Duncan, D. F., and Gold, R. S. Chapter 15: Primary Prevention of Drug Abuse.
In: Drugs and the Whole Person. New York, John Wiley & Sons, 1982.
Primary prevention refers to efforts to keep drug abuse from happening in the first place. It differs from secondary prevention, which is early treatment of drug abuse, and from tertiary prevention, which is the prevention of death or disability and the rehabilitation of the ex-abuser.
In dealing with any health problem, primarily prevention is always the preferable approach. It is more humane to prevent problems than to treat the suffering they cause, and it is usually much more economical. Regrettably, our society’s efforts at primary prevention of drug abuse have met with little success. This chapter will examine the failure of existing approaches and will suggest new directions that may be more effective.
THE FIVE MODELS OF DRUG ABUSE PREVENTION*
Although many approaches to drug abuse prevention have been tried, most of them can be summarized in terms of five general models of prevention, each based on a different set of underlying assumptions about drug-abusing behavior and its motivations.
The law enjorcement model relies on the passage of prohibitory laws and the infliction or threat of punishment to prevent drug abuse. This approach was based on the assumption that drug abuse was a moral issue and that persons who abused drugs because of immorality or weakness in the face of temptation must be punished for their own good and for the good of society. Also implicit in this approach is the assumption that certain drugs are inherently evil or, at least, too powerful for people to be allowed to use. These drugs are seen as being so seductive and potent that only the threat of punishment can keep the public from being tempted to try them and thereby become hopelessly addicted.
Of course, the truth is that the illicit drugs are not necessarily any more appealing or powerful than their licit counterparts, nor are any of the illicit drugs any more addictive than alcohol or the barbiturates or as hard to avoid dependence on as tobacco (nicotine).
Prohibition of drugs has never been a successful strategy. Even extreme measures such as Sultan Murad IV’s crusade against tobacco failed to prevent the growth of tobacco use. Three years after the Harrison Narcotics Act went into effect, the Rainey Committee documented its failure to reduce heroin abuse. Having learned nothing from the failure of our first national effort at drug prohibition~ the "glorious experiment" of Prohibition (1920 to 1933) attempted to keep people away from alcohol, with the inevitable result of all such prohibitions—more drug abuse and more crime resulting from the growth of a black market in the drug (alcohol).
The second model, the medical model, attempts to treat drug abuse as if it were an infectious epidemic. This model relies on the early identification and isolation of drug abusers before they can infect others. It is characterized by pamphlets and charts telling parents and teachers how to identify drug-using teenagers, parents bugging their sons’ and daughters’ phone conversations and searching their rooms, marijuana~sniffing police dogs examining school lockers, strip searches of students, and one-way mirrors in junior high school rest rooms so marijuana smokers can be caught and isolated. Involuntary treatment replaces jail in this model, but the differences between being locked in a prison and being locked in a treatment center are not very great in most cases.
An extension of the medical model that has been proposed but never really tried is the idea of vaccination. This idea proposes that, just as we protect children from the measles by vaccinating them, we should "vaccinate" high-risk children against heroin by putting them on a regular dosage of a narcotic antagonist such as cyclazocine. The implications of such a program of compulsory daily doses of narcotics antagonists to high-risk adolescents (basically minority and poor white youngsters) are staggering. So far no one in authority seems to have taken this unpleasant notion seriously, but who can say what the future may bring?
The medical model has been as great a failure as the law enforcement model of prevention. How can one hope to isolate the drug users from the nondrug users in a society where the drug users among the young are in the majority (Johnston, et al., 1979)? The main effect of these efforts seems to be that of creating a more and more hostile gap between the young and adult authority. An additional effect may be that drug users who have been labeled drug abusers may come to live up the expectations engendered by that label (Duncan, 1969; Williams, 1976).
The educational model assumes that drug abuse results from bad choices made in ignorance of the true effects and hazards of drugs. It is expected that if young people are educated about the dangers of drug abuse, they will make the right decisions and avoid drug abuse. Applications of the educational model have ranged from scare tactics to a factual presentation of the true effects of drugs. In more recent expansions of this approach drug educators have also concerned themselves with teaching decision-making skills, assertiveness skills (for resisting peer pressure), and alternatives to drugs. Drug education has also made use of values clarification, which helps students to explore their own values and priorities, in the expectation that students will decide that drugs are contrary to their values or at least get in the way of reaching their highest-priority goals. Teachers have sought to serve as role models and have exhorted students to adopt certain values—often doing so under the guise of values clarification.
The educational approach to drug abuse prevention will be considered at length in Chapter 14. At this point, all we will say is that drug education has not been very successful in terms of the criteria it has set for itself. In most instances, drug education has not reduced drug use among the young. It has, in fact, often increased experimentation with drugs.
The psychosocial model sees drug use as a means of coping with the problems and frustrations of adolescence. The answer to drug abuse prevention therefore is seen in providing other means of dealing with those problems and frustrations. ‘Rap rooms,’’ transcendental meditation, peer counseling, crisis hotlines, and education about how to cope with stress and emotional problems are all viewed as strategies for preventing drug abuse. Alternative opportunities for self-expression, adventure, and mystical-religious experience are seen as making drugs unnecessary to meet adolescent needs.
Much less data exist on which the effectiveness of this approach can be judged as opposed to the preceding three models. It has been a common experience, however, that many youngsters get stoned before engaging in alternatives" such as skydiving or meditation. The impact of these approaches remains highly questionable. Even theoretically, little impact could be expected from a single program. This model calls for a whole range of alternatives, and few communities have supported a broad enough range of such services with a vigorous enough outreach to give it a fair trial.
The final model is the sociocultural model, which sees the roots of drug abuse in our society and not in the individual. The solution to drug abuse therefore lies in changing society, not in changing the individual.
A society that discriminates against minorities cannot hope to escape drug abuse and crime by minorities. A society that confines housewives to the home and
counts their labor as trivial while their husbands’ shorter hours of labor is real "work" will have pill-popping housewives. A society that expects men always to compete and get ahead will have men who turn to alcohol or other depressants to reduce their anxieties and increase their aggressiveness or to stimulants such as coffee or amphetamines to give them the energy to compete. A society that advertises a pill to solve every problem will find its young turning to illicit drugs to solve their problems.
The prevention of drug abuse, according to this model, requires the remaking of our society. We must eliminate racism and sexism. We must learn to be cooperative and contemplative instead of competitive and driven. We must learn patience. And we must reduce our use of all drugs, not just the illicit drugs.
To date, our society has not been transformed, so we cannot judge whether this model will work or not. We can be sure that what this model prescribes would be good for us all, whether or not it prevented drug abuse, but it is not a prescription that can easily or rapidly be filled.
THE CRITICAL ERRORS IN PREVENTION EFFORTS
The biggest error made by almost every preventive program has been the failure to distinguish between drug use and drug abuse. Too often a legalistic definition has been accepted. Drinking 10 cups of coffee a day is not seen as abuse, but sniffing cocaine once at a party is abuse. The person who smokes a joint occasionally is as
much an abuser as the person who cannot make it through the day without stopping to smoke marijuana several times. The businessman who needs two martinis at lunch and several more at home in the evening "to unwind" is not an abuser, but his daughter who shares a joint with friends at a party is.
This assumption makes no sense. Drug abuse is a matter of an interaction among the person, the drug, and the circumstances. It is not possible to say that all use of any drug is abuse. In fact, for most drugs the users outnumber the abusers in a proportion of about 9 to I. Heroin, for all its bad reputation, can be used with no significant hazards, as the "British system" has demonstrated for years. Even tobacco is used instead of abused by some smokers, although it is the rare case of a drug that is more often abused than used.
Evaluation of prevention is especially complicated because of this error. Who can say whether drug education really reduced drug abuse or not when we persist in evaluating it by counting the number of users, misusers, and abusers together as if they were all the same? If drug abuse prevention is to be effective it must focus on preventing abuse and not on preventing use. This is a more complex task, but it is possible. Moreover, the prevention of drug use is a task that no society has ever been able to succeed at.
The second critical error is closely related to the first. Preventive efforts have tended to ignore the existence of a substantial body of users, as opposed to abusers,
for every drug. For every drug of concern there are people who take that drug nonmedically to achieve an effect and who do achieve that effect with a minimum of hazard to themselves or others. The factors that differentiate between users and abusers of drugs may be of key importance to preventing drug abuse.
Howard Becker (1963), in his classic paper ‘Becoming a Marijuana User," introduced the concept that a person must learn how to be a drug user. He described three steps in becoming a marijuana user: (1) learning the technique of marijuana smoking; (2) learning to perceive the mild and ambiguous effects of marijuana; and (3) learning to enjoy those effects. Also necessary, according to Becker, was the adoption of a set of rationalizations needed to allow one to violate comfortably society’s taboo on marijuana. This process of learning and adopting values took place in a peer group setting.
Although Becker’s thesis scarcely seems startling today, it was a major contribution to our understanding of drug-taking behavior. People do learn how to use drugs and how to value that use. The drug-using peer group teaches techniques, rituals, rules, and values regarding the use of drugs. Whether the drug taker will become a user or an abuser may depend greatly on the set of norms learned from the drug-using peer group.
Rules and Rituals in Drug Use
The user learns a set of implicit or explicit rules and adopts a set of rituals from the drug-using peer group. By rules we mean learning when and how to use and not use the drug according to the standards of the peer group. Rituals refer to stylized and predictable interchanges between people (Berne, 1972), in this case involving the use of drugs.
The first of these rules and rituals are concerned with how the drug is used, what effects are to be expected, and what is pleasurable about those effects. Learning how to inhale smoke (whether from tobacco or from marijuana) requires instruction and practice. In the same sense, one’s first drink of Scotch is not likely to be entirely pleasant until one has learned not to mind the burning in one’s mouth and throat and to enjoy a taste that more likely was first perceived as unpleasant. This learning of how to use the drug tends to be paired with learning how not to use it. The user has learned to take the drug of choice in a minimally hazardous manner and has learned to control the dosage so as to obtain the desired level of effects.
• The drug-using peer group prescribes limits as to how much of the drug effect the user should experience. The user then learns to titrate the dose in order to reach that acceptable level of effect. Since the dose needed varies from person to person, each user learn’s his or her own "limit." At the same time, the dose needed to achieve the desired effect also varies somewhat for each person depending on factors such as physical and emotional state and recency of meals. Therefore the user tends to learn to take the drug gradually in small doses until the desired level of
• effects is reached. Sipping several drinks instead of "chugging" a bottle or passing a joint around a circle instead of smoking it continuously by oneself are examples of such behavior.
The group rules often define the setting in which drugs are to be used. This setting is likely to be defined in terms of physical, social, and interpersonal environment as well as in terms of time. The user does not use drugs in a physically hazardous environment. Drug use is generally regulated by a rule that it is not to be done while alone, but only with friends. Drug use, unlike most drug abuse, is a social activity engaged in with friends.
Time rules are very common. The practice of not drinking before a fixed hour in the evening is a common rule among alcohol users in our society. Some drug users restrict their drug use to weekends only. Zinberg, Harding, and Winkeller (1977) report that some controlled illicit drug users in their studies have a rule against drug use on Sunday evening so that they will not be too tired to be effective at work on Monday. This latter rule is also typical of the way users often have rules that support nondrug-related obligations.
The group rules and rituals also help the user to interpret and control the effects of the drug. The user learns that drugs are not the all-powerful substances they are often made out to be. The user learns to control what the drug does instead of the drug controlling the user. Jacobson and Zinberg (1975) argue that controlled drug use can develop only when the principles of set and setting are consciously or unconsciously understood and applied by the user.
Young (1971) notes that the "lore" of drug users provides prescriptions for
keeping drug use in check and contains informal sanctions against going beyond those bounds. The drug-using group can bring informal sanctions to bear on the drug taker who takes too much or indulges too often or under the wrong circumstances. Such sanctions tend to keep the social user from becoming an abuser as long as membership in the group is valued.
Drug users tend to be drug takers who feel good about themselves. They feel that they are worthwhile and are valued as worthwhile by others. Drug users tend to see themselves as having multiple roles. Being a drug user is not the only role in which
they can take pride. They also take pride in their other roles, such as mother, employee, citizen, and neighbor. They do not have to rely on their ability to ‘drink anyone under the table," for instance, as their one claim to distinction and source of pride.
The Noncentral Role of Drugs
Related to self-esteem is the fact that drugs are not a central feature of the drug user’s life. Only a small portion of the user’s concerns center around drugs. There are other concerns of greater importance than getting high. Users are involved in work or school. They do not necessarily like their work or school, but they are involved. They show up for work or school on time and are prepared to perform the tasks set for them. Few activities are as valuable a support to maintaining use and not abuse as work and school are (Jacobson and Zinberg, 1975).
Of similar importance are enjoyable affectionate relations. Jacobson and Zinberg (1975) point to the crucial role of a harmonious relationship between the user and her or his mate as a part of maintaining a use level of drug taking. Others have pointed to the role of friendly relations with parents as a factor differentiating adolescent drinkers (users) from adolescents with drinking problems (abusers) (Barnes, 1977).
Stable Situations and Coping Skills
Drug users seem to lead fairly stable lives. The changes they undergo are largely planned for, or at least expected. They are not always moving, changing jobs, or living a life-style indicative of transience or hustling. They are not stuck in a rigid lifestyle, but they maintain a degree of stability by not taking on too many changes at once. Users tend to have good coping skills. When change is necessary, they can accept it and often welcome it—making the change smoothly without disrupting their entire life. They cope effectively with stress. Drugs may be one of the means by which they cope with the pressures of change, but drugs are not their sole, nor often even a major, coping mechanism.
Drug users weigh the cost of a drug purchase against the benefit they expect from it. They carefully consider quality and quantity. They will choose to do without instead of buying poor-quality or overpriced drugs. This is in market contrast to the popular image of the drug addict who will spend anything to support a habit. Drugs are often just another item in the user’s budget. A fixed amount is set aside to buy drugs just as another fixed amount is set for groceries. A large purchase for a special occasion may be saved for in advance and not purchased on the spur of the moment. Drugs
simply are not the most important thing in the user’s life, so money must be spent on other things first.
What, then, are the characteristics that set drug abusers apart from drug users? Why are these individuals unable to control their drug taking in the way that users of the same drugs are? Answers to these questions are not easily found. Much of the research that has been done on the characteristics of drug abusers has been based on a legalistic definition of abuse—all illicit drug taking was considered to be abuse. As a result, most of what is usually stated as being predictive of drug abuse is probably really more predictive of drug use than of abuse or addiction (Robins, 1979).
A simple portrait of the abuser might be derived by simply taking the description already given for the drug user and reversing it, as follows. Drug abusers tend not to have rules and rituals that limit or control drug taking. Drug abusers tend not
to restrict the settings in which drugs are taken. Drug abusers tend to see the drug as all-powerful and to give themselves up to its control instead of seeing themselves as
largely in control of the drug’s effects. Drug abusers tend not to be committed to a
peer group that imposes sanctions on excessive drug taking. Drug abusers tend to have poor self-esteem. Drugs play a central role in the lives of drug abusers, other activities will readily be interrupted or abandoned for the sake of the drug. Drug abusers tend not to weigh the costs of drugs; they regard any price as worth paying if it is necessary to obtain the drug. Drug abusers are likely to have little or no commitment to work or school. Drug abusers tend not to have harmonious affectionate relations. Drug abusers tend to have few group identifications other than with the drug-taking peer group, and even this identification may be weak. Drug abusers tend to live in a state of constant flux, with little or no stability.
One of the strongest findings about drug abusers is that they tend not to like themselves. No empirical research seems to have been done comparing users to abusers in terms of self-esteem, but research has been done demonstrating the low
self-esteem of heroin addicts (Lindblad, 1977). The experience of many who have worked with both abusers and users supports the conclusion that this is a characteristic that clearly separates the two groups.
Duncan (1977) found that adolescent drug abusers were likely to have begun taking illicit drugs during a period of stress related to excessive changes and disruptions in their life-style. Changing schools, separation or divorce of parents, a parent’s loss of a job, increased father absence because of job change, increased arguments between parents, hospitalization, an outstanding personal achievement, or a suspeilsion from school were events particularly more prevalent in the histories of drug abusers just prior to the initiation of illicit drug taking than in nonabusing adolescents.
The usual concern in our society is with drug abuse leading to crime, but there is reason to believe that crime leads to drug abuse. This is not to deny that addicts steal to support their habit when that is necessary or that the use of alcohol or other depressants contributes to crimes of violence. However, a committment to a delinquent or deviant life-style seems to have been typical of many, if not most, abusers before they began to abuse. In a study of two samples of heroin addicts, Duncan (1975) found that 36.6 percent of a group of imprisoned heroin addicts and 21.0 percent of a group of methadone patients reported that they had first taken illicit drugs while in jail (or a detention home or similar institution). More than 75 percent of the methadone patients in this study reported that they had been arrested at least once before their first illicit drug use.
A number of other studies (Lukoff, 1974; Robins and Wish, 1977; Robins and Ratcliff, 1978) have demonstrated that antisocial behavior beginning in childhood is highly predictive of drug abuse in adulthood. Lukoff (1974) found that the younger the age at which delinquency began, the more intense and committed the addictive career that followed.
It may well be that one of the influences that can cause a drug abuser to develop a pattern of abuse was being labeled as an abuser. A federally sponsored review of the evidence on this possibility (Williams, 1976) was able to conclude that the long-range implications of labeling a person as a drug abuser "are not clear at this time."
There are real grounds for concern that labeling someone as a drug abuser may severely alter that individual’s self-concept, lowering self-esteem and fostering identification with a drug-abusing peer group. The labeled ‘abuser" is likely to be cut off from many legitimate opportunities; for instance, expulsion from school or loss of a job may result from such a label. The labeled youth will no longer be welcome in the homes of many friends who could serve as peer role models for nonabusing behavior. At the same time, the labeled youth is thrown into contact with a peer group of abusers—in jail or a detention home, in an institution, in a treatment program, or in the probation office waiting room (Duncan, 1969; Gold and Williams, 1969).
Jacobson and Zinberg (1975) point to serious dealing in drugs as a significant factor in moving some drug takers toward abuse. Almost all drug users engage in occasional profitless or low-profit dealing, but serious dealing greatly increases the probability of abuse. Professional dealers have made dealing their work, so work can no longer be a factor mitigating against abuse. Drugs necessarily become a central factor in the dealer’s life. Furthermore, dealing is a stressful occupation with high risks of being cheated, robbed, or arrested. Such stress may be the motivation for increased drug taking.
A NEW MODEL FOR PREVENTION
Effective prevention of drug abuse must begin with a clear recognition of the distinction between use and abuse of a drug. We must recognize that experimentation with drugs, as with so many other things, is a normal part of a healthy adolescence. Trying to prevent such experimentation only drives it underground-cutting it off from any possibility of adult guidance, making it seem more adventurous, and increasing the risk of abuse. We must also recognize that some of the
experimenters will become users (social-recreational users or occasional situational-circumstantial users) and that this, too must be accepted. We must concern ourselves with prevention of intensified and compulsive abuse and with providing users with the knowledge to prevent accidental abuse, such as that caused by inappropriate drug mixing.
Our educational efforts must be factual and not scare tactics. The use of scare must earn back our credibility in the eyes of the young by carefully avoiding biased tactics in the past has undermined a great deal of our credibility regarding drugs. We presentations of the facts or moralizing in drug education.
We must teach people how to use and not abuse drugs. Our educational efforts in the past have told a great deal about abuse and our mass media have portrayed abuse, but we have not provided nearly so many models for use. The sort of rules and rituals that help the user to maintain a controlled and harmless level of drug use must be conveyed to the general public.
Such education in how to use need not be prescriptive. That is, we need not tell people what to do in using drugs with an implied message that they should use drugs. What we should do, however, is to give users and their behavior at least equal time with abusers in our drug education. We should portray users accurately in the mass media as normal, healthy people whose use of drugs is constrained by certain conventions and by intelligent decision making. Above all, we should stop exaggerating the power and importance of drugs. We must show the public that people can control drug effects much more than drug effects can control people. The
concepts of set and setting should become a universal part of our culture, understood
and applied by everyone in making decisions about drug use. The schools have a role in bringing this about, but the media probably have an even greater responsibility to teach these facts to the majority of the public, who are no longer in school.
We must also recognize the importance of positive self-esteem, affectionate relations, and stress coping skills in the avoidance of drug abuse. Drug abuse prevention is inevitably and inextricably tied to the promotion of mental health. Communications skills and stress coping skills can be taught and should become a part of a required program of health education in every school. Such skills can also be offered through adult continuing education programs at schools, colleges, churches, and civic and professional groups.
The promotion of healthy emotional and social growth of children and adolescents should be as much a concern of schools as their intellectual and physical growth. This is scarcely a new idea. It was not even new when John Dewey wrote his many books and papers on the subject earlier in this century. But it is an idea given more lip service than actual application. We must begin to be serious about this obligation.
Konopka (1978) has identified some of the necessary conditions for healthy emotional and social development of adolescents.
1. Participation as citizens, as members of a household, as workers and as responsible members of society.
2. Experience in decision making.
3. Interaction with peers and gaining a sense of belonging.
4. Reflection on self in relation to others and self-discovery by looking outward as well as inward.
5. Discussion of conflicting values and formulation of their own value system (not acceptance of imposed values).
6. Experimentation with their own identity—trying out various roles without needing to make a commitment to any of those roles.
7. Development of a feeling of accountability for one’s own behavior to peers in a context of equality.
8. Cultivation of a capacity to enjoy life.
As a society, we must make a commitment to provide these necessities to every adolescent. In doing so we will act to prevent drug abuse and to improve our entire society.
Programs aimed at prevention of drug abuse should be programs for everyone. The temptation to identify high-risk groups of adolescents and to provide special programs for them should be resisted. Singling out any such high-risk group would stigmatize the very youths we had set out to help. Such stigma might do more to cause drug abuse than any program could do to prevent it.
Community programs for young people should be positive in nature and should seek to involve all young people. They should be sponsored by a recognized community institution such as the school or the church. They should try to insure a mix of youths, with both those at high risk of abuse and those at low risk involved. They should act on the assumption that young people, even the troublesome ones, have positive resources to contribute to their community, and they should proceed immediately to place the youths in an active role where something of value is being contributed. The programs should not just do something for youth, they should involve youth in doing something for themselves and others. Through such a program we can hope to have a real impact on self-esteem and to reduce the risk of drug abuse while also making our communities better places to live.
STIGMA AND PREVENTION PROGRAMS
A high school in Houston, Texas, initiated a drug abuse prevention program by asking counselors and teachers to identify students they believed to be drug abusers. These students were then assigned to a special class that was to teach about drugs, do values clarification, and explore alternatives to drugs. The evening of the class’s first meeting three of the students in the class were brought to a local crisis center as drug overdoses. The students in the class had held a party after school at which they lived up to the label of drug abuser that the school had placed on them, Of the three students who overdosed on a mixture of alcohol, Quaaludes, and marijuana, one had never taken Quaaludes before and one had never used illicit drugs or taken Quaaludes before. At least three students smoked marijuana for the first time at that party and more took Quaaludes for the first time.
Whatever positive effect that class may have had, it was acting against a powerful negative effect produced by publicly labeling a group of students as drug abusers—most of whom, in fact, were not drug abusers and some of whom were not even users of the illicit drugs the school was worried about. The first rule of prevention should be the old medical maxim of primum nil nocere— first, do no harm.
In summary, the new model we are proposing stresses the prevention of drug abuse, not the prevention of drug taking. It does so by avoiding the scare tactics approach, which exaggerates the power and importance of drugs, by promoting the awareness that drugs can be used appropriately and their effects controlled, and by supporting the emotional and social growth of the young through mental health education and youth participation in meaningful community activities.
In this chapter we reviewed five models of drug abuse prevention: the law enforcement model, the medical model, the educational model, the psychosocial model, and the sociocultural model. Several major errors have been identified that hampered previous efforts to impact on drug abuse in this country. Failure to distinguish between drug use and drug abuse has been the most critical of these errors. We reviewed the differences between drug users and drug abusers and applied the differences to the development of a new model for prevention.