009, November 19). Use of menthol cigarettes. The NSDUH Report. Tavernise, Sabrina (2013, July 24). FDA closer to decision about menthol cigarettes. New York Times, p. A15.
Drugs . . . in Focus
Chapter 16 Nicotine and Tobacco Use ■ 341
addictiveness of nicotine in tobacco products. At that time, tobacco company executives vehemently denied the addic- tiveness of nicotine.
A few years later, the Philip Morris company finally issued a statement, formally admitting that there was “over- whelming medical and scientific consensus that cigarette smoking causes cancer, heart disease, emphysema, and other serious diseases” and that “cigarette smoking is addictive, as that term is most commonly used today.” Obviously, this stance was a complete reversal of the industry’s 1994 congres- sional testimony.
The Tobacco Settlement of 1998 In 1998, the major American tobacco corporations entered into a historic agreement with all 50 U.S. states to resolve claims that the states should be compensated for the costs of treating people with smoking-related illnesses. Under the terms of the settlement, the tobacco industry agreed to pay the states approximately $246 billion in annual installments over 24 years. The tobacco industry also agreed to refrain from marketing tobacco products to those under 18 and pay $24 million annually over 10 years for a research foundation dedicated toward finding ways to reduce smoking among youths. In contrast to earlier proposed settlements, however, tobacco corporations under this agreement would not be penalized if levels of underage smoking did not decline over that period of time. In addition, the settlement did not pre- vent individuals or groups of individuals from suing tobacco corporations in separate actions.
Unfortunately, the 1998 tobacco settlement has had only a mixed effect on smoking behavior. On the one hand, compen- sation funds awarded to the states have been used to keep taxes down or pay off debt, rather than support tobacco use preven- tion programs. In 2013, only six U.S. states (Alaska, Delaware, Maine, Oklahoma, North Dakota, and Wyoming) spent 50 percent or more of the recommendation by the Centers for Disease Control and Prevention for tobacco prevention pro- grams. Twenty-three U.S. states spent less than 10 percent of the recommended amount. On the other hand, an increase in cigarette prices imposed by tobacco companies to finance the settlement, as well as higher excise taxes imposed by U.S. states, made cigarettes more expensive, especially for young people with relatively little money to spend. The decline in cigarette smoking in this age group since 1998 has been attrib- uted, in part, to economic factors surrounding the buying of cigarettes and other tobacco products.12
The Tobacco Control Act of 2009 In 2009, a new era in the history of governmental relations with the tobacco industry began, with the enactment of the federal Tobacco Control Act. This legislation gave the FDA
Nonetheless, the consumption level of tobacco products in the United States is enormous. In 2013, Americans pur- chased more than 273 billion cigarettes, 125 million pounds of smokeless tobacco, 13 billion large cigars, and 700 mil- lion little cigars (see page 352). The tobacco industry spent $9.2 billion on cigarette advertising and promotional expenses in the United States alone, largely through price discounts on cigarettes.11
Changing Times: Tobacco Control since 1990
Beginning in the early 1990s, the tobacco industry in the United States began to face significant challenges from fed- eral governmental agencies, as well as individuals and groups who brought lawsuits against tobacco companies for damages resulting from their ingestion of tobacco products. A number of major events occurred that forever changed the image of tobacco use in American society, as well as its legal and eco- nomic status.
In 1993, the U.S. Environmental Protection Agency (EPA) announced its conclusion from available research that environmental tobacco smoke (ETS), the sidestream smoke in the air that is inhaled by nonsmokers as a result of tobacco smoking, causes lung cancer. This was the first time that con- cerns had ever been raised with respect to the nonsmoker. Since then, U.S. states, cities, and communities have enacted laws mandating smoke-free environments in all public and private workplaces, unless ventilated smoking rooms have been provided. It is now commonplace for restaurants, hotels, and other commercial spaces to be completely smoke-free.
In 1994, congressional hearings were held on allegations that during the 1970s tobacco companies had suppressed research data obtained in their own research laboratories regarding the hazards of cigarette smoking, particularly the
In 1994, tobacco industry executives testified before a congressional committee in defense of cigarette smoking. In 1999, the Philip Morris company formally reversed its earlier position that smoking was not addictive.
environmental tobacco smoke (ETS): Tobacco smoke in the atmosphere as a result of burning cigarettes; also called sidestream or secondary smoke.
342 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
What’s in Tobacco?
When a smoker inhales from a lit cigarette, the temperature at the tip rises to approximately 1,700 degrees Fahrenheit (926 degrees Celsius), as oxygen is drawn through the tobacco, paper, and other additives. This accounts for the bright glow as a smoker inhales from a cigarette. At this intense heat, more than 4,000 separate compounds are oxi- dized and released through cigarette smoke. The smoker inhales the resultant as mainstream smoke, usually screened through the cigarette filter and cigarette paper. As mentioned earlier, the sidestream smoke that is released from the burn- ing cigarette tip itself is unfiltered, and because it is a product of a slightly less intense burning process occurring between puffs, more unburned particles are contained in the smoke.
In general, we can speak of two components in tobacco smoke. The particulate phase, consisting of small particles (one micrometer or larger in diameter) suspended in the smoke, includes water droplets, nicotine, and a collection of compounds that will be referred to collectively as tar. The particles in tar constitute the primary source of carcinogenic compounds in tobacco. The second component is the gaseous phase, consisting of gas compounds in the smoke, including carbon dioxide, carbon monoxide, ammonia, hydrogen cya- nide, acetaldehyde, and acetone. Among these gases, carbon monoxide is clearly the most toxic.
This diverse collection of physiologically active toxins is quite unique to tobacco. One way of putting it is that the 50,000–70,000 puffs per year that a one-pack-a-day cigarette smoker takes in amounts to a level of pollution far beyond even the most polluted urban environment anywhere in the world.16 The following sections will focus on three of the most important compounds in tobacco smoke: carbon mon- oxide, tar, and nicotine.
Carbon Monoxide As most people know, carbon monoxide is an odorless, color- less, tasteless, but extraordinarily toxic gas. It is formed when tobacco burns because the oxidation process is incomplete. In that sense, burning tobacco is similar to an inefficient engine, like a car in need of a tune-up. The danger with car- bon monoxide is that it easily attaches itself to hemoglobin, the protein inside red blood cells, occupying those portions of the hemoglobin molecule normally reserved for the transport of oxygen from the lungs to the rest of the body. Carbon mon- oxide has about 200 times greater affinity for hemoglobin than has oxygen, so oxygen does not have much of a chance. Carbon monoxide is also more resistant to detaching itself from hemoglobin, so there is an accumulation of carbon monoxide over time.
The ultimate result of carbon monoxide is a subtle but effective asphyxiation of the body from a lack of oxygen. Generally, people who smoke a pack a day accumulate levels of carbon monoxide in the blood of 25–35 parts per million blood components (p.p.m.), with levels of 100 p.p.m. for short
for the first time sweeping regulatory authority over tobacco products sold in the United States. The immediate effects of the legislation included creation of a new FDA Center for Tobacco Products to oversee the science-based regulation of tobacco products, the banning of candy-flavored cigarettes, full disclosure of ingredients and additives in tobacco prod- ucts, aggressive moves to stop youth-focused marketing, and new graphic warning labels highlighting the health risks of smoking.13
In 2014, the FDA announced that they had authorized the sale of two new tobacco products, both introduced as Newport cigarettes, but rejected four others. The rejected products could not be named, according to stipulations in the 2009 law. In rules issued in 2011, any changes made after 2007 in the chemical components of tobacco products must be reviewed by the FDA prior to marketing.14
Tobacco Control and Global Economics As will be discussed later in this chapter, many other nations have substantially higher prevalence rates for cigarette smoking, and their governments have taken far fewer steps toward instituting policies to reduce smoking behavior. For American tobacco corporations, an expanding global mar- ketplace for American cigarettes has given them the oppor- tunity for an increase in profits from foreign sales that has largely compensated for their financial losses incurred from a decline in domestic sales.15 In a larger sense, cigarette sales abroad represent a major component of overall U.S. foreign trade. In recent years, U.S. exports of tobacco prod- ucts have exceeded imports by billions of dollars, creating a significant trade surplus. Therefore, the U.S. trade defi- cit (defined as an excess of imports over exports) would be worse than it is today were it not for the export of tobacco products to other nations.
Undoubtedly, tobacco use has presented challenges both from the standpoint of public health and from the standpoint of social and economic policies of the United States in relation to the rest of the world. At this point, it is important to examine the components of tobacco itself. What are the components of tobacco that present bodily harm to the user?
carbon monoxide: An extremely toxic gas that prevents blood cells from carrying oxygen from the lungs to the rest of the body.
gaseous phase: The portion of tobacco smoke that consists of gases.
tar: A sticky material found in the particulate phase of tobacco smoke and other pollutants in the air.
particulate phase: Those components of smoke that consist of particles.
mainstream smoke: The smoke inhaled directly from cigarettes or other tobacco products.
Chapter 16 Nicotine and Tobacco Use ■ 343
excretion from the body are well underway. The elimination half-life of nicotine is approximately two to three hours.
The speed of nicotine absorption ordinarily would be much slower if it were not for the presence of ammonia as an additive in the tobacco blend. The combination of nicotine and ammonia changes the naturally acidic nicotine into an alkalinic free-base form that more easily passes from body tis- sues into the bloodstream. As a result, ammonia increases the availability of nicotine in the blood, much as the addition of alkaline materials like baking soda convert cocaine into crack cocaine (see Chapter 10). The information that ammo- nia had been introduced into the manufacture of cigarette tobacco during the 1970s, in an apparent effort to increase the “kick” of nicotine, came to light in 1995 and was con- firmed by tobacco industry documents released in 1998.20
The primary effect of nicotine is to stimulate CNS receptors that are sensitive to acetylcholine (see Chapter 5). These receptors are called nicotinic receptors because they are excited by nicotine. One of the effects of activating them is the release of adrenalin, which increases blood pressure and heart rate. Another effect is to inhibit activity in the gastrointestinal system. At the same time, however, as most smokers will tell you, a cigarette is a relaxing factor in their lives. Part of this reaction may be due to an effect on the brain that promotes a greater level of clear thinking and con- centration; another part may relate to the fact that nicotine, at moderate doses, serves to reduce muscle tone so that mus- cular tightness is decreased. Research has shown that ciga- rette smoking helps to sustain performance on monotonous tasks and to improve short-term memory. We can assume that it is the nicotine in cigarettes and other tobacco products that is responsible for these effects because nicotine tablets have comparable behavioral effects.21
The Dependence Potential of Nicotine
Historically, the dependence potential of nicotine has been demonstrated at times in which the usual availability of to- bacco has suddenly been curtailed. In Germany, following the end of World War II, for example, cigarettes were rationed to two packs a month for men and one pack a month for women. This “cigarette famine” produced dramatic effects on the behavior of German civilians. Smokers bartered their food rations for cigarettes, even under the extreme circumstances of chronic hunger and poor nutrition. Cigarette butts were
periods of time while actually smoking. Of course, greater use of tobacco produces proportionally higher levels of carbon monoxide. Carbon monoxide is the primary culprit in produc- ing cardiovascular disease among smokers, as well as in caus- ing deficiencies in physiological functioning and behavior.17
Tar The quantity of tar in a cigarette varies from levels of 12–16 mg per cigarette to less than 6 mg. It also should be noted that the last third of each cigarette contains 50 percent of the total tar, making the final few puffs far more hazardous than the first ones.
The major problem with tar lies in its sticky quality, not unlike that of the material used in paving roads, which allows it to adhere to cells in the lungs and the airways lead- ing to them. Normally, specialized cells with small, hair-like attachments called cilia are capable of removing contami- nants in the air that might impede the breathing process. These cilia literally sweep the unwanted particles upward to the throat, in a process called the ciliary escalator, where they are typically swallowed, digested, and finally excreted from the body through the gastrointestinal system. Components in tar alter the coordination of these cilia so that they can no longer function effectively. The accumulation of sticky tar on the surface of the cells along the pulmonary system permits carcinogenic compounds that normally would have been eliminated to settle on the tissue. As will be discussed later, the resulting cellular changes produce lung cancer, and similar carcinogenic effects in other tissues of the body produce cancer in other organs.18
Nicotine Nicotine is a toxic, dependence-producing psychoactive drug found exclusively in tobacco. It is an oily compound varying in hue from colorless to brown. A few drops of pure nicotine, about 60 mg, on the tongue would quickly kill a healthy adult, and it is commonly used as a major ingredi- ent in all kinds of insecticides and pesticides. Cigarettes, however, contain from 0.5 to 2.0 mg of nicotine (depending on the brand), with about 20 percent being actually inhaled and reaching the bloodstream. This means that 2–8 mg of nicotine is ingested per day for a pack-a-day smoker, and 4–16 mg of nicotine for a smoker of two packs a day. Nonetheless, the toxicity of nicotine is a serious concern not only because it is ingested through cigarette smoking but also because it is ingested in a purer form in recently introduced e-cigarette products. The ramifications of nic- otine ingestion with e-cigarettes will be explored in the Drugs. . . in Focus feature on page 000.19
Inhaled nicotine from smoking is absorbed extremely rapidly and easily passes through the blood–brain barrier, as well as through the blood-placental barrier in pregnant women, in a few seconds. The entire effect is over in a matter of minutes. By the time a cigarette butt is extinguished, nico- tine levels in the blood have peaked, and its breakdown and
nicotine: The prime psychoactive drug in tobacco products.
ciliary escalator: The process of pushing back foreign particles that might interfere with breathing upward from the air passages into the throat, where they can be swallowed and excreted through the gastrointestinal tract.
cilia: Small hair cells.
344 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
common symptoms will include headache, an inability to concentrate, irritability, drowsiness, and fatigue, as well as in- somnia and other sleep disturbances. Most striking of all are the strong feelings of craving for a cigarette. Ex-smokers can attest to cravings that slowly diminish but nonetheless linger on for months and, in some cases, for years.25
Nicotine dependence is the central factor in the con- tinuation of smoking behaviors. The level of dependence is significant, even when compared with dependence levels of illicit drugs available on the street. In a study of people who smoked and were also in some form of drug-abuse treatment, 74 percent judged the difficulty of quitting smoking to be at least as great as the difficulty in stopping their drug of choice. One in three considered it “much harder” to quit smoking.26
Health Consequences of Tobacco Use
The adverse health consequences of tobacco use can be clas- sified in three broad categories: cardiovascular disease, re- spiratory disease, and cancer. In addition, there are special health difficulties that smoking can bring to women and haz- ards from using smokeless tobacco. An enormous literature on the adverse effects of tobacco use has grown steadily since the original surgeon general’s report in 1964, though by that time more than 30,000 research studies had been conducted on the question. Smoking remains the leading cause of pre- mature disease and death in the United States.
Beyond all the research reports are the sheer numbers of people who are affected. In the United States alone, of the more than half-million deaths each year that are attributed to substance abuse of one kind or another, approximately 480,000 are specifically tied to tobacco use or secondhand smoke from tobacco use. This figure is higher than the total number of American casualties during World War II (Drugs . . . in Focus). The public health community consid- ers these deaths to be premature deaths because they are entirely preventable; these people would have been alive if their behaviors had been different.
The statistics are simple, and staggering: Smoking- related deaths account for about one out of every five deaths in the United States every year, more than 1,300 deaths each day. It has been calculated that a person’s estimated life expectancy is shortened by 14 minutes every time a cigarette is smoked. Life expectancy for smokers is at least 10 years shorter than for nonsmokers. Unlike alcohol, which presents no significant health hazards when consumed in modera- tion, tobacco is a dangerous product when used as intended (Figure 16.1).27
Cardiovascular Disease Cardiovascular diseases include a number of specific con- ditions. Some of these diseases are coronary heart disease (CHD), in which damage to the heart is incurred due to the restriction of blood flow through narrowed or blocked
picked from the dirt in the streets by people who admitted that they were personally disgusted by their desperate behav- ior. Some women turned to prostitution to obtain cigarettes. Alcoholics of both sexes testified that it was easier to abstain from drinking alcohol than it was to abstain from smoking.22
It is now known that nicotine stimulates the release of do- pamine in the nucleus accumbens, the same area of the brain responsible for the reinforcing properties of opioids, cocaine, and alcohol. In addition, several behavioral factors combine with this physiological effect to increase the likelihood that a strong dependence will be created. One of these factors is the speed with which smoked nicotine reaches the brain. The delivery time has been estimated as five to eight seconds. A second factor is the wide variety of circumstances and set- tings surrounding the act of smoking that later come to serve as learned rewards. A smoker may find, for example, that the first cigarette with a cup of coffee in the morning (a source of another psychoactive drug, caffeine) is strongly reinforcing.23
The Titration Hypothesis of Nicotine Dependence There is considerable evidence that smokers adjust their smoking behavior to obtain a stable dose of nicotine from whatever cigarettes they are smoking, an idea called the titra- tion hypothesis. When exposed to cigarettes of decreasing nicotine content, smokers will smoke a greater number of them to compensate and will increase the volume of each puff. When they inhale more puffs per cigarette, a greater interval of time will elapse before they light up another one. If they are given nicotine gum to chew, the intensity of their smoking behavior will decline, even though they have not been told whether the gum contains nicotine or is a placebo. All these studies indicate that experienced smokers arrive at a consistent “style” of smoking that provides their bodies with a relatively constant level of nicotine.24
Tolerance and Withdrawal First-time smokers often react to a cigarette with a mixture of nausea, dizziness, or vomiting. These effects typically disap- pear as tolerance develops in the nicotinic receptors in the brain. Other physiological effects, such as increases in heart rate, tremors, and changes in skin temperature, show weaker tolerance effects or none at all.
The strongest dependence-related effect of nicotine con- sumption in cigarette smoking can be seen in the symptoms of withdrawal that follow the discontinuation of smoking. Within about six hours after the last cigarette, a smoker’s heart rate and blood pressure will decrease. Over the next 24 hours,
coronary heart disease (CHD): Disease that damages the heart as a result of a restriction of blood flow through coronary arteries.
titration hypothesis: The idea that smokers will adjust their smoking of cigarettes so as to maintain a steady input of nicotine into the body.
Chapter 16 Nicotine and Tobacco Use ■ 345
These statistics are strengthened by the under- standing we have of how cigarette smoking actually produces these dangerous cardiovascular conditions. The major villains are nicotine and carbon monoxide. Nicotine, as a stimulant drug, increases the contrac- tion of heart muscle and elevates heart rate.
At the same time, nicotine causes a constriction of blood vessels, leading to a rise in blood pressure, and also increases platelet adhesiveness in the blood. As a result of a greater adhesiveness, platelets clump together and increase the risk of developing a blood clot. If a clot forms within coronary arteries, a heart attack can occur; a clot traveling into the blood vessels of the brain can produce a stroke. Finally, nicotine in- creases the body’s serum cholesterol and fatty deposits, leading to the development of atherosclerosis.
While nicotine is doing its dirty work, carbon monoxide makes matters worse. A lack of oxygen puts further strain on the ability of the heart to function under already trying circumstances.
Respiratory Diseases The general term chronic obstructive pulmonary disease (COPD) refers to several conditions in which breathing is impaired because of some abnormality in the air passages
coronary arteries; arteriosclerosis, in which the walls of arteries harden and lose their elasticity; atherosclerosis, in which fatty deposits inside arteries impede blood flow; and ischemic stroke, in which interruption or reduction in blood flow causes damage to the brain. In all these diseases, ciga- rette smoking increases the risk dramatically.
We know now that smoking is responsible for approxi- mately 30 percent of all CHD deaths. The risk of CHD dou- bles if you smoke and quadruples if you smoke heavily. On average, smoking also raises the risk of a sudden death (such as from a fatal heart attack) by two to four times, with the degree of risk increasing as a direct function of how many cigarettes are smoked per day. To put it even more boldly, it has been estimated that unless smoking patterns change dramatically in the future, about 10 percent of all Americans now alive may die prematurely from some form of heart dis- ease as a result of their smoking behavior.28
127,700
15,300
36,000 99,300
113,100
47,300
41,300
Other cancers
Chronic lung disease Other diagnoses
Coronary heart disease
Lung cancer Stroke
Secondhand smoke
F igurE 16 .1
The distribution of approximately 480,000 annual U.S. deaths from 2005 to 2009 that have been attributed to tobacco use or secondhand smoke from tobacco use.
Source: Centers for Disease Control and Prevention (2014, February 6). Fact Sheet: Tobacco-related mortality. Atlanta, GA: Centers for Disease Control and Prevention.
chronic obstructive pulmonary disease (COPD): A group of diseases characterized by impaired breathing due to an abnormality in the air passages.
Visualizing 480,000 Annual Tobacco-related Deaths The estimated annual death toll due to tobacco-related diseases is staggering, and it is difficult to appreciate its magnitude. In fact, the number exceeds the estimated 2013 population of the following cities. Imagine the disappearance of the entire popula- tion of any of these cities in a given year—or all of them in a five-year period.
• Sacramento, California (pop. 479,686) • Long Beach, California (pop. 469,428) • Kansas City, Kansas (pop. 467,007) • Virginia Beach, Virginia (pop. 448,479) • Atlanta, Georgia (pop. 447,841)
Source: United States Census Bureau, Estimated population of major U.S. cities, as of July 1, 2013.
Drugs . . . in Focus
ischemic (iz-SKEE-mic) stroke: A disease in which there is an interruption or reduction in blood flow to the brain, causing either paralysis, sensory loss, cognitive deficits, or a combination of neuropsychological effects.
atherosclerosis (ATH-er-oh-scluh-rOH-sis): A disease in which blood flow is restricted because of the buildup of fatty deposits inside arteries.
arteriosclerosis (ar-TEEr-ee-oh-scluh-rOH-sis): A disease in which blood flow is restricted because the walls of arteries harden and lose their elasticity.
346 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
While there has been a steady decline in deaths due to lung cancer among American males overall since 1990, there remains an approximately 32 percent higher mortality rate among African American males due to smoking relative to white males. In general, males who are currently smoking incur a risk of lung cancer that is about 23 times higher than the risk for nonsmokers.
Another important change has occurred over the years with respect to the incidence of lung cancer among women. Like COPD, lung cancer was once considered to be limited largely to male smokers. More recently, however, increasing numbers of women have contracted lung cancer as a result of their increased level of cigarette smoking. The age-adjusted mortality rate for women is still about one-half that for men, but the decline in mortality rates seen among men since 1990 has yet to be realized among women. Since 1988, lung can- cer has exceeded breast cancer as the leading cause of cancer deaths among women (Figure 16.2). In general, females who are currently smoking incur a risk of lung cancer that is about 13 times higher than that for nonsmokers.
These facts about lung cancer become even more tragic when you consider that the overall five-year survival rate after initial diagnosis of lung cancer (for all stages of cancer combined) is only 15 percent. Lung cancer patients have an approximately 50 percent chance of living five years when the disease is still localized at the time of diagnosis, but only 15 percent of lung cancers are diagnosed at this early stage.
As discussed earlier in the chapter, the exposure to tar in cigarette smoke disrupts the necessary action of ciliary cells in the bronchial tubes leading to the lungs. Without their pro- tective function, the lungs are open to attack. Several carcino- genic compounds in the smoke can now enter the lungs and stimulate the formation of cancerous growths, carcinomas, in lung tissue. One of these compounds, benzopyrene, has been found to cause genetic mutations in cells that are identical to the mutations observed in patients who have developed carcinomas in their lungs. This finding is important because it establishes a causal link between a specific ingredient in tobacco smoke and human cases of cancer.30
Other Cancers Certainly lung cancer is the best-known and most common example of smoking-related cancers; unfortunately, other organs are affected in a similar way. In the United States, approximately 30 percent of cancer deaths of all types have been linked to smoking. It has been estimated that smokers increase their risk by two to 27 times for cancer of the larynx, 13 times for mouth or lip cancer, two to three times for blad- der cancer, two times for pancreatic cancer, and five times for cancers of the kidney or uterine cervix.31
Despite a widespread belief to the contrary, using smoke- less tobacco, in the form of chewing tobacco or snuff, does not prevent the user from incurring an increased risk of can- cer. Continuing contact with tobacco in the mouth has been shown to produce precancerous cell changes, as revealed by leukoplakia (white spots) and erythroplakia (red spots) inside
either leading to or within the lungs. Although only 20 percent of smokers in the United States develop COPD, 80–90 percent of all COPD cases are the result of smoking. Historically, COPD has been viewed as “a man’s disease,” but since 1980 the death rate in women has tripled, and since 2000, more women than men have died or been hospi- talized each year as a result of COPD. With the exception of a rare genetic defect, smoking is the only established cause of clinically significant COPD.
Two examples of COPD are chronic bronchitis, in which excess mucus builds up in air passages, leading to an inflammation of bronchial tissue, and emphysema, in which air sacs in the lungs are abnormally enlarged and the air sac walls either become inelastic or rupture, leading to extreme difficulty in inhaling oxygen and exhaling carbon dioxide. In the case of advanced emphysema, more than 80 percent of a patient’s energy is required merely to breathe. In 2010, COPD accounted for approximately 715,000 hospital- izations and 134,000 deaths. An estimated 12 million U.S. adults are forced to lead increasingly debilitating lives, gasp- ing and struggling each day to breathe.
Pulmonary damage, however, is not limited to adults who have been smoking for many years. Cigarette smoking is also associated with airway obstruction and slower growth of lung function in younger populations. Adolescents who smoke five or more cigarettes a day are 40 percent more likely to develop asthma and 30 percent more likely to have symptoms of wheezing but not asthma than those who do not smoke. Among smokers, girls show a greater loss of pulmo- nary function than boys, even though boys report that they smoke more cigarettes.29
Lung Cancer At the beginning of the twentieth century, lung cancer was a rare disease. Its steady increase in the United States as well as the rest of the world since then has occurred in direct pro- portion to the growing prevalence of cigarette smoking and other tobacco use. In 2012, tobacco smoking accounted for nearly 87% of deaths due to lung cancer among approxi- mately 87,000 men and 71,000 women in the United States.
erythroplakia (eh-riTH-ro-PLAY-kee-ah): Small red spots inside the mouth and nasal cavity, indicating precancerous tissue.
leukoplakia (LOO-koh-PLAY-kee-ah): Small white spots inside the mouth and nasal cavity, indicating precancerous tissue.
carcinomas (CAr-sih-NOH-mas): Cancerous tumors or growths.
emphysema (EM-fuh-SEE-mah): An enlargement of air sacs in the lungs and abnormalities in the air sac walls, causing great difficulty in breathing.
chronic bronchitis: A respiratory disease involving inflammation of bronchial tissue following a buildup of excess mucus in air passages.
Chapter 16 Nicotine and Tobacco Use ■ 347
100
80
60
40
20
0
R at
e pe
r 10
0, 00
0 po
pu la
tio n
19 35
19 40
19 45
19 50
19 55
19 60
19 65
19 70
19 75
19 80
19 85
19 90
19 95
20 00
20 05
20 10
19 30
Age-adjusted Cancer Death Rates*, Males and females by site, United States, 1930–2010
*Per 100,000, age adjusted to the 2000 U.S. standard population.
Lung and bronchus cancer for males
Lung and bronchus cancer for females
Prostate cancer for males
Breast cancer for females
F igurE 16 .2
Age-adjusted death rates from lung and bronchus cancer and other cancers among males and females in the United States, 1930–2010.
Source: Based on information from the American Cancer Society (2014). Cancer facts and figures 2014. Atlanta, GA: American Cancer Society, Inc., pp. 2–3.
disease and tooth loss (Help Line). To reinforce the idea that dangers are still present in smokeless tobacco, one of these warnings reads: “This product is not a safe alternative to ciga- rette smoking.”
the mouth and nasal cavity. Even though smokeless tobacco obviously avoids the problems associated with tobacco smoke, it does not prevent the user from being exposed to carcino- gens, specifically a class of compounds called nitrosamines that are present in all tobacco products. As a result of federal legislation enacted in 1986, all forms of smokeless tobacco must contain, on the package, a set of specific warnings that these products may cause mouth cancer as well as gum
nitrosamines (nih-TrAW-seh-meens): A group of carcino- genic compounds found in tobacco.
Help Line Signs of Trouble from Smokeless Tobacco
• Lumps in the jaw or neck area • Color changes or lumps inside the lips • White, smooth, or scaly patches in the mouth or on the
neck, lips, or tongue • A red spot or sore on the lips or gums or inside the mouth
that does not heal in two weeks • Repeated bleeding in the mouth • Difficulty or abnormality in speaking or swallowing
Any of these signs should be reported to a physician as soon as possible. In the meantime, and in the future, use of smokeless tobacco should be discontinued.
Where to go for assistance www.quitnet.com
This Web site is sponsored by the Department of Public Health, Boston University.
Source: Information based on Payne, Wayne A.; and Hahn, Dale B. (1992). Understanding your health. St. Louis: Mosby Year Book, p. 278.
348 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
smoking” can provoke. In other words, environmental to- bacco smoke is a significant health hazard even to people who are not actively smoking.
Approximately 85 percent of the smoke in an average room where people are smoking cigarettes is generated by sidestream smoke, and about three-fourths of the nicotine originating from these cigarettes ends up in the atmosphere. In some cases, the carcinogens released in ETS are so potent that they are dangerous even in their diluted state. For ex- ample, N-nitrosamine (an example of a group of carcinogens mentioned earlier in connection with smokeless tobacco) is so much more concentrated in sidestream smoke than in mainstream smoke that nonsmokers will end up inhaling as much of it after one hour in a very smoky room as will a smoker after smoking 10–15 cigarettes.33
The U.S. surgeon general’s report on involuntary ex- posure to tobacco smoke in 2006 has confirmed previous data on this question and extended its conclusions to the following:
●■ For nonsmoking adults, exposure to environmental smoke raises the risk of heart disease by 25–30 percent in both men and women. The risk of lung cancer is increased by 20–30 percent among nonsmokers who live with a smoker.
●■ Environmental smoke is a cause of sudden infant death syndrome (SIDS), accounting for 430 deaths per year in the United States. The risk is higher for children whose mothers were exposed to tobacco smoke during pregnancy and for children exposed during infancy.
●■ Among children of parents who smoke in the home, there is an increased risk of lower respiratory illnesses such as bronchitis, middle ear disease, wheezing, and childhood asthma.
It is estimated that environmental smoke exposure ac- counts for 46,000 premature deaths from heart disease and 3,400 premature deaths from cancer among adults in the United States each year. Although the proportion of non- smokers has declined substantially as a result of publicity about the hazards of ETS and extensive smoking bans and re- strictions, more than 126 million Americans remain subject to exposure at some time in their lives.34
Patterns of Smoking Behavior in the United States
In 1965, about 40 percent of Americans smoked ciga- rettes, and it is estimated that more than 50 percent did in the 1940s. In 2013, however, according to the Centers for Disease Control and Prevention, approximately 18 percent of all adults in the United States (an estimated 42 million people) were current cigarette smokers, in that they reported smoking every day or some days. As recently as 2005, the per- centage had been 21 percent. Therefore, it is fair to say that cigarette use has declined significantly in American society.
Special Health Concerns for Women Tobacco use presents specific health risk concerns for women. Women who smoke have a more than three times greater risk of dying from stroke due to brain hemorrhaging and an almost two times greater risk of dying from a heart attack. Added to these concerns is the toxic interaction of to- bacco smoke with birth control pills. If they are using birth control pills as well, the risk increases to 22 times and 20 times, respectively.
There is a higher risk of low birth weight and physical defects in the newborn due to the mother’s smoking dur- ing pregnancy. In addition, it has been observed that there is a specific elevation in systolic blood pressure at about two months of age among infants whose mothers smoked during pregnancy. Even though there has been a decline in smoking in recent years among pregnant women, more than one in six pregnant women (17%) have smoked in the past month, with more of them smoking in their first trimester of pregnancy (22%) than in their second or third trimester (14% and 15%, respectively).32
The Hazards of Environmental Smoke In the early days of development of methods for detecting the effects of nicotine in the bloodstream, scientists were puzzled to find traces of a nicotine metabolite in nonsmokers. They suspected at first that there was some flaw in their analysis but later had to conclude that their measurements were indeed accurate. Nonsmokers testing positive had shared car rides or workplaces with smokers shortly before their tests. Today, a large body of evidence indicates not only the presence of tobacco smoke compounds in the bodies of nonsmokers but also the adverse consequences that such “involuntary
Quick Concept Check
Understanding the Effects of Tobacco Smoking Check your understanding of the effects of tobacco smoking by associating each of the following physical effects with (a) carbon monoxide, (b) tar, or (c) nicotine. It is possible to have a combination of two factors as the correct answer.
1. A decrease in oxygen in the body
2. Physical dependence
3. Cellular changes leading to cancer
4. Cardiovascular disease
5. Chronic bronchitis
Answers: 1. a 2. c 3. b 4. a and c 5. b
16.1
Chapter 16 Nicotine and Tobacco Use ■ 349
smoking.” Between 75 and 80 percent of them preferred to date nonsmokers. About 6 out of 10 viewed smoking as a behavior that reflects poor judgment on the part of those who smoked. The disinclination toward dating smokers was observed equally among males and females. It is likely that social disapproval has shown no signs of diminishment in more recent years.37
Regulatory Policy and Strategies for Tobacco Control
Given the reality that tobacco will remain a legal commod- ity in our society for the foreseeable future, we are left with a set of policies regarding the use of tobacco rather than to- bacco itself. The authority of the FDA since 2009 extends to the sale of tobacco products to the public and the protec- tion of the public, as much as possible, from the harm that tobacco products can do. To that end, the regulatory policy can be examined in three categories: (1) regulation by taxa- tion on tobacco purchases, (2) regulation by reduced access of tobacco products to young people, and (3) regulation by increased public awareness of the negative side of tobacco use. In the first two categories, the prosecution of violators of regulatory statutes is the responsibility of law enforcement authorities. In all three categories, as we will see, the tobacco companies have exerted strong opposition.
Regulation by Taxation As has been the practice throughout American history, spe- cific commodities such as alcohol (see Chapter 15) and tobacco have been subject to taxation. The purposes are twofold. First, popular commodities provide substantial sales revenue, which can be used to support governmen- tal programs. Second, taxation provides a means of social control. Alcohol and tobacco use present substantial risk to public and private health, so it is reasonable that an extra burden be placed on the purchaser of these products. In other words, an extra cost in purchasing alcohol or tobacco can be considered a “sin tax.”
It has been concluded, from studies on the price struc- ture of alcohol and tobacco products, that the cost of pur- chase has a definite and predictable effect on the inclination to buy that product. Nonetheless, responses by U.S. states to tax cigarette sales has been uneven, to say the least. While the nationwide average state tax is $1.46 per cigarette pack, the individual state tax amounts vary from a low of 17 cents in Missouri to a high of $4.35 in New York. As a result of the disparity, a substantial amount of cigarette smuggling from U.S. states that have lower tax rates (and, in particular, Native American reservations that have even lower tax rates) into U.S. states that have higher rates (such as New York) takes place. It has been argued that a more equivalent rate of cigarette taxation among U.S. states would reduce this level of cigarette smuggling.38
Nonetheless, the statistics reflect the reality that more than 40 million adults in the United States remain vulnerable to the health hazards posed by cigarette smoking. In addition, the statistics do not include cigarette smokers younger than 18 years old.
Within the adult population, there is substantial varia- tion in prevalence rates. Rates are higher for males (21%) than for females (15%), highest for persons with a general education development (GED) certificate (41%) and lowest for persons with a graduate degree (6%), highest for persons reporting multiple races (27%), and lowest for Asians (10%).
In 2013, 14 percent of college students reported smok- ing cigarettes within the previous month (a measure roughly equivalent to the measure of current smoking in the CDC statistics), down from 20 percent reporting in 2007 and more than 30 percent in 1999. About 16 percent of high school seniors in 2013 and 9 percent of tenth graders reported ciga- rette smoking within the previous month. It is unlikely that many tenth and twelfth graders who have not begun smoking at this point in their lives would ever begin smoking during their lives.35
The Youngest Smokers In the 2013 University of Michigan survey, approximately 5 percent of eighth graders reported smoking at least once in the previous month, down from 7 percent in 2009 and 17 percent in 1999. Fewer than 2 percent of eighth graders reported smoking on a daily basis in 2013 (about a third of the prevalence rate reporting in 1999), and fewer than about 1 percent reported smoking at least a half a pack a day (about half the prevalence rate reporting in 1999).
In previous Michigan surveys, the peak years for start- ing to smoke have been reported to be in the sixth and sev- enth grade, though a significant number of eighth graders qualifying as regular smokers have said that they had started earlier. About 16 percent have reported that they had begun prior to the sixth grade; in fact, about 8 percent have reported that they had started prior to the fifth grade. In general, it has been estimated that between 80 and 90 percent of regular smokers began to smoke by the age of 18.36
Attitudes toward Smoking among Young People Adolescent attitudes toward cigarette smoking have changed dramatically during the early years of the twenty-first century. In general, young people in middle and high school have become less accepting of cigarette smoking. About 88 per- cent of eighth graders, for example, reported in 2013 their disapproval of someone smoking a pack of cigarettes per day and 62 percent reported that such behavior would present “great risk” of harming themselves physically or otherwise.
Interestingly, adolescent attitudes toward the social aspects of smoking have become more negative as well. In 2002, about half of tenth and twelfth graders agreed with the statement “I strongly dislike being near people who are
350 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
Regulation by Reduced Access to Young People Since 1997, all 50 U.S. states have established 18 as the minimum age at which tobacco products can be purchased. Vendors have been required to verify the age of purchasers up to the age of 27 as a means for reducing the access of young people to tobacco. Violators of this law face losing their ven- dor license. In some U.S. states, efforts are under way to raise
Cigarette smoking among minors is a continuing social and public health problem.
the minimum age for tobacco purchase to 19 or 21, while other states have this higher minimum age already in effect. Any upward change from the national standard reduces the possibility of high school seniors buying cigarettes for their younger friends.
With regard to standards set in federal regulations on un- derage smoking, the compliance rate on the part of tobacco retail vendors nationwide reached 90 percent in 2013, which was substantially higher than the 60 percent rate reported in 1996. Ten of the 50 U.S. states achieved a compliance rate of above 95 percent. Nonetheless, for 50 percent of eighth grad- ers reporting in 2013, cigarettes were “fairly easy or very easy to get.” This percentage is significantly lower than percent- ages reported in the 1990s, but it still reflects relatively easy access (Drug Enforcement . . . in Focus).39
Regulation by Increased Awareness of Potential Harm There are continuing efforts to educate the public about the potential harm caused by tobacco products as well as non- tobacco products containing nicotine. A powerful message has been conveyed by a recent decision by a major drugstore chain in the United States to no longer sell cigarettes in their stores. The argument has been made that it is inappropriate to sell products that are associated with so many health haz- ards in an establishment devoted to health needs.40
reducing Youth Access to Tobacco—The Synar Amendment, 1992 In 1992, Congress enacted the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act with an amendment sponsored by Representative Mike Synar of Oklahoma. The amendment aimed at decreasing youth access to tobacco by mandating a number of important changes in the way young people purchase tobacco products and in the practice of commercial tobacco distribution operations. Specifically, the Synar Amendment required • The enactment of state laws prohibiting any manufacturer,
retailer, or distributor of tobacco products from selling or distributing such products to any individual younger than age 18. Law enforcement of violations was to be established “in a manner that can reasonably be expected to reduce the availability of tobacco products to youth.”
• Annual, unannounced inspections in a way that provides a sampling of tobacco sales outlets that are accessible to minors.
• Each state to reduce its retail violation rate (RVR), referring to the rate at which tobacco products were sold to individu- als younger than 18 years of age, to 20 percent or less by 2003. Failure to meet retail violation target rates carries a penalty of loss of up to 40 percent of federal block grant funds for substance abuse prevention and treatment.
Progress has been seen since the enactment of the Synar Amendment. In 1997, the average RVR nationwide was 40.1 per- cent; in 2013, it was 9.6 percent. In 2013, 47 out of the 50 states and the District of Columbia had achieved an RVR below 15 percent; 30 had achieved an RVR below 10 percent. Recently, Maine, Minnesota, and Nevada have been cited as states with the best records in complying with Synar Amendment objectives, achieving an RVR less than 3 percent. At the same time, however, the rela- tively high percentage of eighth graders who continue to report that they had “relatively easy” access to tobacco products suggests that they are getting cigarettes through family members or older friends.
Source: Substance Abuse and Mental Health Services Administration (2014). FFY 2013 annual Synar reports: Tobacco sales to youth. Rockville, MD: Substance Abuse and Mental Health Services Administration.
Drug Enforcement . . . in Focus
Chapter 16 Nicotine and Tobacco Use ■ 351
Currently, the form of smokeless tobacco showing the most consistent gains in recent sales is moist snuff, with some brands sold in cherry or wintergreen flavors. As with ciga- rette tobacco, variations in the alkalinity of different brands of moist snuff allow for different percentages of the nico- tine in the tobacco to be absorbed through the membranes of the mouth. Thus, snuff users typically start with brands that release relatively low levels of nicotine, then “graduate” to more potent brands. The most potent brand on the cur- rent market, Copenhagen, is also the best-selling snuff in the United States.43
Despite continuing warnings that smokeless tobacco pres- ents great risk to one’s health, its popularity continues. As stated earlier, while smokeless tobacco presents no immediate dan- ger to the lungs, there are substantial adverse effects on other organs of the body. At the very least, regular use of smokeless tobacco increases the risk of gum diseases, damage to tooth enamel, and eventually the loss of teeth. More seriously, the direct contact of the tobacco with membranes of the mouth allows carcinogenic nitrosamines to cause tissue changes that can lead to oral cancer. Delay in the treatment of oral can- cer increases the likelihood of the cancer spreading to the jaw, pharynx, and neck. When swallowed, saliva containing nitrosamines can produce stomach and urinary tract cancer.
Probably the most dramatic, and controversial, strategy has been to include vivid graphic displays of packs of ciga- rettes, showing the health consequences of smoking. Since 1984, tobacco companies have been required to put warning labels such as “Warning: Smoking can kill you” on cigarette packs, but this move is considerably more “in the face” of the consumer. According to the Tobacco Act of 2009, large and graphic warnings showing the symptoms of cancer, strokes, and other diseases would replace the text-only warnings that have been considered unnoticed and stale, according to the Institute of Medicine. In a case brought up by the major tobacco companies in 2012, however, the U.S. Court of Appeals for the District of Columbia, in a 2-to-1 ruling, struck down this provision of the 2009 law on the grounds that it violated the First Amendment rights of the tobacco compa- nies. The U.S. Court of Appeals for the Sixth Circuit had earlier ruled to uphold the new warnings. The U.S. Supreme Court refused to consider the case in 2013, in a decision that has been regarded as being in favor of the governmental posi- tion on the matter. Details about the implementation of new graphic displays on cigarette packs are being worked out. In the meantime, Australia and Canada have instituted graphic display warnings on cigarette packs sold in their respective countries.41
Other Forms of Present-Day Nicotine Consumption
Undoubtedly, concerns about the consumption of nicotine as a toxic, dependence-producing psychoactive drug have focused on tobacco products, specifically cigarette smoking. There are other forms of nicotine intake in other types of to- bacco products, however, and, as we are all aware, new prod- ucts that permit the consumption of nicotine independent of any involvement with tobacco itself.
Smokeless Tobacco Smokeless tobacco is ingested, as the name implies, by absorption through the membranes of the mouth rather than by inhalation of smoke into the lungs (Table 16.1). The two most common forms are the traditional loose-leaf chewing tobacco (brand names include Red Man and Beech Nut) and moist, more finely shredded tobacco called moist snuff or simply snuff (brand names include Copenhagen and Skoal). Snuff, by the way, is no longer sniffed into the nose, as in the eighteenth century, but rather placed inside the cheek or alongside the gum under the lower lip. Some variet- ies of snuff are available in a small absorbent-paper sack (like a tea bag) so that the tobacco particles do not get stuck in the teeth. The practice is called “dipping.”
According to the 2013 University of Michigan survey, about 3 percent of eighth graders, 6 percent of tenth grad- ers, and 8 percent of high school seniors had used smokeless tobacco within the previous 30 days.42
moist snuff: Damp, finely shredded tobacco, placed inside the cheek or alongside the gum under the lower lip.
TAbLE 16.1
Forms of smokeless tobacco
TYPE DESCriPTiON
Chewing tobacco
Loose-leaf Made of cigar-leaf tobacco, sold in small packages, heavily flavored or plain
Fine-cut Similar to loose-leaf but more finely cut so that it resembles snuff
Plug Leaf tobacco pressed into flat cakes and sweetened with molasses, licorice, maple sugar, or honey
Twist Made of stemmed leaves twisted into small rolls and then folded
(Chewing tobacco is not really chewed but rather held in the mouth between the cheek and lower jaw.)
Snuff
Dry, moist, sweetened, flavored, salted, scented
(A pinch of snuff, called a quid, is typically tucked between the gum and the lower lip. Moist varieties are currently the most popular.)
Source: Based on information from Popescu, Cathy (1992). The health hazards of smokeless tobacco. In Kristine Napier (Ed.), Issues in tobacco. New York: American Council on Science and Health, pp. 11–12.
352 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
disease (Portrait). Major cigar manufacturers have now agreed to place warning labels on their products, alerting consum- ers to the risk of mouth and throat cancer, lung cancer and heart disease, and hazards to fertility and unborn children.46 Approximately 5 percent of all adults in the United States reported cigar smoking in 2012, with African Americans and American Indian/Alaska Natives reporting a somewhat higher prevalence rate than the adult population at large.47
While traditional cigars have not presented a public health problem among young smokers, the recent introduction of “little cigars” with fruit or candy flavorings certainly have. Virtually indistinguishable from cigarettes in their size, filters, and outer packaging, these flavored little cigars have become popular among large numbers of middle and high school stu- dent smokers. More than 42 percent of students who were cur- rently either smoking cigarettes or little cigars reported in 2011 that they favored the flavored varieties. Considering that nearly 7 percent of middle school students and more than 12 percent of high school students were current smokers in 2012, public health authorities are very concerned about significant role of flavored tobacco in the decision among adolescents to smoke, whether it is in the form of cigarettes or little cigars.48
E-Cigarettes and Nicotine Toxicity The explosive rise in the popularity and availability of e-cigarettes, nontobacco products consisting of propylene glycol infused with nicotine so that it can be inhaled as a smokeless vapor, has raised concerns about nicotine depen- dence to new levels. While the practice of “vaping” (consum- ing nicotine in a nontobacco product) represents only a very small fraction of the $80 billion-a-year market for smoking
Moreover, all the negative consequences of ingesting nicotine during tobacco smoking are also present in the use of smoke- less tobacco. In 2009, Altria, the leading tobacco company in the United States began an aggressive marketing campaign for Marlboro snus, a smokeless tobacco product, with the slogan: “When smoking isn’t your option, reach for Marlboro snus.” Altria’s argument to FDA regulators that smokeless tobacco represents a less harmful alternative to cigarettes is clearly weak, at best (see Help Line on page 347).44
Cigars: Big and Little For a brief time in the 1990s, there was a resurgence in the popularity of cigars, spurred on by images of media stars, both male and female, who had taken up cigar smoking as the tobacco use of choice. The cigar suddenly was fashionable. By the end of the decade, however, the cigar-smoking craze had “gone up in smoke.” While part of the problem related to changing market conditions for imported cigars, a major contributing factor was the increasing recognition that cigars could not be regarded as a safe alternative to cigarettes.45 In fact, cigar smoke is more alkaline than cigarette smoke, so the nicotine content in cigars can be absorbed directly through tissues lining the mouth rather than requiring inhalation into the lungs. In addition, due to the tar content, the risk of lung cancer is five times higher for those who smoke cigars, eight times higher for those smoking three or more cigars per day, and 11 times higher for those inhaling the smoke of cigars, relative to nonsmokers. Regular cigar smokers have a dou- bled risk, relative to nonsmokers, for cancers of the mouth, throat, and esophagus; they also incur a 45 percent higher risk of COPD and a 27 percent higher risk of coronary heart
POrTrAiT Sigmund Freud—Nicotine Dependence, Cigars, and Cancer
Probably the best-known photograph of Sigmund Freud, founder of psychoanaly- sis and one-time proponent of cocaine use (see Chapter 10), shows him with a cigar in hand. Given that Freud typically smoked 20 cigars each day, it is not sur- prising that he did not set it aside merely to have his picture taken. But there is a story behind this photograph, a lesson about the power of smoking over the will to stop and the tragic health conse- quences when the will succumbs.
In 1923, at the age of 67, Freud noted sores on his palate and jaw that failed to heal, a sign of oral cancer. Surgery was indicated and fortunately proved suc- cessful in removing the cancerous tissue. This would be only the first of 33 surgical
operations on the jaw and oral cav- ity that Freud was to endure for the
remaining 16 years of his life. As the leu- koplakia and finally genuine carcinomas returned to his mouth, he was repeatedly warned by specialists that his practice of smoking cigars was the root of his prob- lems and that he must stop. Despite these warnings, Freud kept on smoking.
Freud tried very hard to stop; indeed, sometimes he would not smoke for a few weeks at a time. In addition to his prob- lems with cancer, he suffered from chest pains called “tobacco angina.” In 1936, the angina became acutely painful and as his biographer, Ernest Jones, has noted, “It was evidently exacerbated by nicotine, since it was relieved as soon as he stopped smoking.”
By this time, Freud’s jaw had been entirely removed and an artificial jaw substituted in its place. He was almost constantly in pain, often could not speak, and sometimes could not eat or swallow. Despite the agony, Freud still smoked a steady stream of cigars until he finally died at the age of 83.
Here was a man whom many consider to be one of the intellectual giants of the twentieth century. Yet the giant was a slave to his cigars.
Source: Brecher, Ruth; Brecher, Edward; Herzog, Arthur; Goodman, Walter; Walker, Gerald; and the Editors of Consumer Reports (1963). The Consumer Union’s report on smoking and the public interest. Mount Vernon, NY: Consumer Union, pp. 91–95.
Chapter 16 Nicotine and Tobacco Use ■ 353
independent of American tobacco corporations. Today, the picture has changed dramatically. Between 1985 and 1994 alone, U.S. cigarette exports to Japan increased 700 percent and to South Korea increased 1200 percent. In the late 1990s, American-made cigarettes moved into significant markets in Eastern Europe and Russia, where smoking preva- lence rates are substantially higher than those in the United States (Figure 16.3). Presently, U.S. tobacco exports total more than $6 billion each year.
Tobacco Use in Other Countries Unfortunately, the prevalence rate of smoking in many for- eign countries far exceeds that of the United States, coupled with substantially less public concern for the consequences of smoking on health. In South Korea, Greece, Russia, China, and most Eastern European countries, for example, more than 50 percent of all adult men smoke cigarettes. In many nations of the world, no-smoking sections in restau- rants and offices are uncommon; million outdoor vending machines allow minors to purchase cigarettes easily; and there is little or no governmental opposition to smoking in general.52
Clearly, tobacco use on a global scale presents one of the most significant public health challenges we face in the twenty- first century. According to the World Health Organization (WHO), an estimated 5.4 million people worldwide die each year from tobacco-related diseases, and this figure is projected to increase to more than 8 million by 2030. In the twentieth cen- tury, tobacco smoking contributed to the deaths of 100 million people worldwide. During the twenty-first century, the death toll could rise to as high as a billion people.
Making matters worse, global approaches to reducing the deadly effects of tobacco use are discouragingly weak or absent. Approximately 40 percent of countries in the world still allow smoking in hospitals and schools; only 5 percent of the world’s population lives in a country that imposes a comprehensive national ban on tobacco advertising. Only 5 percent of the world’s population lives in a country in which full services to treat tobacco dependence are widely available.53
In recognition of the enormous health crisis that ex- ists at present and the potential calamity that looms in the future, a Framework Convention on Tobacco Control has been signed by more than 170 members of the World Health Organization, an agency of the United Nations. Implementation of the tobacco-use reduction initiates in the agreement, however, is voluntary and progress on a global level has been slow. A major factor is the fact that governments around the world collect more than $200 bil- lion dollars each year in taxes imposed on tobacco sales. In some cases, governments are dependent on these tax revenues to sustain their economies. In other cases, gov- ernments receive direct profits from state-owned tobacco corporations.54
On the other hand, there are success stories in the ever-changing picture of global tobacco use. In Brazil, for
products in the United States, sales are expected to have dou- bled from 2013 to 2014. Some types of e-cigarettes have a small LED light to mimic the glow of a burning ash.
Essentially, e-cigarettes are nicotine delivery devices. While health hazards of inhaling tar and carbon mon- oxide from traditional tobacco products are eliminated in e-cigarettes, the hazards associated with nicotine consumption remain. In other words, the dependence- producing psychoactive drug that has been the cause for tobacco-use dependence over the centuries continues to be consumed. In addition, a recent laboratory study has shown that nicotine-laced vapors promote the develop- ment of cancer in isolated human lung cells. Whether similar effects produce similar effects on people remains to be determined. However, there is at least preliminary evidence that e-cigarettes may have adverse health con- sequences beyond the potential for nicotine dependence. Public health authorities have noted that marketing of e-cigarettes has followed along the lines of glamorization campaigns of tobacco products in the 1950s and 1960s. They view the present-day advertisements for e-cigarettes as potentially reversing more than 40 years of effects to deglamorize smoking behavior.49
Making matters worse, regular refilling of e-cigarettes with liquid nicotine (so-called e-liquids) has resulted in the availabil- ity of a highly toxic drug either as a new recreational drug or the basis for accidental poisoning. Nationwide, reports of accidental poisoning associated with liquid nicotine increased in 2013 to more than 1,300 cases, three times the number in 2012, and further increases are expected in the future. Since less than a teaspoon of pure nicotine can kill an adult, significant prob- lems exist with respect to children exposed to this toxin, either through carelessness on the part of parents or a general lack of understanding of the potential risks. Tobacco companies are currently developing new devices that increase the level of nico- tine delivered to the brain, matching more closely the level of nicotine delivered by traditional cigarettes.50
A limited form of regulatory control over e-cigarettes ap- pears to be emerging. In 2013, New York established a state law banning sales of e-cigarettes to those younger than 18 years of age, and other U.S. states have followed. The FDA has not issued guidelines as of 2014, but public health au- thorities are confident that some regulatory policy will be in place in the near future on a nationwide basis. In the meantime, the European Parliament approved in 2014 a ban on all advertising for e-cigarettes, graphic health warnings, and childproof packaging in e-cigarette products, effective throughout the European Union in 2016.51
The Global Perspective: Tobacco Use around the World
Since the seventeenth century, the practice of tobacco smok- ing has spread throughout the world, but until the 1980s the behavior itself outside the United States had been largely
354 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
Brazilian deaths from smoking-related causes were averted by 2010 and that 37 million deaths will have been pre- vented by 2050.55
Quitting Smoking: The Good News and the Bad
There is no question that tobacco use of any kind is harmful to your health as well as your wallet, and it is indeed hard to quit once you have started. But there’s some good news with respect to the consequences of quitting.
Quick Concept Check
Present-Day Tobacco Control Policy and Strategies Check your understanding of present-day tobacco control policy and strategies by answering “true” or “false” to the following statements:
statement true false
1. State cigarette taxes have been found to be ineffec- tive in reducing tobacco sales by adults.
_________ _________
2. The Synar Amendment of 1992 was designed to reduce retail sales of tobacco products to minors.
_________ _________
3. Graphic depictions of diseases associated with tobacco use have been on packs of cigarettes in the United States since 2009.
_________ _________
4. Flavored “little cigars” have a greatly reduced level of inhalable smoke.
_________ _________
5. The responsibility for reducing worldwide tobacco use is assumed by UNESCO (United Nations Educational, Scientific, and Cultural Organization).
_________ _________
6. E-cigarettes contain mostly nicotine but a small amount of tar as well.
_________ _________
Answers: 1. false 2. true 3. false 4. false 5. false 6. false
16.2
United States Men
Women 26%
22%
25%
22%
18%
4%
30%
25%
31%
26%
12%
27%
35%
14%
21%
34%
6%
4%
40%
23%
27%
20%
28%
31%
33%
34%
35%
36%
37%
37%
37%
37%
44%
45%
46%
53%
60%
64%
64%
70%
Sweden
Australia
Israel
India
Norway
Argentina
Spain
Germany
Mexico
France
United Kingdom
Japan
Lithuania
Hungary
South Korea
China
Greece
Ukraine
Russia
F igurE 16 .3
Smoking rates for men and women over 15 years old in 20 countries, including the United States.
Note: Percentages for the United States differ from data reported by the Centers for Disease Control and Prevention (see page 348), due to differences in criteria and age range.
Source: World Health Organization (2008). The WHO report on the global tobacco epidemic 2008: The MPOWER package. Geneva, Switzerland: World Health Organization.
example, strict tobacco control efforts begun in 1990 have reduced smoking prevalence rates by 46 percent. Half of this reduction was accomplished by increasing the price of cigarettes. It is estimated that approximately 420,000
Chapter 16 Nicotine and Tobacco Use ■ 355
The Bad News: How Hard It Is to Quit The advantages of quitting are real and most people are aware of them, but the fact remains that, in the words of the surgeon general’s report in 1988, “The pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine.”57 It may be easy to quit smoking for a short while but it is very difficult to avoid a relapse, as any former or present smoker will tell you (Help Line).
About one-third of all smokers in the United States try to quit each year, the vast majority of them without any treat- ment, but only about 3 to 5 percent succeed with their initial attempt. Nonetheless, about half of all smokers do eventually manage to achieve long-term abstinence from the nicotine in tobacco products, but only after an average of eight attempts at quitting.
Research studies on smoking cessation indicate that there are no gender differences with regard to the likelihood that a person will quit smoking for one–four years, though men are more likely than women to have been abstinent for five years or more. Gradual reduction is as effective as abrupt cessation as a smoking cessation strategy. The fact that a higher level of smoking is consistently related to a lower level of education and family income makes it vital that smok- ing cessation programs be available to those who ordinarily would not be able to afford them.58
Medications for Smoking Cessation The options available to smokers who want to quit are numerous. In addition to behaviorally oriented social support groups (Smokers Anonymous, SmokeEnders, Smoke-Stoppers),
The Good News: Undoing the Damage Given the grim story of all the documented health risks as- sociated with tobacco, it is at least reassuring to know that if a smoker does succeed in quitting, some of the damage can be undone. Here are the benefits:
●■ Within eight hours—Carbon monoxide levels in the blood drop to normal.
●■ Within 24 hours—Chances of a heart attack decrease. ●■ Within two weeks to three months—Circulation improves.
Lung function increases by up to 30 percent. ●■ Within one to nine months—Coughing, sinus congestion,
fatigue, and shortness of breath decrease. Cilia regain nor- mal function in the lungs, increasing the ability to handle mucus, clean the lungs, and reduce infection.
●■ Within one year—Excess risk of coronary heart disease is half that of a smoker.
●■ Within 5–10 years—Risk of stroke is reduced to that of a nonsmoker.
●■ Within 10 years—Lung cancer death rate is about half that of a continuing smoker.
●■ Within 15 years—Risk of coronary heart disease is equal to that of a nonsmoker.
On the one hand, smokers who do not stop stand to lose at least one decade of life expectancy, as compared to those who have never smoked in their lifetime. On the other hand, adult smokers who had quit smoking at 25–34, 35–44, or 45–54 years of age stand to gain 10, 9, or 6 years of life, respectively, as compared to those who continue to smoke. That seems to be a powerful motivation to stop as soon as possible.56
Help Line Ten Tips on How to Succeed When Trying to Quit Smoking
• Choose a quit date and stick to it.
• Remember that you are dependent, physiologically and psychologically, on nicotine and that the first few days without cigarettes will be the hardest.
• Change the habits that are associated with smoking. If you have had a cigarette with your morning coffee, drink orange juice instead.
• Tell all the people you know that you are quitting and ask for their support.
• Drink lots of water and brush your teeth frequently to rid yourself of the taste of tobacco.
• Never carry matches or a lighter with you. Put away your ashtrays or fill them with something else.
• Spend time with people who don’t smoke.
• Keep a supply of sugarless gum, celery sticks, or hard candy on hand to use as a cigarette substitute.
• If you have an uncontrollable urge to light up, take ten deep breaths instead. Hold the last breath, then exhale slowly, and tell yourself you have just had a cigarette.
• Think about all the money you are saving by not buying cigarettes. A simple calculation will convince you that the amount saved in five years from just a moderate level of smoking (say half a pack a day) can be more than $5,000.
• Get in touch with your local Department of Health Services or call the National Cancer Institute Quitline at 877-44U-QUIT.
Source: Information gathered from American Cancer Society (2008). Guide to quitting smoking. Atlanta, GA: American Cancer Society.
356 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
nicotine-substitute options include a nasal spray (brand name: Nicotrol NS) and an oral inhalation system (brand name: Nicotrol Inhaler) in which nicotine is inhaled from a cartridge through a plastic mouthpiece, and lozenges (brand name: Commit).61
The Role of Physicians in Smoking Cessation Owing to the fact that tobacco use is the leading cause of preventable death in the United States, it is clear that physi- cians must play a critical role in addressing the issue of to- bacco use in their patients. Guidelines for physicians in this regard have been dubbed the “Five A’s”:
●■ Ask about tobacco use. Identify and document tobacco-use status for every patient at every visit.
●■ Advise to quit. In a clear, strong, and personalized manner, urge every tobacco user to quit.
●■ Assess willingness to make a cessation attempt. Is the tobacco user willing to make a cessation attempt at this time?
●■ Assist in cessation attempt. For the patient willing to make a cessation attempt, use counseling and pharmacotherapy to help him or her quit.
●■ Arrange follow-up. Schedule follow-up contact, preferably within the first week after the cessation date.62
A good idea is for physicians to tell smokers their “lung age,” as determined by the age of an average healthy non- smoker with a comparable level of breathing strength. Smokers evidently get the message. They are twice as likely to quit, compared to smokers who are not informed of this fact. Unfortunately, however, the campaign encouraging physicians or other health professionals to communicate any sort of quit-smoking information to patients has a long way to go. It has been estimated that as many as 42,000 additional lives in the United States would be saved each year if 90 percent of smokers were advised by a health professional to quit and were offered medication or other assistance to do so.63
counseling either in person or through telephone “quitlines,” hypnosis, acupuncture, and specific prescription drugs can help reduce the withdrawal symptoms and feelings of nicotine craving. One example is a sustained-release form of the antide- pressant drug bupropion. Originally marketed as a treatment for depression under the name Wellbutrin, it was approved by the FDA in 1997 for use as an aid for smoking cessation and renamed Zyban when marketed for this purpose. It is recom- mended that Zyban be taken daily for a week prior to the last cigarette to allow drug levels to build up in the bloodstream and buffer the loss of nicotine when smoking stops. About 44 percent of individuals taking Zyban have refrained from smok- ing after seven weeks, and 23 percent remain smoke-free after one year, roughly twice the percentage of those who receive a placebo. Since 1999, the costs of all prescription medications and quit-smoking programs have been tax-deductible as medi- cal expenses.59
In 2006, a twice-daily tablet called Chantix became available in the United States as a nicotine-free stop-smoking medication. Clinical trials of Chantix have shown that the rate of abstinence from tobacco is 22 percent, compared to 16 percent among those taking Zyban. Forty-eight percent of long-time, one-pack-per-day smokers quit after a 12-week treatment with Chantix, compared to 33 percent among Zyban patients. Successful long-term abstinence may require multiple treatments.60
Nicotine Gums, Patches, Sprays, and Inhalers The long-term goal in quitting smoking is to withdraw from dependence-producing nicotine altogether and to be totally free of any hazard associated with tobacco. In the meantime, however, it is possible to employ an alternative route of ingestion for nicotine that avoids inhaling carbon monoxide and tar into the lungs. Chewing gum contain- ing nicotine (brand name: Nicorette), available since the early 1970s as a prescription drug, is now marketed on a nonprescription basis. Transdermal nicotine patches are marketed on a nonprescription basis as well. Prescription
Part of California’s antismoking campaign, this billboard focuses on the dangers of environmental tobacco smoke. Researchers have found that an approach based on the potential decline in social attractiveness reduces the desire among adolescents to start smoking. In 2005, state health officials announced that smoking rates among adolescents and adults in California had declined sharply since the inception of its antitobacco campaign in 1990.
Chapter 16 Nicotine and Tobacco Use ■ 357
Chantix than with a nicotine patch, while the two treatments are equally successful for subjects who metabolize nicotine at a slower rate. For these “slow metabolizers,” the nicotine patch has been recommended as the preferred option, since the patch costs less and has fewer side effects.64
The best option for quitting smoking, of course, is never to have started in the first place, which brings us back to the teen- age years, when virtually all adult smokers pick up the habit. The challenge as we progress into the twenty-first century will be to maintain the communication of effective messages that prevent the initiation of cigarette smoking as well as other forms of tobacco use by young people (see Chapter 17).65
A Final Word on Quitting When these efforts to quit on one’s own have failed, alternative approaches need to be considered. Traditionally, health profes- sionals have emphasized that if one treatment strategy does not work out, the smoker should try another. The process of choos- ing the strategy that has the best chance of success, however, may not necessarily be a matter of trial and error. Recently, it has been found that the way a smoker metabolizes nicotine (see Chapter 4) may determine whether a specific treatment works best. It has been found that subjects who metabolize nicotine within a “normal” amount of time have more success with
Tobacco use through History ●● Tobacco use originated among the original inhabitants of
North and South America, and its introduction to Europe and the rest of the world dates from the first voyage of Columbus. Europeans used tobacco initially in the form of pipe smoking and later in the form of snuff.
●● In the nineteenth-century United States, the most popular form was tobacco chewing and later cigar smoking. It was not until the late nineteenth century and early twentieth century that cigarette smoking became popular.
Health Concerns and Smoking behavior ●● The 1964 surgeon general’s report, the first official statement
on the connection between smoking and adverse health consequences, produced a general reversal in the previously climbing per capita consumption rate of cigarettes.
●● Since 1964, the surgeon general’s reports have solidified the position that nicotine is a clearly addicting component of tobacco and that tobacco use, whether in a smoked or smokeless form, causes significant health risks.
●● Since 1964, there has been increased use of filtered, low- tar, and low-nicotine cigarettes. The prevalence rate for smoking among adults has declined from 42 percent in 1964 to 18 percent in 2013. Premature deaths due to to- bacco use have decreased as well.
Changing Times: Tobacco Control since 1990 ●● Since the early 1990s, most U.S. states, cities, and commu-
nities have enacted laws mandating smoke-free environ- ments in all public and private workplaces.
●● In 1998, the major American tobacco corporations en- tered into a $246 billion settlement agreement with all 50 U.S. states to resolve claims that the states should be compensated for the costs of treating people with smoking- related illnesses.
●● In 2009, the Tobacco Control Act was signed into law, authorizing the FDA to regulate tobacco products sold in the United States. This legislation has been a major step toward controlling tobacco use.
●● On a global level, cigarette production and sales to foreign markets have been an increasing marketing opportunity for American tobacco companies and a significant factor in the balance of U.S. foreign trade.
What’s in Tobacco? ●● The principal ingredients consumed during the smoking
of tobacco are nicotine, tar, and carbon monoxide. ●● The smoker inhales smoke in the form of mainstream
smoke (through the cigarette itself) and sidestream smoke (released from the cigarette tip into the air).
The Dependence Potential of Nicotine ●● Nicotine ingestion produces both tolerance effects and
physical withdrawal symptoms. A prominent feature of nicotine withdrawal is the strong feeling of craving for a return to tobacco use.
●● Smokers typically adjust their smoking behavior to obtain a stable dose of nicotine.
Health Consequences of Tobacco use ●● Tobacco smoking produces an increased risk of cardio-
vascular disease such as coronary heart disease and stroke, lung cancer and other forms of cancer, and respiratory dis- eases such as chronic bronchitis and emphysema.
●● In addition to the hazards to the smoker through the inhalation of mainstream smoke, there are hazards to the developing fetus when the mother is smoking and hazards to nonsmokers who inhale environmental tobacco smoke.
Patterns of Smoking behavior in the united States ●● In 2013, approximately 42 million adults in the United
States were current cigarette smokers. ●● Between 80 and 90 percent of adult smokers are estimated
to have begun to smoke by the age of 18. ●● In general, young people in middle and high school
have become increasingly less accepting of cigarette smoking.
Summary
358 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
●● The new availability of e-cigarettes, nontobacco products consisting of propylene glycol infused with nicotine so that it can be inhaled as a smokeless vapor, presents a significant public health challenge. While tars and carbon monoxide are avoided with e-cigarettes, nicotine consumption remains. Nicotine liquids are available for refilling e-cigarettes and are highly toxic. Accidental poisonings are of particular concern.
The global Perspective: Tobacco use around the World
●● The prevalence rate of smoking in many foreign countries far exceeds that of the United States. In some countries, 60 to 70 percent of adult males are tobacco smokers.
●● Adding to the problem of widespread tobacco use in other countries, many foreign countries do not promote reduc- tions in tobacco use, as does the United States.
●● The World Health Organization (WHO), an agency of the United Nations, works to promote tobacco control pro- grams in nations around the world.
Quitting Smoking: The good News and the bad ●● Research has clearly shown that when people quit smok-
ing, many health risks diminish rapidly. Unfortunately, nicotine dependence is very strong, and it is difficult to quit smoking. Nonetheless, a wide range of smoking cessation treatments are available, and about 50 percent of smokers eventually succeed in quitting on a permanent basis.
●● Present-day approaches toward smoking cessation include behavioral treatment programs, hypnosis, acupuncture, and prescription drugs to reduce withdrawal symptoms and craving, as well as a variety of nicotine substitutes.
●● Physicians and other health care professionals play a sig- nificant role in reducing tobacco use among their patients. A concerted effort is being made to increase their influ- ence in this regard.
Current regulatory Policy and the role of Law Enforcement
●● The regulatory policy with regard to tobacco use has been defined by the Tobacco Control Act of 2009 under the authority of the FDA. Implementation of regulatory policy can be categorized in three general areas.
●● Regulation by taxation is one area of tobacco control. As with alcohol, taxes imposed on tobacco sales vary from state to state. However, the overall intention is to reduce sales by making tobacco products more expen- sive to buy.
●● Regulation by reduced access for young people is another area of tobacco control. Reduced access is accomplished by a minimum age requirement for tobacco sales. While retail vendor compliance with minimum age require- ments is high, about half of eighth graders report that it is fairly easy or very easy to get cigarettes.
●● The third area is regulation by increased awareness of potential harm. This is increasing pressure for cigarette products to carry graphic depictions of diseases associated with tobacco use.
Other Forms of Present-Day Nicotine Consumption ●● Smokeless (or chewing) tobacco is an alternative means
of consuming tobacco. Its popularity continues, despite warnings that smokeless tobacco presents the same risks as tobacco smoking. In fact, smokeless tobacco is associated with increased rates of gum disease, loss of teeth, and can- cers of the jaw, pharynx, and neck as well as other regions of the body.
●● Cigars are another form of tobacco smoking that presents equivalent health hazards as cigarettes. Public health authorities are concerned that the recent popularity of fla- vored “little cigars” among young people can be an intro- duction to future use of tobacco products of all kinds.
Key Terms
arteriosclerosis, p. 345 atherosclerosis, p. 345 carbon monoxide, p. 342 carcinomas, p. 346 chronic bronchitis, p. 346 chronic obstructive pulmonary
disease (COPD), p. 345 cigarettes, p. 338
cigars, p. 338 cilia, p. 343 ciliary escalator, p. 343 coronary heart disease (CHD),
p. 344 emphysema, p. 346 environmental tobacco smoke
(ETS), p. 341
erythroplakia, p. 346 gaseous phase, p. 342 ischemic stroke, p. 345 leukoplakia, p. 346 mainstream smoke, p. 342 moist snuff, p. 351 nicotine, p. 343 nitrosamines, p. 347
particulate phase, p. 342 sidestream smoke, p. 339 snuff, p. 337 snuffing, p. 337 tar, p. 342 titration hypothesis, p. 344
1. Explain changes in American society that made tobacco chewing preferable over snuffing as a means of tobacco use in the 1700s.
2. Explain why it was at first difficult to introduce cigarette smoking in America. What events or circumstances helped their accep- tance into American society, particularly among male smokers?
3. Discuss the changes in tobacco control policy in the United States as a result of (1) the release of a major report by the Environmental Protection Agency in 1993, (2) the Tobacco Settlement of 1998, and (3) the Tobacco Control Act of 2009.
Review Questions
Chapter 16 Nicotine and Tobacco Use ■ 359
You are living with your parents, and your mother is a chronic tobacco smoker. You observe a gradual increase in health issues in your mother as well as a gradual increase of health issues in your
father and yourself. Your mother has failed in quitting smoking several times and has essentially given up. Obviously, you are very concerned. What would you do?
Critical Thinking: What Would You Do?
1. Brooks, Jerome E. (1952). The mighty leaf: Tobacco through the centuries. Boston: Little, Brown, pp. 11–14. Fairholt, Frederick W. (1859). Tobacco: Its history and associations. London: Chapman and Hill, p. 13.
2. Brooks, The mighty leaf, pp. 74–80. White, Jason M. (1991). Drug dependence. Englewood Cliffs, NJ: Prentice Hall, pp. 32–33.
3. Austin, Gregory A. (1978). Perspectives on the history of psy- choactive substance use. Rockville, MD: National Institute on Drug Abuse, pp. 1–12.
4. Brooks, The mighty leaf, p. 181. Lehman Brothers (1955). About tobacco. New York: Lehman Brothers, pp. 18–20.
5. Kluger, Richard (1996). Ashes to ashes: America’s hundred-year cigarette war, the public health, and the “unabashed” triumph of Philip Morris. New York: Knopf, p. 14. Tate, Cassandra (1989). In the 1800s, antismoking was a burning issue. Smithsonian, 20(4), 111.
6. Quotation originally in Bain, John, and Werner, Carl (1905). Cigarettes in fact and fancy. Boston: H. M. Caldwell. Cited in Brooks, The mighty leaf, p. 259.
7. Kluger, Ashes to ashes, pp. 16–20. Lehman Brothers, About tobacco, pp. 24–27. Slade, John (1992). The tobacco epidemic: Lessons from history. Journal of Psychoactive Drugs, 24, 99–109.
8. Lehman Brothers, About tobacco, p. 30. 9. Lehman Brothers, About tobacco, p. 31.
10. Centers for Disease Control and Prevention (2012, August 3). Consumption of cigarettes and combustible tobacco—United States, 2000–2011. Morbidity and Mortality Weekly Report, 61, 545–569. Connolly, Gregory N.; Alpert, Hillel R.; Wayne, Geoffrey F.; and Koh, Howard (2007, January). Trends in smoke nicotine yield and relationship to design character- istics among popular U.S. cigarette brands 1997–2005. A report of the Tobacco Research Program, Harvard School of Public Health, Boston. Federal Trade Commission Report to Congress (1992). Pursuant to the Federal Cigarette Labeling and Advertising Act, p. 31. IHS Global, Inc. (2014, September 9). A forecast of U.S. cigarette consumption (2014–2040) for the Niagara Tobacco Asset Securitization Corporation. Philadelphia, PA: IHS Global Inc. Wilson, Duff (2010, February 19). Coded to obey law, lights become Marlboro Gold. New York Times, pp. B1, B5.
11. Brody, Jane E. (2014, January 21). Changing the view on smoking. New York Times, p. D5. Centers for Disease Control and Prevention (2015, April 16). Economic facts about U.S.
tobacco production and use. Atlanta, GA: Centers for Disease Control and Prevention. Holford, Theodore R.; Mesa, Rafael; Warner, Kenneth E.; Meernik, Cloare; Jean, Jhyoun; et al. (2014). Tobacco control and the reduction in smoking-related premature deaths in the United States, 1964–2014. Journal of the American Medical Association, 311, 164–171.
12. Campaign for Tobacco-Free Kids (2014, February 27). A broken promise to our children. The 1998 state tobacco settlement 15 years later. Washington, DC: Campaign for Tobacco-Free Kids. National Women’s Health Information Center (2009, December 19). States slash funding for tobacco prevention programs. Washington, DC: National Women’s Health Information Center, U.S. Department of Health and Human Services.
13. Office of the Press Secretary, the White House (2009, June 22). Fact Sheet: The family smoking prevention and tobacco control act of 2009. Washington, DC: Office of the President.
14. Tavernise, Sabrina (2013, June 26). In first, FDA rejects tobacco products. New York Times, p. A18. Wilson, Duff (2011, January 23). Firms told to divulge all changes to tobacco. New York Times, p. B3.
15. Kell, John (2013, April 22). Where there’s smoke, there’s still profit. Wall Street Journal, p. B2.
16. Centers for Disease Control and Prevention (2008). Smoking and tobacco use: Frequently asked questions. Atlanta, GA: Centers for Disease Control and Prevention.
17. Schlaadt, Richard G. (1992). Tobacco and health. Guilford, CT: Dushkin Publishing, p. 41.
18. Gahagan, Dolly D. (1987). Switch down and quit: What the cigarette companies don’t want you to know about smoking. Berkeley, CA: Ten Speed Press, p. 44.
19. Julien, Robert M. (2005). A primer of drug action (10th ed.). New York: Worth, pp. 233–234. Richtel, Matt (2014, March 24). Selling a poison by the barrel: Liquid nicotine for E-cigarettes. New York Times, pp. A1, A3.
20. Meier, Barry (1998, February 23). Cigarette maker manipu- lated nicotine, its records suggest. New York Times, pp. A1, A15. Pankow, J. F.; Mader, B. T.; Isabelle, L. M.; Luo, W. T.; et al. (1997). Conversion of nicotine and tobacco smoke to its volatile and available free-base form through the action of gaseous ammonia. Environmental Science & Technology, 31, 2428–2433.
21. Julien, A primer of drug action, pp. 234–238. Phillips, Sarah; and Fox, Pauline (1998). An investigation into the effects of
Endnotes
4. Describe the composition and physiological effects of the three principal components of tobacco: (1) carbon monoxide, (2) tar, and (3) nicotine.
5. Describe and discuss two adverse health consequences of tobacco use in each of three categories of disease: (1) cardio- vascular disease, (2) respiratory disease, and (3) cancer.
6. Discuss the following three categories of regulatory policy with respect to tobacco control: (1) regulation by taxation, (2) regulation by reduced access, and (3) regulation by increased awareness of potential harm. To what extent are these means for tobacco control effective?
7. Describe five health benefits that result from quitting smoking.
360 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
nicotine gum on short-term memory. Psychopharmacology, 140, 429–433.
22. Brecher, Edward M.; and the editors of Consumer Reports (1972). Licit and illicit drugs. Boston: Little, Brown, pp. 220–228. DiFranza, Joseph R. (2008, May). Hooked from the first ciga- rette. Scientific American, pp. 82–87.
23. Pontieri, Francesco E.; Tanda, Gianluigi; Orzi, Francesco; and DiChiara, Gaetano (1996). Effects of nicotine on the nucleus accumbens and similarity to those of addictive drugs. Science, 382, 255–257.
24. Herning, Ronald I.; Jones, Reese T.; and Fischman, Patricio (1985). The titration hypothesis revisited: Nicotine gum reduces smoking intensity. In John Grabowski and Sharon M. Hall (Eds.), Pharmacological adjuncts in smoking cessation (NIDA Research Monograph 53). Rockville, MD: National Institute on Drug Abuse, pp. 27–41. Jarvik, Murray E. (1979). Biological influences on cigarette smoking. In Norman A. Krasnegor (Ed.), The behavioral aspects of smoking (NIDA Research Monograph 26). Rockville, MD: National Institute on Drug Abuse, pp. 7–45.
25. Schuckit, Marc A. (2000). Drugs and alcohol abuse: A clinical guide to diagnosis and treatment (5th ed.), pp. 262–269.
26. Koslowski, Lynn T.; Wilkinson, Adrian; Skinner, Wayne; Kent, Carl; Franklin, Tom; and Pope, Marilyn. (1989). Comparing tobacco cigarette dependence with other drug dependencies. Journal of the American Medical Association, 261, 898–901.
27. Centers for Disease Control and Prevention (2014, February 6). Fact Sheet: Tobacco-related mortality. Atlanta, GA: Centers for Disease Control and Prevention. Thun, Michael J.; Carter, Brian D.; Feskanich, Diane; Freedman, Neal D.; Prentice, Ross; et al. (2014). 50-year trends in smoking-related mortality in the United States. New England Journal of Medicine, 368, 351–364.
28. Howard, George; Wagenknecht, Lynne E.; Burke, Gregory L.; Diez-Roux, Ana; et al. (1998). Cigarette smoking and pro- gression of atherosclerosis. Journal of the American Medical Association, 279, 119–124. U.S. Department of Health and Human Services, Public Health Service, Office of Smoking and Health (1983). The health consequences of smoking: Cardiovascular disease (A report of the surgeon general) Rockville, MD: U.S. Public Health Service, pp. 63–156.
29. American Lung Association (2014). Chronic obstructive pulmonary disease (COPD) Fact Sheet. Chicago, IL: American Lung Association. Gold, Diane R.; Wang, Xiaobin; Wypij, David; Speizer, Frank E.; Ware, James H.; et al. (1996). Effects of cigarette smoking on lung function in adolescent boys and girls. New England Journal of Medicine, 335, 931–937. U.S. Department of Health and Human Services, Public Health Service, Office of Smoking and Health (1984). The health consequences of smoking: Chronic obstructive lung disease (A report of the surgeon general). Rockville, MD: U.S. Public Health Service, pp. 329–360.
30. American Cancer Society (2007). Tobacco and cancer. Atlanta, GA: American Cancer Society. American Lung Association (2015). Lung cancer Fact Sheet. Chicago, IL: American Lung Association. Denissenko, Mikhail F.; Pao, Annie; Tang, Moon- Shong; and Pfeifer, Gerd P. (1996). Preferential formation of benzopyrene adducts at lung cancer mutational hotspots in P53. Science, 274, 430–432. Landi, Maria T.; Dracheva, Tatiana; Rotunno, Melissa;, Figueroa, Jonine D.; et al. (2008). Gene expression signature of cigarette smoking and its role in
lung adenocarcinoma development and survival. PLoS ONE, published online February 20, 2008, by the Public Library of Science, San Francisco, CA.
31. Freedman, Neal D.; Silverman, Debra. T.; Hollenbeck, Albertt R.; Schatzkin, Arthur; and Abnet, Christian C. (2011). Association between smoking and risk of bladder cancer among men and women. Journal of the American Medical Association, 306, 737–745. Schuckit, Drug and alcohol abuse, pp. 270–272.
32. Ebrahim, Shahul H.; Floyd, R. Louise; Merritt II, Robert K; Decoufle, Pierre; and Holtzman, David (2000). Trends in pregnancy-related smoking rates in the United States, 1987–1996. Journal of the American Medical Association, 283, 361–366. Geerts, Caroline C.; Grobbee, Diederick E.; van der Ent, Cornelis K; de Jong, Brita M.; et al. (2007). Tobacco smoke exposure of pregnant mothers and blood pressure in their newborns. Hypertension, 50, 572–578. Li, Yu-Fen; Langholz, Bryan; Salam, Muhammad T.; and Gilliland, Frank D. (2005). Maternal and grandmaternal smoking patterns are associated with early childhood asthma. Chest, 127, 1232–1241.
33. Aligne, C. Andrew; Moss, Mark E.; Auinger, Peggy; and Weitzman, Michael (2003). Association of pediatric dental caries with passive smoking. Journal of the American Medical Association, 289, 1258–1264.
34. U.S. Department of Health and Human Services, Public Health Service, Office of Smoking and Health (2006). The health consequences of involuntary exposure to tobacco smoke (A report of the surgeon general). Rockville, MD: U.S. Public Health Service.
35. Centers for Disease Control and Prevention (2014, November 28). Current cigarette smoking among adults— United States, 2005–2013. Morbidity and Mortality Weekly Report, 63, 1108–1112. Johnston, Lloyd M.; O’Malley, Patrick M.; Bachman, Jerald G.; Schulenberg, John E.; and Miech, Richard A. (2014). Monitoring the future: National survey results on drug use, 1975–2013, Vol II: College students and adults ages 19–55. Ann Arbor, MI: Institute for Social Research, University of Michigan, Table 2-3.
36. Johnston; O’Malley; Bachman; Schulenberg; and Miech, Monitoring the future, Vol. II, Tables 2-3 and 2-4.
37. Johnston Lloyd M.; O’Malley, Patrick M.; and Bachman, Jerald G. (2002, December 16). Teen smoking declines sharply in 2002, more than offsetting large increases in early 1990s. University of Michigan News and Information Services, Ann Arbor, pp. 4–5. Johnston, Lloyd M.; O’Malley, Patrick M.; Bachman, Gerald G.; Schulenberg, John E.; and Miech, Richard A. (2014). Monitoring the future: National survey results on drug use, 1975–2013, Vol I: Secondary school students. Ann Arbor, MI: Institute for Social Research, University of Michigan, Tables 8-1 and 8-4.
38. Davis, Kevin C.; Grimshaw, Victoria; Merriman, David; Farrelly, Matthew C.; Chernick, Howard;, et al. (2013, December 11). Cigarette trafficking in five northeastern US cities. Published online in Tobacco control. doi:10.1136tobaacocontrol-2013-051244.
39. Johnston; O’Malley; Bachman; Schulenberg; and Miech, Monitoring the future, Vol. I, Table 9-6. Substance Abuse and Mental Health Services Administration (2014, August 14). SAMHSA News Release: State/federal effort to reduce illegal tobacco sales to minors remains effective. Substance Abuse and Mental Health Administration, Rockville, MD. Substance
Chapter 16 Nicotine and Tobacco Use ■ 361
51. Jolly, David (2014, February 27). Europe putting e-cigarettes under strict regulations. New York Times, pp. B1, B2. Lipton, Eric (2014, July 23). Officials focus on e-cigarette ads aimed at youths. New York Times, p. A15. Virtanen, Michael (2013, January 1). New state laws include ban on e-cigarettes. Newsday, p. A5.
52. World Health Organization (2008). The WHO report on the global tobacco epidemic 2008: The MPOWER package. Geneva, Switzerland: World Health Organization.
53. Hampton, Tracy (2008, April 2). Global report highlights tobacco use, offers countermeasures for nations. Journal of the American Medical Association, 299, 1531–1552.
54. Marsh, Bill (2008, February 24). A growing cloud over the planet. New York Times, p. 4. Reeves, Hope (2000, November 5). Blowing smoke: What’s one little worldwide antismoking treaty compared to the force of 1.1 billion nicotine-craving cigarette fiends? New York Times Magazine, p. 26. Shafey, Omar; Eriksen, Michael; Ross, Hana; and MacKay, Judith (2009). The tobacco atlas (3rd.ed.). Atlanta: American Cancer Society, pp. 22–23. World Health Organization (2008). WHO report on the global tobacco epidemic.
55. Brazil slashes smoking rates (2012, December 19). Journal of the American Medical Association, 308, 2449.
56. Based on information from the American Cancer Society, Atlanta. Cited in The world almanac and book of facts 2000 (1999). Mahwah, NJ: Primedia Reference, p. 733. Jha, Prabhat; Ramasundarahettige, Chinthanie; Landsoman, Victoria; Rostron, Brian; Thun, Michael; et al. (2014). 21st-cenury hazards of smoking and benefits of cessation in the United States. New England Journal of Medicine, 368, 341–350.
57. U.S. Department of Health and Human Services, Public Health Service, Office of Smoking and Health (1988). The health consequences of smoking: Nicotine addiction (A report of the surgeon general). Rockville, MD: Public Health Service, p. 9.
58. American Legacy Foundation (2003). Fact Sheet: Quitting smoking. Washington, DC: American Legacy Foundation. Rigotti, Nancy (2012). Strategies to help a smoker who is struggling to quit. Journal of the American Medical Association, 308, 1573–1580. Lindson-Hawley, Nicola; Aveyard, Paul; and Hughes, John R. (2013). Gradual reduc- tion vs. abrupt cessation as a smoking cessation strategy in smokers who want to quit. Journal of the American Medical Association, 310, 91–92.
59. Ahluwalia, Jasjit S.; Harris, Kari Jo; Catley, Delwyn; Okuyemi, Kolawole S.; and Mayo, Matthew S. (2002). Sustained-release bupropion for smoking cessation in African Americans: A randomized controlled trial. Journal of the American Medical Association, 288, 468–474. Jain, Anjali (2003). Treating nicotine addiction. British Medical Journal, 327, 1394–1395. Zickler, Patrick (2003). Genetic variation may increase nicotine craving and smoking relapse. NIDA Notes, 18(3), 1, 6.
60. Nides, Mitchell; Oncken, Cheryl; Gonzales, David; Rennard, Stephen; Watsky, Eric J.; et al. (2006). Smoking cessation with varenicline, a selective alpha-4-beta-2 nicotinic receptor partial agonist. Archives of Internal Medicine, 166, 1561–1568.
61. Franzon, Mikael; Gustavsson, Gunnar; and Korberly, Barbara H. (2002). Effectiveness of over-the-counter nicotine replace- ment therapy. Journal of the American Medical Association,
Abuse and Mental Health Services Administration (2014). FFY 2013 Annual Synar Reports. Rockville MD: Substance Abuse and Mental Health Services Administration.
40. Strom, Stephanie (2014, February 6). CVS vows to quit selling tobacco products. New York Times, p. B1.
41. Editorial: “Warning: Smoking can kill you.” (2012, August 28). New York Times, p. A22. Siegel, Matt (2013, July 11). Labels leave a bad taste. New York Times, pp. B1, B4.
42. Johnston; O’Malley; Bachman; Schulenberg; and Miech, Monitoring the future, Vol. I, Table 2-3.
43. Freedman, Alix M. (1994, October 26). How a tobacco giant doctors snuff brands to boost their “kick.” Wall Street Journal, pp. A1, A14.
44. U.S. Department of Health and Human Services, Public Health Service, Office of Smoking and Health (1986). The health consequences of smokeless tobacco (A report of the advi- sory committee to the surgeon general). Rockville, MD: Public Health Service. Wilson, Duff and Creswell, Julie (2010, January 31). Where there’s no smoke, Altria hopes there’s fire. New York Times, pp. B1, B5.
45. Hamilton, Kendall (1997, July 21). Blowing smoke. Newsweek, pp. 54–60.
46. Ackerman, Elise (1999, November 29). The cigar boom goes up in smoke. Newsweek, p. 55. Baker, Frank; et al. (2000). Health risks associated with cigar smoking. Journal of the American Medical Association, 284, 735–740. Substance Abuse and Mental Health Administration (2001, December 21). The NHSDA report: Cigar use. Rockville, MD: Office of Applied Studies, Substance Abuse and Mental Health Administration.
47. Centers for Disease Control and Prevention. Fact Sheet on cigars. www.cdc.gov/tobacco/data_statistics/fact_sheets/ tobacco_industry/cigars/ (accessed April 14, 2014). Chen, Jiping; Ketermann, Anna; Rostron, Brian L.; and Day, Hannah R. (2014). Biomarkers of exposure among U.S. cigar smokers: An analysis of 1999–2012 National Health and Nutrition Examination Survey (NHANES) data. Cancer, Epidemiology, Biomarkers, and Prevention. Published online first November 7, 2014; doi: 10.1158/1055-EPI14-0849.
48. Centers for Disease Control and Prevention (2013, November 13). Tobacco product use among middle and high school students—United States, 2011 and 2012. Morbidity and Mortality Weekly Report, 62, 893–897. King, Brian A.; Tynan, Michael A.; Dube, Shanta R.; and Arrazola, Rene (2014). Flavored-little-cigar and flavored-cigarette use among U.S. middle and high school students. Journal of Adolescent Health, 54, 40–46.
49. Alderman, Liz (2013, June 13). E-cigarettes at a crossroads. New York Times, pp. B1, B7. Elliott, Stuart (2013, August 30). E-cigarette markers’ ads echo tobacco’s heyday. New York Times, pp. B1, B5. Meier, Barry (2014, April 17). E-cigarette study data may raise concerns. New York Times, pp. B1, B6. Richtel, AMatt (2014, July 16). E-cigarettes’ fruit cocktails: Makers in an arms race for vapor flavors. New York Times, pp. B1, B2.
50. Meier, Barry (2014, December 25). Race to deliver nicotine’s punch, with less risk. New York Times, p. A1. Richtel, Matt (2014, March 24). Selling a poison by the barrel: Liquid nicotine for e-cigarettes. New York Times, pp. A1, A3. Richtel, Matt (2014, May 4). Some e-cigarettes deliver a puff of carcinogens. New York Times, pp. A1, A4.
362 ■ Part Four On the Margins of Criminal Justice: Regulating Legal Drugs
services would save 100,000 lives each year. Washington, DC: Partnership for Prevention, National Commission on Prevention Priorities.
64. Lerman, Caryn; Schnoll, Robert A.; Hawk, Larry W.; Cinciripini, Paul; et al. (published online, 2015, January 11). Use of nicotine metabolite ratio as a genetically informed biomarker of response to nicotine patch or varenicline for smoking cessation: a randomized, double-blind placebo- controlled trial. Lancet Respiratory Medicine. http://dx.doi. org/10.1016/S2213-2600(14)70294-2.
65. Goldman, Lisa K.; and Glantz, Stanton A. (1999). Evaluation of antismoking advertising campaigns. Journal of the American Medical Association, 279, 772–777. Raising kids who don’t smoke (2003), created by Philip Morris USA Youth Smoking Prevention. Story, Louise (2007, January 2). Kicking an addiction, with real people. New York Times, p. C7. Two questions to identify future smokers (2008, July 15). New York Times, p. F6.
288, 3108–3110. Mathias, Robert (2001). Nicotine patch helps smokeless tobacco users quit, but maintaining abstinence may require additional treatment. NIDA Notes, 16(1), 8–9. Shiffman, Saul; Dresler, Carolyn M.; and Rohay, Jeffrey M. (2004). Successful treatment with a nicotine lozenge of smok- ers with prior failure in pharmacological therapy. Addiction, 99, 83–92.
62. Fiore, Michael C.; Hatsukami, Dorothy K.; and Baker, Timothy, B. (2002). Effective tobacco dependence treatment. Journal of the American Medical Association, 288, 1768–1771. Spangler, John G.; George, Geeta; Foley, Kristie Long; and Crandall, Sonia J. (2002). Tobacco intervention training: Current efforts and gaps in U.S. medical schools. Journal of the American Medical Association, 288, 1102–1109.
63. McAfee, Tim (2013). Encouraging smokers to talk with their physicians about quitting. Journal of the American Medical Association, 309, 2329–2330. Partnership for Prevention (2008). New study: Boosting five preventive
Substance Abuse Prevention and
Treatment Daniel and I sat together in the lounge of Daytop Village. Daniel was
23 years old and a recovering multiple substance abuser. I asked him
what it was like being into drugs and how it was that he came to
Daytop for treatment. He leaned over to tell me a little about his per-
sonal story:
“This is the short version,” Daniel began, “I would lie about
everything, absolutely everything, and I lied to everybody. I was so
good at it because it was so easy to do. My parents were in major
denial, and I played off of that big time. What is all that drug stuff
in my room? Oh, I’m just holding it for a friend. It would get me so
angry that the lies worked so well with them. They would never call
me on anything.”
“Drugs became a way of life. And after a while I got sick and
tired of all the lying. And I started to think long and hard about the
possibility that I might be dead at an early age. Last year, a friend
of mine died; a couple of guys I know are in jail. That’s why I came
here to get help. I had to change somehow. It really just came
down to that. It was all about change…all about change.”
After you have completed this chapter, you should have an understanding of the following:
●● Primary, secondary, and tertiary prevention as three levels of intervention
●● The concept of resilience in substance abuse prevention
●● Substance abuse prevention in the context of public health
●● Approaches to substance abuse prevention that have failed in the past
●● Successful school-based substance abuse prevention programs
●● Community-based preven- tion and the impact of mass media
●● The importance of family systems in substance abuse prevention
●● Substance abuse prevention in the workplace
●● Substance abuse treatment programs and the concept of stages of change
PA r t F i v e
Drug-Control Policy and Intervention
Strategies
17chapter
364 ■ Part Five Drug-Control Policy and Intervention Strategies
intervention has its own target population and specific goals. By definition, primary prevention, secondary prevention, and tertiary prevention populations vary according to the extent of prior drug use.
●■ In primary prevention, efforts are directed to those who have not had any experience with drugs or those who have been only minimally exposed. The objective is to prevent substance abuse from starting in the first place, “nipping the problem in the bud” so to speak. Targets in primary prevention programs are most frequently elementary school or middle school youths, and intervention usu- ally occurs within a school-based curriculum or specific educational program, though community involvement is encouraged. For example, a primary prevention program would include teaching peer-refusal skills that students can use when offered marijuana, alcohol, or cigarettes (“ways to say no”).
●■ In secondary prevention, the target population has already had some experience with alcohol, nicotine, and other drugs. The objective is to limit the extent of substance abuse (reducing it, if possible), prevent its spread of abuse behavior beyond the drugs already encountered, and teach strategies for the responsible use of alcohol if the legal minimum age has been met. Ordinarily, those individuals receiving secondary prevention efforts are older than those involved in primary prevention programs. High school students who are identified as alcohol or other drug users, for example, may participate in a program that emphasizes social alternatives (after-school programs, sports, etc.) to drug-taking behavior. College students may focus on the skills necessary to restrict their behavior to the moderate use of alcohol, the significant dangers of combining drink- ing and driving, and the signs of chronic alcohol abuse. Secondary prevention efforts are consistent with the phi- losophy of harm reduction rather than zero tolerance of drug-taking behavior (Drugs . . . in Focus).
●■ In tertiary prevention, the objective is to ensure that an individual who has entered treatment for some form
In this final chapter, we turn to drug-control policies and interventions related to prevention and treatment. Before we begin, however, it is important to be reminded once again that drug-taking behavior encompasses a wide range of potentially abusable substances. They include illicit drugs, alcohol, and nicotine, as well as prescription and nonpre- scription medications.
It is useful to use the phrases substance abuse prevention and substance abuse treatment, so we can focus on preven- tion and treatment strategies that can be applied to problems associated with the entire range of abusable drugs—including illicit drugs, prescription and nonprescription medications, alcohol, and nicotine. As we will see, the principles of effective substance abuse prevention and substance abuse treatment programs have been adapted to deal with a number of behav- ioral problems such as excessive eating and gambling as well as high-risk social behaviors such as unsafe driving, unsafe sex, and delinquency in general. We begin with issues associated with prevention.
Levels of Intervention in Substance Abuse Prevention
Substance abuse prevention can be considered in terms of three types of intervention. We will refer to them as primary, secondary, and tertiary levels of intervention. Each level of
primary prevention: A type of intervention in which the goal is to forestall the onset of drug use by an individual who has had little or no previous exposure to drugs.
secondary prevention: A type of intervention in which the goal is to reduce the extent of drug use in individuals who have already had some exposure to drugs.
tertiary (ter-shee-eh-ree) prevention: A type of interven- tion in which the goal is to prevent relapse in an individual following recovery in a drug treatment program.
22.7 million Estimated number of individuals aged 12 or older in the United States who needed treatment for a problem with alcohol or illicit drugs in 2013
2.5 million Estimated number of individuals who received such treatment in 2013 89 Percentage of individuals needing treatment but not receiving it in 2013 $4–$7 Estimated reduction in the cost of drug-related crime, criminal justice costs, and theft alone for every $1 invested
in substance-abuse treatment programs. When savings related to health care are included, total savings exceed costs by a ratio of 12 to 1.
Sources: National Institute on Drug Abuse (2009, April). Principles of drug addiction treatment: A research-based guide (2nd ed.). Rockville, MD: National Institute on Drug Abuse, p. 13. Center for Behavioral Health Statistics and Quality (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, pp. 92–98.
Numbers Talk…
Chapter 17 Substance Abuse Prevention and Treatment ■ 365
had significant drug experiences of their own. We recognize that the potential for young people to engage in drug use themselves is substantial, and only through an effective pri- mary prevention can we keep that potential from turning into reality. It is increasingly clear that the age of onset for drug- taking behavior of any kind is a key factor in determining problems later in life, particularly with respect to licit drugs. For example, a young person who begins drinking before the age of 15 is twice as likely to develop a pattern of alcohol abuse and four times as likely to develop alcohol dependence
of substance abuse or substance dependence problem becomes drug free after treatment has ended, without reverting to former patterns of drug-taking behavior. Successful prevention of relapse is the ultimate indication that the treatment has taken hold. Issues related to tertiary prevention will be reviewed later in the chapter.
In the case of primary prevention, we are assuming that the target population for these interventions may have been exposed to drug-taking behavior in other people but have not
National Drug-Control Policy and the War on Drugs From time to time in our nation’s history, the metaphor of war has been invoked to carry the emotional significance of a domestic or international crisis, even when we are not waging war in the traditional sense. President Lyndon Johnson announced a “War on Poverty” in 1964 to convey the importance of creating a Great Society. President George W. Bush called on the nation in late September of 2001 to fight a “War on Terror” on an international scale. When President Richard Nixon described drug abuse as America’s “Public Enemy No. 1” and declared a “War on Drugs” in 1971, it was metaphorically a call to arms.
The rhetoric of “waging a War on Drugs” has diminished, but we still find ourselves drawing upon metaphors that relate to war. In primary prevention, for example, we speak of engaging in the first line of defense against a powerful enemy. Antidrug pro- motional materials that deglamorize drug-taking behavior have been criticized as merely “magic bullets” in this fight. Protective factors in an individual’s life are viewed as a kind of body armor against the onslaught of circumstances (risk factors) that increase the likelihood of substance abuse in the future. Resilience is mea- sured by the extent to which young people emerge victorious.
In secondary prevention, we speak of engaging in a second line of defense. We are now addressing an older population for whom some level of drug-taking behavior has already taken place. Prevention programs for high school students focus on “tactical maneuvers” such as providing social alternatives to alcohol and other drugs. Prevention programs for college stu- dents emphasize the moderate use of alcohol as opposed to no use at all. In this case, we employ a strategy of harm reduction.
Does the government have the right to issue a “War on Drugs” declaration in the first place? The nineteenth-century British philosopher, John Stuart Mill, argued that the state (meaning the government) does not have the right to intervene in order to protect individual adult citizens from harming themselves. The government does have the right, however, to intervene when there is harm done to others as a consequence. As Mill expressed it,
The only purpose for which power can be rightfully executed over any member of a civilized community, against his will, is to prevent
Drugs … in Focus
harm to others. His own good, either physical or moral, is not a suf- ficient warrant . . . Over himself, over his own body and mind, the individual is sovereign..
By this standard, governmental intervention with respect to drug- taking behavior among adults is justified. Clearly, drug-taking behavior causes harm to other people.
The nature of governmental intervention for adults in the United States has been an evolving story over the course of American history. Metaphorically speaking, the present-day national drug-control policy can no longer be characterized as an all-out “War on Drugs” but rather as a series of military campaigns utilizing a zero tolerance approach, a harm reduction approach or a combination of both, depending on the psychoac- tive substance. The campaign with respect to alcohol use places its primary focus on harm reduction rather than zero tolerance. The campaign with respect to tobacco smoking uses a hybrid approach of zero tolerance (lowering the prevalence rate of tobacco use) and harm reduction (minimizing the adverse effects of secondhand smoke). The campaigns with respect to other sub- stances, such as heroin, cocaine, and methamphetamine, center on zero tolerance exclusively. In the case of marijuana, however, the nature of governmental intervention remains highly contro- versial. As detailed in Chapter 12, the U.S. federal government has maintained the position of zero tolerance, while many states and communities have not. The conflict remains to be resolved.
Sources: Denning, Patt (2003). Over the influence: The harm reduction guide for managing drugs and alcohol. New York: Guilford Press. Des Jarlais, Don C. (2000). Prospects for a public health perspective on psychoactive drug use. American Journal of Public Health, 90, 335–337. How did we get here? History has a habit of repeating itself (2001, July 28–August 3). Economist, pp. 4–5. Quotation of John Stuart Mill on p. 5. Levinthal, Charles F. (2003). Question: Should harm reduction be our overall goal in fighting drug abuse? Point/Counterpoint: Opposing perspec- tives on issues of drug policy. Boston: Allyn and Bacon, pp. 70–73. Marlatt, G. Alan (Ed.) (2002). Harm reduction: Pragmatic strate- gies for managing high-risk behaviors. New York: Guilford Press. Resnicow, Ken; Smith, Matt; Harrison, Lana; and Drucker, Ernest (1999). Correlates of occasional cigarette and marijuana use. Are teens harm reducing? Addictive Behaviors, 24, 251–266.
366 ■ Part Five Drug-Control Policy and Intervention Strategies
a division of the U.S. Department of Health and Human Services. According to CSAP guidelines, substance abuse prevention is accomplished through two principal efforts. The first is the promotion of constructive lifestyles and norms that discourage substance abuse. The second is the devel- opment of social and physical environments that facilitate drug-free lifestyles so that they can act as buffers against the development of substance abuse behaviors.
You may recall from Chapter 5 that two groups of factors play a major role in predicting the extent of drug- taking behav- ior in a particular individual: (1) risk factors that increase the likelihood of drug-taking behavior and (2) protective factors that decrease it. You can think of the goals of substance abuse prevention in those terms. The optimal substance abuse prevention program will be effective in reducing the impact of risk factors in an individual’s life and, at the same time, enhancing the impact of protective factors.
Resilience and Primary Prevention Efforts Successful primary prevention programs are built around the central idea that an individual is less inclined to engage in substance abuse if the protective factors in his or her life are enhanced and the risk factors are diminished. Only then can a young person be resilient enough to overcome the temptations of alcohol, tobacco, and other drugs. Resilience, defined as the inclination to resist the effect of risk factors through the action of protective factors, can be a make-or- break element in one’s social development. The promotion of positive social skills and the encouragement of a proactive rather than a passive approach to problem solving enhance the “buffering effect” of protective factors with respect to drug-taking behavior and other forms of deviant behavior. Since a young population is the principal target for primary prevention, programs are customarily implemented in the school. To be most effective, however, it is necessary to incor- porate aspects of a young person’s life outside of school. In a later section, we will turn to primary prevention programs that involve the community at large.2
Measuring Success in a Substance Abuse Prevention Program Evaluating the success or failure of a substance abuse pre- vention program is more complicated than people often think. In the public mind, a school-based substance abuse prevention program might be considered successful, for example, if it enjoys support from parents, administrators, and teachers. There might be a long list of testimonials among participants as to their belief that they have benefit- ted from the program. It might be considered successful if there is evidence of a change in a child’s view away from drug use or a change in a child’s stated inclination to engage in drug use in the future. If a child develops a non-drug life- style, people might automatically assume that it was due to exposure to a substance abuse prevention program.
than an individual who begins drinking at the age of 21. In general, if the age of onset can be delayed significantly or even moderately, there is the possibility of reducing the inci- dence of substance abuse or dependence.1
In the case of secondary prevention, we are concentrat- ing on the lifestyle of a somewhat older population, and our goal is to minimize the problems associated with drug-taking behavior, assuming that some level of that behavior already exists. Emphasis is placed on social alternatives to behav- iors involving alcohol and other drugs among high school students. At the college level, the moderate use of alcohol, and particularly the avoidance of alcohol binging, as well as education about the personal risks of designer synthetic drugs and the nonmedical use of prescription medications, are all elements in a program of secondary prevention.
Strategies for Substance Abuse Prevention
The U.S. federal agency specifically charged with preven- tion programs is the Center for Substance Abuse Prevention (CSAP), a division of the Substance Abuse and Mental Health Services Administration (SAMHSA), which is in turn
Quick Concept Check
Understanding Levels of Intervention in Substance Abuse Prevention Programs Check your understanding of the three basic levels of interven- tion in drug-abuse prevention by matching the following five sce- narios with (a) primary, (b) secondary, or (c) tertiary prevention.
1. Midnight basketball sessions keep teenagers from drinking on weekends out of boredom.
2. Young children receive lessons on how to refuse the offer of drugs from a friend or acquaintance.
3. A child learns about “good drugs” and “bad drugs” in the first grade.
4. A man learns how to live without cocaine following a successful cocaine treatment program.
5. College students organize a “responsible drinking” program on campus.
Answers: 1. b 2. a 3. a 4. c 5. b
17.1
resilience: The inclination to resist the negative impact of risk factors in a person’s life through the positive impact of protective factors. Sometimes referred to as resiliency.
Chapter 17 Substance Abuse Prevention and Treatment ■ 367
As we will see, effective school-based prevention programs do exist, but the overall effectiveness is enhanced when there is a combination of education and community action.
●■ Priority II—Healing America’s drug users. Efforts toward substance abuse treatment and tertiary prevention of drug-taking behavior have been substantial. In 2003, for example, a federal “voucher program” was instituted for people in need of treatment for services that could be obtained in a variety of contexts, including emergency departments in hospitals, health clinics, the criminal jus- tice system, schools, or the faith community. In addition, drug court programs were expanded to provide treat- ment, mandatory drug testing, and vigorous aftercare ser- vices to help sustain drug-abuse recovery. Despite these programs, however, a wide disparity exists between those who need substance abuse treatment and those who receive it.
●■ Priority III—Disrupting the market. Attacking the eco- nomic basis of the drug trade, from the cultivation of raw materials for illicit drugs and drug trafficking on domes- tic and international levels to the sale of illicit drugs at the local level, forms the “supply side” approach to the drug-abuse problem. Chapter 2 reviewed the complexi- ties of the global illicit drug trade and the difficulties involved in reducing its influence on drug-taking behav- ior at home. Chapters 7 and 8 addressed efforts to reduce the extent of illicit drug-taking behavior through law enforcement and the criminal justice system. Chapters 15 and 16 covered our continuing efforts to reduce the sale of alcohol and tobacco to individuals below legally defined age limits.
Substance Abuse Prevention and Public Health Policy It is important to recognize that a drug-free life constitutes a major element in a healthy life and, in turn, a healthy society. Figure 17.1 shows dramatically how substance abuse impacts
However gratifying these positive outcomes may be to the community and however persuasive they might be to the general public, they do not impact on the core issue: Is the prevalence of substance abuse reduced as a result of the pro- gram? The goal of any prevention program, particularly a pri- mary prevention program aimed at young people, is to lower the numbers of new drug users or to delay the first use of alcohol and tobacco toward an age at which they are considered adults. To be considered “evidence-based,” primary prevention pro- grams must be evaluated against a control group that did not receive the intervention; otherwise, it is impossible to deter- mine whether the effect of the program itself was greater than doing nothing at all. Positive change per se is not enough. For example, if drug use among eighth graders has declined as a result of a prevention program but this decline is not greater than a decline among eighth graders in the control group, then the prevention program is essentially ineffective. Secondary prevention programs are judged to be effective by a similar comparison against a control group. When success- ful prevention programs are reviewed later in this chapter, their effectiveness will have been measured by this rigorous “yardstick” of performance. The effectiveness of substance abuse treatment programs must be evaluated in the same way.
Substance Abuse Prevention in the Context of National Drug-Control Policy The overall national policy for the control of drug use in the United States is coordinated by the Office of National Drug Control Policy (ONDCP). Based upon a 2015 bud- get of $25.5 billion, three major priorities have been set as a guide for ONDCP programs. Two of the three priorities established as components of a national drug-control strategy pertain specifically to substance abuse prevention.3
●■ Priority I—Stopping drug use before it starts. Primary pre- vention programs are essentially the first line of defense against substance abuse problems among young people.
Illicit drugs 2%
Diet/activity 32%Motor vehicles 4%
Sexual behavior 2%
Firearms 3%
Toxic agents 5%
Microbial agents 7% Tobacco 38%
Alcohol 7%
F igure 17 .1
The relative incidence of preventable deaths annually in the United States.
Source: Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, Rockville, MD.
368 ■ Part Five Drug-Control Policy and Intervention Strategies
Prevention Approaches That Have Failed
When deciding how to solve a problem, it always helps to look at what has not worked in the past. That way, we can avoid wasting time, effort, and money on programs that do not work. In the general opinion of health professionals and researchers, the following efforts have been largely unsuccess- ful with regard to primary prevention, when positioned as the major thrust of a particular program. Nonetheless, some of these approaches have been incorporated successfully as one of several components within an overall effective package.
Reducing the Availability of Drugs It is reasonable to expect that problems of illicit drug abuse could be prevented if the availability of these drugs were reduced or eliminated altogether. This is essentially the “supply/availability” argument in drug prevention and con- stituted approximately 57 percent of the federal budget on drug control in fiscal year 2015.7
the nation’s health in general. As you can see, about one-half of all preventable deaths in the United States are accounted for by the abuse of alcohol products (7%), tobacco products (38%), or illicit drugs (2%). Each year, well over a half- million deaths are attributed to these three circumstances (Drugs . . . in Focus).4
In addition, the monetary impact is immense, with the estimated costs of substance abuse exceeding $1 trillion each year. Some of these costs are incurred through acci- dents, crime, academic underachievement from underage drinking ($64 billion), drug-related hospital emergency visits ($4 billion), incarceration of individuals committing drug-law offenses ($30 billion), alcohol-related workplace injuries and absenteeism ($28 billion), and DWI-related collisions on highways ($230 billion). More than $18 could be saved for every dollar spent on effective school- based prevention programs.5 It should not be surprising that when the U.S. Public Health Service established in the 1990s a comprehensive, national health promotion and disease prevention agenda in a program called Healthy People 2000 (now updated to Healthy People 2020), a major component was devoted to behaviors related to sub- stance abuse.6
the Public Health Model and the Analogy of infectious Disease Control The idea that reducing the negative consequences of drug- taking behavior is a desirable goal for the enhancement of the overall health of society is often referred to as the Public Health Model. As Avram Goldstein, a prominent drug-abuse researcher and policy analyst, has pointed out, the problems of reducing drug-taking behavior have many similarities to wresting control over an infectious disease. A virus, for example, infects some people who are relatively more suscep- tible than others (in other words, there are risk factors), while some people will be relatively immune (in other words, there are protective factors). Public health measures can be estab- lished to reduce or eradicate the virus (just as we attempt to reduce the supply of illicit drugs from reaching the consumer); specific vaccinations can be discovered to increase a person’s resistance to the virus (just as we search for effective primary prevention programs in drug abuse).
We can carry the analogy further. Medical treatment for an infectious disease is considered uncontroversial and neces- sary for two reasons. First, we are alleviating the suffering of the infected individual; second, we are reducing the pool of
Drugs … in Focus
infection to limit the spread to others. Analogously, drug-abuse treatment is desirable to relieve the negative consequences of drug abuse, as well as reduce the social influence of drug abus- ers on nondrug abusers in our society.
Goldstein asks a provocative question:
There are individuals who contribute to the AIDS epidemic by having promiscuous sexual contacts without taking elementary precautions. Are those behaviors, which contribute to the spread of infectious disease, really different in principle from that of pack-a-day cigarette smokers who will not try to quit, despite all the evidence of physical harm to themselves and their families?
There is certainly no consensus on how the problem of drug abuse should be conceptualized. Some have objected to the implications of the Public Health Model, arguing that it ignores the moral and ethical choices that are made in establishing a pattern of drug-taking behavior. You may recognize a similar controversy, discussed in Chapter 15, regarding the question of whether alcoholism should be considered a disease.
Sources: Goldstein, Avram (1994). Addiction: From biology to drug policy. New York: Freeman. Quotation on p. 10. Jonas, Steven (1997). Public health approaches. In Joyce H. Lowinson; Pedro Ruiz; Robert B. Millman; and John G. Langrod (Eds.), Substance abuse: A comprehensive textbook. Baltimore, MD: Williams & Wilkins, pp. 775–785.
Chapter 17 Substance Abuse Prevention and Treatment ■ 369
abuse illicit drugs for fear of being arrested, prosecuted, con- victed, and incarcerated. The available statistics show that this deterrent factor has failed to take hold. The enticements of many psychoactive drugs are extremely powerful, and the imposition of harsh penalties has frequently been delayed or inconsistent. Mandatory minimum-sentencing laws (see Chapter 8) have resulted in a clogged judicial system and vastly overcrowded prisons, without any noticeable dent in the trafficking in or consumption of illicit drugs. Although the enforcement of these penalties may be defended in terms of an overall social policy toward illicit drugs, it has evidently failed as a means for either primary or secondary prevention.10
Scare Tactics and Negative In the late 1960s, the suddenly widespread use of marijuana, amphetamines, barbiturates, LSD, and other hallucinogens, first among students on college campuses and later among youth at large, spawned a number of hastily designed programs based on the arousal of fear and exaggerated or blatantly inac- curate information about the risks involved. They were the products of panic rather than careful thought.
As might be imagined, such efforts turned young people off precisely at the time when they were turning themselves on to an array of exotic and seemingly innocuous drug-taking experiences. Professionals have called it the “reefer madness approach,” an allusion to the government-sponsored movie of the 1930s that attempted to scare people away from experi- menting with marijuana (see Chapter 12). These programs accomplished little, except to erode even further the cred- ibility of the adult presenters in the eyes of youths who often knew (or thought they knew) a great deal more about drugs and their effects than their elders.11
Objective Information Approaches At the opposite end of the emotional spectrum are pro- grams designed to present information about drugs and their potential dangers in a straightforward, nonjudgmental way. Unfortunately, evaluations of this “just the facts, ma’am” approach have found that youths exposed to such primary prevention programs are no less likely to use drugs later in their lives and sometimes are more likely to use them. These programs tend to increase their curiosity about drugs in general, obviously something the program planners want to avoid.12
Despite these failures, however, it would be a mistake to dismiss the informational aspect of any substance abuse pre- vention program completely out of hand, particularly when the information is presented in a low-fear atmosphere.13 The overall value of an informational approach appears to depend on whether the target population consists of high-risk or low-risk children. When low-risk young people are pre- sented with drug-related information, the evidence indicates that they really understand the dangers and the chances of remaining drug free are increased. High-risk youth, on the
According to the economic principle of supply and demand, however, a decline in supply or availability works to produce an increase in value and an increase in demand. If one accepts the first viewpoint, then reductions in supply or availability should help prevent drug-taking behavior; if one accepts the second viewpoint, then such reductions should exacerbate the situation. Which theoretical viewpoint is oper- ating with respect to illicit drugs (or with respect to alcohol, tobacco, and other licit drugs) is a point of controversy among health professionals both inside and outside the government.
Given the fact that the United States has adopted the policy of reducing the supply or availability of illicit drugs as part of an overall national drug-control strategy, how success- ful have we been? Have we been able, for example, to reduce the production of illicit drugs around the world and their influx into the United States? Unfortunately, drug cultivation (such as the harvesting of opium, coca leaves, and marijuana) and the exportation of processed illicit drugs from their points of ori- gin are so deeply entrenched in many regions of the world and the resourcefulness of drug producers is so great that our global efforts have been frustratingly inadequate. As was pointed out in Chapter 2, a production crackdown in one region merely serves to create a marketing vacuum that another region quickly fills. Moreover, efforts to control international drug trafficking have been embarrassingly unsuccessful, despite well-publicized drug busts, arrests, and seizures. It is estimated that only a small frac- tion of illicit drugs is interdicted (intercepted) at U.S. borders.8
With respect to alcohol, a strategy of reduced availability has been implemented on a nationwide basis since 1984 for a specific age group, by prohibiting alcohol to young people under the age of 21 (see Chapter 15). Prior to this time, some states had adopted this policy, while neighboring states had not, allowing for comparisons in alcohol consumption rates and the incidence of alcohol-related automobile accidents. In one study, the percentage of teenage, nighttime, single- vehicle accident fatalities in Massachusetts was found to have declined in 1979 (the year the legal drinking age in that state was raised to 21) to a significantly greater degree than in New York, which at that time still had a minimum drinking age of 18. That was the good news.
The bad news was that levels of alcohol consumption in this age range stayed the same. Therefore, although one particular consequence of immoderate alcohol use (drunk driving) was reduced as a secondary prevention intervention, the prevalence of alcohol use itself as a result of a primary prevention inter- vention was unaffected. As we are all aware, underage drinking still is widespread; minors still find opportunities to drink and to drink in excess. The fact that minimum-age requirements have only a limited effect on drinking among minors reinforces the complexity of dealing with primary prevention, whether we are considering licit or illicit drugs.9
Punitive Measures There is a common expectation, when policies related to law enforcement and the criminal justice system are consid- ered, that an individual would be less inclined to use and
370 ■ Part Five Drug-Control Policy and Intervention Strategies
and poor interpersonal communication skills, programs were instituted that incorporated role-playing exercises with other assignments designed to help young people get in touch with their own emotions and feel better about themselves.
This effort, called affective education, was an attempt to deal with underlying emotional and attitudinal factors rather than specific behaviors related to drug use (in fact, alcohol, tobacco, and other drugs were seldom mentioned at all). Affective education was based on the observation that drug users had difficulty identifying and expressing emotions such as anger and love. In a related set of programs called values clarification, moral values were actively taught to children, on the assumption that they frequently had a poorly devel- oped sense of where their life was going and lacked a “moral compass” to guide their behavior.
Difficulties arose, however, when parents, community leaders, and frequently educators themselves argued that the emphasis of affective education was inappropriate for public schools. In regard to values clarification, there was concern that a system of morality was being imposed on students with- out respecting their individual backgrounds and cultures. This kind of instruction, it was felt, was more suited for faith- based education settings.16
Beyond these social considerations, the bottom line was that neither affective education nor values clarifica- tion was effective in preventing drug-taking behavior. Some researchers have recently questioned the basic premise that self-esteem is a major factor at all. As a result, affective issues are no longer viewed as central considerations in primary or secondary prevention. Nonetheless, they can be found as components in more comprehensive prevention programs that have been more successful.17
Components of Effective School-Based Prevention Programs
One of the major lessons to be learned from evaluations of previous substance abuse prevention efforts is that there is a far greater chance for success when the programs are multifaceted than when they focus on only a single aspect of drug-taking behavior. The following are elements of school- based, substance abuse prevention programs that have been shown to work.
Peer-Refusal Skills A number of school-based programs developed during the 1980s have included the teaching of personal and social skills as well as techniques for resisting various forms of social pressure to smoke, drink, or use other drugs (often referred to as peer-refusal skills). The emphasis is directed toward an indi- vidual’s relationships with his or her peers and the surround- ing social climate. Rather than simply prodding adolescents to
other hand, may not be so easily dissuaded, and additional intervention appears to be necessary.14
Magic Bullets and Promotional Campaigns A variety of antidrug promotional materials such as T-shirts, caps, rings, buttons, bumper stickers, posters, rap songs, school assembly productions, books, and brochures are available and frequently seen as “magic bullets” that can clinch success in substance abuse prevention programs. Their appeal lies in their high visibility; these items give a clear signal to the public at large, eager for signs that the drug-abuse problem might eas- ily go away, that something is being done. Yet, although they may be helpful in deglamorizing drug-taking behavior and providing a forum for young people to express their feelings about drugs, promotional items are inadequate by themselves to reduce substance abuse overall. They do, however, remain viable components of more comprehensive programs that have proved to be successful in primary prevention.15
Self-Esteem Enhancement and Affective Education In the early 1970s, several substance abuse prevention pro- grams were developed that emphasized the affective or emotional component of drug-taking behavior rather than specific information about drugs. In the wake of research that showed a relationship between drug abuse and psychological variables such as low self-esteem, poor decision-making skills,
Elementary school children display their handprint art projects. Designations of drug-free pledges are prominent features of many school-based drug abuse prevention programs.
affective education: An approach in prevention programs that emphasizes the building of self-esteem and an im- proved self-image.
values clarification: An approach in prevention programs that teaches positive social values and attitudes.
peer-refusal skills: Techniques by which an individual can resist peer pressure to use alcohol, tobacco, or other drugs.
Chapter 17 Substance Abuse Prevention and Treatment ■ 371
pressure to engage in drug-taking behavior.20 An example of a successful school-based prevention effort is the Life Skills Training (LST) program, developed by Gilbert J. Botvin at the Cornell University Medical College in New York City. Three LST programs have been designed with develop- mentally appropriate content for young people in elemen- tary school, middle school, or high school. The elementary school program can be taught either during the third grade or over the course of the fourth, fifth, and sixth grades. The middle school program is taught over the course of the sev- enth, eighth, and ninth grades. The high school program is taught in one year, either as a stand-alone program or as a maintenance program in conjunction with earlier sessions in middle school. The major elements include the following:
●■ A cognitive component designed to provide information con- cerning the short-term consequences of alcohol, tobacco, and other drugs. Unlike traditional prevention approaches, LST includes only minimal information concerning the long-term health consequences of drug-taking behavior. Evidently, it is not useful to tell young people about what might happen when they are “old.” Instead, information is provided concerning immediate negative effects, the impact on social acceptability, and actual prevalence rates among adults and adolescents. This last element of the lesson is to counter the myth that drug-taking behavior is the norm in their age group—that “everyone’s doing it.”
●■ A decision-making component designed to facilitate criti- cal thinking and independent decision making. Students learn to evaluate the role of the media in behavior as well as to formulate counterarguments and other cognitive strategies to resist advertising pressures.
●■ A stress reduction component designed to help students develop ways to lessen anxiety. Students learn relaxation techniques and cognitive techniques to manage stress.
●■ A social skills component designed to teach social assertive- ness and specific techniques for resisting peer pressure.
●■ A self-directed behavior change component designed to facilitate self-improvement and encourage a sense of per- sonal control and self-esteem. Students are assigned to identify a skill or behavior that they would like to change or improve and to develop a long-term goal over an eight- week period and short-term objectives that can be met week by week.
Originally designed as a smoking prevention program, LST presently focuses on issues related to the entire spectrum of drug-taking behavior. Over a period of as long as six years following exposure to the program, participants have been found to have a 50–75 percent lower incidence of alcohol, tobacco, and marijuana use, a 66 percent lower incidence of multiple-drug use, a 25 percent lower incidence of pack-a-day cigarette smoking, and a lower incidence of inhalant, opiate, and hallucinogen use, relative to controls.21 Reductions in drug use have been seen among inner-city minority students as well as among white middle-class youths, an encouraging
“just say no,” these programs teach them how to do so when placed in often uncomfortable social circumstances.
Primary prevention programs using peer-refusal skill training have been shown to reduce the rate of tobacco smoking, as well as alcohol drinking and marijuana smok- ing, by 35–45 percent, considerably better than any change in control comparison groups. With respect to tobacco smok- ing, this approach has been even more effective for young people identified as being in a high-risk category (in that their friends or family smoked) than for other students.18
Anxiety and Stress Reduction Adolescence can be an enormously stressful time, and drug- taking behavior is frequently seen as an option to reduce feelings of anxiety, particularly when an individual has inad- equate coping skills to deal with that anxiety. It is therefore useful to learn techniques of self-relaxation and stress man- agement and to practice the application of these techniques to everyday situations.
Social Skills and Personal Decision Making Peer-refusal skills are but one example of a range of assertive- ness skills that allow young people to express their feelings, needs, preferences, and opinions directly and honestly, with- out fearing that they will jeopardize their friendships or lose the respect of others. Learning assertiveness skills not only helps advance the goals of primary prevention but also fosters positive interpersonal relationships throughout life. Tasks in social skills training have included the ability to initiate social interactions (introducing oneself to a stranger), offer a compliment to others, engage in conversation, and express feelings and opinions. Lessons generally involve a combina- tion of instruction, demonstration, feedback, reinforcement, behavioral rehearsal, and extended practice through behav- ioral homework assignments.
A related skill is the ability to make decisions in a thought- ful and careful way. Emphasis is placed on the identification of problem situations, the formulation of goals, the generation of alternative solutions, and the consideration of the likely consequences of each. Lessons also focus on identifying per- suasive advertising appeals and exploring counterarguments that can defuse them. Primary prevention programs using a social skills training approach have been shown to reduce the likelihood by 42–75 percent that a young person will try smoking and to reduce the likelihood by 56–67 percent that a nonsmoker will be a regular smoker in a one-year follow-up.19
An Example of an Effective School-Based Prevention Program Substance abuse prevention professionals are in general agreement that the most effective programs should be com- prehensive in nature, with special emphasis on the teaching of specific social decision-making skills such as resisting peer
372 ■ Part Five Drug-Control Policy and Intervention Strategies
resist peer pressure and a lower estimate of how many of their peers smoked cigarettes. However, there are no significant differences between DARE and non-DARE control groups. There is little evidence for differences in drug use, drug attitudes, or self-esteem when young people are measured 10 years after the administration of the DARE program. Multiple studies have confirmed this conclusion.25
The DARE program has also been criticized for advocat- ing that children be questioned about possible drug offend- ers in their families. A DARE lesson called “The Three R’s: Recognize, Resist, Report” encourages them to tell friends, teachers, or police if they find drugs at home. Critics of DARE have viewed this and related elements of the program as a mechanism for turning young children into informants.26
Why DARE remains popular when its effectiveness and questionable practices have been consistently challenged is an interesting question. Some health professionals in this field theorize that the popularity of DARE is, in part, a result of the perception among parents and DARE supporters that it appears to work through a process of informally comparing children who go through DARE against an imagined percep- tion of those children who do not.
The adults rightly perceive that most children who go through DARE do not engage in problematic drug use. Unfortunately, these individuals may not realize that the vast majority of children, even without any intervention, do not engage in problematic drug use … That is, adults may believe that drug use among adolescents is much more frequent than it actually is. When the children who go through DARE are compared to this “normative” group of drug-using teens, DARE appears effective.27
In 2001, in response to the criticism leveled against its lack of impact on drug use, the DARE program was modified to become “enhanced DARE.” In this new approach, more emphasis has been placed on student interaction, providing more opportunities for children to participate rather than being lectured by police officers.28 In effect, DARE adminis- trators have adopted many of the basic components of effec- tive school-based prevention programs such as LST.
Community-Based Prevention Programs
Community-based prevention programs offer several obvi- ous advantages over those restricted to schools. The first is the greater opportunity to involve parents and other family members, religious institutions, and the media as collabor- ative agents for change. The most important factor here is the comprehensive nature of such programs. They draw on multiple social institutions that have been demonstrated to represent protective factors in an individual’s life, such as the family, religious groups, and community organizations. In addition, corporations and businesses can be contrib- uting partners, in both a financial and nonfinancial sense.
sign that these primary prevention strategies can have a posi- tive influence on adolescents from varying social backgrounds. In effect, as Botvin has expressed it, LST and similar programs work “in cities and towns and villages across the United States without having to develop separate intervention approaches for each and every different population.”22
LST programs have also demonstrated positive influ- ences in a number of high-risk social behaviors beyond simply drug-taking behavior. Reductions in violence and delinquency have been observed among sixth-grade LST participants, relative to controls. There has also been a reduc- tion in risky driving behaviors among adolescent participants. Young adults who have participated in LST programs have a reduced level of HIV-risk behaviors, as indicated by mul- tiple sex partners, frequency of intercourse while drunk or high, and recent high-risk substance use (e.g., administration by needle injection). These studies illustrate the long-term protective results of effective primary and secondary preven- tion programs for a range of life decisions. Similar programs emphasizing life skills and other forms of social development have been reported with equivalent success.23
Drug Abuse Resistance Education (DARE)
The Drug Abuse Resistance Education program, commonly known as DARE, is undoubtedly the best-known school- based primary prevention program in the United States and perhaps the world. It was developed in 1983 as a col- laborative effort by the Los Angeles Police Department and the Los Angeles United School District to bring uniformed police officers into kindergarten and elementary grade class- rooms to teach basic drug information, peer-refusal skills, self- management techniques, and alternatives to drug use.
The DARE program has expanded quite rapidly. Today, it has been established in all 50 U.S. states, in all Native American schools administered by the Bureau of Indian Affairs, the U.S. Department of Defense schools worldwide, and school systems in many foreign countries. There are also teacher-orientation sessions, officer–student interactions at playgrounds and in caf- eterias, and parent-education evenings.24
Responses to Project DARE from teachers, principals, students, and police officers are typically enthusiastic, and it is clear that the program has struck a responsive chord over the years for a public that has pushed for active prevention programs in the schools. Part of this enthusiasm can be seen as coming from the image of police departments shifting their emphasis from exclusively “supply reduction” to a more proactive social role in “demand reduction.”
Yet, despite its success in the area of public relations, the research-based evidence supporting the effectiveness of DARE in achieving genuine reductions in drug use is weak. In general, children who participated in the DARE program have a more negative attitude toward drugs one year later than children who did not, as well as a greater capability to
Chapter 17 Substance Abuse Prevention and Treatment ■ 373
Alternative-Behavior Programming It should not be surprising that it is easier to say no to drugs when you can say yes to something else. In community-based prevention programs, a major effort is made to provide the activities and outlets that steer people away from the high-risk situations. Owing to the fact that adolescents spend a major- ity of their time outside school, and it is outside school that the preponderance of drug-taking behavior occurs, commu- nity programs have the best chance of providing the neces- sary interventions. In fact, high-risk adolescents are the least likely even to be attending school on the days that prevention efforts are delivered.30
Alternative behaviors vary over a wide range of activities, corresponding to a particular individual’s interests and needs (Table 17.1). One way of thinking about alternative-behavior programming is that a person is trading a negative depen- dence (on alcohol, tobacco, or other drugs) that causes harm on a physical or psychological level for a positive dependence that causes no harm and taps into pleasures from within.
In a 1986 review of its effectiveness based on well- controlled research studies, alternative-behavior programming was identi- fied as being highly successful for at-risk adolescents such as illicit drug users, juvenile delinquents, and students having problems in school. On the basis of these evaluations, the gen- eral view is that alternative-behavior programming can work and deserves to have a place in comprehensive prevention programs.31
The Impact of the Media In the words of a major 2005 study analyzing the lifestyles of 8–18-year-olds, young people today live “media- saturated lives, spending an average of nearly 6½ hours a day with media.” Since about one-fourth of the time they are engaged in media multitasking (reading, listening to music, text messaging with friends, for example), they are actually crowd- ing 8½ hours of media into each day—the equivalent of a full-time job. These individuals (dubbed “Generation M” to reflect the dominance of media in their lives) are the first generation to have grown up with easy access to computers and particularly the Internet.32
Because of the unprecedented media access available at home (frequently in the privacy of their bedrooms), it is important to evaluate the impact of media messages on drug- taking behavior in their lives and the potential for media exposure to promote primary prevention. It turns out that young people are exposed to more than 80 explicit refer- ences to substance use per day in the course of listening to popular music. A relationship has been identified between the amount of exposure among 10–14-years-olds to alcohol drinking in popular movies and early-onset teen drinking,
Undoubtedly, we are in a better position to tackle the com- plexities of drug-taking behavior through the use of multiple strategies rather than a single approach.
Components of an Effective Community-Based Program Typically, many of the prevention components that have been incorporated in the schools are also components in community- based programs, such as the dissemination of information, stress management, and life skills training. Other approaches can be handled better in a community setting. For example, although schools can promote the possibility of alternative student activities that provide positive and construc- tive means for addressing feelings of boredom, frustration, and powerlessness (activities such as Midnight Basketball and Boys and Girls Clubs), the community is in a better position than the schools to actually provide these activities.
There is also a greater opportunity in the community to elicit the involvement of significant individuals to act as positive role models, referred to as impactors, and to enlist the help of the mass media to promote antidrug messages in the press and on television. In addition, community-based programs can be more influential in promoting changes in public policy that foster opportunities for education, employment, and self-development.29
Quick Concept Check
Understanding Substance Abuse Prevention Strategies Check your understanding of substance abuse prevention strategies by deciding whether the following approaches would or would not be effective (in and of themselves) in reducing drug or alcohol use or delaying its onset, based on the avail- able research.
would be effective
would not be effective
1. Scare tactics □ □
2. Life skills training □ □
3. Peer-refusal skills training □ □
4. Values clarification □ □
5. Objective information □ □
6. Anxiety reduction and stress management
□ □
7. Assertiveness training □ □
8. Training in problem solving and goal setting
□ □
Answers: 1. would not 2. would 3. would 4. would not 5. would not 6. would 7. would 8. would
17.2
impactors: Individuals in the community who function as positive role models to children and adolescents in substance abuse prevention programs.
374 ■ Part Five Drug-Control Policy and Intervention Strategies
Making matters worse, the percentage of adolescents report- ing that they remember seeing or hearing substance abuse prevention messages has declined.35
An Example of an Effective Community-Based Prevention Program An intensive and coordinated program of preventive services and community-based law enforcement has been designed by the National Center on Addiction and Substance Abuse at Columbia University in New York, called CASASTART. (The first part of the acronym refers to the center that designed it, and the latter part stands for “Striving Together to Achieve Rewarding Tomorrows.”) The target population for the program is defined as children between 8 and 13 years of age who have at least four risk factors for substance abuse problems. These risk factors may involve school (such as poor academic performance, in-school behavior prob- lems, or truancy), family (such as poverty, violence at home, or a family member involved with gangs, drug use or sales, or a criminal conviction within five years), or the individual child (such as a history of known or suspected drug use or sales, past arrest, gang membership, or being a victim of child maltreatment).
even after controlling for variables such as socioeconomic status, personality characteristics, school performance, and gender. In other words, exposure to movie alcohol use can be viewed as an independent risk factor for drinking behavior in this population.33
Traditionally, anti-drug messages have been largely confined to public service announcements, brief commer- cials, and limited program series. Even so, the potential impact can be substantial. A prominent example is a series of memorable and persuasive anti-drug advertisements on TV, on the radio, in print, and in other media sources, sponsored by the Partnership for a Drug-Free America (PDFA), a nonprofit coalition of professionals in the com- munications industry whose mission is to reduce demand for drugs in America. In the early 1990s, a number of PDFA spots targeted inner-city youths living in high-risk drug-use environments, and a 1994 study indicated that these mes- sages had a significant effect in promoting increasingly anti-drug attitudes, particularly among African American children attending schools in areas where many families had incomes below the poverty line.34
Unfortunately, Internet media has undermined these efforts. A rapidly growing number of Internet Web sites are devoted to information about marijuana cultivation, drug paraphernalia, and illicit drug use in general. These pro-drug outlets have proliferated since the advent of online services.
tAble 17.1
Alternative behaviors to drug use
level oF exPerieNCe NeeDs AND Motives AlterNAtives
Physical Physical satisfaction, more energy Athletics, dance/exercise, hiking, carpentry, or outdoor work
Sensory Stimulation of sensory experience Sensory awareness training, sky diving, “experiencing”
Emotional Relief from anxiety, mood elevation, emotional relaxation
Individual counseling, group therapy
Interpersonal Peer acceptance, defiance of authority figures
Confidence training, sensitivity groups, helping others in distress
Social/environmental Promotion of social change or identification with a subculture
Social service; community action; helping the poor, aged, handicapped; environmental activism
Intellectual Escape from boredom, curiosity, or inclination to explore one’s own awareness
Reading, creative games, memory training, discussion groups
Creative/aesthetic Increase in one’s creativity or enjoyment of images and thoughts
Nongraded instruction in visual arts, music, drama, crafts, cooking, gardening, writing, singing
Philosophical Discovery of the meaning of life, organization of a belief system
Discussions, study of ethics or other philosophi- cal literature
Spiritual/mystical Transcendence of organized religion, spiritual insight, or enlightenment
Study of world religions, meditation, yoga
Miscellaneous Adventure, risk taking, “kicks” Outward-bound survival training, meaningful employment
Source: Based on information from Cohen, Allan Y. (1972). The journey beyond trips: Alternatives to drugs. In David E. Smith and George R. Gay (Eds.), It’s so good, don’t even try it once: Heroin in perspective. Englewood Cliffs, NJ: Prentice Hall, pp. 191–192.
Chapter 17 Substance Abuse Prevention and Treatment ■ 375
may need and genuinely want to participate, but they may have difficulty attending because of lack of child care at home, lack of transportation, scheduling conflicts with their employment, or language differences. Several of the fac- tors that prevent their attendance are the same factors that increase the risk of substance abuse among their children.37
Special Role Models in Substance Abuse Prevention Although obstacles exist, comprehensive substance abuse prevention programs strive to incorporate parents or guard- ians, as well as other family members such as grandparents, into the overall effort. The reason lies in the variety of special roles they play in influencing children:
●■ As role models, parents or guardians may drink alcoholic beverages, smoke, or drink excessive amounts of caffein- ated coffee, not thinking of these habits as drug-taking behaviors. They can avoid sending their children signals about abstinence that are inconsistent at best, hypocritical at worst.
●■ As educators or resources for information, they can help by conveying verbal messages about health risks that are accurate and sincere.
●■ As family policymakers and rule setters, they can convey a clear understanding of the consequences of drug-taking
In the CASASTART program, a case manager serving 15 children and their families coordinates a variety of ser- vices, including social support, family and educational services, after-school and summer activities, mentoring, incentives, and juvenile justice intervention. The objective is to build resilience in the child, strengthen families, and make neighborhoods safer for children and their families. Relative to controls, CASASTART children have been found to be 60 percent less likely to sell drugs, 20 percent less likely to have used drugs in the past 30 days, 20 percent less likely to com- mit a violent act, and more likely to be promoted to the next grade in school.36
Family Systems in Primary and Secondary Prevention
It can be argued that family influences form the cornerstone of any successful substance abuse prevention program. In effect, the family is the first line of defense against substance abuse (Figure 17.2). Reaching the parents or guardians of youths at greatest risk, however, is a difficult task. Too often, substance abuse prevention programs are attended by those parents or guardians who do not really need the informa- tion; those who need the information the most—parents who are either in denial, too embarrassed, or too out of control themselves—are notably absent. Other parents or guardians
Religious and voluntary organizations Schools
Private sector and
public employees
Health careLaw enforcement and regulatory
agencies
Media Youth
Families
Families
F igure 17 .2
A schematic of various factors that impact upon young people in substance abuse prevention.
Source: Adapted from Fields, Richard (1998). Drugs in per- spective (3rd ed.). Dubuque, IA: WCB McGraw-Hill, p. 309. Reprinted with permission of the McGraw-Hill Companies. Copyright 1998.
Communication between grandparents and grandchildren can be an important tool in substance abuse prevention.
376 ■ Part Five Drug-Control Policy and Intervention Strategies
behaviors. If a parent or guardian cannot or will not back up family rules with logical and consistent consequences, the risk increases that rules will be broken.
●■ As stimulators of enjoyable family activities, parents or guardians can provide alternative-behavior programming necessary to steer youth away from high-risk situations.
●■ As consultants against peer pressure, parents or guardians can help reinforce the peer-refusal skills of their children. Children and adolescents frequently report that a strongly negative reaction at home was the single most important reason for their refusing alcohol, tobacco, and other drugs from their peers.
Parental Communication in Substance Abuse Prevention In recognition of the importance of parental communication in efforts to reduce substance abuse, the program “Parents: The Antidrug” has been a feature in public service announcements in recent years.38 The need for better lines of communication between parents and teenagers is illustrated in a PDFA survey. When asked whether they talked to their teenagers about drugs at least once, 98 percent of parents reported that they had done so, but only 65 percent of teenagers recalled such a conversation. Barely 27 percent of teenagers reported learning a lot at home about the risks of drug use, even though virtually all of their parents said they had discussed the topic. Justifiably, anti-drug media campaigns have focused on parent–child communica- tion skills, specifically on the difficulty many parents have in talking to their children about sensitive subjects like drugs and
testing for Drugs in the Home: Whom Can You trust? Since 1995, commercial kits have been available that are capable of testing for illicit drugs in the home. Marketed for parents who wish to check for possible drug abuse among their children, these kits typically consist of a small premoistened pad that can be wiped across desk tops, telephones, books, clothing, or other items. The pad is then mailed to the company, where an analysis for the pres- ence of cocaine, crack cocaine, heroin, methamphetamine, LSD, marijuana, and PCP is performed. The testing destroys the sample, so it cannot be used later in any court proceedings. The results of the analysis are then mailed to the parents.
The fact that test kits are designed to be used by parents with or without their child’s knowledge raises a number of controver- sial issues. On the one hand, these kits are promoted as a potent
new weapon in the battle against the increased levels of drug abuse among young people. From this point of view, parents are now able to get early help for their children before drug- abuse problems become too great. On the other hand, these kits can be viewed as a new weapon in the battle of the generations. Detractors argue that it may increase an already significant degree of distrust between parents and their children. In that sense, these test kits may exacerbate dysfunctionality within the family
What do you think? If you were a parent, would you consider using this testing kit as a step forward or a step backward in the effort to prevent drug abuse in your family?
Sources: Kit to test for drugs at home (1995, March 29). Newsday, p. A8. Winslow, Olivia; and Lam, Chau (1995, March 30). Test fuels drugs debate. Newsday, pp. A6, A51.
Drug Enforcement … in Focus
Early communication between parents and children is a key factor in the prevention of underage drinking.
the role of drug-taking behavior in their children’s social lives.39 Drug Enforcement . . . in Focus examines an option that may be necessary, however, when family communication breaks down.
The Triple Threat: Stress, Boredom, and Spending Money Substance abuse prevention in young people can sometimes be simpler and more straightforward than we realize. A recent survey of teenagers aged 12–17 measured the effects of
Chapter 17 Substance Abuse Prevention and Treatment ■ 377
Changing the Culture of Alcohol in College A major challenge with regard to prevention programs at colleges and universities comes from the widely regarded expectation that heavy alcohol drinking, during the col- lege years represents something of a rite of passage. College alumni (and potential benefactors) frequently impede the implementation of drug and alcohol crackdowns, argu- ing that “we did it when we were in school.”42 The 2013 University of Michigan survey has indicated that by the end of high school about 68 percent of all students have consumed alcoholic beverages, and 53 percent have been drunk at least once. The percentages for alcohol consump- tion are lower than previous years, but they are still relatively high. In other words, two out of three incoming freshmen have had some experience with alcohol and more than one- half of them have drunk at some previous time.43 Given this base of prior exposure, there is a compelling argument for secondary and tertiary prevention programs to be in place at this point.
The emphasis on most campuses is on the prevention and control of alcohol problems (Drugs . . . in Focus). However, it is less common for college administrators to focus on the problems associated with drugs other than alcohol. Although alcohol-abuse programs are virtually certain to be found on college campuses, attention directed toward comparable pro- grams related specifically to drugs other than alcohol lags behind. Frequently, the only policy in place involves a pro- cedure of punitive action if a student-athlete tests positive for an illicit drug. While no-smoking campuses exist practically everywhere, few if any programs are in place to help reduce the level of tobacco use among college students.
Substance Abuse Prevention on College Campuses On the positive side, college campuses have the potential for being ideal environments for comprehensive substance abuse prevention programs because they combine features of school and community settings. Here are some suggested strategies for prevention on the college campus:
●■ Develop a multifaceted prevention program of assessment, education, policy, and enforcement. Involve students, fac- ulty, and administrators in determining the degree of avail- ability and demand for alcohol and other drugs on campus and in the surrounding community and initiate public information and education efforts.
●■ Incorporate alcohol and other drug education into the curriculum. Faculty members can use drug-related situ- ations as teachable moments, include drug topics in their course syllabi, and develop courses or course projects on issues relating to alcohol and other drugs.
●■ Ensure that hypocrisy is not the rule of the day. Substance abuse prevention is not a goal for college students only but
three circumstances on the likelihood that a teenager might engage in some form of substance abuse: (1) the degree of stress they feel they are under, (2) the frequency with which they are bored, and (3) the amount of money they have to spend in a typical week. High-stress teens (one-fourth of teens interviewed) were twice as likely as low-stress teens (a little more than one-fourth of teens interviewed) to smoke, drink, get drunk, and use illicit drugs. Teens reporting that they were frequently bored were 50 percent more likely than not- often-bored teens to engage in these behaviors. Teens with $25 or more a week in spending money were nearly twice as likely as teens with less spending money to smoke, drink, and use illicit drugs, and they were more than twice as likely to get drunk. Combining two or three of these risk factors (high stress, frequent boredom, and too much spending money) made the risk of smoking, drinking, and illicit drug use three times higher than when none of these characteristics was present.40
Substance Abuse Prevention and the College Student
Effective substance abuse programs among college students present an unusual challenge, in that we are hardly speak- ing of a homogeneous population. U.S. college students represent all racial, ethnic, and socioeconomic groups and are likely to come from all parts of the world. They include undergraduate and graduate students, full-time and part- time students, residential students and commuters, students of traditional college age, and students who are considerably older. Each of these groups has a different perspective on drug- taking behavior, different opportunities for drug-taking behavior, and different life experiences.
In particular, there are marked differences in the objectives of a prevention program between those younger than 21 years and those who are older. In the former group, the goal may be “no use of” (or abstinence from) alcohol, tobacco, and other drugs, whereas in the lat- ter group the goal may be the low-risk (i.e., responsible) consumption of alcohol and no use of tobacco and other drugs. The term “low-risk consumption” refers to a level of use restricted by considerations of physical health, fam- ily background, pregnancy risk, the law, safety, and other personal concerns.
With respect to alcohol, secondary prevention guide- lines might stipulate that pregnant women, recovering alco- holics or those with a family history of alcoholism, people driving cars or heavy machinery, people on medications, or those under the age of 21 should not drink alcohol at all. Although the distinction between “under-21” and “over-21” preventive goals is applicable in many community-oriented programs, it is an especially difficult challenge for prevention efforts on a college campus when the target population con- tains both subgroups so closely intermingled.41
378 ■ Part Five Drug-Control Policy and Intervention Strategies
fraternities. There is substantial risk of an alcohol-related injury, for example, from underage drinking at a univer- sity fraternity party during the first week of a new college year.45
Since 2000, when one in five fraternity chapters in the United States began to phase in a policy forbidding alcohol of any kind anywhere in the fraternity house, even in rooms of members who were of legal drinking age, there has been a steady upward trend in the number of alcohol-free fraternity (and sorority) houses around the country.46
Prevention and Treatment in the Workplace
Since 1988, all U.S. federal agencies have been mandated to establish employee assistance programs (EAPs) in order to identify and counsel workers with personal problems associated with substance abuse or dependence and to pro- vide referrals to community agencies where these individu- als can get further help. Nongovernmental organizations
is a larger issue that affects all members of the academic community, including faculty and administration.
●■ Encourage environments that lessen the pressures to engage in drug-taking behavior. Foster more places where social and recreational activities can take place spontane- ously and at hours when the most enticing alternative may be the consumption of alcohol and other drugs. A recent promising sign is the growing popularity of drug-free dormitories on many college campuses, where student res- idents specifically choose to refrain from alcohol, tobacco, and other drugs.44
The seriousness of the drug-taking behavior on college campuses could not be demonstrated more clearly than in the context of alcohol drinking among members of college
Alcohol 101 on College Campuses A familiar experience among many students entering college for the first time is referred to by public health officials as the “college effect”—defined as an increase in drinking and negative behaviors associated with it (Chapter 15). One increasingly popular approach intended to minimize this phenomenon is a three-hour Web-based online course called AlcoholEdu, developed by Outside the Classroom, Inc. More than 500 colleges and universities nationwide are currently participating in this program.
AlcoholEdu is oriented toward responsible drinking behav- ior rather than abstinence. Topics include an understanding of blood alcohol concentrations, activities that increase the likelihood of blacking out, discredited remedies for hangovers, as well as an appreciation of the alcohol beverage industry’s role in fostering the image of alcohol consumption as a means for advancing social and interpersonal relationships. Participants are given an exam that tests their knowledge of the information provided in the course.
Colleges and universities have varying policies regard- ing students taking AlcoholEdu. Some require students to complete and pass the course with a minimum score on the exam prior to the first day of classes or prior to register- ing for the next semester. Others convey an expectation that the AlcoholEdu should be completed and warn that severe consequences will be imposed for those students who fail to finish the course and commit an alcohol violation in the
future. There are early indications that student participation in AlcoholEdu results in significantly fewer negative conse- quences of drinking, such as missing class, attending class with a hangover, blacking out, and abusive behavior. Intensive studies of effectiveness, both short term and long term, however, need to be carried out.
In the meantime, additional programs addressing a wider range of alcohol problems on campuses have been developed. AlcoholEdu for Sanctions is an intervention program suited for students who have violated academic policies on alcohol, aimed at reducing recidivism rates. Alcohol Innerview is a brief motivational intervention tool for students who have experi- enced alcohol problems or are in alcohol-abuse counseling. AlcoholEdu for Parents is designed to support parents with college-age children in fostering conversations that can help shape healthy decisions about alcohol use at college.
Recent developments in online prevention programs by Outside the Classroom, Inc. include MentalHealthEdu, raising campus community awareness of college student mental-health issues, and SexualAssaultEdu, focusing on relationships and decision making to reduce the incidence of sexual assaults on campus.
Sources: Fact sheet on alcohol issues, University of Colorado at Boulder (2004, August 11). Boulder, CO: Office of News Services, University of Colorado. Kesmodel, David (2005, November 1). Schools use web to teach about booze. Wall Street Journal Online. Outside the Classroom (2008). www.outsidetheclassroom.com.
Drugs … in Focus
employee assistance programs (eAPs): Corporate-based services designed to identify and counsel employees with personal problems that are connected to substance abuse or dependence and to provide referrals to community agencies where these individuals can get further help.
Chapter 17 Substance Abuse Prevention and Treatment ■ 379
a major impact on workplace productivity. The CSAP has estimated that, relative to nonabusers, abusers of alcohol and other drugs are
●■ 5 times more likely to file a workers’ compensation claim ●■ 3.6 times more likely to be involved in an accident on
the job ●■ 5 times more likely to be personally injured on the job ●■ 3 times more likely to be late for work ●■ 2.2 times more likely to request early dismissal from work
or time off ●■ 16 times more likely to take sick leave
Overall, the estimated costs from productivity lost as a result of such behavior amount to $60–$100 billion each year.48
The Impact of Drug-Free Workplace Policies It makes sense that substance abuse prevention programs would have the greatest impact in companies within the trans- portation industry, owing to the close relationship between drug-induced impairments in performance and the incidence of industrial accidents. Beyond this application, however, it is widely recognized that a similar impact, if not one as dramatic in magnitude, can be demonstrated in any business setting. The reasons relate to the basic goals of prevention, as discussed earlier: deterrence and rehabilitation. The practice of testing for illicit drug use in the workplace functions as an effective deterrent among workers because the likelihood is strong that illicit drug use will be detected. Treatment options are an important component in a comprehensive plan. Substance abuse treatment programs in the workplace can function as an effective rehabilitative tool because those workers who might otherwise not receive help with drug-abuse problems will be referred to appropriate agencies for treatment services.49
Multicultural Issues in Prevention and Treatment
In the case of substance abuse prevention messages and administration of substance abuse treatment programs, it is important to remember that information intended to reach individuals of a specific culture passes through a series of sociocultural filters. Understanding this filtering process is essential to provide effective substance abuse prevention and treatment programs.
have since been encouraged (but not required) by the act to establish EAPs as well. Traditionally, the emphasis on EAPs or union-supported member assistance programs (MAPs) has been on problems resulting from alcohol abuse, which is understandable, given that this category represents such a large proportion of substance abuse in general (Chapter 15). In recent years, EAPs and MAPs have expanded their services to focus on psychological problems that do not necessarily concern substance abuse.
Even a modest amount of treatment that results from an EAP or MAP intervention has proven to be beneficial to both the employee and the employer. In one study, heavy drinkers who received brief intervention over a two- month period had significantly fewer accidents, hospital visits, and other events related to problem drinking dur- ing the following year. The cost of each brief intervention was $166 per employee, while the medical savings to the employee was $523.47
Specifically, organizations must initiate a comprehen- sive and continuing program of drug education and aware- ness. Employees must also be notified that the distribution, possession, or unauthorized use of controlled substances is prohibited in that workplace and that actions will be taken against any employee violating these rules. Supervisors are advised to be especially alert to changes in a worker that might signal early or progressive stages in the abuse of alcohol and/or other drugs. These signals include chronic absenteeism, a sudden change in physical appearance or behavior, spasmodic work pace, unexpectedly lower quan- tity or quality of work, partial or unexplained absences, a pattern of excuse making or lying, the avoidance of super- visors or coworkers, and on-the-job accidents or lost time from such accidents.
In effect, achieving a drug-free workplace is made pos- sible by a combination of secondary prevention and tertiary prevention interventions.
The Economic Costs of Substance Abuse in the Workplace High-profile instances of on-the-job accidents involving the effects of either illicit drugs or alcohol are often given as examples of the scope of substance abuse in the workplace and the need for workplace drug testing, but we have to be careful in generalizing from these reports. First of all, everyday instances of adverse effect are not covered by the news media. We cannot estimate substance abuse problems in the work- place through the news, any more than we can estimate the impact of drug toxicity on our society through stories of public figures and celebrities who have died of drug overdoses (see Chapter 1). Second, in many cases, we are limited in deter- mining the extent to which we can connect drug use with the tragic consequences of an accident because some drugs leave metabolites in the system long after they have stopped producing behavioral effects (see Chapter 13).
Nonetheless, risk estimates have been calculated, leav- ing little doubt that the abuse of alcohol and other drugs has
sociocultural filters: A set of considerations specific to a particular culture or community that can influence the reception and acceptance of public information.
member assistance programs (MAPs): Corporate-based services similar to employee assistance programs (EAPs) that are sponsored and supervised by labor unions.
380 ■ Part Five Drug-Control Policy and Intervention Strategies
alcohol and other drugs. The protective factors of staying in school, solid family bonds, strong religious beliefs, high self-esteem, adequate coping strategies, social skills, and steady employment all build on one another to provide resilience on the part of high-risk children and adoles- cents. As noted before, prevention programs developed with protective factors in mind have the greatest chance for success.51
Native American Communities Individuals in Native American communities have particu- lar difficulties with substance abuse. In 2013, 12 percent of American Indians or Alaska Natives, aged 12 or older, were current illicit drug users. Twenty-four percent reported binge alcohol drinking, and 40 percent reported current use of a tobacco product. All of these prevalence rates are higher than the average within the general U.S. population. A strong sense of ethnic identity and strong identification with one or more Indian cultural group are major protective factors (see Chapter 5) with respect to substance abuse of all kinds. For this reason, the incorporation of Native American beliefs can be an effective way of promoting substance abuse pre- vention. For example, a program that emphasizes the values and morals passed down through the generations that define the relationship of Native Americans to their environment, society, and the universe has the best chance of success. A substance abuse prevention message that “evil spirits [refer- ring to illicit drugs and alcohol] break the bonds between ourselves and our elders, disrupt the circle of our family, and destroys the harmony between us and all creation” reinforces these values.52
Substance Abuse Treatment: The Journey to Recovery
Individuals who seek help in a treatment program have typi- cally been “jolted” by some external force in their lives. They may have no other option except imprisonment for drug offenses; they may be at risk of losing their job because their supervisor has identified an unproductive pattern of behav- ior; a spouse may have threatened to leave if something is not done; a friend may have died from a drug overdose or a drug- related accident. Any of these crises or others similar to them can force the question and the decision to seek treatment.
The prospect of entering a treatment program is prob- ably the most frightening experience the abuser has ever had in his or her life. Public health researchers have compared the early days in recovery to a climber’s first step up a great mountain. Change does not happen overnight, and “road blocks” seem to appear in every step of the way. Treatment counselors frequently hear the questions, “Couldn’t I just cut down?” or “Couldn’t I just give up drugs temporarily?” or “How will I be able to take the pain of withdrawal?” or “How will I be able to stand the humiliation?” Far from stalling
Latino Communities A good example of the need to recognize sociocultural filters is the set of special concerns associated with com- municating drug-related information to Latinos, a diverse group representing more than 13 percent of the U.S. pop- ulation and expected to represent more than 25 percent by 2050. The following insights concerning elements of the Latino community can enhance the chances of success in Latino-targeted prevention and treatment initiatives.
●■ Because of the importance Latinos confer on the family and religious institutions, prevention and treatment efforts should be targeted to include the entire family and, if pos- sible, its religious leaders. Prevention and treatment efforts will be most effective when counselors reinforce family units and value them as a whole.
●■ Prevention programs are needed to help Latino fathers recognize how important their role or example is to their sons’ and daughters’ self-image regarding alcohol and other drugs. Because being a good father is part of machismo, it is important that the men become full partners in parenting. Mothers should be encouraged to learn strategies for including their husbands in family interactions at home.
●■ Because a Latina woman with alcohol or other drug prob- lems is strongly associated with a violation of womanly ideals of purity, discipline, and self-sacrifice, educational efforts should concentrate on reducing the shame associ- ated with her reaching out for help. One particular Web site that addresses the needs of the Latino community is sponsored by the National Latino Council on Alcohol and Tobacco Prevention (NLCATP).50
African American Communities Another set of special concerns exists with regard to commu- nicating drug-related information in African American com- munities. Some basic generalizations have proven helpful in optimizing the design of prevention and treatment programs.
●■ African American youths tend to use drugs other than alcohol after they form social attitudes and adopt behav- iors associated with delinquency. The most common examples of delinquency include drug dealing, shoplift- ing, and petty theft. With regard to the designing of media campaigns, it is the deglamorization of the drug dealer that appears to be most helpful in primary prevention efforts among African American youths.
●■ Drug use and social problems are likely to be interrelated in primarily African American neighborhoods. The effects of substance abuse are intensified when other factors exist, such as high unemployment, poverty, poor health care, and poor nutrition.
●■ Several research studies have shown that most African American youths, even those in low-income neighbor- hoods, do manage to escape from the pressures to use
Chapter 17 Substance Abuse Prevention and Treatment ■ 381
●■ Contemplation. In the contemplation stage, individuals are aware that a problem exists and are thinking about over- coming it but have not yet made a commitment to take action. At this point, drug abusers may struggle with the prospect of the tremendous amount of effort and energy needed to overcome the problem. Counselors can help them by highlighting the negative aspects of drug use, mak- ing reasonable assurances about the recovery process, and building the self-confidence that is necessary to change.
●■ Preparation. Individuals in the preparation stage are defined as those who are seriously considering taking action in the next 30 days and have unsuccessfully taken action over the past 12 months. Alcohol abusers or tobacco smokers may at this point set a “quit date,” or a heroin abuser may make a firm date to enter a therapeutic community within the next month. Because drug abusers are fully capable of stating a clear commitment to change at the preparation stage, coun- selors can begin to discuss the specific steps in the recovery process, strategies for avoiding problems or postponements, and ways to involve friends and family members.
tactics, these questions represent real fears and significant obstacles to taking the crucial first steps to recovery.53
In the previous chapters, there have been substance abuse treatment options for specific abused substances. Some types of substance abuse require a specialized form of treatment. Drugs . . . in Focus lists these specific treatment options and the location in previous chapters where they have been reviewed.
A Common Feature of Substance Abuse Treatment: Stages of Change Treatment options may vary, depending on the substance of abuse, but the process of treatment is the same. There is little disagreement as to the steps that must be taken for an individual to reach a level of recovery. Here are five distinct “stages of change” through which the recovering individual must pass: (1) precontemplation, (2) contemplation, (3) preparation, (4) action, and (5) maintenance54. The following is a descrip- tion of each stage in detail.
●■ Precontemplation. Individuals who are in the precontem- plation stage may wish to change but lack the serious inten- tion to undergo change in the foreseeable future or may be unaware of how significant their problems have become. They may be entering treatment at this time only because they perceive that a crisis is at hand. They may even dem- onstrate a change in behavior while the pressure is on, but once the pressure is off, they revert to their former ways. It is often difficult for a counselor to deal with a drug abuser during the precontemplation stage because the abuser still feels committed to positive aspects of drug use. A principal goal at this point is to induce inconsistencies in the abuser’s perception of drugs in general.
reviewing specific treatment strategies for six substances of Abuse In the previous chapters, treatment strategies have been reviewed for specific abused substances. Here is a listing with reference to chapter and page numbers where the information can be found:
Heroin and other opioids Chapter 9 (pages 169–171) Cocaine Chapter 10 (pages 189–192) Methamphetamine Chapter 10 (page 197) Barbiturates Chapter 14 (page 280) Alcohol Chapter 15 (pages 326–328) Tobacco (nicotine) Chapter 16 (pages 354–357)
Drugs … in Focus
preparation stage: A stage of change in which the individ- ual seriously considers taking action to overcome a problem in the next 30 days and has unsuccessfully taken action over the past 12 months.
contemplation stage: A stage of change in which the individual is aware that a problem exists and is thinking about overcoming it but has not yet made a commitment to take action.
precontemplation stage: A stage of change in which the individual may wish to change but either lacks the serious intention to undergo change in the foreseeable future or is unaware of how significant his or her problem has become.
382 ■ Part Five Drug-Control Policy and Intervention Strategies
recycle through the stages multiple times before he or she is totally rehabilitated. Unfortunately, relapse is the rule rather than the exception in the process of substance abuse recovery.
Stages of Change for Other Problems in Life If the stages of change listed above seem vaguely familiar to you, even without a substance abuse problem, it is no acci- dent. Problems may take many different forms, but the dif- ficulties that we face when we confront these problems have a great deal in common. We may wish to lose weight, get more exercise, stop smoking, end an unhappy relationship, seek out a physician to help a medical condition, or any of a number of actions that might lead toward a healthier and more productive life. We only have to witness the popularity of New Year’s Eve resolutions to appreciate the fact that our desire to take steps to change is part of simply being human. And yet, we often feel frustrated when our intentions do not prevail and those New Year’s Eve resolutions are left unful- filled. You may find it helpful to look at your own personal journey toward resolving a problem in your life in terms of the five stages of change.55
The Challenges of the Recovery Process Rehabilitation from substance abuse and substance depen- dence has three major challenging goals. First, the long decline in physical and psychological functioning that has accumulated over the years must be reversed. Drugs take a heavy toll on the user’s medical condition and his or her personal relationships. Second, the use of all psychoactive substances must stop, not simply the one or two causing the immediate problem, and not merely for a limited period of time. Thus, the motivation to stop using alcohol and other drugs and to remain abstinent on a permanent basis must be strong, and it must stay strong. Third, a lifestyle free of
●■ Action. The action stage is the point at which individu- als actually modify their behavior, their experiences, and their environment in an effort to overcome their problem. Drug use has now stopped. This is the most fragile stage; abusers are at a high risk of giving in to drug cravings and experiencing mixed feelings about the psychological costs of staying clean. If they successfully resist these urges to return to drug use, the counselor should strongly rein- force their restraint. If they slip back to drug use tempo- rarily and then return to abstinence, the counselor should praise their efforts to turn their life around. An important message to be conveyed at this stage is that a fundamental change in lifestyle and a strong support system of friends and family will reduce the chances of relapse.
●■ Maintenance stage. Individuals in the maintenance stage have been drug free for a minimum of six months. They have developed new skills and strategies to avoid backslid- ing and are consolidating a lifestyle free of drugs. Here, the counselor must simultaneously acknowledge the suc- cess that has been achieved and emphasize that the strug- gle will never be totally over. The maintenance stage is ultimately open ended, in that it continues for the rest of the ex-user’s life. Therefore, it may be necessary to have booster sessions from time to time so that the maintenance stage is itself maintained.
Rather than thinking of these stages as a linear progres- sion, however, it is more accurate to think of them as points along a spiral (Figure 17.3); more than likely, a person will
Maintenance
Preparation
Contemplation
Termination
Act ion
Ac tio
n
Maintenance
Precontemplation Contemplation
Precontemplation Preparation
F igure 17 .3
A spiral model of the stages of change in the recovery from drug abuse and dependence.
Source: Prochaska, James O.; DiClemente, Carlo C.; and Norcross, John C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1104. Copyright © 1992 by the American Psychological Association. Reprinted with permission.
maintenance stage: A stage of change in which the indi- vidual has become drug free for a minimum of six months and has developed new skills and strategies that reduce the probability of relapse.
action stage: A stage of change in which the individual actually modifies his or her behavior and environment to overcome a problem.
Chapter 17 Substance Abuse Prevention and Treatment ■ 383
Needing Versus Receiving Substance Abuse Treatment According to U.S. government estimates in 2013, approxi- mately 22.7 million people needed treatment for an illicit drug or alcohol use problem (or both), and only 11 percent received treatment at a specialty facility. Figure 17.4 shows, in visual terms, the wide gap between treatment needed and treatment received. Only 5 percent of people needing treatment in 2013 for either an illicit drug or alcohol use problem, but who did not receive it, personally felt a need to seek help.57
What can be done to reduce this disparity between treat- ment needed and treatment received? What can be done to encourage more people to seek treatment in the first place? Obviously, more work must be done to increase the number of substance abusers who recognize that they need to seek treat- ment and understand that treatment will not have a negative impact in their lives. An encouraging new program called Screening, Brief Intervention, and Referral to Treatment (SBIRT) serves to help in getting individuals into treatment at an early stage and with less resistance. The program creates a system within community and/or medical settings—including physician offices, hospitals, educational institutions, and men- tal health centers—that screens for and identifies individuals with or at-risk for substance use-related problems. The screen- ing determines the severity of substance use and identifies the appropriate intervention. There is a brief intervention with the community setting and referral to more extensive services if needed. The intent is to make interventions in a relatively nonthreatening manner and hopefully increase the numbers of individuals who receive treatment.58
alcohol and other drugs must be rebuilt, from scratch if nec- essary. This frequently means giving up the old friends and the old places where drugs were part of an abuser’s life and finding new friends and places that reinforce a drug-free existence. A determination to stay clean and sober requires avoiding high-risk situations, defined as those that increase the possibility of relapse.
How successful are treatments for substance abuse? Unfortunately, relatively few treatment programs allow out- side evaluators to determine whether or not there has been a genuine benefit to treatment. The need for evidence- based treatment strategies is just as important as the need for evidence-based prevention strategies, and the judgment of effectiveness must be made in the same way. All too often, treatments appear to be successful in the short term, but they end up failing in the long term. Short-term successes can be deceiving. A substance abuser may be “discharged” after 60 vis- its or 60 days, and everyone is crying and hugging and feeling proud. Feelings abound that the abuser has been “cured.”56
Illicit drugs 0
5,000
10,000
15,000
20,000
25,000
7,600
18,000 20,200
Alcohol Illicit drugs or alcohol
N um
be rs
in t
ho us
an ds
n ee
di ng
tr
ea tm
en t
in p
as t
ye ar
Did not receive specialty treatment Received specialty treatment
1,500 1,400 2,500
F igure 17 .4
The gap between treatment needed and treatment received among individuals over the age of 12 in the United States.
Source: Center for Behavioral Health Statistics and Health (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, pp. 92–98.
Quick Concept Check
Understanding the Stages of Change Check your understanding of the stages of change by matching each quotation, on the left, with the appropriate stage in treatment, on the right. Quotations are assumed to be statements made by a substance abuser at a particular point in the process of treatment and recovery.
17.3
1. “Yeah, I know I drink too much but I’m not ready to do something about it yet.”
2. “I may need a boost right now to help me hold on to the changes I’ve made. It’s been nearly two years since I used drugs.”
3. “I don’t have any big problems. I have a right to do whatever I want.”
4. “Although I like snorting coke, it might be time to quit.”
5. “It’s New Year’s Eve and I’ve set two weeks from now as the day I’m quitting. I want everyone to know that.”
6. “It’s been six weeks since I smoked a joint, and I can tell already how different things seem to be.”
a. precontemplation stage
b. contemplation stage
c. preparation stage
d. action stage
e. maintenance stage
Answers: 1. b 2. e 3. a 4. b 5. c 6. d
384 ■ Part Five Drug-Control Policy and Intervention Strategies
of our communities. From everything that has been reviewed in this introduction to drug-taking behavior in today’s society and its ramifications for the criminal jus- tice system, it is clear that we need all the help we can get (Portrait).
Fortunately, information and guidance are all around us. For local referral sources for treatment programs, check out the yellow pages of your telephone book under Alcoholism Information or Drug Abuse and Addiction Information. There are also numerous Web sites on the Internet that are specifically designed to provide assis- tance with any problem associated with all forms of substance abuse. The most comprehensive source for sub- stance abuse prevention and treatment information is the National Clearinghouse for Alcohol and Drug Information (NCADI). Educational materials regarding virtually any aspect of drug use, misuse, or abuse can be ordered free by calling 800-729-6686 or accessing NCADI’s Web site at www.health.org or the Web site for the Substance Abuse and Mental Health Services Administration at www.sam- hsa.gov. For residents of Canada, the Canadian Centre on Substance Abuse is a useful source of help; it can be reached by calling 613-235-4048 or accessing its Web site at www.ccsa.ca. For residents of the United Kingdom, the following Web sites are available: www.talktofrank.com and www.drugs.homeoffice.gov.uk/drug-strategy.
Additionally, more work must be done to provide accessible and affordable substance abuse treatment for those individuals who want it and are willing to seek it out. Fortunately, affordable substance abuse treatment in the United States took a major step forward to this end when the Mental Health Parity and Addiction Equity Act of 2008 was passed by the U.S. Congress. In the past, Americans seek- ing help for psychological problems (including problems related to substance abuse) were reimbursed differently from Americans seeking help with medical conditions. Since 2010, individuals seeking treatment for substance use or a mental health disorder do not need to face unfair and arbitrary restrictions on their benefits coverage, relative to coverage for other forms of health treatment. Since 2014, the Affordable Care Act (ACA) mandates all new small group and individual market plans to cover substance use disorder services, at parity with medical and surgical ben- efits. The ACA mandate builds upon the 2008 law. More than 62 million Americans have been extended “parity pro- tection” for substance abuse treatment.59
For Those Who Need Help and Want to Get It
Throughout our lives, we will need to confront the reality that licit and illicit substance abuse represents a signifi- cant factor in our personal health and the public health
PortrAit Meeting the Challenge—The Long Island Council on Alcoholism and Drug Dependence
Fighting the continuing battle against the devastation that alcohol and illicit drugs bring to the personal lives of people and their families demands multiple layers of ser- vices. It requires professional staffing for treatment and counseling services, pre- vention and educational programming, and, importantly, a coordination with social agencies, schools, religious groups, businesses, and the community at large. It also requires recognition of the over- lapping issues of alcoholism and other forms of drug dependence. The Long Island Council on Alcoholism and Drug Dependence (LICADD), serving Nassau and Suffolk counties in New York exem- plifies the much-needed comprehensive approach to substance abuse today.
Since its founding in 1956, the LICADD has developed drug and alco- hol assessments, brief intervention and treatment referrals, relapse prevention
and professional training services, anger management programs, and
outreach support including the grassroots advocacy group, People United to Stop Heroin (PUSH), dedicated to address the heroin epidemic in the region and Open Arms EAP, an employee assistance pro- gram serving more than 60,000 employ- ees on Long Island and along the Eastern Seaboard. LICADD has been a promi- nent lobbyist for passage of the Internal System for Tracking Over-Prescribing (I-STOP) Act in New York State and sponsor for local Narcan workshops, fol- lowing passage of legislation in New York that allows nonmedical professionals to be trained in Narcan injections, in cases of heroin overdose emergencies (see Chapter 9).
In 2014, Steven Chassman, for- merly clinical director of LICADD, was appointed its executive director. Combining extensive experience as a
clinical social worker and substance abuse counselor, a keen “street-smart” perspective on the current drug scene, and a passion for doing what has to be done to combat the present-day challenges of alcoholism and drug dependence, Chassman has been hailed as the ideal choice to lead LICADD in the future (see photo).
Fortunately, LICADD is not alone in the nationwide fight against alcohol- ism and drug dependence. It is affiliated with similar agencies in 26 U.S. states and the District of Columbia, through an organization collectively known as the National Council on Alcoholism and Drug Dependence (NCADD).
Sources: Information courtesy of the Long Island Council on Alcoholism and Drug Dependence, Mineola, New York; and the National Council on Alcoholism and Drug Dependence, New York City, New York.
Chapter 17 Substance Abuse Prevention and Treatment ■ 385
levels of intervention in substance Abuse Prevention
●● Substance abuse prevention efforts fall into three basic lev- els of intervention: primary, secondary, and tertiary.
●● Primary prevention focuses on populations that have had only minimal or no exposure to drugs. Secondary preven- tion focuses on populations whose drug experience has not yet been associated with serious long-term problems. Tertiary prevention focuses on populations who have en- tered treatment; the goal is to prevent relapse.
strategies for substance Abuse Prevention ●● The U.S. federal agency specifically charged with pre-
vention programs is the Center for Substance Abuse Prevention (CSAP), a division of the Substance Abuse and Mental Health Services Administration (SAMHSA), which is in turn a division of the U.S. Department of Health and Human Services.
●● The overall strategy for substance abuse prevention is to minimize the risk factors in a person’s life with respect to drug-taking behavior and maximize the protective factors. The inclination to resist the effects of risk factors for drug- taking behavior through the action of protective factors is referred to as resilience.
●● In order to be “evidence based,” primary and secondary prevention programs must evaluated against a control group that did not receive the intervention. Positive change per se is not enough for a judgment of success.
●● The overall national policy for the control of drug use in the United States is coordinated by the White House Office of National Drug Control Policy (ONDCP). In a recent formulation of this policy, three priorities have been established as components of a national strategy: stopping drug use before it starts through primary preven- tion, healing America’s drug users through tertiary preven- tion, and disrupting the market through efforts to reduce the availability of illicit drugs.
●● The federal program, Healthy People 2020, has set spe- cific objectives with regard to aspects of personal health, including those that pertain to substance use.
Prevention Approaches that Have Failed ●● Several strategies have been largely unsuccessful in meet-
ing the goals of substance abuse prevention. They include the reliance on supply/availability reduction, punitive ju- dicial policies, scare tactics, objective information, and self-esteem enhancement/affective education.
Components of effective school-based Prevention Programs
●● Effective school-based programs have incorporated a com- bination of peer-refusal skills training, relaxation and stress management, and training in social skills and personal decision making.
●● The Life Skills Training program is an example of a com- prehensive program that incorporates several of these school- based components for effective substance abuse prevention. On the other hand, several evaluative studies have shown the popular Drug Abuse Resistance Education (DARE) pro- gram, in its original form, to be of little effectiveness in pri- mary prevention. Later versions have incorporated many of the components that have been demonstrated to be effective.
Community-based Prevention Programs ●● Community-based programs make use of a broader range
of resources, including community leaders and public fig- ures as positive role models, opportunities for alternative- behavior programming, and the media.
●● Specific media sources can have a positive or negative im- pact on substance abuse prevention in both high-risk pop- ulations and others in the community. The Partnership for a Drug-Free America (PDFA) has been a leader in anti-drug communications in the media, while numerous online Internet sources tend to promote either pro-drug or misinformation about drug-taking behavior.
●● CASASTART is an example of a community-based pro- gram that incorporates intensive communitywide compo- nents of substance abuse prevention.
Family systems in Primary and secondary Prevention ●● Community-based prevention programs are increasingly
mindful of the importance of the family, particularly par- ents, as the first line of defense in prevention efforts.
●● The major emphasis in primary and secondary prevention programs has been on the special roles of parents, grand- parents, guardians, and other family members. Improved lines of communication within the family are crucial ele- ments in the promotion of substance abuse prevention.
substance Abuse Prevention and the College student
●● On college campuses, substance abuse prevention pro- grams are incorporating features of both school-based and community-based approaches. There is a compelling argument for the need to change the culture of alcohol and other drug use in college.
●● Substance abuse prevention programs on college campuses should involve faculty and administrators, as well as students, in an overall comprehensive strategy. College fraternities have taken important strides toward an alcohol ban in frater- nity houses, even when members are of legal drinking age.
substance Abuse Prevention and treatment in the Workplace
●● The 1988 Drug-free Workplace Act mandated that any company or business receiving U.S. federal contracts or grants provide a drug-free workplace. This is carried out through a comprehensive and continuing program of drug
Summary
386 ■ Part Five Drug-Control Policy and Intervention Strategies
Needing versus receiving substance Abuse treatment
●● According to U.S. government estimates, approximately 8 million people aged 12 or older need treatment for an illicit drug problem; more than 18 million people need treatment for an alcohol problem. A small fraction, how- ever, have received treatment at a specialized facility in the past 12 months or any treatment facility.
●● Of those individuals who have needed treatment for illicit drug or alcohol use problems but have not received it, only about 5 percent personally felt the need to seek it out. Reasons for not seeking treatment include the lack of financial means to pay for treatment services and inadequate health insurance coverage. The Mental Health Parity and Addiction Equity Act and the Affordable Care Act allow individuals in substance abuse treatment to receive reimbursement on a par with treatment for medi- cal or surgical health benefits.
Final Note: For those Who Need Help… ●● The most comprehensive sources for substance abuse
treatment information in the United States is the National Clearinghouse for Alcohol and Drug Information (NCADI) and the Substance Abuse and Mental Health Administration (SAMHSA), accessible through www .health.org and www.samhsa.gov, respectively. Similar information sources exist in Canada, the United Kingdom, and most other nations.
education and awareness. It is estimated that substance abuse costs as much as $60–$100 billion each year.
●● One element of most drug-free workplace programs is an employee assistance program (EAP), serving to help work- ers with abuse problems. Where unions exist, member as- sistance programs (MAPs) supplement and complement the work of EAPs.
●● Frequently, substance abuse prevention efforts in the workplace entail drug testing among employees, either as a prescreening procedure for new job applicants or as a continuing program for all employees.
Multicultural issues in Prevention and treatment ●● Special cultural considerations need to be made when
communicating about substance abuse with specific pop- ulation subgroups such as individuals in Latino, African American, and Native American communities.
substance Abuse treatment: the Journey to recovery
●● The road to recovery can be understood in terms of five dis- tinct “stages of change.” These stages are precontemplation, contemplation, preparation, action, and maintenance. It is possible to cycle through these stages multiple times in a kind of spiraling pattern before long-term recovery is attained.
●● The five stages of change are applicable to the resolution of any life problems, not just those associated with sub- stance abuse.
Key Terms
action stage, p. 382 affective education, p. 370 contemplation stage, p. 381 employee assistance programs
(EAPs), p. 378
impactors, p. 373 maintenance stage, p. 382 member assistance programs
(MAPs), p. 379 peer-refusal skills, p. 370
precontemplation stage, p. 381 preparation stage, p. 381 primary prevention, p. 364 resilience, p. 366
secondary prevention, p. 364 sociocultural filters, p. 379 tertiary prevention, p. 364 values clarification, p. 370
1. Describe the primary, secondary, and tertiary levels of intervention in substance abuse prevention. Include in your answer the specific target population and goals in each level of intervention. What is the relationship between resilience and primary prevention?
2. Describe the components of effective school-based prevention programs, using the Life Skills Training program as a model for school-based interventions.
3. How is a community-based prevention program different from a school-based program? In what ways, can a community-based program be more effective in substance abuse prevention?
4. Discuss the “triple threat” concept (stress, boredom, and spend- ing money) in drug-taking behavior among young people.
5. Why is it particular difficult to implement substance abuse prevention programs on college campuses, compared to pro- grams in the community, in the workplace, or in earlier educa- tional settings?
6. Discuss the particular challenges of substance abuse preven- tion and treatment in Latino, African American, and Native American communities?
7. Review the stages of change in substance abuse treatment.
Review Questions
You have a close friend who is a substance abuser, who has experienced significant problems associated with substance abuse. Your friend could be male or female; let us assume your friend is female. She is adamant in her refusal to enter into any treatment for her substance abuse. She is convinced that she
does not need it; and that it is inconvenient or embarrassing to seek treatment even if she needed it. Yet, all objective evidence points to a decline in her physical, social, and psychological well-being. As a friend, what can you do to help her receive the treatment she needs?
Critical Thinking: What Would You Do?
Chapter 17 Substance Abuse Prevention and Treatment ■ 387
1. Grant, Bridget F.; and Dawson, Deborah A. (1997). Age at onset of alcohol use and its association with DSM-IV alcohol abuse and dependence: Results from the National Longitudinal Alcohol Epidemiological Survey. Journal of Substance Abuse, 9, 103–110. Grant, Bridget F.; and Dawson, Deborah A. (1998). Age of onset of drug use and its associa- tion with DSM-IV drug abuse and dependence: Results from the National Longitudinal Alcohol Epidemiological Survey. Journal of Substance Abuse, 10, 163–173.
2. Brook, Judith S.; and Brook, David W. (1996). Risk and protec- tive factors for drug use. In Clyde B. McCoy; Lisa R. Metsch; and James A. Inciardi (Eds.), Intervening with drug-involved youth. Thousand Oaks, CA: Sage Publications, pp. 23–44. Clayton, Richard R.; Segress, Melissa J. H.; and Caudill, Crystal A. (2008) Prevention of substance abuse. In Marc Galanter and Herbert D. Kleber (Eds.), Textbook of substance abuse treatment (4th ed.). Washington, DC: American Psychiatric Publishing, pp. 681–688. Glantz, Meyer D.; and Johnson, Jeannette, L. (Eds.) (2003). Resilience and development: Positive life adapta- tions. New York: Kluwer Academic/Plenum. Wong, Maria M.; Nigg, Joel T.; Zucker, Robert A.; Puttler, Leon I.; et al. (2006). Behavioral control and resiliency in the onset of alcohol and illicit drug use: A prospective study from preschool to adoles- cence. Child Development, 77, 1016–1033.
3. Biglan, Anthony; Mrazek, Patricia J.; Carnine, Douglas; and Flay, Brian R. (2003). The integration of research and prac- tice in the prevention of youth problem behaviors. American Psychologist, 58, 433–441. Office of National Drug Control Policy (2014, March). National drug control budget: FY 2015 funding highlights. Washington, DC: White House Office of National Drug Control Policy.
4. Mokdad, Ali H.; Marks, James S.; Stroup, Donna F.; and Gerberding, Julie L. (2004). Actual causes of death in the United States, 2000. Journal of the American Medical Association, 291, 1238–1245. Mokdad, Ali H.; Marks, James S.; Stroup, Donna F.; and Gerberding, Julie L. (2005). Correction: Actual causes of death in the United States, 2000. Journal of the American Medical Association, 293, 298.
5. Califano, Joseph A., Jr. (2007). High society: How substance abuse ravages America and what to do about it. New York: Public Affairs. Center for Substance Abuse Prevention (2009). Substance abuse prevention dollars and cents: A cost-benefit analysis. Rockville, MD: Substance Abuse and Mental Health Services Administration.
6. Public Health Service (October–November 2009). Healthy People 2020: Public meeting. 2009 draft objectives. Bethesda, MD: Public Health Service.
7. Office of National Drug Control Policy, National drug control strategy, Table 1.
8. Goode, Erich (2008). Drugs in American society (7th ed.). New York: McGraw-Hill College, pp. 400–403. National Drug Intelligence Center (2008). National drug threat assessment 2009. Washington, DC: U.S. Department of Justice, pp. 25–32.
9. Hingson, Ralph W.; Scotch, Norman; Mangione, Thomas; Meyers, Allan; Glantz, Leonard; et al. (1983). Impact of leg- islation raising the legal drinking age in Massachusetts from 18 to 21. American Journal of Public Health, 73, 163–170.
10. Goode, Drugs in American society, pp. 385–417. Greenhouse, Linda (2007, December 11). Justices restore judges’ control over sentencing. New York Times, pp. A1, A28. Peters, Jeremy
W. (2009, March 11). Legislation to overhaul Rockefeller drug laws advances swiftly. New York Times, p. 20. Steinberg, Neil (1994, May 5). The law of unintended consequences. Rolling Stone, pp. 33–34.
11. Funkhouser, Judith E.; and Denniston, Robert W. (1992). Historical perspective. In Mary A. Jansen (Ed.), A promising future: Alcohol and other drug problem prevention services improvement (OSAP Prevention Monograph 10). Rockville, MD: Office of Substance Abuse Prevention, pp. 5–15.
12. Flay, Brian R.; and Sobel, Judith L. (1983). The role of mass media in preventing adolescent substance abuse. In Thomas J. Glynn; Carl G. Leukenfeld; and Jacqueline P. Ludford (Eds.), Preventive adolescent drug abuse. Rockville, MD: National Institute on Drug Abuse, pp. 5–35.
13. Williams, Raymond E., Ward, David A., and Gray, Louis N. (1985). The persistence of experimentally induced cognitive change: A neglected dimension in the assessment of drug prevention programs. Journal of Drug Education, 15, 33–42.
14. Meeks, Linda; Heit, Philip; and Page, Randy (1994). Drugs, alcohol, and tobacco. Blacklick, OH: Meeks Heit Publishing, p. 201.
15. Ibid., p. 202. 16. McBride, Duane C.; Mutch, Patricia B.; and Chitwood, Dale
D. (1996). Religious belief and the initiation and prevention of drug use among youth. In Clyde B. McCoy; Lisa R. Metsch; and James A. Inciardi (Eds.), Intervening with drug-involved youth. Thousand Oaks, CA: Sage Publications, pp. 110–130.
17. Schroeder, Debra S.; Laflin, Molly T.; and Weis, David L. (1993). Is there a relationship between self-esteem and drug use? Methodological and statistical limitations of the research. Journal of Drug Issues, 22, 645–665. Yuen, Francis K. O.; and Pardeck, John T. (1998). Effective strategies for preventing substance abuse among children and adolescents. Early Child Development and Care, 145, 119–131.
18. Best, J. Allan; Flay, Brian R.; Towson, Shelagh M. J.; Ryan, Katherine B.; et al. (1984). Smoking prevention and the concept of risk. Journal of Applied Social Psychology, 14, 257–273. Pandina, Robert J.; Johnson, Valerie L.; and White, Helene R. (2010). Peer influences on substance use during adolescence and emerging adulthood. In Lawrence M. Scheier (Ed.), Handbook of drug use etiology: Theory, methods, and empirical findings. Washington, DC: American Psychological Association, pp. 383–402.
19. Botvin, Gilbert J.; and Griffin, Kenneth W. (2010). Advances in the science and practice of prevention: Targeting individual- level etiological factors and the challenge of going to scale. In Lawrence M. Scheier (Ed.), Handbook of drug use etiology: Theory, methods, and empirical findings. Washington, DC: American Psychological Association, pp. 631–650. Botvin, Elizabeth M. (1992). School-based and community-based preven- tion approaches. In Joyce H. Lewisohn; Pedro Ruiz; and Robert B. Millman (Eds.), Substance abuse: A comprehensive textbook (2nd ed.). Baltimore, MD: Williams & Wilkins, pp. 910–927.
20. Culpers, Pim (2002). Effective ingredients of school-based drug prevention programs: A systematic review. Addictive Behaviors, 27, 1009–1023. Faggiano, Fabrizio; Vigna-Taglianti, Federica; Versino, Elizabetta; Zambon, Alberto; and Lemma, Patrizia (2005). School-based prevention for illicit drugs’ use. Cochrane Database of Systematic Reviews, Issue 2. Article No.: CD003020doi: 10.1002/14651858.CD0030.pub2.
Endnotes
388 ■ Part Five Drug-Control Policy and Intervention Strategies
interventions and effective prevention. American Psychologist, 58, 441–448.
30. Rhodes, Jean E.; and Jason, Leonard A. (1991). The social stress model of alcohol and other drug abuse: A basis for com- prehensive, community-based prevention. In Ketty H. Rey; Christopher L. Faegre; and Patti Lowery (Eds.), Prevention research findings: 1988 (OSAP Prevention Monograph 3). Rockville, MD: Office of Substance Abuse Prevention, pp. 155–171.
31. Tobler, Nancy S. (1986). Meta-analysis of 143 adolescent drug prevention programs: Quantitative outcome results of program participants compared to a control group. Journal of Drug Issues, 16, 537–567.
32. Ridout, Victoria; Roberts, Donald F.; and Foehr, Ulla G. (2005, March). Generation M: Media in the lives of 8–18-year- olds: Executive summary. Menlo Park, CA: Kaiser Family Foundation. Quotation on p. 6.
33. Masten, Ann S.; Faden, Vivian B.; Zucker, Robert A.; and Spear, Linda P. (2008). Underage drinking: A developmen- tal framework. Pediatrics, 121, S235–S251. Primack, Brian; Dalton, Margaret A.; Carroll, Mary V.; Agarwal, Aaron A.; and Fine, Michael J. (2008). Content analysis of tobacco, alcohol, and other drugs in popular music. Archives of Pediatric and Adolescent Medicine, 162, 169–175. Sargent, James D.; Wills, Thomas A.; Stoolmiller, Mike; Gibson, Jennifer; and Gibbons, Frederick X. (2006). Alcohol use in motion pictures and its relation with early-onset teen drinking. Journal of Studies in Alcohol, 67, 54–65.
34. Partnership for a Drug-Free America (1994, July 12). Press release: New study shows children in NYC becoming more anti-drug, bucking national trends. Partnership for a Drug-Free America, New York.
35. Office of National Drug Control Policy (2006, July 21). Media campaign fact sheets: Teens and technology fact sheet. National Youth Anti-drug Media Campaign, Office of National Drug Control Policy, Washington, DC. Partnership for a Drug-Free America, New York. Substance Abuse and Mental Health Services Administration (2009, April 3). SAMHSA News Release: National survey finds a decrease in the percentage of adolescents seeing substance use prevention messages in the media. Rockville, MD: Substance Abuse and Mental Health Services Administration.
36. Information courtesy of the Substance Abuse and Mental Health Services Administration, Rockville, MD.
37. Kliewer, Wendy (2010). Family processes in drug use etiology. In Lawrence M. Scheier (Ed.), Handbook of drug use etiology: Theory, methods, and empirical findings. Washington, DC: American Psychological Association, pp. 365–382. National Center on Addiction and Substance Abuse at Columbia University (1999). No safe haven: Children of substance- abusing parents. New York: National Center on Addiction and Substance Abuse at Columbia University. Seizas, Judith S.; and Youcha, Geraldine (1999). Drugs, alcohol, and your children: What every parent needs to know. New York: Penguin Books.
38. The Ad Council. (2008, March/April). Underage drinking pre- vention: Alcohol initiation rates highest during summer. PSA Bulletin, p. 1. Lae, Andrew; and Crano, William D. (2009). Monitoring matters: Meta-analytic review reveals the reliable linkage of parental monitoring with adolescent marijuana use. Perspectives on Psychological Science, 4, 578–586. Wooldridge, Leslie Quander (2007, March/April). Ads, billboards highlight younger children. SAMHSA News, p. 11.
21. Botvin, Gilbert J.; Baker, Eli; Dusenbury, Linda; Botvin, Elizabeth M.; and Diaz, Tracy (1995). Long-term follow-up results of a randomized drug abuse prevention trial in a white middle-class population. Journal of the American Medical Association, 273, 1106–1112. Botvin, Gilbert J.; Epstein Jennifer A.; Baker, Eli; Diaz, Tracy; and Ifill-Williams, Michelle (1997). School-based drug abuse prevention with inner-city minor- ity youth. Journal of Child and Adolescent Substance Abuse, 6, 5–19. Botvin, Gilbert J.; and Tortu, Stephanie (1988). Preventing adolescent substance abuse through life skills training. In Richard M. Price; Emory L. Cowen; Raymond P. Lorion; and Julia Ramos-McKay (Eds.), Fourteen ounces of prevention: A casebook for practitioners. Washington, DC: American Psychological Association, pp. 98–110.
22. Mathias, Robert (1997, March/April). From the ’burbs to the ’hood … This program reduces student’s risk of drug use. NIDA Notes, pp. 1, 5–6. Quotation on p. 6.
23. Beets, Michael W.; Flay, Brian R.; Vuchinich, Samuel; Snyder, Frank J.; Acock, Alan; et al. (2009). Use of a social and character development program to prevent substance use, violent behaviors, and sexual activity among elementary- school students in Hawaii. American Journal of Public Health, 99, 1438–1445. Botvin, Gilbert J.; Griffin, Kenneth W.; and Nichols, Tracy D. (2006). Preventing youth violence and delinquency through a universal school-based prevention approach. Prevention Science, 7, 403–408. Griffin, Kenneth W.; Botvin, Gilbert J.; and Nichols, Tracy D. (2006). Effects of a school-based drug abuse prevention program for adoles- cents on HIV risk behaviors in young adulthood. Prevention Science, 7, 103–112. Griffin, Kenneth W.; Botvin, Gilbert J.; and Nichols, Tracy D. (2004). Long-term follow-up effects of a school-based drug abuse prevention program on adolescent risky driving. Prevention Science, 5, 207–212.
24. Cavazos, Lauro F. (1989). What works: Schools without drugs. Washington, DC: U.S. Department of Education, p. 38.
25. Clayton, Richard R.; Cattarello, Anne M.; and Johnstone, Bryan M. (1996). The effectiveness of Drug Abuse Resistance Education (Project DARE): 5-year follow-up results. Preventive Medicine, 25, 307–318. Lynam, Donald R.; Milich, Richard; Zimmerman, Rick; Novak, Scott P.; Logan, T. K.; et al. (1999). Project DARE: No effects at 10-year follow-up. Journal of Consulting and Clinical Psychology, 67, 590–593. Pan, Wei and Bai, Haiyan (2009). A multivariate approach to a meta-analytic review of the effectiveness of the D.A.R.E. program. International Journal of Environmental Research and Public Health, 6, 267–277.
26. Miller, Joel (2004). Bad trip: How the war against drugs is destroying America. New York: Nelson Thomas.
27. Lynam et al., Project DARE, p. 593. 28. Zernike, Kate (2001, February 15). Antidrug program says it
will adopt a new strategy. New York Times, pp. A1, A29. 29. Gardner, Margo; Barajas, R. Gabriela; and Brooks-Gunn,
Jeanne (2010). Neighborhood influences on substance use etiology: Is where you live important? In Lawrence M. Scheier (Ed.), Handbook of drug use etiology: Theory, methods, and empirical findings. Washington, DC: American Psychological Association, pp. 423–442. Snyder, Leslie B.; and Nadorff, P. Gayle (2010). Youth substance use and the media. In Lawrence M. Scheier (Ed.), Handbook of drug use etiol- ogy: Theory, methods, and empirical findings. Washington, DC: American Psychological Association, pp. 475–492. Wandersman, Abraham; and Florin, Paul (2003). Community
Chapter 17 Substance Abuse Prevention and Treatment ■ 389
39. The National Center on Addiction and Substance Abuse at Columbia University (2005, September). The importance of family dinners II. New York: National Center on Addiction and Substance Abuse at Columbia University. The National Center on Addiction and Substance Abuse at Columbia University (2006, August). National Survey of American Attitudes on Substance Abuse XI: Teens and parents. New York: National Center on Addiction and Substance Abuse at Columbia University. Partnership for a Drug-Free America (1998). Partnership attitude tracking survey: Parents say they’re talking, but only 27% of teens—1 in 4—are learning a lot at home about the risk of drugs. Partnership for a Drug-Free America (1999). Partnership attitude tracking survey: More parents talking with kids about drugs more often, and appear to be having an impact. Information courtesy of Partnership for a Drug-Free America, New York.
40. The National Center on Addiction and Substance Abuse at Columbia University (2003, August). National Survey American Attitudes on Substance Abuse VIII: Teens and par- ents. New York: National Center on Addiction and Substance Abuse at Columbia University.
41. Castro, Ralph J.; and Foy, Betsy D. (2002). Harm reduction: A promising approach for college health. Journal of American College Health, 51, 89–91. Lewis, David C. (2001). Urging college alcohol and drug policies that target adverse behav- ior, not use. Journal of American College Health, 50, 39–41. Weitzman, Elissa R.; Nelson, Toben F.; Lee, Hang; and Wechsler, Henry (2004). Reducing drinking and related harms in college: Evaluation of the “A Matter of Degree” program. American Journal of Preventive Medicine, 27, 187–196.
42. Freedman, Samuel G. (2007, September 12). Calling the folks about campus drinking. New York Times, p. B6. National Institute on Alcohol Abuse and Alcoholism (2002, October). Changing the culture of campus drinking. Alcohol Alert, No. 58. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism.
43. Johnston, Lloyd M.; O’Malley, Patrick M.; Bachman, Jerald G.; Schulenberg, John E.; and Miech, Richard A. (2014). Monitoring the future: National survey results on drug use, 1975–2013, Vol II: College students and adults ages 19–55. Ann Arbor, MI: Institute for Social Research, University of Michigan, Table 2-1.
44. Office of Educational Research and Improvement (1990). A guide for college presidents and governing bodies: Strategies for eliminating alcohol and other drug abuse on campuses. Washington, DC: U.S. Department of Education.
45. Denizet-Lewis, Benoit (2005, January 9). Band of brothers. New York Times Magazine, pp. 32–39, 52, 73. Quotation on p. 35. A guide for college presidents and governing boards. U.S. Department of Education, Washington, DC, 1990.
46. Busteed, Brandon (2010, March 19). Is high-risk drinking at college on the way out? Chronicle of Higher Education, p. A76. Crump, Sarah (2008, March 6). Fraternity life without keg parties safer, saner, say Phi Delta Theta guys. www.cleveland.com/lifestyles/2008.
47. Center for Substance Abuse Treatment (2010, April 4). Issue Brief #12 for Employers: What you need to know about substance abuse treatment. Rockville, MD: Substance Abuse and Mental Health Services Administration. Larson, Sharon L.; Eyerman, Joe; Foster, Misty S.; and Gfroerer, Joseph C. (2007). Worker substance use and workplace policies and programs. Rockville, MD: Substance Abuse and Mental
Health Services Administration, p. 2. Lehman, Wayne E. K.; Farabee, David J.; and Bennett, Joel B. (1998). Perceptions and correlates of co-worker substance use. Employee Assistance Quarterly, 13, 1–22.
48. Center for Substance Abuse Prevention (1994). Making the link: Alcohol, tobacco, and other drugs in the workplace. Rockville, MD: Substance Abuse and Mental Health Services Administration.
49. Blum, Terry C.; and Roman, Paul M. (1995). Cost-effectiveness and preventive implications of employee assistance programs. Rockville, MD: Substance Abuse and Mental Health Services Administration.
50. Hernandez, Lawrence P.; and Lucero, Ed (1996). La Familia community drug and alcohol prevention program: Family- centered model for working with inner-city Hispanic families. Journal of Primary Prevention, 16, 255–272. El-Guebaly, Nady (2008). Cross-cultural aspects of addiction. In Marc Galanter and Herbert D. Kleber (Eds.), Textbook of sub- stance abuse treatment (4th ed.). Washington, DC: American Psychiatric Publishing, pp. 45–52. Office of Substance Abuse Prevention (1990). The fact is … reaching Hispanic/Latino audiences requires cultural sensitivity. Rockville, MD: National Clearinghouse for Alcohol and Drug Information, National Institute on Drug Abuse. U.S. Census Bureau (2005). The Hispanic population in the United States: March 2004. Washington, DC: U.S. Department of Commerce.
51. Hahn, Ellen J.; and Rado, Mary (1996). African-American Head Start parent involvement in drug prevention. American Journal of Health Behavior, 20, 41–51. Office of Substance Abuse Prevention (1990). The fact is … alcohol and other drug use is a special concern for African American families and com- munities. Rockville, MD: National Clearinghouse for Drug and Alcohol Information, National Institute on Drug Abuse.
52. Kulis, Stephen; Napoli, Maria; and Marsiglian, Flavio Francisco (2002). Ethnic pride, biculturalism, and drug use norms of urban American Indian adolescents. Social Work Research, 26, 101–112. Melton, Ada Pecos; Chino, Michelle; May, Phillip A.; and Gossage, J. Phillip. (2000). Promising practices and strategies to reduce alcohol and substance abuse among American Indians and Alaska Natives. An OJP Issues and Practices Report. Washington, DC: U.S. Department of Justice. Center for Behavioral Health Statistics and Quality (2014). Results of the 2013 National Survey on Drug Use and Health: National summary. Rockville, MD: Substance Abuse and Mental Health Services Administration, pp. 26, 38, and 52.
53. Connors, Gerard J.; Donovan, Dennis J.; and DiClemente, Carlo C. (2001). Substance abuse treatment and the stages of change: Selecting and planning interventions. New York: Guilford Press. DiClemente, Carlo C.; Bellino, Lori E.; and Neavins, Tara M. (1999). Motivation for change and alco- holism treatment. Alcohol Research and Health, 23, 86–92. Schuckit, Marc A. (1995). Educating yourself about alcohol and drugs: A people’s primer. New York: Plenum Press, pp. 131–153.
54. DiClemente, Carlo C.; Garay, Miranda; and Gemmell, Leigh (2008). Motivational enhancement. In Marc Galanter and Herbert D. Kleber (Eds.), Textbook of substance abuse treatment (4th ed.). Washington, DC: American Psychiatric Publishing, pp. 361–372. Dijkstra, Arie; Roijackers, Jolanda; and DeVries, Hein (1998). Smokers in four stages of readiness to change. Addictive Behaviors, 23, 339–350. Prochaska, James O.; DiClemente, Carlo C.; and Norcross, John C. (1992). In search of how people change. American Psychologist, 47, 1102–1114.
390 ■ Part Five Drug-Control Policy and Intervention Strategies
58. McClellan, A. Thomas (2008). Evolution in addiction treat- ment concepts and methods. In Marc Galanter and Herbert D. Kleber (Eds.), Textbook of substance abuse treatment (4th ed.). Washington, DC: American Psychiatric Publishing, pp. 93–108. Substance Abuse and Mental Health Services Administration (2009, November/December). Screening, brief intervention, and referral to treatment. SAMHSA News, pp. 1–2.
59. Beronio, Kirsten; Po, Rosa, Skopec; and Glied Sherry (2013 February). Affordable Care Act will expand mental health and substance use disorder benefits and parity protections for 62 million Americans. ASPE Research Brief. Washington, DC: U.S. Department of Health and Human Services. Parity: What does the new law mean? (2008, November/December). SAMHSA News, pp. 1–4. Center for Behavioral Health Statistics and Quality, Results from 2013 National Survey on Drug Use and Health, p. 7.
55. Norman, Gregory J.; Velicer, Wayne F.; Fava, Joseph L.; and Prochaska, James O. (1998). Dynamic typology clus- tering within the stages of change for smoking cessation. Addictive Behaviors, 23, 139–153. Prochaska, James O. (1994). Changing for good. New York: William Morrow. Velicer, Wayne F.; Norman, Gregory J.; Fava, Joseph L.; and Prochaska, James O. (1999). Testing 40 predictions from the transtheoretical model. Addictive Behaviors, 24, 455–469.
56. Schuckit, Educating yourself, pp. 186–216. 57. Markel, Howard (2003, October 21). Treatment for addic-
tion meets barriers in the doctor’s office. New York Times, pp. F5, F8. Center for Behavioral Health Statistics and Quality, Results of the 2013 National Survey on Drug Use and Health, pp. 92–98. Substance Abuse and Mental Health Services Administration (2009, July 16). Substance use treatment need and receipt among Hispanics. The NSDUH Report, Figures 1 and 2.
391
Chapter 1 Page 2, William Campbell/Sygma/Corbis; 8, Pearson Education; 10, Radius Images/Corbis; 21, Boris Roessler/dpa/picture-alliance/Newscom.
Chapter 2 Page 31, Adam Butler/AP Images; 34(t), Reuters/Corbis; 34(b), Luca Zanetti/laif/Redux; 35, David Maung/AP Images.
Chapter 3 Page 48, Blickwinkel/Alamy; 49, 914 collection/Alamy; 51, Food Collection/Alamy; 54, Hulton Archive/Getty Images; 55, AMC/Everett Collection; 57, Jonathan Ernst/Reuters.
Chapter 4 Page 68, Piotr Marcinski/Fotolia; 69, Garo/Phanie/Science Source; 74(t), Arthur Turner/Alamy; 74(b), Akg-images/Newscom; 88, NIDA(NIH).
Chapter 5 Page 90, David Orcea/Shutterstock; 92, Timothy Tadder/Corbis; 98, Ace Stock Limited/Alamy.
Chapter 6 Page 111, Suffolk County Police Department/AP images.
Chapter 7 Page 123, Eye Ubiquitous/Alamy; 125, Kathryn Cook/AP Images; 126, Hans Deryk/AP Images; 130, St Petersburg Times/ZUMAPRESS/ Newscom; 131, ARF/ZOJ/Alberto Reyes/WENN/Newscom.
Chapter 8 Page 147, Whiteman Osterman & Hanna LLP; 149, Adam Wisneski/Tulsa World.
Chapter 9 Page 158, Rahmat Gul/AP Images; 159, Glasshouse Images/Alamy; 161, DEA Museum; 162, Bettmann/Corbis; 175, Pearson Education.
Chapter 10 Page 184, Bettmann/Corbis; 188, Wesley Bocxe/Photo Researchers, Inc./Science Source; 191(l), Culver City Police Department/AP Images; 191(r), Krista Kennell/Sipa Press/AP Images; 195, C.E. Jones/The Grundy County Herald/AP Images.
Chapter 11 Page 210(t), Nancy Hoyt Belcher/Alamy; 210(b), Ron Wolfson/Landov; 211, INSADCO Photography/Alamy; 214, Vaughan Fleming/Photo Researchers, Inc./Science Source; 217, Francois Gohier/Photo Researchers, Inc./Science Source.
Chapter 12 Page 229, Enrique Marcarian/Reuters/Landov; 230, F1online digitale Bildagentur GmbH/Alamy; 232, Bettmann/Corbis; 233(l), James W. Prichard/The New York Times/Redux Pictures; 233(r), Hulton Archive/Moviepix/Getty Images; 247, David Yee/UPI/Newscom.
Chapter 13 Page 257(t), AP Images; 257(b), PCN Photography/Alamy; 258, Mike Blake/Reuters/Newscom; 260, Imago sportfotodienst/Newscom; 272, Blair Seitz/Photo Researchers, Inc./Science Source.
Chapter 14 Page 280, W McIntyre/Photo Researchers, Inc./Science Source; 282, AP Images; 285, Bettmann/Corbis; 288, Vanderlei Almeida/Reuters/ Corbis; 292, David Hoffman Photo Library/Alamy; 294, Eric Risberg/AP Images.
Chapter 15 Page 306(t), Darko Veselinovic/Thinkstock/Getty Images; 306(b), George Steinmetz/Corbis; 307, Wallenrock/Shutterstock; 311, Victor Biro/ Alamy; 314, Scott Applewhite/AP Images; 318, National Clearinghouse for Alcohol & Drug Information, Substance Abuse and Mental Health Administration. Public access.; 322(t), Martin M. Rotker/Science Source; 322(b), Biophoto Associates/Science Source; 324, Rick’s Photography/Shutterstock.
Chapter 16 Page 339, Image Courtesy of The Advertising Archives; 341, Reuters/Corbis; 350, F1online digitale Bildagentur GmbH/Alamy; 352, National Library of Medicine; 356, California Department of Public Health.
Chapter 17 Page 370, Jeff Greenberg/PhotoEdit, Inc.; 375, Partnership For Drug-Free Kids. drugfree.org; 376, Substance Abuse and Mental Health Services Administration (SAMHSA) www.stopalcoholabuse.gov; 384, LICADD.
Photo Credits
392
drug abuse prevention approaches among, 379
and ethnicity association of cocaine with, 50 mentholated cigarettes smoked by, 340 nicotine metabolism in, 76, 340 racial profiling and, 128
Aggression. See also Crime; Violence testosterone and, 260–1
AIDS (acquired immuno-deficiency syndrome), 170, 244
spread through injections, 68 Air Branch, U.S. Customs, 126 Al-Anon, 328 Alateen, 328 Alcohol, 3, 7, 299–329
acute behavioral effects of, 311–13 acute physiological effects of, 308–11 in America before prohibition, 52 barbiturates mixed with, 279–80 benzodiazepines combined with, 283 biotransformation rate of, 70 black-market, during Prohibition, 313 blood levels of, 303, 311 BluntGen subculture and use of, 109 in brain, effects of, 303, 323–4 cardiovascular effects, 323 chronic physiological effects of, 321–4 cocaine and, 183–4 in college, 17, 307, 377, 378 creating, 300–1 cross-tolerance and, 75 deaths from, 12, 15 demographics of consumption, 307 detection periods for, 270 diuretic effects of, 309 driving while under the influence of, 59, 311 elimination of, 309 emergencies related to, 12 emergency signs and procedures for
intoxication, 309 gender and, 76 hangovers from, 310–11 health benefits of, 315–16 heat loss and, 309 history of, 306–8 interactions with other drugs, 7, 310 legality of, 5, 6 lethal dosage of, 308 Life Skills Training program to combat, 371–2 as men’s recreational drug in 1800s, 160 metabolism of, 76, 301–5 methadone-maintenance clients’ abuse of, 169 minimum drinking age, 17, 314 neurochemical system in brain and, 87–8 neurotransmitters and effects of, 87–8 patterns of consumption, 304–6 pharmacological violence and, 110 pharmacology of, 301–5 in post-World War II U.S., 55–6 pregnancy and consumption of, 302, 310, 324 prevalence and economic costs of workplace
use of, 308 reduced availability, 266 regulation of, 50–3 restricted access, regulation by, 313 security and spectator sports, 312 sexual desire and performance, 312–13 sleep patterns and, 309 Temperance Movement, 52–3 toxic reactions to, 308–9
traffic fatalities, regulation to reduce, 314 withdrawal from, 78, 283, 321–2
Alcohol consumption underage drinkers, 307–8 Alcohol, Drug Abuse, and Mental Health Admin-
istration Reorganization Act (1992), 350 Alcohol abuse
cancer from, 323 cardiovascular problems from, 323 dementia, 323 effects of chronic, 321–4 fetal alcohol syndrome (FAS) from, 324 liver disease from, 322–3 patterns of, 320–1 regulation of, 313–14 tolerance to and withdrawal from, 321–2 Wernicke-Korsakoff’s syndrome from, 323 in workplace, 308
Alcohol dehydrogenase, 302 AlcoholEdu, 378 AlcoholEdu for Sanctions, 378 Alcoholic beverages
alcohol equivalencies of, 304 four-loko effect, 75 production of, 300–1 sources of, 301
Alcoholic cirrhosis, 322, 322–31 Alcoholic dementia, 323, 323–4 Alcoholic hepatitis, 322 Alcoholics
benzodiazepine use, 282 children of (COAs), 325 types of, 326
Alcoholics Anonymous (AA), 190, 327, 327–8 Alcoholism, 317, 317
biologically based treatments of, 326–7 demographics of, 317 emotional problems and, 317 family dynamics, 324–5 genetics of, 85–6 Long Island Council on Alcoholism and
Drug Dependence, 384 non-disease model, 329 physical problems associated with, 319 preoccupation with drinking and, 317 SMART Recovery for, 328 vocational, social, family dynamics of, 319 in workplace, 308
Alcohol use disorder, 319-20, 320 Alcohol withdrawal syndrome, 321 Aldactone, 310 Ale, 301 Alpert, Richard, 209 Alprazolam, 282 Alternative-behavior programming, 373 Alternative maintenance programs, 170 Altria, 352 Alzheimer’s disease, drug-induced dementia
versus, 283 Amanita muscaria, 48, 71, 208, 219 Ambien (zolpidem), 284 American Bar Association, 146 American Cancer Society, 347 American Medical Association, 49, 325 American Psychiatric Association, 79, 319 American Temperance Society, 52 Amitriptyline, 282 Ammonia as cigarette additive, 343 Amobarbital, 270, 279, 280, 281 Amotivational syndrome, 239–40, 239 Amphetamine psychosis, 194
Index
Note: Boldface indicates key terms and the pages where they are defined.
AA (Alcoholics Anonymous), 190, 327, 327–8 Absorption, 69
through gastrointestinal tract, 67–8 through skin or membranes, 69
Abstinence, 317 Acamprosate, 327 Acetaldehyde, 302 Acetaldehyde dehydrogenase, 302 Acetaminophen, 172, 173, 310 Acetates, 286 Acetic acid, 302 Acetic anhydride, 123 Acetone, 286, 288 Acetylcholine, 87
hallucinogens related to, 206, 219–20 Acetylsalicylic acid (ASA), 161 Acid blotters, 211 Acne, steroid use and, 259 Acquired immuno-deficiency syndrome.
See AIDS (acquired immuno-deficiency syndrome)
Acromegaly, 264 Action stage of change, 382 Actiq (fentanyl), 172 Active placebo, 77 Acullicadores, 182 Acute toxicity, 9, 9, 15 ADAM II (Arrestee Drug Abuse Monitoring
Program), 106–7 Adaptations to anomie, 91–2 Adderall, 6–7, 198, 199 Addiction, brain effects of, 88. See also
Dependence Additive effect, 71 Adenergy, 264 ADHD. See Attention-deficit hyperactivity
disorder (ADHD) ADHD/ADD, adderall in sports, 266 Adhesiveness, platelet, 345 Adjudication, 139 Administration
routes of, 67–9 timing of, 71
Adolescents, drug use among alcohol, 307 crime and, 109 marijuana, 239, 242 peers and, 93, 109 reasons for, 95–8 smoking, 348–9, 356 social bonds and, 93 steroids, 261
Adolescents Training and Learning to Avoid Steroids (ATLAS) program, 263
Adopted children, alcoholism among, 325 Adrenocortical steroids, 255 Adult Drug Court, 148 Adulteration of drugs, 242–3 Advertising for tobacco, 338, 341, 351 Advil (ibuprofen), 269 Aerosol inhalation, 285–6 Affective education, 370, 370 Afghanistan, heroin from, 30, 31, 162 African Americans
acute alcohol intoxication, 309 cocaine propaganda, 50 cocaine use, 186
Index ■ 393
Australia, smoking in, 354 Autonomic nervous system, sympathetic branch
of, 186 Aversion therapy for alcoholism, 327 Avinza (morphine), 172 Axon, 87 Ayahuasca, 215 Aztecs, drug use among, 214–15
Baba Ram Dass, 209 BAC (blood-alcohol concentration),
303, 303–4 blackouts, 311 calculating, 303 driving skills and, 311–12 toxic reactions, 308–9 at which drivers are legally drunk, 303, 315
“Bagging,” 287 Bahamas, 32 Bahamas, marijuana from, 33 BALCO, 258 Balzac, Honoré de, 231 Banisteriopsis vine, harmine from, 215 Bank Secrecy Act of 1970, 116–17 Barbiturates, 278, 278–81
in 1950s, 1960s, and 1970s, 281 acute effects of, 279–80 alcohol mixed with, 280 benzodiazepines compared to, 281 brain and, 279, 280 categories of, 279 chronic effects of, 280 cross-tolerance and, 75 deaths from, 11 detection periods for, 270 overdose, 279 street names, 281 use among adults aged 26 and older, 19 withdrawal from, 78, 280
Barbituric acid, 278 Barley malt, 300 Bartholdi, Frederic, 183 Baseball
dietary supplements and, 264–5 steroid use and, 253, 258, 263 stimulant medication, 265
Baudelaire, Charles, 231 Bayer Company, 160–1 Bazuco, 182 BC Bud, 36, 36 Beech Nut, 351 Beer, 301, 302, 306–7
consumption of, 305 Behavior. See also Crime; Deviance; Drug-taking
behavior alcohol and, 311–13 alternative behavior programming, 373 compulsive, neurochemical system in brain
and, 87, 88 criminal, drug use as cause of, 113 LSD and, 213 marijuana and, 234–6
Behavioral programs, 170 Behavioral theories, 90, 90 Behavioral tolerance, 72, 72, 72–3 Belief(s)
as protective factor, 98 as social bond, 92
Belladonna, 48 Belushi, John, 11, 187 Benemid (probenecid), 269 Bennett, William J., 59 Bennies. See Amphetamines Benzedrine, 193 Benzene, 286, 288, 288
Antianxiety drugs, 278. See also Benzodiazepine alcohol withdrawal, 321 buspirone, 284 deaths from, 12, 13 development of, 281–2 ethnicity and, 76 use among adults aged 26 and older, 19 zolpidem, 284
Antibiotics, 310 quinolone, 269
Anticholinergic drugs, 220–1 Anticoagulants, alcohol mixed with, 310 Anticonvulsants, alcohol mixed with, 310 Antidepressants, 62, 79, 284
for anxiety disorders, 284 deaths from, 12, 13
Antidiuresis, 309, 311 Antidiuretic hormone (ADH), 309 Anti-Drug Abuse Acts (1986 and 1988), 58–9 Anti-drug campaigns
anti-drug legislation in 1980s, 59 Antihistamines, 310
toxic reaction, 11 Antihypertensives, 310 Anti-Opium Smoking Act (1875), 59 Antipsychotic drugs, 76, 79
ethnicity and, 76 Anti-Saloon League, 53 Antisocial behavior, 97 Antisocial personality disorder, 89 Antitussive drug, 173 Anxiety, 281–2. See also Antianxiety drugs
cocaine abuse, 89, 186 as precursor to drug abuse, 89 reduction to prevent drug abuse, 371
Anxiety disorders, 283 AP-CNBC poll, 247 Appalachia marijuana industry in, 36 Appetite, marijuana’s effect on, 234 Apresoline, 310 Aqua vitae, 306 Arellano-Félix Organization, 37 Argentina, smoking in, 354 Arizona Proposition 200 (1996), 59 Armstrong, Lance Edward, 257 Arteriosclerosis, 345 Artest, Ron, 312 ASA (acetylsalicylic acid), 160–1 Asians, drug effects in, 76 Asima (paroxetine), 285 Aspirin, 161, 173
alcohol metabolism and, 302 source of, 47
Asset forfeiture, 132, 132–4 Asthma, 346
ephedrine for, 192 marijuana to treat, 243
Atenolol, 284 Athletes, drug abuse and, 253–4. See also
Anabolic steroids Athletes Targeting Healthy Exercise and Nutrition Alternatives (ATHENA)
Ativan (lorazepam), 282 ATLAS program, 263 Atomoxetine, 198 Atropa belladonna, 208, 220 Atropine, 207, 208, 219 Attachment, 92 Attenade, 198 Attention, marijuana’s effect on, 235 Attention deficit disorder (ADD), 6, 266 Attention-deficit hyperactivity disorder
(ADHD), 197, 198–9, 265, 266 Attitude(s)
placebo effect and, 77–8
Amphetamines, 181–2, 192–4, 193 acute and chronic effects of, 193–4 brain and, 194 detection periods for, 270 forms of, 193 heroin combined with, street names for, 167 history of, 192–3 medications and stimulants, 197–8 molecular structure of, 193 neurochemical system in brain and, 87 patterns of abuse and treatment, 193–4 in sports, 254, 265 street names, 196 use among youth, 16 withdrawal from, 197
Amyl nitrite, 290, 290 Amytal (amobarbital), 279, 281 Anabolic, 255 Anabolic-androgenic steroids, 255. See also
Anabolic steroids Anabolic steroid abuse, patterns of, 261 Anabolic steroids Athletes Targeting Healthy
Exercise and Nutrition Alternatives (ATHENA), 263
Anabolic Steroid Control Act of 2004, 60, 254, 265
Anabolic steroids, 253–64, 255 abuse patterns, 261–4 adolescents’ use of, 261 baseball and, 253, 258, 264 black market for, 254 cardiovascular effects of, 260 counterfeit, 263 currently available, 256 detection periods for, 269–70 hazards of, 258–61 hormonal systems and, 259–60 liver and, 260 masking drugs to hide, 269 in modern Olympic Games, 256–7 in professional and collegiate sports, 258 psychological problems and, 260–1 reasons for taking, 272 social context of, 271–2 testing for, 265–70 women’s use of, 260, 263
Anabolic Steroids Control Act, 265 Analgesic drugs
acetaminophen, 173, 175, 310 aspirin, 47, 161, 173, 302 ibuprofen, 269 narcotic, 15
Anandamide, 236 Androderm transdermal system, 256 Androgenic drugs, 255 Android (methyltestosterone), 256 Androstenedione, 264, 264–5 Anesthesia
barbiturates used in, 279 nitrous oxide as, 285
Anesthetics cocaine as, 182, 186 ketamine as, 222 PCP as, 221
Angel dust. See Phencyclidine (PCP) Angina, 352 Anhydrous ammonia, methamphetamine
manufacture using, 195 Anodyne, 286 Anomie, 91 Anomie/strain theory, 91–2 Anorexia, endorphins and, 165 Anslinger, Harry, 55, 57, 232 Antabuse (disulfiram), 310, 326 Antagonistic effect, 72, 73
394 ■ Index
Castor oil, 48 Catabolic effect, 255 Catheter, 78 Cathinone, new form of stimulant abuse, 197 CBP. See Customs and Border Protection (CBP) Celebrities
drug use and, 92, 190 product endorsements, 183
Cell body, 87 Center for Substance Abuse Prevention
(CSAP), 366 Centers for Disease Control and Prevention, 106 Central Intelligence Agency, U.S. (CIA), 208–9 Cerebral cortex, 279. See also Brain alcohol’s
effect on Cesamet (nabilone), 244 Champagne, 301 Chantix, 356 Chassman, Steven, 384 CHD (coronary heart disease), 315, 344, 352 Chemical Diversion and Trafficking Act, 37 Chemotherapy, marijuana to relieve nausea
from, 244 Chewing tobacco, 69, 337, 351–2 Child abuse and neglect, 189 Children
of gin-using parents, 306 of methamphetamine-dependent
parents, 189, 194 opium given to, 159–60 of smokers, hazards of smoke to, 348
Children of alcoholics (COAs), 325 risk for alcoholism, 325
China cigarette smoking in, 354 Communist, 56 marijuana in, 229 opium in, 158, 159–60 People Republic, 232
China White, 30, 163 Chinese, opium smoking regulations and, 51–2 Chipping, 168 Chloral hydrate, 281, 310 Chlorazepate, 282 Chlordiazepoxide, 282, 283 Choral Hydrate, 62 Chromosomal damage, LSD and, 213–14 Chronic bronchitis, 346 Chronic obstructive pulmonary disease
(COPD), 345, 345–6 Chronic toxicity, 15 CIA, 209–10 Ciba-Geigy, 199 Cigarettes, 364, 364–5. See also Tobacco
mentholated, 340 per capita consumption, 339 tar in, 342, 343 unfiltered vs. filtered, 339 use by youth, 16–18 warning label on package, 339
Cigars, 338, 352 Cilia, 343 Ciliary escalator, 343 Ciprofloxacin (Cipro), 269 Cirrhosis, alcoholic, 322, 322–3 Civil forfeitures, 133 Civil War, opiate dependence of
soldiers in, 48, 160 Claviceps tulasne, 208 Clinton, Bill, 60 Clonazepam, 282 Clorazepate, 282 Club des Hachichins, 231 “Club drugs,” 15, 292–3. See also MDMA
methamphetamine, 194
nicotine and, 88 opioids effects on, 164–5 stimulant treatment of ADHD and, 199
Brain alcohol’s effect on, 319 Brand names, 6 Brandy, 301, 304 Bratton, William J., 131 Breast cancer, alcohol and, 323 Breathalyzers, 302 Brewing, 300 Britain
gin consumption in, 306 opium in, 159–60
Bronchitis, chronic, 346 Bruce, Lenny, 11 Bufotenine, 48, 216 Bulletin of the Atomic Scientists, LSD
article in, 209 Buprenorphine, 170, 170–1 Burma (Myanmar), 30, 163 Bush, George W., 40 Business model of street dealing, 114 Buspirone (BuSpar), 284 Butalbarbital, 279 Butane, 286 Butylacetate, 286 Butyl nitrite, 290, 290
Caffeine, tolerance of, 72 Cali drug cartel, 33, 33, 35 California
LSD production, 37 marijuana possession, 58 marijuana production, 229 methamphetamine trafficking, 36, 194,
195, 197 California Proposition 215 (1996), 59 Campesinos, 32 Campral (acamprosate), 327 Campus Drug Court, 148 Canada
drug trade, 125, 197 marijuana trade, 35–6 substance abuse treatment hotline, 383
Canadian Centre on Substance Abuse, 384 Cancer(s)
from alcohol abuse, 323 Lance Armstrong Foundation for, 257 lung, 346 from marijuana, 238 oral, 346–7, 352 from tobacco, 346–7, 352
Cannabidiol (CBD), 229,236-7 Cannabinoids, 229 Cannabis, 228, 236 Cannabis sativa, 228–9, 228. See also Marijuana Canseco, José, 253 Capone, Al, 54 Carbonated beverages, 302 Carbon monoxide, 342, 342, 355 Carbon tetrachloride, 286 Carcinogens, 323 Carcinomas, 346 Cardiac arrhythmia, 186 Cardiac dysrhythmia, 288 Cardiovascular effects
of ADHD medications, 197 of alcohol, 322 of marijuana, 237 of steroid use, 260 of tobacco, 344, 346
Cartels, drug. See also Drug trafficking Medellin and Cali, 32–4, 126
Carter, Jimmy, 58 CASASTART, 374
Benzodiazepine, 282, 282–3 acute effects of, 283 alcohol mixed with, 283 chronic effects of, 283 detection periods for, 270 elimination half-life of, 283 factors predicting successful treatment
with, 283 Benzopyrene, 346 Bernays, Martha, 185 Bernhardt, Sarah, 183 Berserkers, 48, 220 Beta blockers, 284 Beta-endorphins, 165 Bhang, 230 Bias, Len, 11, 191 Binge drinking, 17, 307, 308 Biological perspectives on drug abuse, 85–8 Biopsychosocial model, 4, 85, 85 Biotransformation, 70
individual differences in rate of, 75 Birth control pills, interaction of tobacco smoke
with, 348 Black market
for alcohol, during Prohibition, 53 Harrison Act and, 51, 161 for heroin, 161–2 for steroids, 254
Black Mass, 220 Blackout, 311 Black tar, 32, 56, 163 Blended whiskey, 301 Blood-alcohol concentration (BAC), 303, 303–4
blackouts, 311 calculating, 303 driving skills and, 311 toxic reactions, 308–9 at which drivers are legally drunk, 303, 314
Blood-brain barrier, 68, 343 Blood-placental barrier, 343 Blotter acid, 211 Blue mass, 49 BluntGen subculture, 109 Bodybuilding, ergogenic drugs used in, 260, 298.
See also Anabolic steroids Body fat, alcohol consumption and, 302 Boggs Act (1951), 56 Boldanone undecylenate, 256 Bolivia
crop eradication programs in, 32, 123 Tactical Analysis Teams (TATs), 127
Bonding theory, 92–3 subcultural recruitment and socialization
theory and, 93–4 Bonds, Barry, 258 Boniface VIII, Pope, 77 Bonsack, James, 338 Bootlegging, 54 Boredom, teenage drug abuse and, 376 Bosnia, smoking in, 357 Botvin, Gilbert, 371 Bourbon whiskey, 301 Brain
addiction’s appearance in, 88 alcohol and, 303, 323–4 amphetamines and, 193–4 barbiturates and, 279, 280 benzodiazepines and, 283–4 blood-brain barrier, 68, 312 cocaine and, 186–7 drug effects on, 68 hemorrhaging and tobacco use with birth
control pills, 348 LSD effects on, 211 neurochemical systems in, 87–8, 89
Index ■ 395
Copenhagen (chewing tobacco), 351 Cordial, 301 Coronary heart disease (CHD), 315, 344, 352 Correctional system
cost of building and maintaining prisons, 59 drug use among inmates, 107–8, 142–4 prison-based treatment programs, 151–2
Cortisone, 255 Coughing
after smoking cessation, 355 narcotic drugs to treat, 172–3
Coumadin (warfarin), 310 Couriers, drug, 32
“mules,” 32, 124–5 Courts, drug, 147, 147–8 Crack cocaine (crack), 15, 58, 188, 188, 189
dealing organizations, 114, 116 distribution, 34 economically compulsive crime and, 109 federal penalties for, 144, 146 freelance sale of, 114 heroin mixed with, 167 pharmacological violence and, 110 street names, 196 systemic violence and, 106, 189 use among adults aged 26 and older, 19 use among American youth, 18, 60
CrackGen subculture, 109 Crack houses, 112 “Crank,” 36 Creatine, 265 Creativity
LSD and, 213 marijuana and, 234
Crime, 103–52 as cause of drug use, 113 causes, 113 crack cocaine and, 188 deviant life-style and, 112 drug-defined offenses, 104 drug-related offenses, 105 drug trafficking (See Drug trafficking) drug use and, 106–9 drug use as cause of, 106, 113 economically compulsive, 105, 110–12 heroin abuse and, 162, 167, 169 illicit drug dealing, 113–14 incarceration rates of drug offenders, 106 LSD use and, 213 methadone maintenance and reduction of, 169 methamphetamine-related, 194 money laundering, 116–17 OxyContin abuse and, 173, 174 during Prohibition, 53 psychopharmacological, 108–10 statistics, 106 systemic, 112–13 violence and, 109
Crime deaths, 15 Criminal justice system, drugs and, 121–35.
See also Drug laws correctional system and, 149–52 drug courts, 147–9 drug-law violators in, 140–2 interdiction, 124–7 judicial events, phases of, 140 mandatory minimum sentencing, 145–7, 369 source control, 122–4 specialty courts in, 148 street-level drug-law enforcement, 128–32
Criminal Justice System, specialty courts in, 148 Criminal model of drug use and crime, 113 Criminal organizations, Prohibition and, 53.
See also Drug cartels; Organized crime “Criss-crossing,” 167
Cognitive enhancers, stimulant medications as, 199 Cold medications
detection periods for, 270 College students
alcohol, 114, 307–8, 377 amphetamines, 193 drug abuse prevention, 377–8 drug use among, 17. (See also Youth)
Collegiate sports, steroid use in, 258 Colombia, 60–1, 125, 126
cocaine production in, 189 cocaine trafficking, 32–5 crop eradication in, 123 heroin from, 165 Medellin and Cali drug cartels, 33–5 money laundering by traffickers in, 116–17 opium and heroin from, 29, 32, 165
Columbus, Christopher, 336 Combat Methamphetamine Epidemic Act
(2005), 60, 61, 123 Commit, 356 Commitment (social bond), 92 Communication within family, dysfunctional,
375–6 Communism, 56 Community-based prevention, 372–5
alternative-behavior programming, 373 CASASTART, 374 media influence, 389–92
Comprehensive Crime Control Act of 1984, 59, 59
Comprehensive Drug Abuse Prevention and Control Act of 1970, 11, 55, 56, 59, 133, 142–3, 246
Comprehensive Methamphetamine Control Act (1996), 59, 60
Comprehensive Textbook of Psychiatry, 187 Compulsive behavior
amphetamine abuse, 194 economically compulsive crime, 114 neurochemical system in brain and, 87, 88
Concerta, 198 Conditioned cues, 90, 191 Conditioned-learning effects, heroin
abuse and, 166 Conditioned tolerance, 72–4, 73
heroin abuse and, 166–7 Conditioning, Pavlovian, 72–3, 90 Confabulation, 323 Confessions of an English Opium Eater
(DeQuincey), 160 Confiscation Act of 1862, 133 Conformity
adaptation to anomie, 91 social bonds promoting, 92
Congeners, 310 Consent search, 132 Constipation, heroin abuse and, 164, 172 Constitution, U.S.
Eighteenth Amendment, 53–4, 53, 59 Fourth Amendment, 271 Twenty-first Amendment, 53, 54, 59
Contemplation stage of change, 381, 381–2 Contraceptives, smoking and, 347 Controlled buy, 129 Controlled Substances Act. See Comprehensive
Drug Abuse Prevention and Control Act of 1970
Controlled Substance Analogue Act (1986), 163 Controlled substances
federal trafficking penalties, 143 schedules of, 11, 62 violation type and, 142
COPD (chronic obstructive pulmonary disease), 345, 345–6
COAs (children of alcoholics), 325 Coast Guard, interdiction by U.S., 125, 126 Coca, 187
crop eradication programs, 123 value in conversion to crack cocaine, 189
Coca-Cola, 48, 183, 184 Cocaethylene toxicity, 183 Cocaine, 70, 181–92. See also Crack cocaine
(crack) abuse of, 187–8 acute effects of, 185–6 alcohol and, 183 arrestees’ use of, 106 benzodiazepines combined with, 284 brain and, 186 chronic effects of, 186 commercial uses of, 183–5 contamination in U.S. paper currency, 190 crime and, 90 deaths from, 12, 13 detection periods for, 269, 270 dopamine-receptor loss and, 186 drug laws and, 52 drug-related deaths from, 12 ED visits for, 12, 13 extraction process, 187 fatal effects of, 182, 186 federal penalties for, 143, 146 federal trafficking penalties, 143 free-base, 196 Freud and, 181, 182, 184 Global Black Market, 192 heroin combined with, 167, 196 hidden toxicity, 10 history of, 182–5 hotline for, 189 intravenous, 185 LSD combined with, 188 medical uses of, 184, 186 methadone clients’ abuse of, 169 methamphetamine abuse compared to, 194 neurochemical system in brain and, 87 in 1980s, 58 in 19th century, 48, 182 Pavlovian conditioning and associations
with, 90 penalties for crack possession vs., 143 pharmacological violence and, 105 precursor chemicals, 123–4 price of, 188 production of, 187 propaganda, 51 psychological dependence on, 9 regulation of, 51 snorted, 185, 186 street names, 188 trafficking of, 192 treatment for abusers, 189–92 use among adults aged 26 and older, 19 use among youth, 16–17
Cocaine Anonymous, 190, 328 Cocaine hydrochloride, 188, 188 Cocaine psychosis, 186 Cocaine speedball, mixture of heroin and, 188 Coca leaves, chewing of, 182 Coca paste, 188 Codeine, 160, 173, 174
combined with Doriden, street names for, 167
toxicity, 11 Code of Hammurabi, 306 Codependency, 324–5, 325 Cognitive-behavioral therapy for cocaine
abusers, 190 Cognitive effects of marijuana smoking, 239–40
396 ■ Index
Digital Currency Exchange (DCE), 117 Dilantin (phenytoin), 310 Dilaudid (hydromorphone), 172 Dimethyltryptamine (DMT), 207, 215, 215 Dipping, 351 Diprivan, 11 Disease
distinction between non-disease and, 329 Disinhibition theory, 312 Dissociative anesthetic hallucinogens, 221 Distillation, 300, 300–1 Distilled spirits, 301, 301–2, 304, 310, 314 Disulfiram, 310, 326 Diuretic effects of alcohol, 309 Diuretics, 309 Diuril, 310 DMT, 48, 207, 215 Dole, Vincent, 169 “Doll’s eyes,” 221 Dolorphine (methadone), 172 DOM, 207, 216 Domestic Law Enforcement and military
operations, 127 Doors of Perception, The (Osmond), 209 Dopamine, 87, 87, 88
amphetamines and, 193–4 cocaine abuse treatment, 190 cocaine and, 186 molecular structure of, 193 nicotine and release of, 343 psychological dependence and, 89 reinforcement and, 88 stimulant treatment of ADHD and, 198 synthetic heroin, 167
Dopamine receptor, 88 Doriden (glutethimide), 310 Dose, 8
effective, 9–10 lethal, 9–10 psychological effects and, 77 timing and, 71
Dose-response curve, 9, 9–10 Double-blind procedures, 77 Downey, Robert, Jr., 191 Draft beer, 301 Dr. Agnew’s Catarrh Powder, 48 Drinking, symptomatic, 317. See also entries
related to alcohol Drink Safe Technology, 294 Driving skills
alcohol and, 311–13 marijuana and, 235 nitrous oxide, 286
Driving under the influence (DUI), 141 Driving while impaired (DWI), 148 Driving while intoxicated (DWI), 311–12
Anti-Drug Abuse Act of 1988, 59 cocaine use and, 186 court, 148 ED visits and, 12
Dronabinol, 244 Drostanolone, 256 Drug abuse, 7. See also specific drugs
biological perspectives on, 85–8 biopsychosocial model of, 95 dependence and, 8–9 harm-reduction approach to, 365, 366 inhalant abuse as gateway to future, 289 penalties for, 146 (See also Criminal justice
system) prevalence and economic costs of
workplace, 308 protective factors, 95, 96–9 psychological perspectives on, 89–90 risk factors, 95–8
“Deodand” (forfeiture), 133 Dependence, 78–9. See also Physical
dependence; Psychological dependence alcohol, 321 on barbiturates, 280 on benzodiazepines, 283 on heroin, 78–9 on inhalants, 289 LSD and, 211 on marijuana, 237 on meprobamate, 282 on nicotine, 343–4 on opioids, 161 physical, 78–9, 280 on steroids, 263 substance, 8
Depressants, 278–81. See also Sedative-hypnotics alcohol as, 303 antianxiety drugs, 281–2 barbiturates, 278–81 benzodiazepines, 282–3 cross-tolerance and, 75 downward continuum of arousal levels
induced by, 279 gamma-hydroxybutyrate (GHB), 293 nonbenzodiazepine, 283–4 sedative-hypnotics, 281 synthetic, 221–2 withdrawal from, 78, 280
Depression alcohol and, 317 blue mass (19th century remedy) for, 49 following cocaine usage, 185–6, 189 as precursor to drug abuse, 89 selective serotonin reuptake inhibitors for, 284
DeQuincey, Thomas, 159 DESA. See Drug-facilitated sexual assault Designer drugs, 163 Deterrence, 151 Detoxification, 169 Developmental assets, 97–8 Deviance
differential association theory of, 93 drug use and crime as deviant life-style, 113 primary, 94 private language and, 94 risk factor, 96 secondary, 94
Deviant subculture, 94 Devil’s Harvest (film), 233 Dexedrine (d-amphetamine), 193 Dextroamphetamine (d-amphetamine), 20, 196 Dextromethorphan, 173, 173 Diabetes mellitus, moderate alcohol
consumption and, 315 Diagnostic and Statistical Manual, fourth edition
(DSM-IV), 79–80 alcohol use disorder, 320 criteria for substance dependence and
abuse in, 10 Diagnostic and Statistical Manual, fifth edition
(DSM-5) alcohol use disorder, 79–80, 319–20 criteria for substance use disorder,
79–80, 151, 263 “Diagonal driving,” 186 Dianabol (methandrostenolone), 256 Diarrhea, Opioid for treatment of, 172 Diazepam, 282, 282
toxicity, 11 withdrawal, 282
Dietary Guidelines for Americans (2000), 315 Dietary supplements, as performanceenhancing
aids, 264–5 Differential association theory, 93
Crohn’s disease, 244 Crop eradication, 123, 123 Cross-tolerance, 75
alcohol and, 198 from benzodiazepines, 283 buspirone, 284 between LSD and psilocin, 215
Crystal meth (ice), 195–6 CSAP (Center for Substance Abuse
Prevention), 366 Cuba, cocaine trafficking and organized crime
from, 33 Customs and Border Protection (CBP), U.S.,
21, 126 interdiction by, 126, 127
Cyanosis, 216 Cycling pattern of steroid abuse, 262 Cyclohexane, 289
Dalmane (flurazepam), 283 D-amphetamine, 193, 193 Danazol, 256 Danocrine capsules (danazol), 256 DARE, 372 Dark Web, policing the, 21 Darvocet-N (propoxyphene), 172 Darvon (propoxyphene), 169, 172, 270 Date-rape drugs, 223, 292, 293 Datura stramonium, 208, 220 Davy, Humphrey, 285 DAWN. See Drug Abuse Warning Network
(DAWN) Daytrana, 198 DCE. See Digital Currency Exchange DEA, 41, 56, 125
anabolic steroids, 254 asset forfeitures, 132 interdiction by, 125–7 MDMA, 218 meth lab seizure, 60 precursor chemical monitoring, 124
Death(s) from alcohol, 13, 14, 303 from antianxiety drugs, 13 from antianxiety medications, 14 from antidepressant medications, 14 from cocaine, 13, 14 drug-related (1962-2007), 11 drug-related, DAWN reports on, 12–13, 14 from heroin, 13, 14 from inhalants, 287 lethal dose, 9–10 from LSD, 211 from methadone, 13 from morphine, 13, 14 from tobacco, 344–5, 348
de Blasio, Bill, 131 Deca-Durabolin IM (nandrolone decanoate), 256 Decision making, training in, 371–2 Decriminalization, 245
of marijuana, 245 Delatestryl IM (testosterone enantrate), 256 Delirium tremens (DTs), 322 Delphi, oracle at, 285 Delta-9-tetrahydrocannabinol (THC), 229,
234–6. See also Marijuana in BC Bud Deltasone (prednisone), 310 Dementia
alcoholic, 323 drug-induced, 283 moderate alcohol consumption and, 315
Demerol (meperidine), 172 toxicity, 11
Dendrites, 87 Denial of alcoholism, 319
Index ■ 397
Mexican connection, 37–9 moving target, 37 PCP, 37 penalties for, 142 southwest and southeast asian origins, 31 structure of, 113–14 Tamez, Alejo Garza, 40
Drug trafficking routes, 56 DSM-IV (Diagnostic and Statistical Manual,
fourth edition) alcohol abuse, 320 criteria for substance dependence and
abuse in, 10 DSM-5 (Diagnostic and Statistical Manual,
fifth edition) alcohol use disorder, 79–80, 319–20 criteria for substance use disorder, 79–80,
151, 263 DTs, 283, 322 Dumas, Alexandre, 231 Dunlap, Eloise, 109 Dunne, John R., 147 Durabolin IM (nandrolone phenprionate), 256 Duragesic (fentanyl), 172 Duramorph (morphine), 172 Durkheim, Emile, 91 DWI, 311 DWI Court, 148 DWI. See Driving While Impaired Dylan, Bob, 210 Dynorphins, 165 Dysentery, 173
EAPs (employee assistance programs), 270–1, 308, 378–9, 386
Eastern Europe, smoking in, 353 East German athletes, 256–7 East India Company, 159 Ebers Papyrus, 48, 158 E-Cigarettes, 352–3 Economically compulsive crime, 105, 114 Economics, tobacco and, 37, 342 Economic success, anomie and inability to
obtain, 91–2 Ecstasy (MDMA), 62, 93, 207, 218–19
decline in use, 219 ED visits for, 15
learning techniques to use and enjoy, 93 toxicity of, 218 use among youth, 18
Edison, Thomas, 183 Education
inhalant abuse, 290 legalization of drugs and, 150–1
Educational experience, as protective factor, 98 ED visits. See Drug-related ED visits Effective dose, 9, 9–10
alcohol, 303 heroin, 167
Ego, 89 EIA, 266, 268 Eighteenth Amendment to U.S. Constitution,
53–4, 59 Eighth graders
cigarette smoking among, 348 drug use among, 16
Elderly, the alcohol abuse among, 320–1 benzodiazepines for, 283, 284
Elimination half-life, 71 Ellis, Albert, 328 Embeda, 165, 172 Emergency department (ED) visits. See
Drug-related ED visits Emergency medical service (EMS), 10
for amphetamines, 194 for cocaine, 189 hydrocodone and oxycodone, 15 involving marijuana, 234 for LSD, 210 prescription pain medications, 173
Drug-related offenses, 105 Drugs, 4
and adult crime, 106–8 contradictory messages about, 3 criminal penalties for offenses, 142 deaths, 14 defining, 5 and delinquency, 106 diverse society, youth in a, 18 elimination from body, 70 emergency departments, 12 factors determining physiological impact of, 71–6 high-tech, dealing with, 21 history of, 47–50, 55–8 intent in use of, 5–8 legality of, 5 measuring impact on society, 55–6 names, 6 regulation of, 50–3, 58–60 routes of administration, 67–9 sexual assaults, reduce facilitated 293–4 society and, 3–4 types of, 3
Drug screening testing, in workplace, 270–1 Drug-taking behavior
behavioral tolerance and, 72–3 biological, psychological view of, 3 compulsive pattern of, 87, 88 DAWN statistics on, 33–6 drug abuse, 7–8 drug dependence and, 4 drug misuse, 7–8 ethnic differences in, 77 health perspective, 8–10 instrumental use, 5–7 orally based pattern of, 89 post-World War II, 55–6 predictions of future, 96–7 psychological factors in, 76–7 recreational use, 7 renewed efforts at control (1980-present),
58–60 in sports, 254–5 through history, 47–60 tolerance effects in, 72–5, 72 tolerance of 1960-1980 period, 56–8
Drug testing, 265–71 at home, 376 masking drugs and chemical manipulations, 269 pinpointing time of drug use, 269–70 in schools, 270 sensitivity and specificity of, 268–9 in sports, 257–8 techniques, 266–7 in the workplace, 59, 271–2
Drug trafficking, 29–41, 56, 60–1, 142 Andean region origins, 33 asset forfeiture, 132–4 cocaine, 32–5, 192 couriers in, 32 domestic and National security, 61 gang factor, 115–16 global problem of, 29 hallucinogens, 37, 223 heroin, 29, 30–1, 165 interdiction to prevent, 124–7 LSD, 223 marijuana, 35–6, 243 methamphetamine, 36–7, 197
schedules of controlled substances, 11 sociological perspectives on, 90–4
Drug Abuse Law Enforcement, 57 Drug Abuse Resistance Education (DARE), 372 Drug Abuse Warning Network (DAWN), 12,
12–15, 281 on alcohol, 310 on cocaine, 189 on LSD, 210–11 on marijuana, 234
Drug cartels Medellin and Cali, 33–4 Mexican, 32–3, 37 Z-40, 40
Drug-control policy, 61 Drug Control Policy, Director of National, 58, 59 Drug courts, 147, 147–8 “Drug czar,” 58, 59, 60 Drug dealers/dealing. See also Drug trafficking
retail level, 113–14 social structure, 113–14
Drug-defined offenses, 104 Drug dependence, 4 Drug Enforcement Administration (DEA), 21,
36, 56, 57, 125 anabolic steroids, 254 asset forfeiture, 132–4 diversion control program, 57 employees, 57 intelligence program, 57 interdiction by, 125–7 marijuana crop seizure, 246 MDMA, 218 meth lab seizure, 36 precursor chemical monitoring, 124 salvia divinorum, 223
Drug-facilitated sexual assault, depressants drugs than alcohol, involvement in, 292–3 efforts to, 293–4 scope of problem, 291–2
Drug-facilitated sexual assault (DFSA), 291 Drug-free workplace policies, impact of, 59,
270–1 Drug holidays, 198 Drug interactions, 71, 72, 73 Drug interdiction
federal agencies, involved in, 125–7 Drug-law enforcement, 51, 56–8, 58–60
asset forfeiture, 132–4 drug courts, 147–8 entrapment, issue of, 131–2 interdiction, 124–7 knock and talk, 132 mandatory minimum sentencing, issue of,
145–7, 369 profiling and, 127–8 street-level, 128–32 undercover operations in, 128–30
Drug laws, 50–5, 58–60. See also specific laws; Criminal justice system
history of, 59 race and, 50–3
Drug law offenses, criminal penalties for controlled substances, simple possession for,
142–3 drug trafficking, 142 felonies, misdemeanors, and state, 143–4 paraphernalia, 144
Drug misuse, 7 “Drug mules,” 32 Drug paraphrenalia, 144 Drug-related crime, 115 Drug-related deaths. See Death(s) Drug-related ED visits, 12, 12
for alcohol, 310
398 ■ Index
Gangs community policing, 112, 131 vs. drug-related crime, 115 heroin distribution, 165 Hispanic/Latino and PCP trafficking, 115 motorcycle, 36, 115 outlaw Motorcycle, 115 street, 115
Garland, Judy, 11 Gas chromatography and mass spectrometry
(GC/MS), 266 Gaseous phase, 342 Gasoline, 286, 288 Gasoline inhalation, 288 Gastrointestinal tract, absorption through, 67–8 Gateway hypothesis, 240, 240–1
association question in, 241 causation question in, 241–2 developmental sequence, 241 inhalant abuse and, 289
GC/MS, 266, 267, 269 Gender
alcohol and sexual desire and, 312 alcohol metabolism and, 302 DAWN statistics by, 13 drug effect and, 76 lung cancer and, 346 opium use and, 159 respiratory disease in adolescent smokers and, 346 smoking cessation rates, 355
Generic names, 6 Genetic factors, 85–6
in alcoholism, 85–6 GHB (gamma-hydroxybutyrate), 60, 293
ED visits for, 15 G.I. Joe action figures, evolution of muscle
representation on, 262–3 Gin, 301, 302 Giraldo, Greg, 11 Glaucoma, marijuana to treat, 244 GlaxoSmithKline Pharmaceuticals, 267 Global illicit drug trade, 26 Glue inhalation, 286–8, 289, 290 Glutamate, 87 Glutamate receptors, 221, 223 Glutethimide, 310 Goldberg, Linn, 263 Golden Crescent, 30, 163 Golden Triangle, 30, 163 Goldstein, Avram, 368 Goldstein tripartite model of drugs and
violence, 105 Golub, Andrew, 109 Goode, Erich, 7, 93, 241, 329 Goodman, Benny, 231 Good Samaritan law, Hudson, New York
residents, 156 Grain neutral spirits, 301 Grandparents, 375 Grant, Ulysses S., 183 Great Depression, 232 Greece, smoking in, 354 Gums, nicotine, 356 Gynecomastia, 259
Hague, conference on opium trade in the (1912), 51
Halcion (triazolam), 62 Half-life, elimination, 71 Hallucinations, 206–7. See also Hallucinogens
from inhalants, 287 LSD vs. schizophrenia, 212 PCP-induced, 221 hallucinogen persisting perception disorder, 213
Hallucinogens, 89
Family Smoking and Tobacco Control Act (2009), 341–2
FARC, 41 Farley, Chris, 11, 191 FAS, 324 Fast-flushing, 302 Fatty liver, 322 FDA. See Food and Drug Administration (FDA) Feal, Lorenzo, 292 Federal agencies involved in interdiction, 125–7 Federal Bureau of Investigation (FBI), 56 Federal Bureau of Narcotics (FBN),
55, 231–3 Federal Food, Drug, and Cosmetic Act
of, 1938, 55 Federal Reentry/Drug Court, 148 Federal Trade Commission, 339 Felony, 143 Fenichel, Otto, 89 Fentanyl, 163, 164
federal penalties for, 143 Fermentation, 300 Fetal alcohol syndrome (FAS), 324, 324 Flashbacks, 214, 222–3 Flavored snuff, 351 Fleischl-Marxow, Ernst von, 184 Floxin (ofloxacin), 269 Flunitrazepam, 143, 292–3
penalties for, 143 Flurazepam, 282 Fly agaric (Amanita muscaria), 48, 219 Focalin, 198 Food and Drug Administration (FDA), 10, 55,
208, 261 “black box” warning on ADHD medications, 198 dietary supplements, 265 tobacco control, 341
Food-drug interactions, 73 Football players, steroid use by, 258 Ford, Gerald, 57 Forfeiture, asset, 132–4 Formication, 185, 186 Fortified wines, 301, 304 Four-Loko effect, 75 Fourth Amendment, 127 “Fourth-Year Fifth,” 312 Fourth-years Acting Responsibly (FAR), 312 Framework Convention on Tobacco Control
(2003), 353–4 France
smoking in, 354 snuffing in, 337
Franklin, Benjamin, 337 Free-base cocaine, 188, 188 Freelance model of retail drug distribution, 114 French Connection, 29 French paradox, 315 French Wine Cola, 183 Freon, 288 Freud, Sigmund, 49, 89, 181–2, 184
GABA receptor sensitivity to alcohol, 87 treatment, 327
Galen, Claudius, 158 Gallup Poll
on LSD use (1967-1971), 212 on medical marijuana use (2009), 245
Gamblers Anonymous, 328 Gamma aminobutyric acid (GABA), 87
alcohol sensitivity, 303 benzodiazepines and facilitation of, 283 nonbenzodiazepine depressants, 283–4
Gamma-hydroxybutyrate (GHB), 60, 278, 293, 293
penalties for, 144
Emergency room (ER), DAWN reports of cases in, 12–13
EMIT (Enzyme-Multiplied Immunoassay Technique), 267, 271
Emotional problems alcoholism and, 319 marijuana and, 235
Empathogens, 218 Emphysema, 346 Employee assistance programs (EAPs),
308, 378 EMS. See Emergency medical service Enablers, 319, 319–20 Encephalopathy, Wernicke’s, 323 Endocannabinoids, 234 Endogenous opioid peptides, 165, 165. See also
Endorphins Endorphins, 77, 87, 165, 166
heroin withdrawal, 166 Endorphin-sensitive receptors, 166 Enforcement of drug laws, 51, 56–62, 58–60 England, gin drinking in, 306. See also Britain English law, forfeitures recognized in, 133 Enkephalins, 165 Enslavement model of drug use and crime, 106 Environmental cues in heroin abuse, 163, 167 Environmental Protection Agency (EPA), 341 Environmental tobacco smoke (ETS), 341, 348 Enzyme immunoassay (EIA), 266, 268 Enzyme-Multiplied Immunoassay Technique
(EMIT), 267 Ephedra, 38 Ephedra vulgaris, 192 Ephedrine, 192 Epilepsy
barbiturates for, 278, 280 benzodiazepines for, 283
Epitestosterone, 269 EPO (erythropoietin), 257 Ergogenic drugs, 253–4, 255, 256. See also
Anabolic steroids testing procedures and policies, 265–70
Ergot, 208 Ergotism, 208, 209 Ernest and Julio Gallo Winery, 306 Erythroplakia, 346 Erythropoietin (EPO), 257 Erythroxylon coca, 182. See also Cocaine Escobar, Pablo, 33–4 ESPAD. See European School Survey Project on
Alcohol and Other Drugs Estazolam, 282 Estradiol, 259 Estrogen, 69 Eszopiclone, 283–4, 284 Ether, 285, 286 Ethnicity. See Race and ethnicity Ethyl alcohol, 300 ETS (environmental tobacco smoke), 341, 348 Euphoria seekers, 90 European School Survey Project on Alcohol and
Other Drugs (ESPAD), 26 Excitation, 87 Excretion of drugs, 70 Expectation effects, 77
cognitive-expectation theory, 312 secondary deviance and, 94
Extinction, 90
Families Against Mandatory Minimums (FAMM), 146
Family alcoholism and, 319, 324–5 prevention and, 375–7
Family Dependency Treatment Court, 148
Index ■ 399
luteinizing, 239 marijuana’s effect, 238 nonsteroid, 264
“Huffing,” 287 Hugo, Victor, 231 Human chorionic gonadotropin (HCG), 260 Human growth hormone (hGH), 264, 264 Human immunodeficiency virus (HIV) infection,
98, 163, 167 Humatrope (genetically engineered hGH), 264 Hungary, smoking in, 354 Huxley, Aldous, 209 Hycodan (hydrocodone), 172 Hydrocodone, 172, 173
emergency department visits, 15 Hydrocortone injection (cortisone), 255 Hydromorphone, 172 Hydroponic cultivation techniques for
marijuana, 36 Hyoscine, 207. See also Scopolamine Hyoscyamine, 207, 219, 220 Hyperactivity, 197–8, 265 Hyperadditive effect, 71, 72 Hypodermic syringe, invention of, 48, 160 Hypoxia, 286 Hysingla ER (hydrocodone), 172
Ibotenic acid, 207, 208 Ibuprofen, 269 Ice(crystal meth), 195, 195–6 ICE. See Immigration and Customs Enforcement Id, 89 Ignition interlock device, 314–15 Illicit Drug Anti-Proliferation Act (2003), 60 Illicit drugs, 4, 60. See also Crime deaths
drug subcultures, 93–5 emergencies related to, 15 global business, 26 use among adults aged 26 and older, 19 use among eighth graders and tenth graders, 16 use among youth, 18 worldwide prevalence rates, 27
Illicit drug trade. See Drug trafficking Illusionogenic drugs. See Hallucinogens Immigrants
Mexican, 210 Prohibition and anti-immigrant sentiment, 53
Immigration and Customs Enforcement (ICE), 57 Immune system, marijuana effects on, 239 Imodium, 173 Impactors, 373 Inca civilization, 182 Incarceration, 139 Inderal (propanolol), 284 India, 159, 230
smoking in, 354 Individual differences in drug effects, 76 Infants, opium given to, 159–60 Infectious disease control, analogy to drug abuse
prevention, 468 Inhalants, 277–8, 278
abuse potential of, 286 acute effects of, 287 amyl nitrite and butyl nitrite, 290 chronic effects of, 289 dangers of abuse, 287–8 dependence on, 289 DMT, 215 as gateway for future drug abuse, 289 glue, solvent and aerosol inhalation, 277,
286–8 history of, 285–6, 291 household products with abuse potential, 286 patterns of abuse, 288–9 signs of abuse, 287
Pavlovian conditioning and associations with, 90 pharmacological violence and, 105 physical dependence on, 78–9 physiological factors of abuse, 86–7 precursor chemicals, 123–4 property crime and price of, 111 psychological dependence on, 78 purity of, 162, 163, 165 range of tolerated doses of, 72 reinforcement of use, 90 routes of administration, 165 since the 1980s, 163–4 smoked, 166, 167 society’s image of heroin abuser, 168–9 source control, 122 source of, 29 speedball, mixture of cocaine and, 188 street names for, 167 supply routes for, 165 symptoms of administering, 166 synthetic, 167 tolerance of, 166 trade routes for, 56 trafficking of, 39, 113, 165 treatment for abuse of, 169–71 use among adults aged 26 and older, 19 use among youth, 18 Vietnam war and abuse of, 91 white, 167 withdrawal, 78, 166
Heroin abuse, treatments for alternative maintenance programs, 170 behavioral and social-community programs,
170–1 domination of, 156 heroin detoxification, 169 methadone maintenance, 169–70 reality of opioid and recovery, 171
Heroin chic, 163 HeroinGen subculture, 109 Heroin Surge and Narcan, first responders, 168 Heroin, trafficking of
French connection, 29 golden triangle and golden crescent, 30 Mexico and Colombia, 32
Hexane, 286, 288 Hexing drugs, witchcraft and, 220–1
hGH, 264 Hicks, Tom, 255 High-density lipoprotein (HDL), 315 High school students, drug use among. See also
Youth, drug use among anomie/strain theory of
LSD use, 211 marijuana, 239, 242 performance-enhancing drugs, 272 prescription pain medications, 173 seniors, 16, 95–6, 377
“Hippie” subculture of 1960s, 56, 92, 93 Hispanics/Latinos, 37. See also Latino groups Histamine, heroin use and sudden release of,
164, 167 HIV infection, 163, 167, 365 Hoffmann, Friedrich, 286 Hoffmann-La Roche, 293 Hofmann, Albert, 205–6, 208, 210, 215 Hogarth, William, 306 Home environment, as protective factor, 97 Homeland Security, Department of, 126 Hong Kong, 30, 159 Hops, 300 Hormonal systems, steroid use and, 259–60 Hormones
antidiuretic, 309 human growth, 264
Hallucinogens, 205–23, 206. See also Lysergic acid diethylamide (LSD); Phencyclidine (PCP)
botanical sources for, 207 categories of, 207 definitions of, 206–7 dissociative anesthetic, 221, 222–3 in early times, 47–8 ketamine, 15, 222–3, 294 miscellaneous, 207, 221–2 related to acetylcholine, 207, 219–20 related to norepinephrine, 207, 216–19 related to serotonin, 207, 214–15 synthetic, 216–19 theory of drug abuse, 90 trafficking in, 37, 223 use among adults aged 26 and older, 19 use by youth, 18
Halstead, William, 184 Hangovers, 310–11 Hard cider, 301 Harmine, 207, 215 Harm reduction approach, 365, 367 Harrison, Francis Burton, 51 Harrison, Thomas, 85 Harrison Act of 1914, 50–1, 59, 161, 183, 232 Harvard University, LSD experiments
around, 209 Hashish, 230
federal trafficking penalties, 144 history of, 230–3 use among adults aged 26 and older, 19
Hashish oil, 230 federal trafficking penalties, 143
Hashish oil crystals, 230 Hatfield, Bobby, 11 Hawaii, marijuana grown in, 230 H. B. Fuller Company, 289 HDL (high-density lipoprotein), 315 Health benefits of alcohol consumption,
315–16 Health risks of smoking, 339, 344–8 Heat loss, alcohol consumption and, 309 Hedberg, Mitch, 11, 191 Hell’s Angels motorcycle gang, 36 Hemp, growing in America, 229 Henbane, 48 Hendrix, Jimi, 11 Hepatitis, 68, 167
alcoholic, 321 Herbicides, crop eradication using, 123 Heroin, 160, 161
acute effects of, 167 arrestees’ use of, 106 behavioral theory of abuse, 90 benzodiazepines combined with, 292 black tar, 32, 56, 163 chipping, 168 cocaine combined with, 167, 188 crime and use of, 110 deaths from, 11, 12, 13, 156, 168 detection periods, 270 drug laws, 58, 143 ED visits for, 13, 15 hidden toxicity, 10 history of, 160–1 intravenous, 167 laws, 59 learning techniques to use and enjoy, 93 lethality of, 166–7 metabolic-defect theory of abuse, 86–7 morphine’s relationship to, 29 neurochemical system in brain and, 87 new forms of, 15 in 1960s, 1970s, and 1980s, 56–8, 162–3 patterns of abuse, 165–8
400 ■ Index
LSD. See Lysergic acid diethylamide (LSD) LST (Life Skills Training), 371–2 Lunesta (eszopiclone), 284 Lung cancer, 238, 343, 346, 348 Luteinizing hormone (LH), 239 Lysergic acid amide (LAA), 207, 215, 215 Lysergic acid diethylamide (LSD), 37, 206,
207–12 acute effects of, 211 bad trip on, 213 brain and, 211–12 chromosomal damage and, 213–14 cocaine combined with, 188 creativity and, 213 criminal or violent behavior and, 214 cross tolerance between psilocin and, 215 DAWN report on, 211 dependence and, 212 ED visits for, 15, 210 effective dose of, 211 emergency guidelines for bad trip, 213 facts and fictions about, 212–14 history of, 56 learning techniques to use and enjoy, 93 mescaline effects compared to, 216 panic or psychosis produced by, 212–13 patterns of use, 212 penalties for, 143 personality disorder, 89 production of, 113 psychedelic era and, 208–10 residual effect of, 214 toxicity of, 211 trafficking in, 37 use among youth, 18
MADD, 314, 315 Mafia, money laundering by, 116. See also
Organized crime “Magic bullets” approach to prevention, 370 Ma huang (Ephedra vulgaris), 192 Mainlining, 68, 165 Mainstream smoke, 342, 342–3 Maintainers, 90 Maintenance stage of rehabilitation, 382 Major League Baseball, 258, 265–6 Malt liquor, 301, 304 Mandatory minimum sentencing, 145,
145–7, 369 Mandrake, 48, 220 Manhattan Silver, 228 MAO inhibitors, alcohol mixed with, 310 MAOI. See Monoamine oxidase inhibitor MAPs (member assistance programs), 271,
308, 379, 386 Margin of safety, 10, 10, 12 Mariani, Angelo, 183, 185 Marihuana: Weed with Roots in Hell (film),
55, 231 Marijuana, 3, 227–48, 230
acute effects of, 234–6 alcohol mixed with, 310 antimarijuana crusade, 231–3 arrestees’ use of, 106 assassin of youth, 232 BluntGen use of, 109 botanical source of, 228 brain and, 236 cardiovascular effects of, 238 chronic effects of, 237–40 cultivation of, 123 deaths from, 12 decriminalization of, 246–7 dependence on, 237–8 detection periods for, 269, 270
Kefauver-Harris Amendment of, 1962, 55 Kelly, Raymond, 131 Kennedy, David A., 11 Kenya, 41 Ketalar. See Ketamine Ketamine, 207, 222, 222–3
ED visits for, 15 trafficking, 37
Kindling effect, 187 Klonopin (clonazepam), 282 Knock and talk, 132 Korsakoff’s psychosis, 323
LAA (lysergic acid amide), 207, 215 LAAM (levo-alpha-acetylmethadol), 170, 170 Labeling theory, 94, 94 Labor, endorphins and, 165 Lager beer, 301 Laissez-faire, 49 L-amphetamine, 193 Language of drug subculture, private, 94 Laos, 30, 158 Latency period, 71 Latino groups
cocaine use, 186 drug abuse prevention approaches in, 379 racial profiling, 128
Laudanum, 158 Laughing gas. See Nitrous oxide Laundromats, money laundering originating
from, 116 LDL (low-density lipoprotein), 315 Lean Stack, 264 Leary, Timothy, 209, 210, 212, 233 Ledger, Heath, 11 Legalization of drugs, 150–1 Legal status of drugs, 7 Leo XII, Pope, 183 Lethal dose, 9, 9–10
alcohol, 303 heroin, 166
Lethal emergencies. See Deaths Leukoencephalopathy, 167 Leukoplakia, 346 Levoamphetamine (l-amphetamine), 20, 193 Leyva, Arturo Bertrán, 38 Librium (chlordiazepoxide), 282–3, 283 LICADD. See Long Island Council on
Alcoholism and Drug Dependence Licit (legal) drugs, 4
emergencies related to, 13 Lidocaine, 186 Life Skills Training (LST), 371–2 Lightner, Candace, 314 Limbic system, 165 Limbitrol (chlordiazepoxide and amitriptyline), 282 Lincoln, Abraham, 49 Lipid-soluble, 68 Liqueur, 301 Liquor. See Distilled spirits Lithuania, smoking in, 354 Liver
alcohol abuse and, 321–2 cancer of, 323 fatty, 322 screening of orally-administered drugs by, 68 steroid use and, 260
London Summer Olympic Games, 267 Long Island Council on Alcoholism and Drug
Dependence (LICADD), 384 Loperamide, 173 Lopressor (metoprolol), 284 Lorazepam, 282 Lortab (hydrocodone), 172 Low-density lipoprotein (LDL), 315
Inhalants (continued) society’s responses to abuse of, 289–90 sudden deaths from, 288 use by youth, 18
Inhalation, 68–9, 70 Inhalers
amphetamine, 193 nicotine, 356
Injection, 68, 70 Inmates. See Prisoners Innocent VIII, Pope, 230 Innovation, as adaptation to anomie, 91 Inpatient treatment for cocaine, 190–1 In rem civil forfeitures, 133 Insomnia
barbiturates to treat, 280 benzodiazepine to treat, 283 non-barbiturates to treat, 281 nonbenzodiazepine drugs to treat, 283–4
Institute of Medicine, 244 Instrumental use, 6, 7 Insulin, 68, 69–70, 310 Intensification model of drug use and crime, 106 Interactional circumstances, 112, 112–13 Internal Revenue Service (IRS), 54, 161 Internal System for Tracking Over- Prescribing
(I-STOP), 384 International Association of Chiefs of Police, 128 International drug code for sport competitions, 256 International drug regulation, 60–1 International Monetary Fund, 124 International Narcotics Control Strategy Report
on Money Laundering, 117 Internet
prescription pain relievers, buying on, 20, 21 steroid suppliers on, 254, 271
Intervention, levels of, 364–6. See also Prevention strategies
Intestinal spasm, 173 Intramuscular (i.m.) injections, 68, 70 Intranasal administration, 69 Intravenous (i.v.) injection, 68, 70
heroin, 167 Involvement (social bond), 92, 93 Iran, heroin from, 31, 163 ischemic stroke, 345 IRS. See Internal Revenue Service (IRS) Isopropane, 286 Israel smoking in, 354 I-STOP. See Internal System for Tracking
Over- Prescribing
Jackson, Michael, 11 Jamaica, marijuana in, 234 James I of England, King, 337 Japan, smoking in, 353, 354 Japanese Yakuza, 34 Jazz world, marijuana’s popularity in, 231 Jerez, Rodrigo de, 336 Jimsonweed, 220 “Jitters,” 332 Johnson, Bruce, 93, 94 Johnston, Lloyd D., 242, 349 Joint, 234. See also Marijuana Jones, Ernest, 185, 352 Jones, Kenneth L., 324 Joplin, Janis, 11 Journal of Studies on Alcohol, 300 Jungle, The (Sinclair), 50 Justice, Department of, 112, 245 “Just Say No” campaign, 58 Juvenile Drug Court, 148
Kadian (morphine), 172 Karzai government in Afghanistan, 39
Index ■ 401
smoking in, 354 smuggling at U.S.-Mexican border, 125
“Mickey Finn,” 281 Microdots, 211 Micrograms (mikes), 211 Midazolam, 282 Military, U.S., interdiction by, 126–7 Mill, John Stuart, 365 Miltown (meprobamate), 282 Minor League Baseball, 259 Minor tranquilizers. See Antianxiety drugs Misdemeanor, 143 Mitchell, George J., 258 Mithradates VI of Pontus, King, 74 Mithridatism, 74 MLB. See Major League Baseball Modafinil, 199 Moderation Management (MM), 328, 329 Moist snuff, 351, 351 Molly, 219 Money, cocaine-contaminated paper, 190 Money laundering, 116, 116–17 Money Laundering Control Act of,
1986, 117 Money laundering, digital currency
exchanges, 117 Monitoring the Future (MTF) Study, 16 Monoamine oxidase inhibitor (MAOI), 73 Monoamine oxidase (MAO) inhibitors, alcohol
mixed with, 310 Monroe, Marilyn, 11 Mood, 87
amphetamines and swings of, 193 anabolic steroids and swings of, 260
“Moonshiners,” 53 Morales, Alejandro Treviño, 40 Moral model, 85 Morning glory seeds, 207, 215 Morphine, 68, 72, 77, 48, 160, 173, 270
deaths from, 11, 12 heroin production from, 29 history of, 160–1 medical uses of, 172 possible adverse effects of, 171 street names for, 167 tolerance for, 72–3
Morphine-sensitive receptors, 157, 165 Mothers Against Drunk Driving (MADD), 314 Motorcycle gangs, 36, 115–16 Motor tasks, marijuana’s effect on, 235 Motrin (ibuprofen), 269 MPTP, 167 MS Contin (morphine), 172 “Mules” (couriers), 32, 125 Multicultural issues in prevention, 379 Multimodality programs, 171 Multiple substance abuse, 363 Muscle dysmorphia, 262 Muscle Power, 265 Mushrooms. See Amanita muscaria; Psilocybin Muslims, history of hashish and, 230 Myanmar (Burma), 30, 163
Nabilone, 244 Nalmefene, 327 Naloxone, 164, 165, 169 Naltrexone, 165, 165, 327 Nandrolone decanoate, 256 Nandrolone phenprionate, 256 Narcan (naloxone), 164 Narcolepsy, 199 Narcoterrorism, 232 Narcoterrorism in Afghanistan, 39 Narcoterrorism in Colombia, 39 Narcotic analgesics, 15
Melvoin, Jonathan, 11 Member assistance programs (MAPs),
271, 308 Membranes, absorption through, 69–70 ME mentions. See Death(s) Memory, marijuana’s effect on, 194 Men for Sobriety (MFS), 328 Mental Health Court, 148 Mental Health Parity and Addiction Equity
Act of 2008, 384 Mental retardation, 324 Mentholated cigarettes, 340 Meperidine, 172 Mephobarbital, 279 Meprobamate, 282 Mercury poisoning, 49 Merton, Robert, 91–2 Mescaline, 207, 216 Metabolic-defect theory of heroin abuse, 86 Metabolites, 70
alcohol, 76, 301–3, 302 nicotine, 76 THC, 234
Metadate, 198 Methadone, 169, 172
deaths from, 13 detection periods, 270
Methadone maintenance, 169, 169–70 Methamphetamine, 193, 193–4
abuse, present day, 195 arrestees’ use of, 106 crime and, 109, 110 drug laws, 59–60 drug-related deaths from, 13 ED visits for, 12, 15 epidemic across America, 194–5 in Heartland of America, 194–5 manufacture of, 194–5 methadone clients’ abuse of, 170 molecular structure of, 193 patterns of abuse, 196–7 penalties for, 143 street names, 196 trafficking of, 36–7, 197 treatment, 197
Methamphetamine Trafficking, North Korea, 196
Methandrostenolone, 256 Methanol, 286 Methaqualone, 281 Methcathinone, 197 Methedrine (methamphetamine), 193, 194–7 Meth Hot Spots program, 61 Methotrexate, 310 Methyl chloride, 286 Methylenedioxymethamphetamine (MDMA).
See MDMA (Ecstasy) Methylphenidate, 20, 198–9 Methyltestosterone, 256 Metoprolol, 284 Mexican drug trafficking organizations, 35, 40
hallucinogens trafficked by, 37 methamphetamine trafficking by, 36, 194,
195, 197 money laundering by, 116–17
Mexican immigrants anti-marijuana crusade and, 231 drug laws and, 56
Mexico cocaine shipments, 189 heroin from, 39–40, 163, 165 inhalant abuse, 288 life and death in, 40 marijuana from, 36, 55, 230 psilocybin, 214
domestic cultivation of, 36 drug laws and, 56, 145 elimination rate of, 234, 237 false positives, 268 gateway hypothesis of use, 240–2 heroin combined with, street names for, 167 hidden toxicity, 10 history of, 55, 58, 230–4 immunological effects of, 238 killer weed, 232 learning techniques to use and enjoy, 93 Life Skills Training program to combat, 371–2 long-term cognitive effects and amotivational
syndrome, 239–40 Marijuana smoking, current trends in, 242–3 medical emergencies from, 13 medical uses for, 243–5 in 1990s, 59 in 1960s, 1970s, and 1980s, 56, 58 odds ratio for use, 97 passive inhalation of, 269 patterns of smoking, 242 Pavlovian conditioning and associations with, 90 physiological effects of, 234 prevalence and economic costs in
workplace of, 308 psychological and behavioral effects of, 234–6 regulation of, 54, 245–6 respiratory effects and risk of cancer from, 238 risk factors, 97 risk factors for using, 97 sales of, 114 sexual functioning and reproduction,
effects on, 234, 239 terminology, 228–9 tolerance of use, 237–8 trafficking of, 35–6, 243 use among adults aged 26 and older, 19 use among youth, 16–17, 55, 72, 240, 242 withdrawal, 237–8
Marijuana in BC Bud, 36 Marijuana Tax Act of 1937, 54, 55, 232 Marine Branch, U.S. Customs, 126 Marinol (dronabinol), 244 Mash, 300 Masking drugs, 269 Massive cross-border drug tunnel, 35 Mass media, influence of, 372–5 Masteron (drostanolane), 256 McCaffrey, Barry, 60 McCarthy, Joseph R., 232 McGlothin, William, 239 McGwire, Mark, 253, 265 McKinley, William, 183 MDA, 207. See also MDMA (Ecstasy) MDMA (Ecstasy), 62, 93, 114, 218, 218–19
decline in use, 218–19 ED visits for, 15 learning techniques to use and enjoy, 93 toxicity of, 218
Mead, 306 Mebaral (mephobarbital), 279 Medellin and Cali drug cartels, 33, 33, 35 Media, prevention and, 372–3 Medical marijuana, 244–5
decriminalization and legalization, 245–6, 248 federal versus state drug enforcement, 245 laws, evolving status of, 244–5 muscle spasticity and chronic pain, testing, 244 nausea and weight loss, treating, 244 public sentiment for a liberalization, 247 state referendum, decriminalization by, 246 state referendum, legalization by, 246–7
Medical model of drug use and crime, 106 Megorexia (muscle dysmorphia), 262
402 ■ Index
pain medications, 175–6 response to, 176
Opioids, 156 derivatives, 157 drugs, 157 in history, 158 synthetic, 157
Opium, 50, 61, 158 association with China and Chinese culture,
158, 159–60 in Britain, 159–60 given to infants and children, 159 harvesting, 158 history of, 47, 48, 158–9 legislation against, 161–2 medicinal value of, 172–3 smoking of, 159–60 source control and, 122 source of, 56 in United States, 159–60
Opium-addict writer, 159 Opium poppy (Papaver somniferum), 158
crop eradication programs, 123 Opium War, 158 Oral administration, 67–8, 70 Oral and narcissistic stage of development in
infancy, 89 Oral cancer, 352 Oral contraceptives, smoking and, 347 Oral fluid testing, 269 Oramorph and Oramorph SR (morphine), 172 Oregon, marijuana possession in, 58 Organized crime, 56–7
drug cartels, 32–5 French connection, 56, in Prohibition era, 53
Orlaam (LAAM), 157 Osmond, Humphrey, 208 OTC drugs. See Over-the-counter
(OTC) drugs Outlaw motorcycle gangs, 115 Outpatient treatment, 190–1
alcoholism, 321 Outside the Classroom, Inc., 378 Overdose, tolerance effect and, 75, 167 Overeaters Anonymous, 328 Overnight delivery services, 37 Over-the-counter (OTC) drugs
acetaminophen, 137, 310 aspirin, 47, 160–1, 173 containing pseudoepinephrine, limiting
sales of, 61 cough-and-cold medications, 124, 195 detection periods for, 270 emergency department visits, 13 ibuprofen, 269
Oxidation, 302 Oxyandrolone (Oxandrin), 256 Oxycodone, 20, 173, 173
emergency department visits, 15 OxyContin (oxycodone), 172, 173, 173–4
use among adults aged 26 and older, 19 Oxymetholone, 256 Oxymorphone, 172
Pain relief narcotic drugs for, 169–71 placebo effect and, 77
Pakistan, heroin from, 163 Palladone (hydromorphone), 172 Panic, LSD-induced, 212–13 Papaver somniferum (opium poppy), 158
crop eradication programs, 123 Paracelsus, 158 Paranoia, cocaine abuse and, 186
NFLIS. See National Forensic Laboratory Information System
NFL. See National Football League NHL. See National Hockey League Nicorette, 356 Nicotine, 70, 343, 343–4. See also Tobacco
cigarette content increases from 1997-2005, 340 dependence on, 343–4, 352 elimination half-life of, 343 ethnic differences in metabolism of, 76 metabolism of, 776, 340 neurochemical system in brain and, 87 tolerance, 344 withdrawal from, 344
Nicotine Anonymous, 328 Nicotine gums, patches, sprays, and inhalers, 356 Nicotinic receptors, 343 Nicotrol Inhaler, 356 Nicotrol NS, 356 NIDA, 88 Niemann, Alfred, 183 Nightshade, 220–1 Nitrite inhalation abuse, 290 Nitro-bid (nitroglycerin), 310 Nitroglycerin, 69, 310 Nitrosamines, 347 Nitrous oxide, 285, 285–6, 290 Nixon, Richard M., 56 N-nitrosamine, 348 Noctec (chloral hydrate), 310 Norms of drug subculture, 94 Norepinephrine
ADHD and, 198 amphetamines and, 193–4 hallucinogens related to, 206, 216–19 molecular structure of, 193
North Carolina, tobacco growing in, 338 Norway, smoking in, 354 NSDUH. See National Survey of Drug Use and
Health (NSDUH) Study Nucleus accumbens, 87, 87, 88, 187, 237, 344 Numorphan (oxymorphone), 157 Nuprin (ibuprofen), 269 Nyswander, Marie, 169
Objective-information approach to prevention, 369
Office of National Drug Control Strategy, 244 Offshore banks, money laundering through, 116 Ofloxacin, 269 Oil of mustard, 290 Ololuiqui, 215. See also Lysergic acid amide
(LAA) Olympic Games, 235, 256–7, 264, 267 Ondansetron, 327 Operation Golden Flow, 162 Opiates. See also Heroin; Morphine; Thebaine;
Codeine alcohol mixed with, 310 brain and, 164–5 deaths from, 12, 13 dependence on, 161 detection periods for, 269, 270 detoxification for, 169 emergency room visits, 15 medical uses of, 172–3 physiological factors of abuse, 86–7 possible adverse effects of, 171 regulation of, 50–1 street names, 167 synthetic, 163–4 in United States, 161–4
Opioid medication abuse, prescription drug diversion and overdose, 174–5 OxyContin abuse, patterns of, 173–4
Narcotics, 156–76, 157. See also Heroin; Morphine; Opiates; Opium
classification of, 52 possible adverse effects of, 171 street names for, 167 treatment for, 169–71
Narcotics Anonymous, 328 Nasal decongestants, 199 National Association of Counties, 194 National Basketball Association (NBA), 257, 266 National Cancer Institute, 355 National Center on Addiction and Substance
Abuse, 374 National Clearinghouse for Alcohol and Drug
Information (NCADI), 384 National Collegiate Athletic Association
(NCAA), 266 National Commission on Marijuana and Drug
Abuse, 246 National Council on Alcoholism and Drug
Dependence (NCADD), 384 National Drug Control Policy, Office of, 59, 60,
365, 367 National Drug Control Strategy, Office of, 244 National Football League, 258, 266 National Football League (NFL), 266 National Forensic Laboratory Information
System (NFLIS), 57 National Guard, role in drug interdiction, 127 National Highway Traffic Safety
Administration, 313 National Hockey League (NHL), 259, 266 National Household Survey on Drug Abuse. See
National Survey of Drug Use and Health (NSDUH) Study
National Inhalants and Poisons Awareness Week, 290
National Institute of Drug Abuse (NIDA), 88, 183 National Institute on Alcohol Abuse and
Alcoholism (NIAAA), 326 National Prohibition Party, 53 National Survey of Drug Use and Health
(NSDUH) Study, 175 of 2013, 189, 242
Native American Church of North America, peyote use by, 217
Native American communities, 380 Natural-product names, 6 NBA. See National Basketball Association NCAA, 266 NCAA. See National Collegiate Athletic
Association NCADD. See National Council on Alcoholism
and Drug Dependence Needle freaks, 166 Negative education, 369 Nembutal (pentobarbital), 279, 281
death from, 11 Nerve impulse, 186 Ness, Eliot, 54 Neurochemical systems in brain, 87–8 Neurochemical “Yin and Yang” of
Cannabis, 236 Neurons, 87
nucleus accumbens, 88, 89, 187, 237 synaptic communication, 87
Neurotransmitters, 87–8, 87 cocaine and, 186
Newborns, marijuana smoking during pregnancy and, 239 (See also Pregnancy)
New York City computerized crime-tracking system, 131 crack abuse, 188 drug law reform in, 147 eras of drug scene in, 109
Index ■ 403
Prosecution and pretrial services, 139 ProSom (estazolam), 282 Prostitution, 112 Protective factors, 95, 95, 96–8 Protropin (genetically engineered hGH), 264 Provigil (modafinil), 199 Pseudoephedrine
cold remedies containing, 195 methamphetamine manufacture and, 194
Psilocin, 215 Psilocybe mexicana, 214 Psilocybin, 207, 209, 214
drug dependence and, 6 Psychedelic drugs. See Hallucinogens Psychedelic era, beginning of, 210 Psychoactive drugs, 4. See also Inhalants;
Alcohol biochemistry, 87
Psychoanalytic theories, 89, 89 Psychodysleptic drugs. See Hallucinogens Psychological dependence, 78, 78–9
on alcohol, 303 on cocaine, 78 on crack cocaine, 188 on heroin, 78 on marijuana, 237 neurochemical basis for, 87–8
Psychological effects, 77 of anabolic steroids, 260–1 of marijuana, 234–6
Psychological perspectives on drug abuse, 89–90 Psychopharmacological crime, 105 Psycholytic drugs. See Hallucinogens Psychosis
amphetamine, 193 cocaine, 186 Korsakoff’s, 323 LSD, 212
Psychotomimetic drugs. See Hallucinogens Public Health Model, 368 Punitive measures for drug addicts, 369. See also
Crime; Criminal justice system Purdue Pharma, 174 Pure Food and Drug Act (1906), 50, 51, 59 PUSH. .See People United to Stop Heroin
(PUSH) Pyramiding pattern of steroid abuse, 262
Quaalude (methaqualone), 281 Quinolone antibiotics, 269
Race and ethnicity alcohol metabolism and, 302 cancer mortality and, 346 drug effects and, 76 drug laws and, 50–5 inhalant use by, 288 penalties for cocaine vs. crack possession
and, 144 racial profiling and, 127–8
Racial profiling, 128, 127–8 Racism, 51 Racketeer Influenced and Corrupt Organization
(RICO), 132 Randolph, Dr. Elmo, 128 Rape
alcohol intoxication and, 110 drugs used for, 223, 293, 294
Rape, Abuse, and Incest National Network (RAINN), 292
Rapid-eye movement (REM) sleep alcohol and reduction of, 309 barbiturates, 279
Rational emotive behavior therapy (REBT), 328 Reagan, Nancy, 58
Plastic cement, 290 Platelet adhesiveness, 345 Police, racial profiling by, 127–8 Politics, tobacco and, 337 Polydrug use, 13,
arrestees’ use of, 106 during Vietnam War, 162
Poppers (amyl nitrate), 290 Positive reinforcement, 90 Positron emission tomography (PET), 88 Posse Comitatus Act of 1878, 127 Potassium permanganate, 124 Potentiation, 72 Precontemplation stage of change, 381 Precursor chemicals, 124 Predisposition model of drug use and crime, 106 Prednisone, 310 Pregnancy
alcohol consumption and, 302, 310, 323–4 inhalant exposure and, 286 marijuana smoking during, 238 smoking during, 347–8
Preparation stage of change, 381 President’s Commission on Law Enforcement
and Administration of Justice, 1967, 141 Presley, Elvis, 11 Prevention strategies, 364–80. See also ATOD
prevention college students and, 377–8 community-based, 372–5 failed, 368–70 family and, 375–7 “magic bullets” and promotional campaigns, 370 measuring success, 366 multicultural issues, 379 national policy of harm reduction, 365, 367 objective information approach, 369 primary, 364, 366–7 public health policy, 367–8 punitive measures for drug addicts, 369 reducing availability, 368–9 scare tactics and negative education, 369 school-based, 370–2 secondary, 364 self-esteem enhancement and affective
education, 370 tertiary, 364 in workplace, 378–9
Priapism, 259 Prices, economically compulsive crime and drug,
112, 114 Primary deviance, 94 Primary prevention, 364, 366
resilience and, 366–7 Prisoners
drug use among inmates, 106, 142–4 drug use prior to first crime, 112
Prison system, cost of building and maintaining, 59
Probenecid, 269 Productivity, legalization of drugs and, 150–1 Professional sports, steroids use in, 258
suspension penalties, 259 Profiling and drug-law enforcement, 127–8 Prohibition, 53–5, 53, 313, 336
ether’s popularity during, 286 marijuana’s popularity during, 231
Promotional campaigns, prevention through, 370 Proof of distilled spirits, 301 Propane, 286 Propanolol, 284 Property crime and price of heroin, 111 Propofol, 11 Propoxyphene, 169, 268 Proprietary and Patent Medicine Act of 1908, 183
Parke, Davis, and Company, 48, 221 Parkinson’s disease
amphetamine use, 194 MPTP and symptoms of, 167
Parole, 139 Paroxetine, 285 Particulate phase, 342 Partnership for a Drug-Free America (PDFA),
290, 374 Patches
methylphenidate, 198–9 nicotine, 356
Patent medicine, 50, 50–1 PATRIOT II, 61 Patterson, David A., 147 Pavlovian conditioning, 72–3, 90 Paxil (paroxetine), 285 PCP. See Phencyclidine (PCP)
ED visits for, 12 PeaCe Pill, 222 Pearson, David, 272 Peele, Stanton, 329 Peer influence, 95, 97, 170–1
adolescent drug abuse and, 92–3, 190–1 Peer-refusal skills, 370 Pemberton, John, 183 Penalties for drug abuse, 144, 146. See also
Criminal justice system crack vs. cocaine possession, 144
Penicillin, 310 Pentobarbital, 279, 279, 281 People United to Stop Heroin (PUSH), 384 Percocet (oxycodone), 15, 172, 173 Percodan (oxycodone), 172 Personality theories
nonpsychoanalytic, 89 psychoanalytic, 89
Peru coca chewing, 182 cocaine production, 189 crop eradication programs in, 32, 123
PET (positron emission tomography), 88 Peter the Great, Czar, 337 Petroleum products, 286 Peyote, 216 Peyotism, 217 Pharmaceutical Companies and Anti-Doping
Authorities in Alliance, 267 Pharmacological violence, 110, 233 Pharmacy Act of 1868, 59 Phencyclidine (PCP), 87, 207, 221, 221–2, 270
crack cocaine combined with, 188 history and abuse of, 222 patterns of abuse, 222 penalties for, 143 street names, 222 trafficking in, 37
Pheniline Forte, 279 Phenobarbital, 279, 279 Phenytoin, 310 Phoenix, River, 11, 170 Physical dependence, 78, 78–9
on barbiturates, 280 on heroin, 78–9 on marijuana, 237
Physical problems of alcoholism, 319 Physicians
effectiveness of antianxiety drugs, 283 role in smoking cessation, 356–7
Physiological factors, 86–7 “Pinpoint pupils,” narcotic abuse and, 164 Pius X, Pope, 183 Placebo effect, 48, 77
of counterfeit steroids, 263 Placebos, 77, 77–8
404 ■ Index
Sernyl (PCP), 221 Serotonin, 87, 211
hallucinogens related to, 207, 214–15 Serotonin-sensitive receptors, 211 Sertraline, 285 Sertürner, Friedrich Wilhelm Adam, 160 Sex and sexual desire
alcohol and, 110, 312–13 cocaine’s effect on, 186 heroin’s effect on, 166 marijuana and, 234, 238 nitrite inhalation and, 290
Sexual assault, 293 “Shakes,” 280 Shaman, 47 Shamanism, 47 Shen Nung, emperor, 192, 230 Shoemaker’s glue, 289 Shooting, 165 “Shotgunning,” 262 Shrooms. See Psilocybin Sidestream smoke, 339, 348 SIDS (sudden infant death syndrome), 348 Siegel, Shepard, 72–3, 75 Silicon chip patches, 69 Simple possession, 142 Sinclair, Upton, 50 Sinsemilla, 230 Skin, absorption through, 69, 70 Skin-popping, 68, 165 Skoal, 351 Sleep
barbiturates, 279–80 neurotransmitters and, 87 opiates for medical use, 87 patterns, alcohol and, 309
Sleep aids, 283–4. See also Barbiturates “Smart pills,” stimulants used as, 199 SMART Recovery, 328 Smith, David W., 324 Smith, Kline and French Laboratories, 193 Smoke, tobacco
comparison of components of marijuana and, 237
components in, 342–3 environmental tobacco smoke (ETS), 348 hazards of, 348 mainstream, 342–3 sidestream, 339, 348
SmokeEnders, 355 Smokeless tobacco, 347, 351–2 Smokers Anonymous, 355 Smoke-Stoppers, 355 Smoking. See also Cigarettes; Marijuana;
Nicotine; Tobacco by American youth, 341, 348–9, 364 behavioral theory, 90 cessation, medications for, 355–6 of crack cocaine, 188 drugs administered through, 68–9, 70 health concerns and, 338 of heroin, 163, 165 Life Skills Training program to combat,
371–2 methamphetamine, 194 of opium, 160 oral contraceptives and, 347 patterns of, 348–9 patterns of marijuana, 241–2 Pavlovian conditioning and associations
with, 90 PCP, 221 physiological responses, 76 in post-World War II U.S., 55–6 quitting, 354–7
Risk factors, 95–7, 95 Risks of drug use, perception of, 18–19 Ritalin (methylphenidate), 20, 62, 88, 198 Ritualism, as adaptation to anomie, 91 Road to National Prohibition, 53 “Roaring Twenties,” 53 Robbery, 109, 110 Rockefeller Drug Laws, 145, 147 Rodriguez, Alex, 258, 264 Rogers, Don, 191 Rogue Pharmacies, 176 Rohypnol (flunitrazepam), 292, 293 “Roid rage,” 260 Role models, parents and guardians as, 375–6 Roosevelt, Franklin D., 54 Roosevelt, Theodore, 50 Routes of administration, 67–9 Rude awakening, heroin abuse, 156 Rum, 301, 306 Runner (street dealing), 114 Russia, smoking in, 337, 338, 353, 354 RxPatrol, 111 Rye whiskey, 301
S2 receptors, 211 SADD (Students Against Drunk Driving), 314 Safety, margin of, 10 Saint Bernard myth, 309 Sake, 301 Salem witch trials, role of ergotism in, 209 Salt Lake City Winter Olympic Games, 267 Salvia divinorum, 207, 223 Sandoz Pharmaceuticals, 208, 210–11 Sarin and chemical warfare, 41 Sativex, 245 Scare tactics, 369 Schedules of controlled substances, 11 Schizophrenia
amphetamine psychosis and, 193 LSD hallucinations compared to, 213 tranquilizers, 282
School-based prevention, 370–2 anxiety and stress reduction, 371 Drug Abuse Resistance Education (DARE), 372 drug testing, 59 Life Skills Training (LST) program, 371–2 peer-refusal skills, 370 social skills and personal decision making,
370–1 Scopolamine, 207, 208, 220 Scotch whiskey, 301 Screening, Brief Intervention, and Referral
to Treatment (SBIRT), 383 Search Institute, 97 Search warrant, 132 Sears, Roebuck catalog, 160 Secobarbital, 279, 281 Seconal (secobarbital), 279, 281 Secondary deviance, 94 Secondary prevention, 364, 366 Secular Organization for Sobriety (SOS), 328 Sedative-hypnotics, 278. See also Barbiturates
nonbarbiturate, 281 Seizures
alcohol withdrawal syndrome and, 321 cocaine and, 186
Selective serotonin reuptake inhibitors (SSRIs), 285
Self-esteem enhancement, 370 Senna plant, 47 Sentencing and sanctions, 139 Sentencing, mandatory minimum, 145,
145–7, 369 September 11, 2001 attacks
drug smuggling methods since, 124–5
Reagan, Ronald, 58 Rebellion, as adaptation to anomie, 92 REBT, 328 Receptor binding, 87 Receptors
benzodiazepine, 283 dopamine, 87 endorphin-sensitive, 166 glutamate, 221, 223 morphine-sensitive, 164 nicotinic, 343 THC-sensitive, 236
Recreational use, 7, 7 Recruitment and socialization theory,
subcultural, 93–4 Red Man, 351 Red table wine, 301, 311, 315 Reefer, 234. See also Marijuana Reefer Madness (film), 55, 231 Reefer madness approach, 369 Reefer songs, 231 Regulation, 50–3, 58–60
of alcohol, 52 of anabolic steroids, 265 lack of, in 19th century, 48 of marijuana, 55, 245–6 minimum-age, for smoking, 349 of narcotics, 51–2 tobacco, economics and, 337
Reentry Drug Court, 148 Rehabilitation, 151 Rehabilitation, stages of change and, 381–2 Rehnquist, William H., 128 Reinforcement
behavioral theory of, 90 dopamine and, 87 negative, 90 positive, 90
Relation-back doctrine, 132 Religious Freedom Restoration Act of 1993, 217 Remoxy, 174 REM sleep
alcohol and reduction of, 309 barbiturates, 279
REM sleep rebound, 279 Reproduction
LSD effects on, 214 marijuana effects on, 238
Research methodology, 77 Resilience, 366, 366–7 Resistol, 289 Resistoleros, 289 Respiratory depression
heroin use and, 164, 167 opioid pain medications, 172
Respiratory disease from tobacco, 345–6 Respiratory effects of marijuana, 238 Restoril (temazepam), 282
resveratrol, 315 Retail service business, money laundering using
cash-based, 116 Retreatism, as adaptation to anomie, 91–2 Reverse anorexia, 262 Reverse sting, 128 Reverse sting operation, anatomy of, 130 Reverse tolerance, 237 Revex (nalmefene), 327 ReVia (naltrexone), 165, 327 Revolutionary Armed Forces of Colombia
(FARC), 40 RICO. See Racketeer Influenced and Corrupt
Organization (RICO) RICO statute, 132, 132–3 Rig-Veda, 219 Rise of the Temperance Movement, 52
Index ■ 405
Teratogenic, 324 Tertiary prevention, 364 Testing for drugs at home, 376 Testing for ergogenic drugs, 265–70 Testoderm transdermal system, 256 Testor Corporation, 289, 290 Testosterone, 256, 259–60
aggression and, 260–1 anabolic steroids and level of, 258–9 effects of, 255 marijuana’s effect on level of, 235, 239
Testosterone cyprionate, 260 Testosterone enantrate, 256 Testred (methyltestosterone), 256 Tetraethyl lead, 286 Tetrahydrocannabinol (THC), 230, 234–5, 270 Thailand, 163 THC, 230, 234–6
in BC Bud, 36 detection periods for, 270
THC-sensitive receptors, 236 Thebaine, 160, 163 Theoretical perspectives on drug use and
abuse, 84–99 biological perspectives, 85–8 biopsychosocial model, 85 integrating, 95 protective factors, 95, 96–8 psychological perspectives, 89–90 risk factors, 95–8 sociological perspectives, 90–5
Therapeutic communities, 151, 170 Therapeutic index, 10
for alcohol, 303 “Therapeutic window,” 71 Thiamine, 323 Thiopental, 279 Timing of drug administration, 71–2 Titration hypothesis, 344 Tkachenko, Nadezhda, 257 Tobacco, 335–7. See also Cigarettes; Nicotine;
Smoking advertising for, 338, 339, 356 cancers linked to, 346–7 cardiovascular disease from, 344, 348 chewing, 69, 337 cigars and cigarettes, 338, 352 coca paste mixed with, 182 components of, 342–3 control since 1990, 341–2 deaths from, 288, 289, 347, 348 economics and, 337 global marketplace for, 342 health risks, 339, 344–8 high school and college students, 18 legality of, 7 lung cancer from, 346 minimum age for purchase of, 350 politics and, 337 regulation, 341–2 respiratory disease from, 345–6 smokeless, 69, 337, 347, 351–2 through history, 336–8 in twentieth century, 338 use among American youth, 17 women and, 338, 348–9 worldwide use of, 353–4
Tobacco angina, 352 Tobacco control (1990), 341–2 Tobacco control, policy and strategy
potential harm, awareness of, 350–1 taxation, regulation by, 349 young people, reduced access by, 350
Tobacco Control Act (2009), 60, 341 Tobacco settlement (1998), 341
Stress, 282 endorphins and, 165 teenage drug abuse and, 370, 371, 376
Stress reduction, 371 Stroke, moderate alcohol consumption and, 345 Strychnine, 255 Students, drug use by, 3. See also College
students; High school students Students Against Drunk Driving (SADD), 314 Subcultural recruitment and socialization
theory, 93, 93–4 Subculture, 93
deviant, 94–5 “hippie,” of 1960s, 56, 92, 93 in New York City, 109 private language of drug, 94 rise and fall of drugs and violence, 109
Subcutaneous (s.c. or sub-Q) delivery, 68, 70
Sublingual administration, 69 Suboxone (buprenorphine in combination with
naloxone), 157, 170 Substance abuse, 80 Substance dependence, 80
LSD, 211 Substance use disorder, 79 Subutex (buprenorphine), 170 Sudden infant death syndrome (SIDS), 348 Suicide, suicide attempts, suicidal thoughts
alcohol abuse and, 317 barbiturates and, 280, 282 cocaine abuse and, 185–6
Sullivan, John L., 338 Superego, 89 Supply/availability argument, 368 Suppository, 69 Surgeon general’s report on smoking, 338 Sutherland, Edwin, 93 Sweden, smoking in, 354 Sydenham, Thomas, 158 Sydenham’s Laudanum, 158 Sympathetic branch of autonomic nervous
system, cocaine’s effect on, 186 Symptomatic drinking, 317 Synaptic knob, 87 Synar, Mike, 350 Synar Amendment, 350 Synergism, 72
between alcohol and barbiturates, 279 Synesthesia, 211 Synthetic depressants, 221–2 Synthetic hallucinogens, 217–18 Synthetic heroin, 167 Syringe, invention of, 48 Systemic crime, 105 Systemic violence, 105–6 Systems approach, 324, 324–5
Tactical Analysis Teams (TATs), 127 Taliban, 39 Tamez, Alejo Garza, 40 Tannin, 311 Tar in cigarettes, 342, 343 TAT. See Tactical Analysis Teams (TATs) Taverns, 52 Taxes
alcohol regulation through, 313–14 on cigarettes, 342 drug abuse regulation through, 51
TCP, 288 Tea pads (marijuana clubs), 231 Temperance movement, 52, 52–3 Tenormin (atenolol), 284 Tenth graders, drug use among, 16 Teonanacatl, 214. See also Psilocybin
Smuggling, drug interdiction to prevent, 124–8 “Smurfing,” 116 Snappers (amyl nitrite), 290 Snorting heroin, 163, 165 Snuff, 351, 377 Snuffing, 337 Snus, 352 Social class. See Socioeconomic status Social-community programs, 170 Social control theory, 92, 92–3
subcultural recruitment and socialization theory and, 93–4
Socialization theory, subcultural recruitment and, 93–4
Social problems, alcoholism and, 319 Social skills training, 370–1 Sociocultural filters, 379 Socioeconomic status
labeling of behavior and, 94 Sociological perspectives on drug abuse, 90–4 Sokolow, Andrew, 127 Solvent inhalation, 286–8 Sopor (methaqualone), 281 SOS, 328 Source control, 122, 122–4
chemical controls, 123–4 crop eradication, 123–4 U. S. certification, 124
South America, opium and heroin from, 163. See also Colombia
Southeast Asia, Golden Triangle of, 30, 163 South Korea, cigarette smoking in, 354 Spain, smoking in, 354 Sparkling wine, 301 Speakeasies, 53 Special K, 222 Speed. See Methamphetamine Speedball, 255 Speed freaks, 194 Spending money, teenage drug abuse
and, 376 Spiral model of recovery, 382 Sports. See also Anabolic steroids
alcohol and security issues in, 312 amphetamines, 256 drug testing in, 265–70 performance-enhancing drugs, 255–8 spectator, 312
Spousal abuse, alcohol intoxication and, 110 Sprays, nicotine, 356 SSRIs, 285 Stacking, 218 Stanozolol, 256 St. Anthony’s fire, 208 States’ rights, regulation of drugs and, 50 Stepan Company, 184 Stern, David, 312 Steroids, anabolic. See Anabolic steroids Stimulants, 19. See also Amphetamines;
Cocaine for ADHD, 198–9 nonmedical use in baseball, 265 as “smart pills,” 199
STP, 207, 217 Strain/anomie theory, 91–2 Strattera (atomoxetine), 198 Street dealing, business model of, 114 Street gangs, 115 Street-level drug-law enforcement, 128–9 Street names
amphetamines, 194 cocaine, 188 marijuana, 243 opioid, 167 PCP, 222
406 ■ Index
Vietnam, heroin from, 30 Vietnam War, 56, 91, 162–3 Viking warriors, 220 “Vin Mariani,” 183–4 Violence
alcohol and, 315–16 crack cocaine and, 110, 112 domestic, 106
Virginia, tobacco trade in, 337 Virilon (methyltestosterone), 256 Virilon IM (testosterone cyprionate), 256 Vitamin B1 (thiamine) deficiency, 323 Vitamin B6, 315 Vitamin K, 222 Vivitrol, 327 Vocational problems, alcoholism and, 319 Vodka, 301, 310 Volkow, Nora D., 88 Volstead, Andrew, 53 Volstead Act (1919), 53 Von Baeyer, Adolf, 278
Warfarin, 310 War on Drugs, 58, 122, 365 War on terrorism, 60–1 Washington, George, 52, 228 Water retention, 265 WCTU, 53 Weight, drug effect and, 75 Weight loss
amphetamine use, 194 from chemotherapy, medical marijuana
to reduce, 244 Wellbutrin, 356 Wells, Horace, 285 Wernicke-Korsakoff’s syndrome, 323, 323 West, Louis, 239–40 WFS, 328 Whippets, 286 Whiskey, 301, 304, 306, 310 Whiskey Rebellion, 59, 313 White, Patricia, 292 White heroin, 167 White table wine, 301 Willow bark, 47 Windowpanes, 211 Wine, 301, 306, 304
fortified, 301 Wine coolers, 304 Winfrey, Oprah, 257 Winstrol (stanozolol), 256 Witchcraft, 48, 220
Salem witch trials, role of ergotism in, 209 “Witch’s brews,” 48 Withdrawal, 8
from alcohol, 77, 283, 321–2 from amphetamine, 197 from barbiturates, 78, 280 from cocaine, 189 from crack, 110 from heroin, 78, 166 from marijuana, 237 from nicotine, 344 from Valium, 283
Women alcohol and sexual desire, 312–13 cigarettes marketed to, 338, 347–8 crack abusers, child abuse/neglect
and, 189 as drug “mules,” 125–6 environmental tobacco smoke
exposure of, 348 morphine dependence, 48 opium use, 159–60 patent medicine abuse, 50
Ultracet (tramadol), 157 Ultram (tramadol), 157 Ultram ER (tramadol), 172 Ultrasound, low-frequency, 69 Unions, member assistance programs (MAPs)
of, 271 United Kingdom
smoking in, 354 substance abuse treatment hotline, 384
United Nations Chemical Weapons Convention, 41
United Nations Office on Drugs and Crime (UNODC), 26
United States alcohol consumption pattern, 305–6 Anti-Doping Agency/Olympic Sports, 266 domestic marijuana cultivation, 36 drug use, prevalence rates of, 15–17 federal drug control budget, 122 flow of cocaine into, 34–5 flow of heroin into, 32 opium in, 159–60 substance abuse treatment hotline, 384 tobacoo and alcohol, death, 15 tobacco use, 338, 353
University of Michigan survey, 37 of 1986, 212 of 1992, 243 of 2013, 199, 242, 281, 288, 262, 308, 349
University of Virginia, 312 UNODC. See United Nations Office on Drugs
and Crime Untouchables, Ness and, 54 Urinary excretion of drugs, 70 Urine tests, 266–7
of arrestees, 106 drug screening, 268 pinpointing time of drug use and, 269–70 THC levels, 24
USA PATRIOT Act of 2001, 61 U.S. Centers for Disease Control and
Prevention, 341 US. Certification, 124, 124 U.S. Constitution Eighteenth Amendment,
53, 59 Fourth Amendment of, 271 Twenty-first Amendment, 54, 59
U.S. Department of Agriculture, 315 U.S. Department of Health and Human
Services, 315 U.S. Department of Justice, 112, 245 U.S. Department of Treasury, 117 U.S. paper currency, cocaine contamination
in, 190 U.S. Supreme Court
for feiture, 133 Harrison Act, 161 mandatory sentencing, 146 Marijuana Tax Act, 232–3 United States v. Sokolow, 127
Valium (diazepam), 282–3, 284 toxicity, 11 withdrawal, 283
Values clarification, 370 Vaporous inhalation, 70 Vasoconstriction, 186 Vaso XP Xtreme Vasodilator, 264 Verne, Jules, 183 Veronal, 279 Versed (midazolam), 282 Veterans Treatment Court, 148 Veterinary facilities, 37 Vicodin (hydrocodone), 15, 172, 173
use by young adults, 17
Tobacco smoke. See Smoke, tobacco Tolerance, 72–5, 72
to alcohol, 321–2 to barbiturates, 280 behavioral, 72–73 to benzodiazepines, 283 chronic heroin abuse and, 166 to chronic inhalant abuse, 289 to cocaine, 186 conditioned, 72–3, 166 cross-tolerance, 75, 284 to LSD and other hallucinogens, 215 to marijuana, 236–7 to nicotine, 344 reverse, 237
Toluene, 286, 288 “Tootsie Roll” (heroin), 32 Toxicity, 8, 8–11
acute, 9, 15 of alcohol, 303 chronic, 15 cocaethylene, 183 DAWN reports and, 13–15 of drug interactions, 71, 72 drug-related deaths, 14 ergot, 208 of heroin, 166–7 judging from drug-related deaths, 13–4 of LSD, 211 of MDMA, 218
Trafficking. See Drug trafficking Tramadol, 172 Tranquilizers, 87. See also Antianxiety drugs Transdermal patch, 69, 172, 356 Transnational Narcoterrorism, 41 Tranxene (chlorazepate), 282 Treasury Department, 51, 52, 56 Treatment, 57, 379–402
for alcoholism, 326–8 for cocaine abuse, 189–91 for heroin abuse, 169–71 conditioned cues, 90 drug-taking behavior, 79–80 under legalization, 150–1 methadone maintenance program, 57,
169–70 for methamphetamine abuse, 197 for narcotic abuse, 169–71 needing versus receiving, 383–4 recovery process, challenges of, 382–3 stages of change, 382–3 in workplace, 59
Trends, DAWN statistics on, 13 Treviño, Miguel Ángel, 40 Trexan. See ReVia (naltrexone) Triazolam, 282 Tribal Healing to Wellness Court, 148 Trichloroethane, 286 Trichloroethylene, 286 Triorthocresyl phosphate (TCP), 288 “Truth serum,” depressants as, 280 Tuinal (secobarbital and amobarbital), 279, 281 Tumors, liver, 260 Turkey
heroin from, 56, 162 tobacco smoking, 337
“Tweaking,” 194 Twelve Steps, 327 Twenty-first Amendment, 54, 59 2,5,-Dimethoxy-4-methylamphetamine (DOM or
STP), 207, 217 Tylenol (acetaminophen), 173, 310
Über Coca (Freud), 185 Ukraine, smoking in, 354
Index ■ 407
social bonds and, 93 stress, boredom, and spending money and,
376–7 Youth Risk Behavior Surveillance (YRBS)
program, 106 YRBS. See Youth Risk Behavior Surveillance
program
Zinberg, Norman E., 168 Zofran (ondansetron), 327 Zohydro ER (hydrocodone), 172 Zoloft (sertraline), 285 Zolpidem, 284, 284 Zyban, 356
Xanax (alprazolam), 282 Xenadrine-NRG, 264 XTC. See Ecstasy (MDMA) Xylocaine (lidocaine), 186
Yakuza, Japanese, 34 Yesalis, Charles E., 271 Youth, drug use among
alcohol, 365 anomie/strain theory of, 92 inhalants, 288–9, 289, 290 marijuana, 55, 97, 239, 242 smoking and tobacco, 3, 342,
348–9, 365
smoking and, 338, 347–8 steroid use by, 258–9, 263
Women for Sobriety (WFS), 328 Women’s Christian Temperance Union
(WCTU), 53 Workplace
alcoholism in, 308 prevention and treatment in, 56, 270–1
Workplace, alcohol consumption in, 308 World Anti-Doping Agency (WADA), 257, 267 World Bank, 124 World Health Organization, 353–4 World War II, soldiers’ use of amphetamines
during, 193
This page intentionally left blank
This page intentionally left blank
This page intentionally left blank
This page intentionally left blank
This page intentionally left blank
- Cover
- Title Page����������������������������������������������
- Copyright Page����������������������������������������������������������
- Brief Contents����������������������������������������������������������
- Contents����������������������������������������
- Preface�������������������������������������
- PART ONE The Challenge of Drugs in Our Society
- CHAPTER 1 Understanding the Drug Problem in America
- Numbers Talk����������������������������������������������������
- Social Messages About Drug Use����������������������������������������������������������������������������������������������������������
- Two Ways Of Looking At Drugs And Society����������������������������������������������������������������������������������������������������������������������������������������
- A Matter Of Definition: What Is A Drug?�������������������������������������������������������������������������������������������������������������������������������������
- Instrumental Drug Use/ Recreational Drug Use����������������������������������������������������������������������������������������������������������������������������������������������������
- DRUGS … IN FOCUS : Understanding Drug Names
- Drug Misuse Or Drug Abuse?����������������������������������������������������������������������������������������������
- PORTRAIT : From Oxy To Heroin: The Life And Death Of Erik
- The Problem Of Drug Toxicity����������������������������������������������������������������������������������������������������
- DRUGS . . . IN FOCUS : Acute Toxicity In The News: Drug-related Deaths
- QUICK CONCEPT CHECK 1.1: Understanding Margins Of Safety
- The Dawn Reports����������������������������������������������������������������
- Emergencies Related To Illicit Drugs����������������������������������������������������������������������������������������������������������������������������
- Drug-related Deaths�������������������������������������������������������������������������
- Judging Drug Toxicity From Drug-related Deaths����������������������������������������������������������������������������������������������������������������������������������������������������������
- Demographics And Trends�������������������������������������������������������������������������������������
- Multiplying The Problem Of Drug Toxicity: How Many Drug Users?����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
- Prevalence Rates Of Drug Use In The United States�������������������������������������������������������������������������������������������������������������������������������������������������������������������
- Illicit Drug Use Among High School Seniors����������������������������������������������������������������������������������������������������������������������������������������������
- Illicit Drug Use Among Eighth Graders And Tenth Graders�������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
- Illicit Drug Use Among College Students�������������������������������������������������������������������������������������������������������������������������������������
- Alcohol Use Among High School And College Students����������������������������������������������������������������������������������������������������������������������������������������������������������������������
- Tobacco Use Among High School And College Students����������������������������������������������������������������������������������������������������������������������������������������������������������������������
- Drugs Among Youth In A Diverse Society����������������������������������������������������������������������������������������������������������������������������������
- Drug Use And Perceived Risk�������������������������������������������������������������������������������������������������
- Illicit Drug Use Among Adults Aged 26 And Older�������������������������������������������������������������������������������������������������������������������������������������������������������������
- QUICK CONCEPT CHECK 1.2: Understanding Prevalence Rates of Drug Use in the United States
- Continuing Challenges�������������������������������������������������������������������������������
- DRUG ENFORCEMENT . . . IN FOCUS : Dealing with High-Tech Drug Dealing: Policing the “Dark Web”
- Looking Ahead�������������������������������������������������������
- Summary
- Key Terms
- Review Questions
- Critical Thinking: What Would You Do?
- Endnotes
- CHAPTER 2 Understanding the Drug Problem in Global Perspective
- Numbers Talk
- Worldwide Prevalence Rates Of Illicit Drug Use����������������������������������������������������������������������������������������������������������������������������������������������������������
- European Prevalence Rates For Illicit Drugs, Alcohol, And Tobacco�������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
- The Global Problem Of New Psychoactive Drugs����������������������������������������������������������������������������������������������������������������������������������������������������
- QUICK CONCEPT CHECK 2.1: Understanding Prevalence Rates of Drug Use in America and Elsewhere
- The Global Problem Of Drug Trafficking����������������������������������������������������������������������������������������������������������������������������������
- The Trafficking Of Heroin�������������������������������������������������������������������������������������������
- Heroin, Turkey, And The “french Connection”�������������������������������������������������������������������������������������������������������������������������������������������������
- The Golden Triangle And The Golden Crescent�������������������������������������������������������������������������������������������������������������������������������������������������
- Heroin Trafficking in Mexico and Colombia
- The Trafficking Of Cocaine����������������������������������������������������������������������������������������������
- PORTRAIT: Pablo Escobar: The Violent Life of the King of Cocaine
- The Trafficking Of Marijuana: Foreign And Domestic����������������������������������������������������������������������������������������������������������������������������������������������������������������������
- DRUG ENFORCEMENT . . . IN FOCUS : Massive Cross-Border Drug Tunnel Detected (Again)
- The Trafficking Of Methamphetamine: Foreign And Domestic����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
- The Trafficking Of Lsd, Pcp, And Ketamine�������������������������������������������������������������������������������������������������������������������������������������������
- Drug Trafficking As A Moving Target�������������������������������������������������������������������������������������������������������������������������
- Drug Trafficking/violence: The Mexican Connection�������������������������������������������������������������������������������������������������������������������������������������������������������������������
- QUICK CONCEPT CHECK 2.2: Understanding Global Drug Trafficking
- Drugs And Narcoterrorism����������������������������������������������������������������������������������������
- Narcoterrorism In Afghanistan And Colombia����������������������������������������������������������������������������������������������������������������������������������������������
- DRUGS . . . IN FOCUS : Life and Death in Mexico: Don Garza Tamez and a Man Called Z-40
- Transnational Narcoterrorism����������������������������������������������������������������������������������������������������
- DRUGS . . . IN FOCUS : Sarin and Chemical Warfare: Neurotoxicity on the Battlefield
- Looking Ahead�������������������������������������������������������
- Summary
- Key Terms
- Review Questions
- Critical Thinking: What Would You Do?
- Endnotes
- CHAPTER 3 The History of Drug Use and Drug-Control Policy
- Numbers Talk
- Drugs In Early Times����������������������������������������������������������������������������
- Drugs In The Nineteenth Century�������������������������������������������������������������������������������������������������������������
- DRUGS . . . IN FOCUS : Abraham Lincoln, Depression, and Those “Little Blue Pills”
- Drug Regulation In The Early Twentieth Century����������������������������������������������������������������������������������������������������������������������������������������������������������
- QUICK CONCEPT CHECk 3.1: Understanding the Early History of Drugs and Drug-Taking Behavior
- Drug Regulation, 1914–1938����������������������������������������������������������������������������������������������
- The Harrison Act of 1914
- Alcohol in America before Prohibition
- The Rise of the Temperance Movement
- The Road to National Prohibition
- The Beginning and Ending of a “Noble Experiment”
- PORTRAIT: Eliot Ness and the Untouchables
- Marijuana and the Marijuana Tax Act of 1937
- The Federal Food, Drug, and Cosmetic Act of 1938
- Drugs and Society from 1945 to 1960
- Turbulence, Treatment, and the War on Drugs, 1960–1980
- DRUG ENFORCEMENTt . . . IN FOCUS : The Drug Enforcement Administration Today
- Renewed Efforts at Control, 1980–2000
- DRUGS . . . IN FOCUS : A History of American Drug- Control Legislation
- Global Politics and National Security: 2001–Present
- QUICK CONCEPT CHECK 3.2: Understanding the History of U.S. Drug-Control Legislation
- Domestic Drug Trafficking and National Security: 2001–Present
- The Aims of Drug-Control Policy: Public Health and Public Safety
- Drug-control Policy Today: Five Schedules of Controlled Substances
- Summary
- Key Terms
- Review Questions
- Critical Thinking: What Would You Do?
- Endnotes
- CHAPTER 4 Fundamentals of Drug-Taking Behavior
- Numbers Talk…
- How Drugs Enter the Body
- Oral Administration�������������������������������������������������������������������������
- Injection�������������������������������������������
- Inhalation����������������������������������������������
- Absorption through the Skin or Membranes
- DRUGS . . . IN FOCUS : Ways to Take Drugs: Routes of Administration
- How Drugs Exit the Body
- Factors Determining the Behavioral Impact of Drugs
- Timing����������������������������������
- Drug Interactions�������������������������������������������������������������������
- Tolerance Effects�������������������������������������������������������������������
- HELP Line : The Possibility of a Drug-Drug or Food-Drug Combination Effect
- QUICK CONCEPT CHECK 4.1: Understanding Drug Interactions
- PORTRAIT: Mithridates VI of Pontus: Drug Tolerance and the Story of the Poison King
- DRUGS . . . IN FOCUS : Conditioned Tolerance in Alcoholic Beverages: The Four-Loko Effect
- Cross-tolerance�������������������������������������������������������������
- Individual Differences����������������������������������������������������������������������������������
- Psychological Factors in Drug-Taking Behavior
- Expectation Effects�������������������������������������������������������������������������
- Drug Research Methodology�������������������������������������������������������������������������������������������
- Physical and Psychological Dependence
- Physical Dependence�������������������������������������������������������������������������
- Psychological Dependence����������������������������������������������������������������������������������������
- Drug-Taking Behavior and Treatment: The Health Professional Perspective
- Summary
- Key Terms
- Review Questions
- Critical Thinking: What Would You Do?
- Endnotes
- CHAPTER 1 Understanding the Drug Problem in America
- PART TWO Drugs, Crime, and Criminal Justice
- CHAPTER 5 Theoretical Perspectives on Drug Use and Abuse
- Numbers Talk…
- Biological Perspectives on Drug Abuse
- Genetic Factors�������������������������������������������������������������
- Physiological Factors�������������������������������������������������������������������������������
- Neurochemical Systems in the Brain
- DRUGS . . . IN FOCUS : Understanding the Biochemistry of Psychoactive Drugs
- PORTRAIT: Dr Nora D. Volkow—Imaging the Face of Addiction in the Brain
- Psychological Perspectives on Drug Abuse
- Psychoanalytic Theories�������������������������������������������������������������������������������������
- Nonpsychoanalytic Personality Theories����������������������������������������������������������������������������������������������������������������������������������
- Behavioral Theories�������������������������������������������������������������������������
- Sociological Perspectives on Drug Abuse
- QUICK CONCEPT CHECK 5.1: Understanding Biological and Psychological Perspectives on Drug Use and Abuse
- Anomie/Strain Theory
- Social Control/Bonding Theory
- Differential Association Theory�������������������������������������������������������������������������������������������������������������
- Subcultural Recruitment And Socialization Theory����������������������������������������������������������������������������������������������������������������������������������������������������������������
- DRUGS . . . IN FOCUS : The Private Language of a Drug Subculture
- Labeling Theory�������������������������������������������������������������
- Integrating Theoretical Perspectives on Drug Abuse
- Risk Factors And Protective Factors�������������������������������������������������������������������������������������������������������������������������
- QUICK CONCEPT CHECK 5.2: Understanding Sociological Perspectives on Drug Use and Abuse
- Specific Risk Factors�������������������������������������������������������������������������������
- Specific Protective Factors�������������������������������������������������������������������������������������������������
- DRUG ENFORCEMENT . . . IN FOCUS : Harm Reduction: A Strategy for Controlling Undesirable Behavior
- Summary
- Key Terms
- Review Questions
- Critical Thinking: What Would You Do?
- Endnotes
- CHAPTER 6 Drugs and Crime
- Numbers Talk…
- Defining the Terms
- Perspectives on Drug Use and Crime
- Collecting the Statistics on Drugs and Crime
- Drugs and Delinquency
- Drugs and Adult Crime
- What the Statistics Tell Us and What They Do Not
- Regarding Psychopharmacological Crime�������������������������������������������������������������������������������������������������������������������������������
- DRUGS . . . IN FOCUS : From HeroinGen and CrackGen to BluntGen: The Rise and Fall of Drugs and Violence
- Regarding Economically Compulsive Crime�������������������������������������������������������������������������������������������������������������������������������������
- PORTRAIT: David Laffer—Pharmacy Robber and Killer of Four
- Regarding Systemic Crime����������������������������������������������������������������������������������������
- The Three Fundamental Questions about Drugs and Crime
- Does Drug Use Cause Crime?����������������������������������������������������������������������������������������������
- Does Crime Cause Drug Use?����������������������������������������������������������������������������������������������
- Do Drug Use And Crime Share Common Causes?����������������������������������������������������������������������������������������������������������������������������������������������
- Social Structures in Illicit Drug Trafficking
- QUICK CONCEPT CHECK 6.1: Understanding the Drug–Crime Connection
- Gangs and Drug-Related Crime
- Outlaw Motorcycle Gangs�������������������������������������������������������������������������������������
- Street Gangs����������������������������������������������������
- QUICK CONCEPT CHECk 6.2: Understanding Gangs and Social Structures in Illicit Drug Trafficking
- Money Laundering in Drug-Related Crime
- DRUG ENFORCEMENT . . . IN FOCUS : The New Money Laundering: Digital Currency Exchanges
- Summary
- Key Terms
- Review Questions
- Critical Thinking: What Would You Do?
- Endnotes
- CHAPTER 7 Drugs and Law Enforcement
- Numbers Talk…
- Source Control����������������������������������������������������������
- Crop Eradication����������������������������������������������������������������
- Chemical Controls�������������������������������������������������������������������
- U.S. Certification
- Drug Interdiction�������������������������������������������������������������������
- Federal Agencies Involved in Drug Interdiction
- Military Operations and Domestic Law Enforcement
- QUICK CONCEPT CHECK 7.1: Understanding Law Enforcement Agencies in Drug Control
- Profiling and Drug-Law Enforcement
- Street-Level Drug-Law Enforcement
- Undercover Operations in Drug Enforcement
- DRUG ENFORCEMENT . . . IN FOCUS : Updating Police Behavior During Traffic and Street Stops
- DRUG ENFORCEMENT . . . IN FOCUS : The Anatomy of a Reverse Sting Operation
- Undercover Operations and the Issue of Entrapment
- PORTRAIT: Commissioner William J. Bratton— New York’s Top Cop Second Time Around
- A Nonundercover Operation: Knock and Talk
- QUICK CONCEPT CHECK 7.2: Understanding Drug-Law Enforcement Operations
- Asset Forfeiture and the RICO Statute
- Summary
- Key Terms
- Review Questions
- Critical Thinking: What Would You Do?
- Endnotes
- CHAPTER 8 Drugs, Courts, and Correctional Systems
- Numbers Talk…
- Drug-law Violators in the Criminal Justice System
- Criminal Penalties for Drug-law Offenses
- Federal Penalties for Drug Trafficking
- Federal Penalties for Simple Possession of Controlled Substances
- Felonies, Misdemeanors, and State Drug Laws
- Drug Paraphernalia����������������������������������������������������������������������
- Rethinking Drug-law Penalties: 1970s–Present
- QUICK CONCEPT CHECK 8.1: Understanding the Criminal Justice System
- The Issue of Mandatory Minimum Sentencing
- DRUG ENFORCEMENT . . . IN FOCUS : Penalties for Crack versus Penalties for Cocaine: Correcting an Injustice
- The Advent of Drug Courts
- PORTRAIT: State Senator John R. Dunne—Drug Warrior/Drug-War Reformer
- DRUG ENFORCEMENY . . . IN FOCUS : Specialty Courts in Today’s Criminal Justice System
- Correctional Systems����������������������������������������������������������������������������
- DRUGS . . . IN FOCUS : A Simulated Debate: Should We Legalize Drugs?
- Prison-based Treatment Programs�������������������������������������������������������������������������������������������������������������
- QUICK CONCEPT CHECK 8.2: Understanding Problem-Solving Courts
- Summary
- Key Terms
- Review Questions
- Critical Thinking: What Would You Do?
- Endnotes
- CHAPTER 5 Theoretical Perspectives on Drug Use and Abuse
- PART THREE Legally Restricted Drugs and Criminal Justice
- CHAPTER 9 Opioids: Heroin and Prescription Pain Medications
- Numbers Talk…
- DRUGS . . . IN FOCUS : Two Small Towns Contending with the Heroin Epidemic
- What are Opioids?
- Opioids in History
- The Opium War�������������������������������������������������������
- Opium in Britain and the United States
- Morphine and the Advent Of Heroin
- Opioids in American Society
- Opioid Use and Heroin Abuse after 1914
- Heroin Abuse in the 1960s and 1970s
- Heroin since the 1980s
- QUICK CONCEPT CHECK 9.1: Understanding the History of Opium and Opioids
- Effects on the Mind and the Body
- How Opioids Work in the Brain
- Patterns of Heroin Abuse
- Tolerance and Withdrawal Symptoms
- The Lethality of Heroin Abuse
- DRUGS . . . IN FOCUS : The Heroin Surge and Narcan for First Responders
- QUICK CONCEPT CHECK 9.2: Understanding the Effects of Administering and Withdrawing Heroin
- Heroin Abuse and Society
- Treatments for Heroin Abuse
- Heroin Detoxification�������������������������������������������������������������������������������
- Methadone Maintenance�������������������������������������������������������������������������������
- Alternative Maintenance Programs����������������������������������������������������������������������������������������������������������������
- Behavioral and Social-Community Programs
- HELP LINE: Buprenorphine: The Bright/Dark Side of Heroin-Abuse Treatment
- The Reality of Opioid Abuse Treatment and Recovery
- Medical Uses of Opioid Drugs
- Beneficial Effects����������������������������������������������������������������������
- Prescription Opioid Medication Side Effects�������������������������������������������������������������������������������������������������������������������������������������������������
- Prescription Opioid Medication Abuse����������������������������������������������������������������������������������������������������������������������������
- Patterns of Oxycontin Abuse
- Prescription Opioid Medication Abuse, Overdose, and Drug Diversion
- PORTRAIT : Billy Thomas and Ricky Franklin—The Two Sides of OxyContin
- Abuse of Other Opioid Pain Medications
- DRUG ENFORCEMENT . . . IN FOCUS : National Prescription Drug Take-Back Day and Rogue Pharmacies
- Responses To Prescription Opioid Medication Abuse�������������������������������������������������������������������������������������������������������������������������������������������������������������������
- Summary
- Key Terms
- Review Questions
- Critical Thinking: What Would You Do?
- Endnotes
- CHAPTER 10 Cocaine and Methamphetamine
- Numbers Talk…
- The History of Cocaine
- Coca and Cocaine in Nineteenth-Century Life
- Commercial Uses of Coca
- HELP LINE: Cocaine after Alcohol: The Risk of Cocaethylene Toxicity
- Freud and Cocaine
- DRUGS . . . IN FOCUS : What Happened to the Coca in Coca-Cola?
- Acute Effects o f Cocaine
- QUICK CONCEPT CHECK 10.1: Understanding the History of Cocaine
- Chronic Effects of Cocaine
- Medical Uses of Cocaine
- How Cocaine Works in the Brain
- Present-Day Cocaine Abuse
- From Coca to Cocaine
- From Cocaine to Crack
- Patterns of Cocaine Abuse
- Treatment for Cocaine Abuse
- DRUGS . . . IN FOCUS : Cocaine Contamination in U.S. Paper Currency
- PORTRAIT: Robert Downey, Jr.—Cleaned Up After Cocaine
- DRUG ENFORCEMENT . . . IN FOCUS : Comparison Shopping Inside the Global Cocaine Black Market
- Amphetamines����������������������������������������������������
- The History of Amphetamines
- The Different Forms of Amphetamine
- Acute Effects of Amphetamines
- Chronic Effects of Amphetamines
- How Amphetamines Work in the Brain
- Methamphetamine�������������������������������������������������������������
- Methamphetamine in the Heartland of America
- Present-Day Methamphetamine Abuse
- DRUG ENFORCEMENT . . . IN FOCUS : North Korea: A New Player in Methamphetamine Trafficking
- Patterns Of Methamphetamine Abuse�������������������������������������������������������������������������������������������������������������������
- QUICK CONCEPT CHECK 10.2: Understanding Patterns of Stimulant Drug Abuse
- Treatment for Methamphetamine Abuse
- Cathinone as a New Form of Stimulant Abuse
- Amphetamines and Other Stimulants as Medications
- Stimulant Medications for Adhd
- Other Medical Applications����������������������������������������������������������������������������������������������
- Ritalin a nd Adderall Abuse
- Stimulant Medications as Cognitive Enhancers
- Summary
- Key Terms
- Review Questions
- Critical Thinking: What Would You Do?
- Endnotes
- CHAPTER 11 LSD and Other Hallucinogens
- Numbers Talk…
- A Matter of Definition
- Categories of Hallucinogens
- Lysergic Acid Diethylamide����������������������������������������������������������������������������������������������
- The Beginning of the Psychedelic Era
- DRUGS . . . IN FOCUS : Strange Days in Salem: Witchcraft or Hallucinogens?
- PORTRAIT : Timothy Leary: Mr. LSD and the Psychedelic Era
- Acute Effects of LSD
- Effects of LSD on The Brain
- Patterns of LSD Use
- Facts and Fictions about LSD
- Will LSD Produce Substance Dependence?
- Will LSD Produce a Panic Attack or Psychotic Behavior?
- HELP LINE: Emergency guidelines for a bad Trip on LSD
- Will LSD Increase Your Creativity?
- Will LSD Damage Your Chromosomes?
- Will LSD Have Residual (Flashback) Effects?
- Will LSD Increase Criminal or Violent Behavior?
- Psilocybin and Other Hallucinogens Related to Serotonin
- Lysergic Acid Amide (LAA)
- Dimethyltryptamine (DMT)
- Harmine�������������������������������������
- DRUGS . . . IN FOCUS : Bufotenine and the Bufo Toad
- Hallucinogens Related to Norepinephrine
- Mescaline�������������������������������������������
- DRUGS . . . IN FOCUS : Present-Day Peyotism and the Native American Church
- Dom�������������������������
- MDMA (Ecstasy)
- HELP LINE : An Examination of MDMA Toxicity
- DRUG ENFORCEMENT . . . IN FOCUS : Who (or What) Is Molly?
- Hallucinogens Related to Acetylcholine
- Amanita Muscaria����������������������������������������������������������������
- The Hexing Drugs a nd Witchcraft
- QUICk CONCEPT CHECK 11.1: Understanding the Diversity of Hallucinogens
- Miscellaneous Hallucinogens�������������������������������������������������������������������������������������������������
- Phencyclidine�������������������������������������������������������
- QUICK CONCEPT CHECK 11.2: Understanding PCP
- Patterns of PCP Abuse
- Ketamine����������������������������������������
- Salvia Divinorum����������������������������������������������������������������
- Summary
- Key Terms
- Review Questions
- Critical Thinking: What Would You Do?
- Endnotes
- CHAPTER 12 Marijuana
- Numbers Talk…
- A Matter of Terminology
- DRUGS . . . IN FOCUS : Growing Hemp in America: Coming Full Circle
- The History of Marijuana and Hashish
- Hashish in the Nineteenth Century
- Marijuana and Hashish in the Twentieth Century
- The Anti-marijuana Crusade����������������������������������������������������������������������������������������������
- PORTRAIT: Commissioner Harry J. Anslinger—From Devil Rum to Devil Weed
- Challenging Old Ideas about Marijuana
- Acute Effects of Marijuana
- Acute Physiological Effects�������������������������������������������������������������������������������������������������
- Acute Psychological and Behavioral Effects
- QUICK CONCEPT CHECK 12.1: Understanding the Effects of Marijuana
- Cannabinoids and Endocannabinoids
- DRUGS . . . IN FOCUS : The Neurochemical “Yin and Yang” of Cannabis
- Chronic Effects of Marijuana
- Tolerance�������������������������������������������
- Withdrawal and Dependence
- Cardiovascular Effects����������������������������������������������������������������������������������
- Risks of Lung Cancer
- Respiratory Effects�������������������������������������������������������������������������
- Effects on the Immune System
- Effects on Sexual Functioning and Reproduction
- Long-Term Cognitive Effects and the Amotivational Syndrome
- Examining the Gateway Hypothesis
- The Sequencing Question�������������������������������������������������������������������������������������
- The Association Question����������������������������������������������������������������������������������������
- The Causation Question����������������������������������������������������������������������������������
- QUICK CONCEPT CHECK 12.2: Understanding the Adverse Effects of Chronic Marijuana Abuse
- Patterns of Marijuana Smoking
- Current Trends in Marijuana Smoking
- HELP LINE: Spice and other Designer Synthetic Cannabinoids
- Medical Marijuana�������������������������������������������������������������������
- Treating Muscle Spasticity and Chronic Pain
- Treating Nausea and Weight Loss
- The Evolving Status of Medical Marijuana Laws
- Medical Marijuana Today�������������������������������������������������������������������������������������
- Medical Marijuana: Federal versus State Drug Enforcement
- Medical Cannabinoids����������������������������������������������������������������������������
- Decriminalization and Legalization
- Decriminalization by State Referendum
- Legalization by State Referendum
- DRUG ENFORCEMENT . . . IN FOCUS : Local Communities in Washington State Just Say No
- Public Sentiment For A Liberalization of Marijuana Laws
- The Ramifications of Decriminalization and Legalization
- Summary
- Key Terms
- Review Questions
- Critical Thinking: What Would You Do?
- Endnotes
- CHAPTER 13 Performanceenhancing Drugs and Drug Screening Tests
- Numbers Talk…
- Performance-Enhancing Drugs in Sports
- What Are Anabolic Steroids?�������������������������������������������������������������������������������������������������
- Anabolic Steroids at the Modern Olympic Games
- PORTRAIT: Lance Armstrong—From Honor to Dishonor
- Anabolic Steroids in Professional and Collegiate Sports
- Performance-Enhancing Drug Abuse and Baseball
- The Hazards of Anabolic Steroids
- DRUG ENFORCEMENT . . . IN FOCUS : Suspension Penalties for Performance-Enhancing Drug Use in Sports
- Effects on Hormonal Systems
- Effects on Other Systems of the Body
- Psychological Problems����������������������������������������������������������������������������������
- Special Problems for Adolescents
- QUICK CONCEPT CHECK 13.1: Understanding the Effects of Anabolic Steroids
- Patterns of Anabolic Steroid Abuse
- The Potential for Steroid Dependence
- HELP LINE: The Symptoms of Steroid Abuse
- Counterfeit Steroids and the Placebo Effect
- Nonsteroid Hormones and Performance-Enhancing Supplements
- Human Growth Hormone����������������������������������������������������������������������������
- Dietary Supplements as Performance-Enhancing Aids
- Nonmedical Use of Stimulant Medication in Baseball
- Current Drug-testing Procedures and Policies
- DRUGS . . . IN FOCUS : ADHD/ADD Exemption Requirements for the Use of Adderall in Sports
- The Forensics of Drug Testing
- DRUG ENFORCEMENT . . . IN FOCUS : Pharmaceutical Companies and Anti-Doping Authorities in Alliance
- Sensitivity and Specificity in Drug Testing
- DRUGS . . . IN FOCUS : Typical Urine Specimen Drug Screening Tests
- Masking Drugs and Chemical Manipulations
- Pinpointing the Time of Drug Use
- QUICK CONCEPT CHECK 13.2: Understanding Drug Testing
- Drug Screening Testing in the Workplace
- The Social Context of Performance-Enhancing Drugs
- Summary
- Key Terms
- Review Questions
- Critical Thinking: What Would You Do?
- Endnotes
- CHAPTER 14 Depressants and Inhalants
- Numbers Talk…
- Barbiturates����������������������������������������������������
- Categories of Barbiturates
- Acute Effects of Barbiturates
- DRUG ENFORCEMENT . . . IN FOCUS : Is There Any Truth Regarding “Truth Serum”?
- Chronic Effects of Barbiturates
- Barbiturate Use and Abuse
- Nonbarbiturate Sedative-hypnotics�������������������������������������������������������������������������������������������������������������������
- The Development of Anxiolytic Drugs
- Benzodiazepines�������������������������������������������������������������
- Medical Uses of Benzodiazepines
- Acute Effects of Benzodiazepines
- Chronic Effects of Benzodiazepines
- Nonbenzodiazepine Medications�������������������������������������������������������������������������������������������������������
- Zolpidem and Eszopiclone
- Buspirone�������������������������������������������
- Beta Blockers�������������������������������������������������������
- Antidepressants�������������������������������������������������������������
- QUICK CONCEPT CHECK 14.1: Understanding the Abuse Potential in Drugs
- Inhalants through History
- Nitrous Oxide�������������������������������������������������������
- Ether�������������������������������
- Glue, Solvent, and Aerosol Inhalation
- Acute Effects of Glues, Solvents, and Aerosols
- HELP LINE: The signs of Possible Inhalant Abuse
- Patterns of Inhalant Abuse
- DRUGS . . . IN FOCUS : Resistol and Resistoleros in Latin America
- Dependence Potential of Chronic Inhalant Abuse
- Responses of Society to Inhalant Abuse
- Amyl Nitrite and Butyl Nitrite
- Depressants and Drug-facilitated Sexual Assault
- QUICk CONCEPT CHECK 14.2: Understanding the History of Inhalants
- The Scope of the Problem
- PORTRAIT: Patricia White—GHB and Drug- Facilitated Sexual Assault
- Involvement of Drugs Other Than Alcohol
- DRUGS . . . IN FOCUS : Rohypnol and Sexual Assaults
- Efforts to Reduce Drug-facilitated Sexual Assaults
- HELP LINE: Drug-facilitated Sexual Assault: Protective Strategies
- Summary
- Key Terms
- Review Questions
- Critical Thinking: What Would You Do?
- Endnotes
- CHAPTER 9 Opioids: Heroin and Prescription Pain Medications
- PART FOUR On the Marginsof Criminal Justice: Regulating Legal Drugs
- CHAPTER 15 Alcohol Use and Chronic Alcohol Abuse
- Numbers Talk…
- The Making of an Alcoholic Beverage
- Processing of Alcohol in the Body
- The Breakdown and Elimination of Alcohol
- Alcohol on the Brain
- Measuring Alcohol Levels in the Blood
- Measuring Alcohol Consumption
- DRUGS . . . IN FOCUS : Multiple Ways of Getting a Standard Drink
- DRUGS . . . IN FOCUS : Visualizing the Pattern of Alcohol Consumption in the United States
- Patterns of Alcohol Consumption
- QUICK CONCEPT CHECK 15.1: Understanding Alcoholic Beverages
- Alcohol Consumption among College Students
- Alcohol Consumption among Underage Drinkers
- Alcohol Consumption in the Workplace
- Acute Physiological Effects of Alcohol
- Toxic Reactions
- HELP LINE: Emergency Signs and Procedures in Acute Alcohol Intoxication
- Heat Loss and the Saint Bernard Myth
- Diuretic Effects
- Effects on Sleep
- Effects on Pregnancy
- Interactions with Other Drugs
- Hangovers
- Acute Behavioral Effects of Alcohol
- Blackouts
- Driving Skills
- Violence and Aggression
- DRUG ENFORCEMENT . . . IN FOCUS : Alcohol, Security, and Spectator Sports
- Sex and Sexual Desire
- Strategies for Regulating Alcohol Consumption
- Present-Day Alcohol Regulation by Restricted Access
- Present-Day Alcohol Regulation by Taxation
- Regulations to Reduce Alcohol-Related Traffic Fatalities
- PORTRAIT: Candace Lightner—Founder of MADD
- Regulations Based on Ignition Interlock Technology
- On the Other Hand: Alcohol and Health Benefits
- HELP LINE: Guidelines for responsible Drinking
- Chronic Alcohol Abuse and Alcoholism
- Alcoholism: Stereotypes, Definitions, and Criteria
- Problems Associated with a Preoccupation with Drinking
- Emotional Problems
- Vocational, Social, and Family Problems
- Physical Problems
- The Interpersonal Dynamics of Alcoholism
- QUICK CONCEPT CHECK 15.2: Understanding the Psychology of Alcoholism
- Alcohol Use Disorder: The Health Care Professional’s View
- DRUGS . . . IN FOCUS : Behavioral Criteria for Alcohol Use Disorder
- Patterns of Chronic Alcohol Abuse
- Physiological Effects of Chronic Alcohol Use
- Tolerance and Withdrawal
- Liver Disease
- Cardiovascular Problems
- Cancer
- Dementia and Wernicke-KorsakoffSyndrome
- Fetal Alcohol Syndrome (FAS)
- The Family Dynamics of Alcoholism
- Risk Factors for Developing Alcoholism
- Diagnosis, Treatment, and Legal Responsibility
- Treatment Options
- Biologically Based Treatments
- Alcoholics Anonymous
- SMART Recovery
- QUICK CONCEPT CHECK 15.3: Understanding Alcoholics Anonymous
- DRUGS . . . IN FOCUS : The Nondisease Model of Alcoholism
- Summary
- Key Terms
- Review Questions
- Critical Thinking: What Would You Do?
- Endnotes
- CHAPTER 16 Nicotine and Tobacco Use
- Numbers Talk…
- Tobacco Use through History
- Politics, Economics, and Tobacco
- Snuffing and Chewing
- Cigars and Cigarettes
- Tobacco in the Twentieth Century
- Health Concerns and Smoking Behavior
- DRUGS . . . IN FOCUS : African Americans, Smoking, and Mentholated Cigarettes
- The Legacy of the Surgeon General’s Reports, 1964–2014
- Changing Times: Tobacco Control since 1990
- The Tobacco Settlement of 1998
- The Tobacco Control Act of 2009
- Tobacco Control and Global Economics
- What’s in Tobacco?
- Carbon Monoxide�������������������������������������������������������������
- Tar�������������������������
- Nicotine����������������������������������������
- The Dependence Potential of Nicotine
- The Titration Hypothesis of Nicotine Dependence
- Tolerance and Withdrawal
- Health Consequences of Tobacco Use
- Cardiovascular Disease����������������������������������������������������������������������������������
- DRUGS . . . IN FOCUS : Visualizing 480,000 Annual Tobacco-Related Deaths
- Respiratory Diseases����������������������������������������������������������������������������
- Lung Cancer�������������������������������������������������
- Other Cancers�������������������������������������������������������
- HELP LINE: Signs of Trouble from Smokeless Tobacco
- Special Health Concerns for Women
- The Hazards of Environmental Smoke
- QUICK CONCEPT CHECK 16.1: Understanding the Effects of Tobacco Smoking
- Patterns of Smoking Behavior in the United States
- The Youngest Smokers����������������������������������������������������������������������������
- Attitudes toward Smoking among Young People
- Regulatory Policy and Strategies for Tobacco Control
- Regulation by Taxation
- Regulation by Reduced Access to Young People
- DRUG ENFORCEMENT . . . IN FOCUS : Reducing Youth Access to Tobacco—The Synar Amendment, 1992
- Regulation by Increased Awareness of Potential Harm
- Other Forms of Present-Day Nicotine Consumption
- Smokeless Tobacco�������������������������������������������������������������������
- Cigars: Big and Little
- PORTRAIT: Sigmund Freud—Nicotine Dependence, Cigars, and Cancer
- E-cigarettes and Nicotine Toxicity
- The Global Perspective: Tobacco Use around the World
- Tobacco Use in Other Countries
- QUICK CONCEPT CHECK 16.2: Present-Day Tobacco Control Policy and Strategies
- Quitting Smoking: The Good News and the Bad
- The Good News: Undoing the Damage
- The Bad News: How Hard It Is to Quit
- HELP LINE: Ten Tips on How to Succeed When Trying to Quit Smoking
- Medications for Smoking Cessation
- Nicotine Gums, Patches, Sprays, and Inhalers
- The Role of Physicians in Smoking Cessation
- A Final Word on Quitting
- Summary
- Key Terms
- Review Questions
- Critical Thinking: What Would You Do?
- Endnotes
- CHAPTER 15 Alcohol Use and Chronic Alcohol Abuse
- PART FIVE Drug-Control Policy and Intervention Strategies
- CHAPTER 17 Substance Abuse Prevention and Treatment
- Numbers Talk…
- Levels of Intervention in Substance Abuse Prevention
- DRUGS . . . IN FOCUS : National Drug-Control Policy and the War on Drugs
- QUICK CONCEPT CHECK 17.1: Understanding Levels of Intervention in Substance Abuse Prevention Programs
- Strategies for Substance Abuse Prevention
- Resilience and Primary Prevention Efforts
- Measuring Success in a Substance Abuse Prevention Program
- Substance Abuse Prevention in the Context of National Drug-Control Policy
- Substance Abuse Prevention and Public Health Policy
- DRUGS . . . IN FOCUS : The Public Health Model and the Analogy of Infectious Disease Control
- Prevention Approaches That Have Failed����������������������������������������������������������������������������������������������������������������������������������
- Reducing the Availability of Drugs
- Punitive Measures�������������������������������������������������������������������
- Scare Tactics and Negative
- Objective Information Approaches����������������������������������������������������������������������������������������������������������������
- Magic Bullets and Promotional Campaigns
- Self-Esteem Enhancement and Affective Education
- Components of Effective School-Based Prevention Programs
- Peer-Refusal Skills
- Anxiety and Stress Reduction
- Social Skills and Personal Decision Making
- An Example of An Effective School-Based Prevention Program
- Drug Abuse Resistance Education (DARE)
- Community-Based Prevention Programs
- QUICK CONCEPT CHECK 17.2: Understanding Substance Abuse Prevention Strategies
- Components of An Effective Community-Based Program
- Alternative-Behavior Programming
- The Impact of the Media
- An Example of An Effective Community-Based Prevention Program
- Family Systems in Primary and Secondary Prevention
- Special Role Models in Substance Abuse Prevention
- Parental Communication in Substance Abuse Prevention
- DRUG ENFORCEMENT . . . IN FOCUS : Testing for Drugs in the Home: Whom Can You Trust?
- The Triple Threat: Stress, Boredom, and Spending Money
- Substance Abuse Prevention and the College Student
- Changing the Culture of Alcohol in College
- Substance Abuse Prevention on College Campuses
- DRUGS . . . IN FOCUS : Alcohol 101 on College Campuses
- Prevention and Treatment in the Workplace
- The Economic Costs of Substance Abuse in the Workplace
- The Impact of Drug-Free Workplace Policies
- Multicultural Issues in Prevention and Treatment
- Latino Communities����������������������������������������������������������������������
- African American Communities����������������������������������������������������������������������������������������������������
- Native American Communities�������������������������������������������������������������������������������������������������
- Substance Abuse Treatment: The Journey to Recovery
- A Common Feature of Substance Abuse Treatment: Stages of Change
- DRUGS . . . IN FOCUS : Reviewing Specific Treatment Strategies for Six Substances of Abuse
- Stages of Change for Other Problems in Life
- The Challenges of the Recovery Process
- QUICK CONCEPT CHECK 17.3: Understanding the Stages of Change
- Needing Versus Receiving Substance Abuse Treatment����������������������������������������������������������������������������������������������������������������������������������������������������������������������
- For Those Who Need Help and Want to Get It
- PORTRAIT: Meeting the Challenge—The Long Island Council on Alcoholism and Drug Dependence
- Summary
- Key Terms
- Review Questions
- Critical Thinking: What Would You Do?
- Endnotes
- CHAPTER 17 Substance Abuse Prevention and Treatment
- Photo Credits
- Index
-
- 2019-04-24T23:31:28+0000
- Preflight Ticket Signature
NB: We do not resell papers. Upon ordering, we do an original paper exclusively for you.
Do you need a similar assignment done from scratch? We have qualified writers to help you. We assure you an A+ quality paper that is free from plagiarism. Order now for an Amazing Discount! Use Discount Code "save15" for a 15% Discount!
Request essay helpYou can trust us for this and even for your future projects
